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Claim Status Inquiry EOB Crosswalk

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					                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
      MILEAGE/PAYMENT REDUCED TO
00001 NEAREST APPROPRIATE FACILITY              F104 FNL/Payment: Payment reflects plan provisions.
                                                 430 Nearest appropriate facility


      THIS SERVICE HAS BEEN RECOUPED
      AS A RESULT OF THE ER
00002 RETROSPECTIVE REVIEW PROCESS.             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      A PROPHYLAXIS WITHIN 90 DAYS OF A
      PERIODONTAL SCALING OR ROOT
00003 PLANING IS NOT PAYABLE.                    F20 FNL/Denied: Claim/line has been denied.
                                                 104 Processed according to plan provisions.

      FAMILY PLANNING PROGRAM
00004 DESIGNATION REQUIRED.                     F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.


      THIS SERVICE DENIED/RECOUPED
      BECAUSE PCP CONTACT IS REQUIRED
00005 PRIOR TO CLIENT TREATMENT                F2019 FNL/Denied: Member not referred by selected primary care provider.
                                                   9 No payment will be made for this claim.

      THIS SERVICE DENIED AS A RESULT
      OF THE ER RETROSPECTIVE REVIEW
00006 PROCESS.                                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.


      CIDC PCN/PROVIDER NUMBER(S) ARE
00007 NOT VALID ON A MEDICAID CLAIM            F2013 FNL/Denied: Patient not eligible/not approved for dates of service.    C&E Recommendation

                                               F2016 FNL/Denied: Provider not eligible/not approved for dates of service.   C&E Recommendation
                                                  21 Missing or invalid information.


                                                                                                                                      Page 1 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE         MESSAGE NARRATIVE                                          NOTES
      TITLE X PROVIDERS MUST PROVIDE
      LEVEL OF PRACTITIONER
00008 INFORMATION.                             F20 FNL/Denied: Claim/line has been denied.
                                               147 Entity's qualification degree/designation (e.g. RN,PhD,MD)

      THIS SERVICE DENIED/RECOUPED
      BECAUSE CLIENT LEFT FACILITY
00009 PRIOR TO TREATMENT                       F20 FNL/Denied: Claim/line has been denied.
                                               234 Patient discharge status.


      THESE SERVICES DENIED/RECOUPED
      DUE TO INAPPROPRIATE REFERRAL
00010 BY PCP TO THE EMERGENCY ROOM             F20 FNL/Denied: Claim/line has been denied.

                                                   9 No payment will be made for this claim.                    C&E Recommendation

                                                91 Entity not eligible/not approved for dates of service.       C&E Recommendation

                                                48 Referral/authorization.                                      C&E Recommendation

      INFORMATIONAL PROCEDURE TO
      INDICATE DENTAL SERVICE
      PERFORMED UNDER GENERAL
00011 ANESTHESIA.                              F20 FNL/Denied: Claim/line has been denied.
                                               239 Dental information.


      FREQUENCY OF VISITS BILLED DOES
      NOT MATCH VISITS AUTHORIZED
00012 THROUGH HOME HEALTH UNIT                F209 FNL/Denied: Service not authorized.
                                                48 Referral/authorization.
                                                84 Service not authorized.

                                               259 Frequency of service.                                        C&E Recommendation




                                                                                                                          Page 2 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES
      THIS SERVICE NOT ALLOWED FOR
00013 THIS DIAGNOSIS.                          F20 FNL/Denied: Claim/line has been denied.
                                               255 Diagnosis code.

      DUE TO INPATIENT UTILIZATION
      REVIEW DENIAL, ALL RELATED
00014 SERVICES ARE DENIED/RECOUPED.           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      CONSULT CODE FOR ESTABLISHED
      PATIENT CHANGED TO FOLLOW-UP
00015 OFFICE VISIT/HOSPITAL VISIT.             F10 FNL/Payment: Claim/line has been paid.
                                                15 One or more originally submitted procedure code have been modified.
                                                65 Claim/line has been paid.

                                               104 Processed according to plan provisions                                 C&E Recommendation

      MEDICAID DOES NOT PAY FOR THESE
      SERVICES NOT COVERED BY
00016 MEDICARE.                                F20 FNL/Denied: Claim/line has been denied.
                                                 9 No payment will be made for this claim.

      MEDICAID ALLOWANCE LIMITED TO
      THE MEDICARE DEDUCTIBLE AND/OR
00018 COINSURANCE                              F10 FNL/Payment: Claim/line has been paid.
                                               182 Allowable/paid from primary coverage.

      MEDICARE PAID THE TOTAL
00019 ALLOWABLE FOR THE SERVICE.             F2010 FNL/Denied: Payer not primary.
                                                 9 No payment will be made for this claim.

      EXAM WITHIN 180 DAYS OF INITIAL
00020 EXAM PAID AS FOLLOW UP EXAM             F104 FNL/Payment: Payment reflects plan provisions.
                                                15 One or more originally submitted procedure code have been modified.

                                                65 Claim/line has been paid                                               C&E Recommendation


                                                                                                                                    Page 3 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE         MESSAGE NARRATIVE                                                     NOTES

                                                  104 Processed according to plan provisions                                  C&E Recommendation

      APPEAL FOR TITLE V OR XX FAMILY
      PLANNING SERVICES RECEIVED PAST
00021 180 DAY FILING DEADLINE.                    F20 FNL/Denied: Claim/line has been denied.
                                                    9 No payment will be made for this claim.


      THE NUMBER OF ACCOMMODATIONS
      BILLED DOES NOT AGREE WITH THE
00022 DATES OF SERVICE.                           F20 FNL/Denied: Claim/line has been denied.

                                                  187   Date(s) of service                                                    C&E Recommendation
                                                  258   Days/units for procedure/revenue code.
                                                  259   Frequency of service.
                                                  476   Missing or invalid units of service

      MULTIPLE SURGICAL PROCEDURES
      PROCESSED ACCORDING TO
00023 SURGERY GUIDELINES.                        F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      ADDITIONAL LENGTH OF STAY NOT
00024 MEDICALLY DOCUMENTED.                      F203 FNL/Denied: Denied due to plan provisions.
                                                  260 Length of medical necessity, including begin date.
                                                  263 Length of time for services rendered.

      REQUESTED INFORMATION NOT
      RECEIVED WITHIN 30 DAYS, DENIAL IS
00025 FINAL.                                      F20 FNL/Denied: Claim/line has been denied.
                                                    9 No payment will be made for this claim.

      CLIENT IS ELIGIBLE FOR MEDICARE,
00026 BILL MEDICARE FIRST.                      F2010 FNL/Denied: Payer not primary.
                                                  171 Other insurance coverage information (health, liability, auto, etc.).


                                                                                                                                        Page 4 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                            NOTES
      ALLOWED AMOUNT REFLECTS OTHER
      INSURANCE PAYMENT THAT MAY
      EQUAL OR EXCEED PROGRAM
00027 LIABILITY                              F2010 FNL/Denied: Payer not primary.
                                               182 Allowable/paid from primary coverage.

      CLAIM ADJUSTED TO MATCH
00028 AUTHORIZATION.                          F103 FNL/Payment: Partial payment made for this claim.
                                                48 Referral/authorization.


      CLIENT MUST BE 21 YEARS OF AGE
00029 ON THE DATE CONSENT WAS SIGNED.         F203 FNL/Denied: Denied due to plan provisions.

                                               104 Processed according to plan provisions                       C&E Recommendation
                                               475 Procedure code not valid for patient age

      CLIENT NAME IS MISSING. PLEASE
      CORRECT AND RESUBMIT YOUR
00030 CLAIM.                                   F20 FNL/Denied: Claim/line has been denied.
                                               125 Entity's name.

      FACILITY PROVIDER NUMBER
      REQUIRED ON THE HCFA 1500 CLAIM
00031 FORM.                                    F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

      CLIENT'S COUNTY OF RESIDENCE
00032 CODE REQUIRED.                           F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

                                               153 Entity's ID Number.                                          C&E Recommendation

      BILLING PROVIDER NUMBER NOT
      AUTHORIZED FOR ELECTRONIC
00033 BILLING. PLEASE CONTACT NHIC.            F20 FNL/Denied: Claim/line has been denied.
                                                24 Entity not approved as an electronic submitter.

                                                                                                                          Page 5 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                             NOTES

      PROCEDURE NOT A BENEFIT MORE
00034 THAN ONCE IN A LIFETIME.                F203 FNL/Denied: Denied due to plan provisions.
                                               483 Maximum coverage amount met or exceeded for benefit period.

      PROCEDURE NOT A BENEFIT MORE
00035 THAN TWICE IN A LIFETIME.               F203 FNL/Denied: Denied due to plan provisions.
                                               483 Maximum coverage amount met or exceeded for benefit period.

      ALL APPLICABLE BLANKS ON
      CONSENT FORM NOT COMPLETED.
      REFER TO PROVIDER PROCEDURE
00036 MANUAL.                                  F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

      PLEASE DOCUMENT SOURCE OF
      CREDIT AMOUNT INDICATED. REFILE
00037 CORRECTED CLAIM.                         F20 FNL/Denied: Claim/line has been denied.
                                               401 Source of payment is not valid


      MEDICAID/MEDICARE DOES NOT PAY
      FOR SERVICES WHEN PAID/DENIED
00038 BY THE CLIENT SELECTED HMO.              F20 FNL/Denied: Claim/line has been denied.
                                               115 Cannot process HMO claims

      THSTEPS-CCP SERVICES ARE NOT
      PAYABLE FOR DATES OF SERVICE
00039 PRIOR TO 040190.                         F20 FNL/Denied: Claim/line has been denied.
                                               483 Maximum coverage amount met or exceeded for benefit period.

      DUPLICATE ITEM OF A CLAIM BEING
      PROCESSED. PLEASE DO NOT FILE A
00040 DUPLICATE CLAIM.                        F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                54 Duplicate of a previously processed claim/line.




                                                                                                                         Page 6 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                      NOTES
      THESE CHARGES ARE INCLUDED IN
      THE GLOBAL AMBULATORY SURGICAL
00041 FACILITY PAYMENT.                          F20 FNL/Denied: Claim/line has been denied.
                                                 104 Processed according to plan provisions.

      THIS IS A DUPLICATE SERVICE THAT
      HAS BEEN PAID TO ANOTHER
00042 PROVIDER.                                 F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                  54 Duplicate of a previously processed claim/line.

      THIS SERVICE WAS PREVIOUSLY PAID
00043 TO PROVIDER/SUPPLIER.                     F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                  54 Duplicate of a previously processed claim/line.


      PAYMENT BY AGENCIES IDENTIFIED
      AS SECONDARY TO THIS PROGRAM
00044 MUST BE REFUNDED TO THE AGENCY.            F10 FNL/Payment: Claim/line has been paid.
                                                 171 Other insurance coverage information (health, liability, auto, etc.).

00045 DENIED ON CLAIM %1 ON %2.                 F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                  54 Duplicate of a previously processed claim/line.

      DATE OF BIRTH IN FIELD MISSING OR
00046 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 158 Entity's date of birth

      PROFESSIONAL OR TECHNICAL
      COMPONENT FEE INCLUDED IN
00047 COMBINED PROCEDURE.                        F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.

      CLIENT HAS NOT BEEN ELIGIBLE FOR
      AT LEAST TWO YEARS / REMOVED                   FNL/Denied: Patient not eligible for benefits for submitted dates of
00048 FROM DHS FILE.                           F2013 service.
                                                  88 Entity not eligible for benefits for submitted dates of service.


                                                                                                                                     Page 7 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
      DIAGNOSIS DOES NOT INDICATE
      MEDICAL NECESSITY FOR SERVICE(S)
00049 TO BE REPEATED.                            F20 FNL/Denied: Claim/line has been denied.
                                                 255 Diagnosis code.

      PATIENT SOCIAL SECURITY NUMBER
00050 REQUIRED.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 148 Entity's social security number.
      THIS ADJUSTMENT IS A RESULT OF A
      RETROSPECTIVE REVIEW OF
00051 READMISSIONS AND TRANSFERS.               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  46 Internal review/audit.


00052 SEX OF PATIENT MUST BE INDICATED.          F20 FNL/Denied: Claim/line has been denied.
                                                 157 Entity's Gender

      THE PHYSICIAN ASSIST-CERT NAME
      AND LICENSE NUMBER NEEDS TO BE
00053 INCLUDED ON THE CLAIM.                     F20 FNL/Denied: Claim/line has been denied.
                                                 142 Entity's license/certification number.

      THIS RECOUPMENT IS A REISSUE OF
00054 PREVIOUS RECOUPMENT.                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

                                                     FNL/Denied: Patient not eligible for benefits for submitted dates of
00055 CLIENT NOT ICF-MR ELIGIBLE.              F2013 service.
                                                 109 Entity not eligible.

      TAKE HOME DRUGS AND SUPPLIES
00056 ARE NOT A BENEFIT.                         F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.




                                                                                                                                    Page 8 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                             NOTES

      ACCORDING TO HCFA REGULATIONS
      PAYMENT REDUCED AS THIS TEST IS
00057 PART OF AN AUTOMATED GROUP.             F103 FNL/Payment: Partial payment made for this claim.
                                                68 Partial payment made for this claim.


      PROCEDURE PAYMENT DETERMINED
      BY PROGRAM/BENEFIT PLAN,
      LOCALITY/SPECIALTY, DATE OF
00058 SERVICE AND BILLED AMOUNT.              F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      ADDITIONAL PAYMENT FOR
      INCIDENTAL SURGERY IS NOT A
00059 BENEFIT.                                 F20 FNL/Denied: Claim/line has been denied.
                                               483 Maximum coverage amount met or exceeded for benefit period.

      PURCHASE PRICE HAS BEEN
      REACHED. RENTAL FEE IS NO
      LONGER PAYABLE FOR THIS
00060 EQUIPMENT.                               F20 FNL/Denied: Claim/line has been denied.
                                               184 Purchase price for the rented durable medical equipment.

      A PHYSICIAN'S PRESCRIPTION FOR
00061 THIS EQUIPMENT IS REQUIRED.              F20 FNL/Denied: Claim/line has been denied.
                                               219 Prescription number.

      CLAIM DENIED. PHYSICIAN
      CERTIFICATION STATEMENT NOT
00062 SUBMITTED.                               F20 FNL/Denied: Claim/line has been denied.
                                               332 Authorization/certification (include period covered).

      RESUBMIT RUN SHEET WITH A
      NARRATIVE DESCRIPTION OF
      CLIENT'S CONDITION AND VITAL
00063 SIGNS.                                   F20 FNL/Denied: Claim/line has been denied.

                                                                                                                         Page 9 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                       NOTES
                                                472 Ambulance Run Sheet

      SCREEN EXCEEDS PERIODICITY
00064 SCHEDULE.                                 F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      VALID PRIMARY BIRTH CONTROL
00065 METHOD REQUIRED.                          F20 FNL/Denied: Claim/line has been denied.
                                                122 Missing/invalid data prevents payer from processing claim.

      SERVICES FOR LOCK-IN CLIENT
      PAYABLE ONLY TO DESIGNATED LOCK-
00066 IN PROVIDER.                            F2018 FNL/Denied: Rendering provider is not selected primary care provider.
                                                 93 Entity is not selected primary care provider.

      PROCEDURE/SERVICE LIMITED TO
00067 ONCE PER CALENDER MONTH.                  F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      THIS PAYOUT IS A REISSUE OF
00068 PREVIOUS PAYOUT.                         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      CONCURRENT CARE DETERMINED
00069 NOT MEDICALLY NECESSARY.                 F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      PROCEDURE BILLED IS NOT A
      BENEFIT OF THIS FAMILY PLANNING
00070 PROGRAM.                                  F20 FNL/Denied: Claim/line has been denied.

                                                104 Processed according to plan provisions                                  C&E Recommendation
                                                453 Procedure Code Modifier(s) for Service(s) Rendered

      DOCUMENTATION NOT RECEIVED
00071 WITHIN TIME LIMIT.                        F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

                                                                                                                                      Page 10 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                    NOTES


      SERVICES CONSIDERED
      EXPERIMENTAL OR INVESTIGATIONAL
00072 ARE NOT A BENEFIT.                        F20 FNL/Denied: Claim/line has been denied.

                                                  9 No payment will be made for this claim.                              C&E Recommendation
                                                453 Procedure Code Modifier(s) for Service(s) Rendered
      INPATIENT DEDUCTIBLE HAS BEEN
00073 MET.                                      F00 Finalized: Claim/encounter has been processed.
                                                 98 Charges applied to deductible.

      INFORMATIONAL CODE FOR MEDICAL
      TRANSPORTATION PROGRAM USE
00074 ONLY.                                     F00 Finalized: Claim/encounter has been processed.
                                                  9 No payment will be made for this claim.

      MISSING, INVALID OR FUTURE DATES
00075 OF SERVICE.                               F20 FNL/Denied: Claim/line has been denied.
                                                187 Date(s) of service.

      MISSING OR INVALID TYPE OF
00076 SERVICE.                                  F20 FNL/Denied: Claim/line has been denied.
                                                250 Type of service.

      THIS PROCEDURE NOT PAYABLE IN
00077 THIS PLACE OF SERVICE.                    F20 FNL/Denied: Claim/line has been denied.
                                                249 Place of service.


      MISSING OR INVALID PROCEDURE
00078 CODE OR DESCRIPTION OF SERVICE.           F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


      REFERRING PROVIDER WAS NOT THE
00079 PCP ON THE DATE OF SERVICE.             F2019 FNL/Denied: Member not referred by selected primary care provider.

                                                                                                                                   Page 11 of 378
                                                                      EOB CSI ANALYSIS

                                            X-WALK
CURR                                        HIPAA
NHIC                                        FINAL
EOB                                         CSCC/CSC
CODE MESSAGE NARRATIVE                      CODE       MESSAGE NARRATIVE                                                        NOTES
                                                    93 Entity is not selected primary care provider.


00080 VALID PATIENT CO-PAY IS REQUIRED.              F20 FNL/Denied: Claim/line has been denied.
                                                       9 No payment will be made for this claim.

                                                     171 Other insurance coverage information (health, liability, auto, etc.)   C&E Recommendation

                                                     453 Procedure Code Modifier(s) for Service(s) Rendered                     C&E Recommendation


      CLAIM BILLED TO NHIC IN ERROR. BILL
      HMO. IF CLIENT IS A STAR+PLUS
00081 MQMB FILE APPEAL TO NHIC.                      F20 FNL/Denied: Claim/line has been denied.
                                                     115 Cannot process HMO claims

      EMERGENCY TRANSFERS CANNOT BE
      APPEALED AS A NON-EMERGENCY
00082 TRANSFER.                                      F20 FNL/Denied: Claim/line has been denied.
                                                       9 No payment will be made for this claim.

      SERVICES BILLED TO NHIC IN ERROR.
00083 BILL VISTA.                                    F20 FNL/Denied: Claim/line has been denied.
                                                     115 Cannot process HMO claims


      X-RAY WITHIN LAST 12 MONTHS
      REQUIRED FOR CHIROPRACTIC
00084 TREATMENT OF CHRONIC CONDITION.                F20 FNL/Denied: Claim/line has been denied.
                                                     318 X-rays.

      PROVIDER NOT ENROLLED FOR
      DATES OF SERVICE. CONTACT NHIC
00085 CUSTOMER SERVICE.                              F20 FNL/Denied: Claim/line has been denied.
                                                     132 Entity's Medicaid provider id.




                                                                                                                                          Page 12 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                      NOTES

      REQUEST FOR EXTENDED PAN HAS
      BEEN DENIED. YOUR CLAIM IS BEING
00086 PROCESSED WITH ROUTINE PAN.               F00 Finalized: Claim/encounter has been processed.
                                                 48 Referral/authorization.


00087 MARITAL STATUS MUST BE ENTERED.           F20 FNL/Denied: Claim/line has been denied.
                                                160 Entity's marital status

      CONSULTS NOT APPROVED BY
00088 MEMBER'S PCP.                             F20 FNL/Denied: Claim/line has been denied.
                                                 25 Entity not approved.


      AIR TRANSFER HAS BEEN APPROVED
      AT NON-EMERGENCY GROUND RATE;
00089 PAYMENT REDUCED.                         F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      THIS ACTION IS THE RESULT OF A
00090 MEDICARE ADJUSTMENT.                     F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      ADULT PHYSICAL EXAMS MUST BE
00091 PERFORMED BY MEMBER'S PCP.              F2018 FNL/Denied: Rendering provider is not selected primary care provider.
                                                 85 Entity not primary.


      THIS IS NOT A VALID PROCEDURE
      FOR DATE OF SERVICE, RESUBMIT
00092 USING THE AUTOMATED TEST CODE.            F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.

      ONLY 2 PELVIC ULTRASOUNDS
00093 ALLOWED PER PREGNANCY.                    F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

                                                                                                                                    Page 13 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES


      ALLOWED DISCOUNT FACTOR FOR
      THIS OUTPATIENT SERVICE IS
      INCREASED BY 5.2% FOR SFY 2000-
      2001 AND SFY 2002-2003. THE
      PREVIOUS RATE OF 80.30% HAS BEEN
      INCREASED TO 84.48% FOR DATES OF
00094 SERVICE 10/01/01 AND AFTER               F102 FNL/Payment: Payment made in full.
                                                 67 Payment made in full.


      ALLOWED AMT FOR THIS OUTPATIENT
      SERVICE IS INCREASED BY 5.2% FOR
00095 SFY 2000-2001 AND 2002-2003              F102 FNL/Payment: Payment made in full.
                                                 67 Payment made in full.


      AIR TRANSFER HAS BEEN APPROVED
      AT EMERGENCY GROUND RATE;
00096 PAYMENT REDUCED.                         F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      PAYMENT ADJUSTED ON THE
      FOLLOWING CLIENT: %1; DATE OF
00097 SERVICE %2; AND ICN %3.                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      NEWBORN CHARGES PENDING
      AWAITING ELIGIBILITY STATUS FROM
00098 DHS-NO FURTHER ACTION REQUIRED.           F00 Finalized: Claim/encounter has been processed.
                                                 56 Awaiting eligibility determination.

00099 PAID AT THE ENCOUNTER RATE.              F102 FNL/Payment: Payment made in full.
                                                 67 Payment made in full.


                                                                                                                                   Page 14 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                     NOTES
      A CHARGE WAS NOT NOTED FOR THIS
00100 SERVICE.                                  F00 Finalized: Claim/encounter has been processed.
                                                110 Claim requires pricing information.

      THIS IS A RECOUPMENT OF
      INDIVIDUAL PROCEDURE CODES THAT
00101 WERE INCORRECTLY PAID.                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS IS A DELETED PROCEDURE THAT
00102 IS A NONCOVERED SERVICE.                  F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      SERVICES EXCEED ALLOWED
00103 BENEFIT LIMITATIONS.                      F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      ADJUSTMENT REFLECTS CORRECT
00104 SDA.                                     F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS PROCEDURE IS NOT
00105 AUTHORIZED. PROCEDURE DENIED.            F209 FNL/Denied: Service not authorized.
                                                 84 Service not authorized.

      PERFORMING PROVIDER NOT
      CERTIFIED. CONTACT NHIC
00106 CUSTOMER SERVICE.                       F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                142 Entity's license/certification number.


      MEDICAID PCN/PROVIDER NUMBER(S)
00107 IS NOT VALID ON A CIDC CLAIM.           F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                132 Entity's Medicaid provider id.

      FACILITY PROVIDER IS NOT
00108 CERTIFIED.                              F2016 FNL/Denied: Provider not eligible/not approved for dates of service.

                                                                                                                                   Page 15 of 378
                                                                  EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               142 Entity's license/certification number.

      CHIROPRACTIC SERVICES REQUIRE
00109 THE RELATED X-RAY DATE.                    F20 FNL/Denied: Claim/line has been denied.
                                                 210 Date of the last x-ray.

      PERFORMING PROVIDER NUMBER
      NOT IDENTIFIED AS PART OF THE
00110 GROUP BILLING NUMBER.                    F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                 132 Entity's Medicaid provider id.

      MORE THAN ONE ASSISTANT
      SURGEON NOT PAYABLE FOR THIS
00111 PROCEDURE.                                 F10 FNL/Payment: Claim/line has been paid.
                                                 104 Processed according to plan provisions.

      MORE THAN TWO ASSISTANT
      SURGEONS NOT PAYABLE FOR THIS
00112 PROCEDURE.                                 F10 FNL/Payment: Claim/line has been paid.
                                                 104 Processed according to plan provisions.

      FURNISH THE MEDICARE
      REMITTANCE ADVICE OR NOTICE FOR
00113 OUR PROCESSING.                          F2010 FNL/Denied: Payer not primary.
                                                 286 Other payer's Explanation of Benefits/payment information.

      THE COMBINATION OF PROCEDURE
      DESCRIPTION AND TYPE OF SERVICE
00114 IS INVALID.                                F20 FNL/Denied: Claim/line has been denied.

                                                 250 Type of service.                                                       C&E Recommendation

                                                 454 Procedure code for services rendered.                                  C&E Recommendation

      THIS SERVICE DENIED AS A
      DUPLICATE OF ANOTHER ITEM ON
00115 THE SAME CLAIM.                           F201 FNL/Denied: Duplicate of a previously processed claim/line.

                                                                                                                                      Page 16 of 378
                                                                   EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                        NOTES
                                                  54 Duplicate of a previously processed claim/line.

      SERVICES BILLED TO NHIC IN ERROR.
00116 BILL PHP.                                    F20 FNL/Denied: Claim/line has been denied.
                                                   115 Cannot process HMO claims

      THIS PROCEDURE IS PART OF
      ANOTHER PROCEDURE/SERVICE
00117 BILLED ON SAME DAY.                          F20 FNL/Denied: Claim/line has been denied.

                                                   106 This amount is not entity's responsibility.                            C&E Recommendation
                                                   483 Maximum coverage amount met or exceeded for benefit period.

      SERVICE(S) REQUIRE PERFORMING
      PROVIDER NAME/NUMBER FOR
00118 PAYMENT.                                     F20 FNL/Denied: Claim/line has been denied.
                                                   132 Entity's Medicaid provider id.

      A QUANTITY FOR THIS BILLED
      AMOUNT IS NEEDED FOR
00119 PROCESSING.                                  F20 FNL/Denied: Claim/line has been denied.
                                                   476 Missing or invalid units of service


      PROCEDURE PAYMENT DETERMINED
      BY PROGRAM/BENEFIT PLAN, DATE
      OF SERVICE AND IS CALCULATED ON
00120 AN INDIVIDUAL BASIS BY NHIC.                F104 FNL/Payment: Payment reflects plan provisions.
                                                   104 Processed according to plan provisions.

      SUBSTITUTE PHYSICIAN'S NAME AND
      PROVIDER NUMBER MUST BE IN
00121 BLOCKS 17A AND 17B.                          F20 FNL/Denied: Claim/line has been denied.
                                                    21 Missing or invalid information.

      THIS CLAIM IS REISSUE OF PREVIOUS
00122 CLAIM.                                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                                                                                                        Page 17 of 378
                                                                 EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               101 Claim was processed as adjustment to previous claim.

      THIS IS AN ADJUSTMENT TO
      PREVIOUS CLAIM %1, WHICH
00123 APPEARS ON R&S %2.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      THANK YOU FOR YOUR REFUND,
      YOUR 1099 LIABILITY HAS BEEN
00124 CREDITED.                                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      CHIROPRACTIC TREATMENT OF AN
      ACUTE CONDITION REQUIRES A
00125 RELATED X-RAY EVERY 3 MONTHS.              F20 FNL/Denied: Claim/line has been denied.
                                                 318 X-rays.

      PAYMENT WAS REDUCED BY %1 DUE
      TO MEDICALLY NEEDY SPEND DOWN
00126 PAYMENT                                   F104 FNL/Payment: Payment reflects plan provisions.
                                                 104 Processed according to plan provisions.

00127 PAID ON CLAIM %1 ON %2.                   F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                  54 Duplicate of a previously processed claim/line.

      THIS DATE OF SERVICE NOT
      AUTHORIZED DURING THE INPATIENT
00128 CONCURRENT REVIEW PROCESS.                F209 FNL/Denied: Service not authorized.
                                                  84 Service not authorized.

      PAYMENT REDUCED BY MEDICAL
00129 REVIEWER.                                 F103 FNL/Payment: Partial payment made for this claim.
                                                  47 Internal review/audit - partial payment made.

      MEDICARE DENIAL INSUFFICIENT TO
      CONSIDER PAYMENT OF CLAIM.
00130 APPEAL/REAPPEAL TO MEDICARE.               F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                    Page 18 of 378
                                                                  EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               171 Other insurance coverage information (health, liability, auto, etc.).

      CLAIM DENIED DUE TO INVALID
      AUTHORIZATION NUMBER. CONTACT
00131 CLIENT'S HMO TO APPEAL.                     F20 FNL/Denied: Claim/line has been denied.
                                                  252 Authorization/certification number.

      EXCEEDS THE LIMIT OF 24
      CHIROPRACTIC VISITS FOR A 12
00132 MONTH PERIOD.                               F20 FNL/Denied: Claim/line has been denied.
                                                  483 Maximum coverage amount met or exceeded for benefit period.

      THIS PAYMENT IS THE RESULT OF A
00133 COST AUDIT SETTLEMENT.                    F104 FNL/Payment: Payment reflects plan provisions.
                                                  46 Internal review/audit.

      VOIDED CLAIMS-THIS AMOUNT HAS
      BEEN CREDITED TO YOUR NET IRS
00134 LIABILITY.                                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      DRG BILLED DOES NOT MATCH DRG
      AUTHORIZED. CLAIM PROCESSED
00135 ACCORDING TO AUTHORIZED DRG.                F10 FNL/Payment: Claim/line has been paid.

                                                   48 Referral/authorization.                                               C&E Recommendation

                                                  256 DRG Code(s)                                                           C&E Recommendation

      PARTIAL PAYMENT WITHHELD DUE TO
00136 A PREVIOUS OVERPAYMENT.                     F00 Finalized: Claim/encounter has been processed.
                                                  483 Maximum coverage amount met or exceeded for benefit period.


      TOTAL BILLED CHANGED TO REFLECT
      THE TOTAL DETAIL CHARGES AND/OR
00137 THE COMBINATION OF CLAIMS.                  F00 Finalized: Claim/encounter has been processed.

                                                                                                                                      Page 19 of 378
                                                                   EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                              NOTES
                                                 103 Claim combined with other claim(s).


      THESE PSYCHIATRIC SERVICES ARE
00138 PAID AT 62.5% OF ALLOWED AMOUNT.            F104 FNL/Payment: Payment reflects plan provisions.
                                                   104 Processed according to plan provisions.


      PAYMENT WAS REDUCED BY %1 DUE
00139 TO OTHER INSURANCE PAYMENTS                  F10 FNL/Payment: Claim/line has been paid.
                                                   286 Other payer's Explanation of Benefits/payment information.

      PROLONGED PHYSICIAN SERVICES
      WITHOUT "FACE TO FACE" PATIENT
00140 CONTACT ARE NOT PAYABLE.                    F203 FNL/Denied: Denied due to plan provisions.
                                                   104 Processed according to plan provisions.

      CLAIM DENIED DUE TO LACK OF
      NOTIFICATION WITHIN 24 HOURS OF
00141 ADMISSION.                                  F209 FNL/Denied: Service not authorized.
                                                    84 Service not authorized.


      HOSPITAL ADMISSION DENIED.
      CERTIFICATION FOR OBSERVATION
00142 ONLY. REFILE AS OUTPATIENT CLAIM.           F209 FNL/Denied: Service not authorized.

                                                  F203 FNL/Denied: Denied due to plan provisions.                   C&E Recommendation
                                                     7 Claim may be reconsidered at a future date.


      MEDICARE ENROLLMENT COMPLETED-
      PLEASE FILE THIS AND FUTURE
00143 SERVICES TO MEDICARE.                     F2010 FNL/Denied: Payer not primary.

                                                    85 Entity not primary.                                          C&E Recommendation


                                                                                                                              Page 20 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                      NOTES

                                                171 Other insurance coverage information (health, liability, auto, etc.).   C&E Recommendation

      THIS PROCEDURE NOT COVERED FOR
00144 THIS PROVIDER TYPE.                     F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  9 No payment will be made for this claim.

      CONSULTATIONS BETWEEN
00145 PHYSICIANS ARE NOT COVERED.              F203 FNL/Denied: Denied due to plan provisions.                              C&E Recommendation

                                                  9 No payment will be made for this claim.                                 C&E Recommendation
                                                104 Processed according to plan provisions.

      THIS SURGICAL PROCEDURE DOES
      NOT REQUIRE THE SERVICES OF AN
00146 ASSISTANT.                               F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      AN ANESTHESIOLOGIST IS NOT A
      COVERED BENEFIT FOR THIS
00147 PROCEDURE.                               F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.


      G0168-NOT IMPLEMENTED BY TX MCD.
      RESUBMIT WITH APPROPRIATE CPT
00148 REPAIR/SURGICAL CODE.                     F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


      PROCEDURE PAYMENT BASED ON
      PROGRAM/BENEFIT PLAN, DATE OF
      SERVICE AND A MAXIMUM PAYMENT
00149 AMOUNT SET BY HCFA OR TDH.               F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.




                                                                                                                                      Page 21 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                      NOTES
      PAID IN ACCORDANCE WITH
00150 MEDICAID GUIDELINES.                       F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THIS SERVICE RECOUPED AT THE
00151 REQUEST OF THE CLIENTS MCO.                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.


      THIRTY DAYS OF INPATIENT HOSPITAL
00152 CONFINEMENT HAVE BEEN UTILIZED.             F00 Finalized: Claim/encounter has been processed.
                                                  483 Maximum coverage amount met or exceeded for benefit period.

      CAPPED SERVICES - HMO NOT PAYOR
00153 (HMO).                                     F204 FNL/Denied: Denied due to contract provisions.

                                                  105 Claim/line is capitated.                                               C&E Recommendation

                                                  107 Processed according to contract/plan provisions.                       C&E Recommendation

      HMO NOT PAYOR - SUBMIT CHARGES
00154 TO NHIC (HMO).                             F204 FNL/Denied: Denied due to contract provisions.

                                                  107 Processed according to contract/plan provisions.                       C&E Recommendation

                                                  116 Claim submitted to incorrect payer.                                    C&E Recommendation

00155 SSI CLIENT - SUBMIT TO NHIC (HMO).         F204 FNL/Denied: Denied due to contract provisions.

                                                  107 Processed according to contract/plan provisions.                       C&E Recommendation

                                                  116 Claim submitted to incorrect payer.                                    C&E Recommendation

      THIS RECOUPMENT RESULTS FROM
00156 AN INCORRECT PAYMENT.                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.


                                                                                                                                       Page 22 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE         MESSAGE NARRATIVE                                                           NOTES
      SERVICES OUTSIDE THE UNITED
00157 STATES ARE NOT A BENEFIT.               F203 FNL/Denied: Denied due to plan provisions.

                                                 9 No payment will be made for this claim.                                       C&E Recommendation
                                               104 Processed according to plan provisions.

      SERVICES RELATED TO DENTAL CARE              FNL/Denied: Patient not eligible for dental benefits for submitted dates of
00158 ARE NOT A BENEFIT.                     F2014 service.
                                                89 Entity not eligible for dental benefits for submitted dates of service.


      PLEASE REFILE USING APPROPRIATE
      CPT PROCEDURE CODE UNDER DOD
00159 PROVIDER NUMBER.                         F20 FNL/Denied: Claim/line has been denied.

                                                   7 Claim may be reconsidered at a future date.                                 C&E Recommendation

                                               132 Entity's Medicaid provider id.                                                C&E Recommendation

                                               454 Procedure code for services rendered.                                         C&E Recommendation

      OUTLIER PMT ADJUSTED AS RESULT
      OF RETROSPECTIVE REVIEW BY
00161 HHSC UTILIZATION REVIEW.                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.


      OUTLIER PAYMENT DENIED AS A
      RESULT OF RETROSPECTIVE REVIEW
00162 BY HHSC - UTILIZATION REVIEW.           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      %1 OF THE TOTAL PAYMENT IS THE
00163 OUTLIER PAYMENT                          F10 FNL/Payment: Claim/line has been paid.
                                                65 Claim/line has been paid.




                                                                                                                                           Page 23 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      THESE SERVICES ARE NOT IN
00164 ACCORDANCE WITH MEDICAL POLICY.           F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      PROCEDURE CODE CHANGED TO
00165 MATCH PROVIDER'S DESCRIPTION.             F00 Finalized: Claim/encounter has been processed.
                                                 15 One or more originally submitted procedure code have been modified.

      PROCEDURE CODE CHANGED IN
      ACCORDANCE WITH PREPAYMENT
00166 REVIEW GUIDELINES.                        F00 Finalized: Claim/encounter has been processed.
                                                 15 One or more originally submitted procedure code have been modified.

      CLAIM WAS NOT RECEIVED W/IN 95
      DAYS. APPEAL W/PREVIOUS R&S
00167 REPORTS IF CLAIM WAS ON TIME.             F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      PAID AT COST REIMBURSEMENT
00168 RATE.                                    F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      THIS ADJUSTMENT IS THE RESULT OF
00169 A NHIC DESK REVIEW.                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      RECEIVED PAST 95 DAY FILING
      DEADLINE. EXCEPTIONS NOTED IN
00170 PROVIDER PROCEDURE MANUAL.                F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      THIS CHARGE IS INCLUDED IN THE
00172 SURGICAL/ANESTHESIA FEE.                 F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.




                                                                                                                                   Page 24 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE         MESSAGE NARRATIVE                                                    NOTES
      SERVICES INCLUDED IN TOTAL
00173 MATERNITY CHARGE.                        F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS PROVIDER NUMBER IS NOT
      ASSIGNED TO THIS AUTHORIZATION
00174 NUMBER.                                 F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                 25 Entity not approved.

      ROUTINE FAMILY PLANNING PHYSICAL
      EXAMS ARE LIMITED TO ONE PER
00175 YEAR.                                     F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      OBSERVATION ROOM/ER CHARGES
      ON DAY OF ADMISSION MUST BE
00176 BILLED ON INPATIENT CLAIM FORM.           F20 FNL/Denied: Claim/line has been denied.

                                                    9 No payment will be made for this claim.                              C&E Recommendation

                                                132 Entity's Medicaid provider id.                                         C&E Recommendation

                                                228 Type of bill for UB-92 claim.                                          C&E Recommendation

                                                230 Hospital admission hour.                                               C&E Recommendation

                                                233 Hospital discharge hour.                                               C&E Recommendation

      OUR RECORDS INDICATE THAT THE
      CLIENT WAS DECEASED AT THE TIME
00177 OF SERVICE.                               F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      PROCEDURE DENIED. REFILE CLAIM
      WITH APPROPRIATE TEXAS MEDICAID
00178 LOCAL CODE                                N/A Per FMT this EOB should be discontinued.


                                                                                                                                     Page 25 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE         MESSAGE NARRATIVE                                                    NOTES
      AS OF 4/7/02 THE TEXAS PROVIDER
      IDENTIFIER (TPI) REPLACES THE
      MEDICAID PROVIDER NUMBER. THIS
      CLAIM WAS BILLED WITH THE OLD
      PROVIDER NUMBER. PLEASE SUBMIT
      THIS AND FUTURE CLAIMS USING
      YOUR TPI. SEE MEDICAID BULLETIN
00179 161 MARCH/APRIL 2002.                    F20 FNL/Denied: Claim/line has been denied.
                                               132 Entity's Medicaid provider id.

      CLIENT NUMBER INVALID. PLEASE
      RESUBMIT WITH ACCURATE CLIENT
00180 INFORMATION.                             F20 FNL/Denied: Claim/line has been denied.
                                               153 Entity's id number.

      CLIENT'S FULL NAME, CLIENT
      NUMBER, SEX & DATE OF BIRTH DO
00181 NOT MATCH INFORMATION ON FILE.           F20 FNL/Denied: Claim/line has been denied.

                                               125 Entity's name.                                                         C&E Recommendation

                                               153 Entity's id number                                                     C&E Recommendation

                                               157 Entity's Gender                                                        C&E Recommendation

                                               158 Entity's date of birth                                                 C&E Recommendation

      OUR RECORDS INDICATE CLIENT IS
      NOT ELIGIBLE FOR BENEFITS FOR                FNL/Denied: Patient not eligible for benefits for submitted dates of
00182 THIS DATE OF SERVICE.                  F2013 service.
                                                88 Entity not eligible for benefits for submitted dates of service.

      SERVICES RELATED TO AN
      UNAUTHORIZED ORGAN TRANSPLANT
00183 ARE NOT PAYABLE.                        F209 FNL/Denied: Service not authorized.

                                                   9 No payment will be made for this claim.                              C&E Recommendation

                                                                                                                                    Page 26 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                   NOTES

                                                  84 Service not authorized.                             C&E Recommendation

      THIS SERVICE PAYABLE AS AN
      INPATIENT SERVICE ONLY, INCLUDED
00184 IN DRG.                                   F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.


      THIS PROCEDURE DENIED/CUTBACK.
      EXCEEDS TOTAL ALLOWED OF $24.38
00185 PER QUADRANT.                             F103 FNL/Payment: Partial payment made for this claim.
                                                  68 Partial payment made for this claim.

      THIS DETAIL/CLAIM CANNOT BE
      PRICED BASED ON THE INFORMATION
00186 PROVIDED                                   F00 Finalized: Claim/encounter has been processed.
                                                 110 Claim requires pricing information.

      CONSENT DOES NOT COMPLY WITH
      HEALTH AND HUMAN SERVICES
00187 GUIDELINES.                               F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.


      PROCEDURE CODE IS NO LONGER
      VALID. RESUBMIT USING EMERGENCY
00189 ROOM AND ANCILLARY CODES.                  F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      CLAIM BILLED TO NHIC IN ERROR.
      BILL TO BHO (VALUE OPTIONS @ 888-
00190 800-6799)                                F2010 FNL/Denied: Payer not primary.

                                                 115 Cannot process HMO claims.                          C&E Recommendation
                                                 116 Claim submitted to incorrect payer.


                                                                                                                   Page 27 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                                     NOTES
      OUR RECORDS INDICATE THAT THE
      NEWBORN IS NOT AND WILL NOT BE                  FNL/Denied: Patient not eligible for benefits for submitted dates of
00192 ELIGIBLE FOR THESE DATES.                 F2013 service.
                                                   88 Entity not eligible for benefits for submitted dates of service.

      DENTAL CARIES (52100) IS NOT A
      PAYABLE DIAGNOSIS FOR CLIENTS
00193 AGE 21 AND OVER.                            F20 FNL/Denied: Claim/line has been denied.
                                                  475 Procedure code not valid for patient age

      THESE SERVICES ARE NOT PAYABLE
      FOR CLIENTS RESIDING IN A NURSING
00194 HOME.                                      F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.


      PAYMENT FOR REPEAT LASER
      TREATMENT WITHIN 90 DAYS IS
00195 INCLUDED IN INITIAL LASER PAYMENT.         F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      STERILIZATIONS PERFORMED ON
      CLIENTS UNDER AGE 21 ARE NOT A
      BENEFIT OF THE MEDICAID
00198 PROGRAM.                                    F20 FNL/Denied: Claim/line has been denied.
                                                  475 Procedure code not valid for patient age

      DOCUMENTATION DOES NOT
      SUPPORT HOMEBOUND CRITERIA
00199 FOR HOME HEALTH SERVICES.                   F20 FNL/Denied: Claim/line has been denied.
                                                  422 Homebound status

      EXCEEDS THE 50 VISITS PER CLIENT
      PER YEAR LIMITATION FOR HOME
00200 HEALTH SERVICES.                            F20 FNL/Denied: Claim/line has been denied.
                                                  483 Maximum coverage amount met or exceeded for benefit period.


                                                                                                                                     Page 28 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE         MESSAGE NARRATIVE                                           NOTES
      VALID HOUR OF DISCHARGE
00201 REQUIRED FOR PROCESSING.                  F20 FNL/Denied: Claim/line has been denied.
                                                233 Hospital discharge hour.

      THIS IS NOT A BENEFIT.
      DOCUMENTATION INDICATES
00202 TRANSFER OF CONVENIENCE.                  F20 FNL/Denied: Claim/line has been denied.

                                                428 Reason for transport by ambulance                             C&E Recommendation

                                                    9 No payment will be made for this claim.                     C&E Recommendation

      MEDICARE DRG CODE MISSING ON
      MEDICARE REMITTANCE ADVICE OR
00203 NOTICE.                                   F20 FNL/Denied: Claim/line has been denied.
                                                122 Missing/invalid data prevents payer from processing claim.

      THIS SERVICE HAS BEEN PREVIOUSLY
      PROCESSED UNDER ANOTHER
      PROGRAM (MEDICAID, MANAGED
00204 CARE, CSHCN, FP).                        F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      DOCUMENTATION DOES NOT JUSTIFY
      AN ADDITIONAL ATTENDANT OR
00205 REGISTERED NURSE.                         F20 FNL/Denied: Claim/line has been denied.
                                                414 Need for more than one physician to treat patient

00207 SERVICE NOT A BENEFIT.                    F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      THIS RECOUPMENT IS DUE TO A
      DUPLICATE PAYMENT TO YOUR
00208 PROVIDER NUMBER.                         F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                 54 Duplicate of a previously processed claim/line.




                                                                                                                            Page 29 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                             NOTES
      PROCEDURE AND/OR PLACE OF
00209 SERVICE CODE MISSING.                    F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

                                               454 Procedure code for services rendered.                         C&E Recommendation

                                               249 Place of service.                                             C&E Recommendation
      MEDICARE PAYMENT INFORMATION
      MISSING. PLEASE RESUBMIT WITH
00210 MEDICARE RA OR NOTICE.                   F20 FNL/Denied: Claim/line has been denied.
                                               286 Other payer's Explanation of Benefits/payment information.

      INJECTIONS WHEN ALTERNATE DRUG
      OR ROUTE IS POSSIBLE REQUIRE
00211 MODIFIER.                                F20 FNL/Denied: Claim/line has been denied.
                                               453 Procedure Code Modifier(s) for Service(s) Rendered

      WAITING TIME MUST BE WELL
      DOCUMENTED FOR CONSIDERATION
00212 OF PAYMENT.                              F20 FNL/Denied: Claim/line has been denied.
                                               337 Ambulance certification/documentation.

      THIS AUTHORIZATION FOR
00213 ORTHODONTICS HAS EXPIRED.                F20 FNL/Denied: Claim/line has been denied.
                                               252 Authorization/certification number.

      NON-FAMILY PLANNING SERVICES
      WILL BE PROCESSED ON ANOTHER
00214 REMITTANCE AND STATUS REPORT.           F107 FNL/Payment: Claim contains split payment.
                                                72 Claim contains split payment.

      POST-OP VISITS ARE INCLUSIVE TO
00215 THE SURGERY FEE.                         F20 FNL/Denied: Claim/line has been denied.
                                               483 Maximum coverage amount met or exceeded for benefit period.




                                                                                                                           Page 30 of 378
                                                              EOB CSI ANALYSIS

                                       X-WALK
CURR                                   HIPAA
NHIC                                   FINAL
EOB                                    CSCC/CSC
CODE MESSAGE NARRATIVE                 CODE       MESSAGE NARRATIVE                                                     NOTES

      LAB OR X-RAY PERFORMED OUTSIDE
      YOUR OFFICE MUST BE BILLED BY
00216 THE PERFORMING FACILITY.                F20 FNL/Denied: Claim/line has been denied.
                                              179 Outside lab charges.

      PAYMENT REDUCED THROUGH
00217 HOSPITAL ACTION.                        F00 Finalized: Claim/encounter has been processed.
                                              425 Itemize non-covered services


      INVALID REFERRING PROVIDER.
      CONSULTATION HAS BEEN CHANGED
00218 TO CORRESPONDING VISIT.                 F00 Finalized: Claim/encounter has been processed.
                                               15 One or more originally submitted procedure code have been modified.

      DOCUMENTATION DOES NOT MEET
      EMERGENCY STERILIZATION
00219 REQUIREMENTS.                          F203 FNL/Denied: Denied due to plan provisions.
                                              104 Processed according to plan provisions.

      EMERGENCY ABDOMINAL SURGERY
      MUST HAVE DESCRIPTION OF
      CIRCUMSTANCES AND MEDICAL
00220 NECESSITY.                              F20 FNL/Denied: Claim/line has been denied.
                                              298 Operative report.


      ACKNOWLEDGEMENT CONSENT
      DOES NOT COMPLY WITH HEALTH
00221 AND HUMAN SERVICES GUIDELINES.         F203 FNL/Denied: Denied due to plan provisions.
                                              104 Processed according to plan provisions.

      DATED SIGNATURE DID NOT APPEAR
      BELOW HYSTERECTOMY
00222 ACKNOWLEDGEMENT.                        F20 FNL/Denied: Claim/line has been denied.
                                              466 Entities Original Signature

                                                                                                                                Page 31 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                          NOTES

      CO-INSURANCE NOT APPLICABLE FOR
00223 THIS DATE OF SERVICE.                      F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.

      ADDITIONAL AUTHORIZATION FOR
      REPLACEMENT RETAINERS IS
00224 REQUIRED PRIOR TO BILLING.                 F20 FNL/Denied: Claim/line has been denied.
                                                 202 Date of dental prior replacement/reason for replacement.

      THIS NON-ROUTINE SERVICE IS
      DENIED DUE TO LACK OF
00225 AUTHORIZATION.                             F20 FNL/Denied: Claim/line has been denied.
                                                  48 Referral/authorization.

      SERVICE DENIED. LACK OF
      AUTHORIZATION, NOTIFICATION OF
      ADMISSION, OR CONCURRENT
00226 REVIEW.                                    F20 FNL/Denied: Claim/line has been denied.
                                                  48 Referral/authorization.

      CLAIM NOT PAYABLE DUE TO DENIED
00227 AUTHORIZATION.                             F20 FNL/Denied: Claim/line has been denied.
                                                  48 Referral/authorization.


      YOUR CLAIM IS PENDING AND WILL BE
      PROCESSED SHORTLY. NO ACTION
00229 ON YOUR PART IS NECESSARY.                 P00 Pending: Claim/encounter is pending.
                                                  38 Awaiting next periodic adjudication cycle.

      LACK OF TRANSPORTATION DOES
      NOT JUSTIFY EMERGENCY/NON-
00231 EMERGENCY TRANSFER.                       F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.




                                                                                                                        Page 32 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                  NOTES
      SEALANTS NOT PAYABLE ON
      SURFACES THAT HAVE BEEN
00232 PREVIOUSLY RESTORED.                     F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THE AUTHORIZATION NUMBER USED
00233 IS FOR ANOTHER CLIENT/PROVIDER.           F20 FNL/Denied: Claim/line has been denied.
                                                 48 Referral/authorization.

      PAYMENT REDUCED FOR MULTIPLE
      TRANSFER; REFER TO PROVIDER
00234 PROCEDURE MANUAL.                        F103 FNL/Payment: Partial payment made for this claim.
                                                 68 Partial payment made for this claim.

      CLIENT IS NOT A TEXAS RESIDENT.
      PLEASE FILE IN THE CLIENT'S HOME
00235 STATE.                                    F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      THIS SERVICE MUST BE SUBMITTED
      WITH A PHYSICIAN PROVIDER
      NUMBER ON A HCFA 1500 CLAIM
00236 FORM.                                     F20 FNL/Denied: Claim/line has been denied.

                                                275 Claim.                                              C&E Recommendation

                                                132 Entity's Medicaid provider id.                      C&E Recommendation

      BENEFIT ONLY AVAILABLE TO
      PROVIDERS CONTRACTED WITH DHS,
      TDH, OR TDPRS; NOT PAYABLE BY
00237 NHIC.                                   F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.

      MEDICARE PAID EQUAL TO OR
      GREATER THAN MEDICAID PAID, NO
00238 FURTHER PAYMENT.                          F00 Finalized: Claim/encounter has been processed.

                                                                                                                  Page 33 of 378
                                                                   EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                               NOTES
                                                182 Allowable/paid from primary coverage.

      THIS PROCEDURE IS NOT PAYABLE AS
      A TOTAL COMPONENT. USE PROC
00239 CODES T-93005 OR T-93041.                   F20 FNL/Denied: Claim/line has been denied.
                                                  250 Type of service.

                                                  454 Procedure code for services rendered                          C&E Recommendation

      ALL BLANKS ON THE PHYSICIANS
      STATEMENT OF THE CONSENT FORM
00240 MUST BE COMPLETED.                          F20 FNL/Denied: Claim/line has been denied.
                                                   21 Missing or invalid information.


      PAYMENTS MADE BY CLIENT FOR
      MEDICAID COVERED SERVICES MUST
00241 BE REFUNDED TO THE CLIENT.                  F10 FNL/Payment: Claim/line has been paid.
                                                  106 This amount is not entity's responsibility.

      CONSENT TO STERILIZATION INVALID
      180 DAYS AFTER DATE OF CLIENT
00242 SIGNATURE.                                 F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      THIS IS A DUPLICATE SERVICE THAT
      WAS ALREADY PAID TO A PHYSICIAN
00243 WITHIN YOUR GROUP.                         F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                   54 Duplicate of a previously processed claim/line.

      REFERRAL CODE 02-11 NOT
      INDICATED BUT IS REQUIRED WHEN
00244 CONDITION CODE IS PRESENT.                  F20 FNL/Denied: Claim/line has been denied.
                                                   48 Referral/authorization.

      PLEASE RESUBMIT CLAIM WITH COPY
00246 OF THE PAID/DENIED R&S.                     F20 FNL/Denied: Claim/line has been denied.

                                                                                                                              Page 34 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE         MESSAGE NARRATIVE                              NOTES
                                                    7 Claim may be reconsidered at a future date.

      HOSPITAL ADMISSION WITHIN 30
      DAYS OF CONSULT FOR SAME
      CONDITION PAYABLE AS HOSPITAL
00247 VISIT.                                   F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      A PHYSICIAN CERTIFICATION
      STATEMENT MUST ACCOMPANY ALL
00248 CLAIMS FOR ABORTION SERVICES.             F20 FNL/Denied: Claim/line has been denied.
                                                291 Reason for termination of pregnancy.

      DOCUMENTATION DOES NOT
      SUBSTANTIATE THE NEED FOR
00250 PRIVATE ROOM.                             F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      DOCUMENTATION DOES NOT
      SUBSTANTIATE NEED FOR LATE
00251 DISCHARGE.                                F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.


      PROCEDURE/SERVICE LIMITED TO
      ONE EVERY 24 MONTHS CALCULATED
00252 FROM LAST DATE OF SERVICE.               F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS IS NOT PAYABLE AS A ROUTINE
      OFFICE VISIT. NARRATIVE FOR
00253 OBSERVATION IS REQUIRED.                  F20 FNL/Denied: Claim/line has been denied.
                                                297 Medical notes/report.

      EXPECTED DATE OF DELIVERY IS
      NEEDED ON CONSENT TO VERIFY 30
00254 DAYS FROM CLIENT'S SIGN DATE.             F20 FNL/Denied: Claim/line has been denied.

                                                                                                             Page 35 of 378
                                                                   EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                        NOTES
                                                199 Date of conception and expected date of delivery.

      RESUBMIT TO NHIC WITH COMPLETE
      OTHER INSURANCE INFO AND
00255 DOCUMENT PAYMENT OR DENIAL.                 F20 FNL/Denied: Claim/line has been denied.
                                                  286 Other payer's Explanation of Benefits/payment information.

      PROCEDURE NOT PAYABLE TO THIS
      PROVIDER TYPE/SPECIALTY FOR
00256 CLIENTS OVER 21 YEARS.                      F20 FNL/Denied: Claim/line has been denied.
                                                  475 Procedure code not valid for patient age

      MEDICARE DEDUCTIBLES, CO-
      INSURANCE, NON-COVERED
      CHARGES AND PAYABLES DO NOT
      BALANCE. PLEASE RESUBMIT WITH
      MEDICARE REMITTANCE ADVICE OR
00257 NOTICE.                                     F20 FNL/Denied: Claim/line has been denied.
                                                  400 Claim is out of balance

      CLAIM DENIED PENDING ELIGIBILITY
      REDETERMINATION. PLEASE ADVISE
      CLIENT TO CONTACT THEIR                         FNL/Denied: Patient not eligible for benefits for submitted dates of
00258 CASEWORKER.                               F2013 service.
                                                   56 Awaiting eligibility determination.


      PROCEDURES/SERVICES DENIED NOT
      AS A BENEFIT CANNOT BE COMBINED
00259 AS PART OF ANOTHER PROCEDURE.               F20 FNL/Denied: Claim/line has been denied.
                                                  483 Maximum coverage amount met or exceeded for benefit period.




                                                                                                                                     Page 36 of 378
                                                                   EOB CSI ANALYSIS

                                            X-WALK
CURR                                        HIPAA
NHIC                                        FINAL
EOB                                         CSCC/CSC
CODE MESSAGE NARRATIVE                      CODE        MESSAGE NARRATIVE                                                    NOTES

      CLIENT IS COVERED BY OTHER
      INSURANCE WHICH MUST BE BILLED
      PRIOR TO THIS PROGRAM - SEE
      "PRIVATE INSURANCE INFORMATION"
00260 BELOW OR ON FOLLOWING PAGE.                F2010 FNL/Denied: Payer not primary.
                                                   116 Claim submitted to incorrect payer.

                                                   286 Other payer's Explanation of Benefits/payment information             C&E Recommendation

      PRIMARY BIRTH CONTROL METHOD
      AT END OF VISIT MUST BE
      CONSISTENT WITH THE FAMILY
      PLANNING PROCEDURE BILLED.
      PLEASE CORRECT AND RESUBMIT
00261 CLAIM.                                       F20 FNL/Denied: Claim/line has been denied.
                                                   454 Procedure code for services rendered.

      SIGNATURE OF THE EMERGENCY
      MEDICAL TECHNICIAN (EMT)
      TRANSPORTING THE CLIENT IS
      REQUIRED ON MEDICAL NECESSITY
00262 DOCUMENTATION.                               F20 FNL/Denied: Claim/line has been denied.
                                                   466 Entities Original Signature

      INITIAL HOSPITAL CARE WITHIN 3
      DAYS OF A NEW PATIENT VISIT IS
      PAYABLE AS A SUBSEQUENT CARE
00263 VISIT.                                       F00 Finalized: Claim/encounter has been processed.
                                                    15 One or more originally submitted procedure code have been modified.

      INITIAL OFFICE VISIT WITHIN 30 DAYS
      OF AN INITIAL OFFICE VISIT FOR
      SAME/RELATED CONDITION PAYABLE
00264 AS FOLLOW-UP VISIT.                          F00 Finalized: Claim/encounter has been processed.
                                                    15 One or more originally submitted procedure code have been modified.


                                                                                                                                       Page 37 of 378
                                                                EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                    NOTES
      EXCEEDS ALLOWED BENEFIT
      LIMITATION. PROCEDURE LIMITED TO
      ONE PER FISCAL YEAR. (SEPT. 1-AUG.
00266 31)                                        F20 FNL/Denied: Claim/line has been denied.
                                                 483 Maximum coverage amount met or exceeded for benefit period.

      YOUR CLAIM INDICATES
      DOCUMENTATION WAS ATTACHED
      BUT NONE WAS RECEIVED. PLEASE
      RESUBMIT DOCUMENTATION AND
00267 COPY OF R&S.                               F20 FNL/Denied: Claim/line has been denied.
                                                 294 Supporting documentation.

      INITIAL OFFICE VISIT WITHIN 3 DAYS
      OF E.R. VISIT FOR SAME/RELATED
      DIAGNOSIS PAID AS FOLLOW-UP
00268 VISIT.                                     F00 Finalized: Claim/encounter has been processed.
                                                  15 One or more originally submitted procedure code have been modified.


      STERILIZATION PROC CONSENTED TO
      BY CLIENT DOES NOT MATCH PROC
      ON PHYS STATEMENT AND/OR CLAIM.
      PLEASE RESUBMIT ALL FORMS WITH
00269 CORRECTED INFORMATION.                     F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

                                                 275 Claim                                                                 C&E Recommendation

      HYSTERECTOMY CLAIMS REQUIRE
      ACKNOWLEDGMENT SIGNED/DATED
      PRIOR TO SURGERY OR PHYSICIAN
      CERTIFICATION FOR EXCEPTIONS.
      REFER TO PROVIDER PROCEDURE
00270 MANUAL.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 466 Entities Original Signature


                                                                                                                                     Page 38 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                        NOTES
      CLAIM DENIED DUE TO INACCURATE
      CLIENT INFORMATION. PLEASE
      CONTACT MEDICARE TO VERIFY
00271 CLIENT ELIGIBILITY INFORMATION.           F20 FNL/Denied: Claim/line has been denied.
                                                 21 Missing or invalid information.

                                                198 Medicare effective date.                  C&E Recommendation

      UNABLE TO PROCESS. SUBMIT AS A
      PAPER CLAIM W/THE APPROPRIATE
00272 DOCUMENTS.                                F20 FNL/Denied: Claim/line has been denied.
                                                277 Paper claim.

                                                294 Supporting documentation.                 C&E Recommendation

                                                311 Pathology notes/report.                   C&E Recommendation

                                                331 History and physical                      C&E Recommendation

      MEDICAL NECESSITY OF THIS
      PROCEDURE MUST BE VERIFIED.
      PLEASE SUBMIT A SIGNED CLAIM, R&S
      COPY, HISTORY, PHYSICAL,
      PATHOLOGY AND/OR OPERATIVE
00274 REPORT.                                   F20 FNL/Denied: Claim/line has been denied.
                                                294 Supporting documentation.

      THIS CLAIM HAS BEEN DENIED AND
      WILL BE RETURNED FOR ADDITIONAL
      INFORMATION. REFILE ORIGINAL
      CLAIM WITH INVOICE FOR PAYMENT
00275 OF THIS SERVICE.                          F20 FNL/Denied: Claim/line has been denied.
                                                285 Vouchers/explanation of benefits (EOB).




                                                                                                        Page 39 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                      NOTES
      CLIENT NOT ENROLLED IN STAR FOR
      THE DATE(S) OF SERVICE. MEDICAID
      ELIGIBLE SERVICES WILL BE
      PROCESSED ON SEPARATE CLAIM. NO
      ACTION ON YOUR PART IS
00276 NECESSARY.                                F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      CLAIM DENIED BECAUSE BILLED
      SERVICES ARE PRIOR TO DATE OF
      BIRTH. PLEASE RESUBMIT WITH
      SIGNED CLAIM COPY, R&S COPY AND
00277 CORRECTED DATES.                          F20 FNL/Denied: Claim/line has been denied.
                                                158 Entity's date of birth

      THE DOCUMENTATION REQUESTED
      HAS BEEN RECEIVED BUT IT IS FOR
      THE WRONG CLIENT/DATE OF
      SERVICE/ETC. PLEASE RESUBMIT
      WITH APPROPRIATE
00278 DOCUMENTATION.                            F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.

      MEDICARE ELIGIBILITY HAS NOT BEEN
      ESTABLISHED. CLIENT MAY BE
      DETERMINED MEDICARE ELIGIBLE AT
00279 A LATER DATE.                             F20 FNL/Denied: Claim/line has been denied.
                                                284 Copy of Medicare ID card.

      CLAIM DENIED DUE TO INCOMPLETE
      PHYSICIAN CERTIFICATION
      STATEMENT. RESUBMIT WITH
00280 COMPLETED CERTIFICATION                   F20 FNL/Denied: Claim/line has been denied.
                                                332 Authorization/certification (include period covered).




                                                                                                                    Page 40 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      NO VALID CONTRACT FOR TITLE V OR
      XX FAMILY PLANNING IS ASSOCIATED
      WITH THIS PROVIDER FOR THE DATES
00281 OF SERVICE BILLED.                       F204 FNL/Denied: Denied due to contract provisions.
                                                107 Processed according to contract/plan provisions.

      THIS RECOUPMENT RESULTS FROM
      PAYMENT TO AN INCORRECT CLIENT
      NUMBER. THE CLAIM WILL BE
      REPROCESSED TO THE CORRECT
00282 CLIENT NUMBER.                           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS RECOUPMENT RESULTS FROM
      PAYMENT MADE INCORRECTLY TO
      YOUR PROVIDER NUMBER. THIS
      CLAIM WILL BE PROCESSED TO THE
00283 CORRECT PROVDER.                         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      THIS RECOUPMENT RESULTS FROM
      AN INCORRECT MEDICAID PAYMENT.
      THE CLIENT IS ELIGIBLE FOR
00284 MEDICARE FOR THESE SERVICES.             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS RECOUPMENT RESULTS FROM
      AN INCORRECT PAYMENT. THIRTY
      BENEFIT DAYS OF HOSPITAL
      CONFINEMENT HAVE BEEN USED IN
00285 FACILITY/FACILITIES.                     F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.




                                                                                                                                   Page 41 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES
      THIS RECOUPMENT RESULTS FROM
      AN INCORRECT PAYMENT. THE FULL
      ALLOWABLE FOR THIS CLAIM WAS
00286 PAID PREVIOUSLY.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      THIS RECOUPMENT RESULTS FROM
      AN INCORRECT PAYMENT. THE
      CLIENT'S PRIVATE INSURANCE HAS
      PAID THE TOTAL MEDICAID
00287 ALLOWABLE FOR THE SERVICE(S).           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PROCEDURES/SERVICES LIMITED TO
      TWICE PER 12 MONTH PERIOD
      CALCULATED FROM THE FIRST DATE
00289 OF SERVICE.                              F20 FNL/Denied: Claim/line has been denied.
                                               483 Maximum coverage amount met or exceeded for benefit period.


      DATED SIGNATURE OF PHYSICIAN ON
      OR AFTER DAY OF SURGERY IS
      REQUIRED ON LAST SECTION OF
      CONSENT FORM. PLEASE REFER TO
00290 PROVIDER PROCEDURES MANUAL.              F20 FNL/Denied: Claim/line has been denied.
                                               466 Entities Original Signature

      PERSON OBTAINING CONSENT MUST
      COMPLETE ALL BLANKS OF
      APPROPRIATE STATEMENT. PLEASE
      REFER TO PROVIDER PROCEDURES
00291 MANUAL.                                  F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.




                                                                                                                                  Page 42 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                                     NOTES
      THE INDICATED SERVICE(S) DO NOT
      DIVIDE EVENLY INTO THE QUANTITY
      BILLED. RESUBMIT WITH CORRECT
00292 QUANTITY BILLED.                            F20 FNL/Denied: Claim/line has been denied.
                                                  476 Missing or invalid units of service

      THSTEPS MEDICAL CHECKUPS AND
      ACUTE CARE TREATMENT SERVICES
      MUST BE BILLED ON SEPARATE CLAIM
00293 FORMS.                                     F103 FNL/Payment: Partial payment made for this claim.
                                                    7 Claim may be reconsidered at a future date.


      PROCEDURE PAYMENT DETERMINED
      BY PROGRAM/BENEFIT PLAN, DATE
      OF SERVICE, BILLED AMOUNT AND
      PROVIDER'S CUSTOMARY RATE. THE
      PREVAILING 50TH PERCENTILE BASED
      ON PROVIDER'S LOCALITY/SPECIALTY
      WILL BE USED IF NO CUSTOMARY
00294 EXISTS.                                    F101 FNL/Payment: Payment reflects usual and customary charges.
                                                   66 Payment reflects usual and customary charges.


      TITLE V AND XX FAMILY PLANNING
      CLAIMS MUST BE FILED W/IN 120 DAYS
      OF DOS EXCEPT AS NOTED IN THE
      FAMILY PLANNING SECTION OF THE
00295 PROVIDER PROCEDURE MANUAL.                  F20 FNL/Denied: Claim/line has been denied.
                                                    9 No payment will be made for this claim.


      VALID PROVIDER NUMBER REQUIRED.
00296 PLEASE CORRECT AND RESUBMIT.              F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  132 Entity's Medicaid provider id.




                                                                                                                                     Page 43 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                NOTES
      THIS SURGERY DOES NOT MEET THE
      CRITERIA FOR FUNCTIONAL
      DISABILITY AS DETERMINED BY
00297 PROGRAM GUIDELINES.                      F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.


      ELIGIBILITY DATE MUST NOT BE
      BLANK, INVALID, OR MORE THAN 365
00298 DAYS BEFORE DATE OF SERVICE.              F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      PHYSICIAN/SUPPLIER SIGNATURE
      MISSING OR NOT IN CORRECT BLOCK
      ON CLAIM. REFILE WITH SIGNATURE
00299 IN CORRECT BLOCK.                         F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature

      CLAIMS FOR TEEN GROUP
      COUNSELING MUST FOLLOW
      PROGRAM GUIDELINES. PLEASE
00300 CORRECT AND RESUBMIT CLAIM.               F00 Finalized: Claim/encounter has been processed.
                                                  7 Claim may be reconsidered at a future date.

                                                104 Processed according to plan provisions.          C&E Recommendation

      CLIENT SIGNATURE IS REQUIRED IN
      BLOCK 11 WHEN BILLING FOR
      EYEWEAR BEYOND PROGRAM
      SPECIFICATIONS AND/OR LOST OR
00301 DESTROYED EYEWEAR.                        F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature




                                                                                                               Page 44 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                            NOTES
      SERVICE PAYABLE ONLY TO
      PROVIDERS WHO ARE APPROVED AS
      TARGETED CASE MANAGEMENT
      PROVIDERS. APPLY TO TDH BUREAU
      OF COMMUNITY ORIENTED PRIMARY
00302 CARE.                                   F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.


      PER HCFA MANDATE, PAYMENT IS
      REDUCED OR DENIED BECAUSE
      AUTOMATED TESTS WERE PAID FOR
      THE SAME DATE OF SERVICE ON THIS
00303 CLAIM OR ON A PREVIOUS CLAIM(S).          F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      TEMPORARY LENSES NOT ALLOWED
      AFTER CONVALESCENT PERIOD (4
      MONTHS AFTER CATARACT
      SURGERY). PROCEDURE CODE
      CHANGED TO PERMANENT LENS
00304 PROCEDURE CODE.                           F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      THE ADDED DETAIL WAS NOT ON THE
      ORIGINAL CLAIM. NEW DAY DETAILS
      MUST BE SUBMITTED ON A CLAIM
00307 FORM AS A NEW DAY CLAIM.                  F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

      YOUR 2017 CLAIM FORM IS MISSING
      REQUIRED INFORMATION. PLEASE
      REFER TO 2017 GUIDELINES AND
00308 RESUBMIT CORRECTED CLAIM.                 F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                275 Claim                                                         C&E Recommendation

                                                                                                                            Page 45 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                    NOTES


      YOUR FAMILY PLANNING CLAIM
      SPANS DIFFERENT FISCAL YEARS.
      PLEASE RESUBMIT SEPARATE CLAIMS
      FOR SERVICES PERFORMED DURING
00309 DIFFERENT FISCAL YEARS.                   F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                187 Date(s) of service.                                                  C&E Recommendation

      SERVICE(S) FILED ON AN INCORRECT
      CLAIM FORM. REFER TO PROVIDER
      PROCEDURES MANUAL AND REFILE
00310 AS AN ORIGINAL CLAIM.                     F20 FNL/Denied: Claim/line has been denied.
                                                275 Claim.

      THESE SERVICES ARE APPROVED
      FOR PAYMENT OF ER TRIAGE FEE
      ONLY. ALL OTHER SERVICES ARE
00311 DENIED/RECOUPED.                          N/A Per FMT this EOB should be discontinued.


      THIS SERVICE DENIED/RECOUPED
      BECAUSE PCP CONTACT IS REQUIRED
      PRIOR TO TREATMENT OF CLIENT
00312 DURING REGULAR OFFICE HOURS.            F2019 FNL/Denied: Member not referred by selected primary care provider.
                                                 94 Entity not referred by selected primary care provider.

      CLAIM INDICATES MULTIPLE
      TRANSPORT. PLEASE PROVIDE
      NAMES AND PCNS OF ADDITIONAL
00313 CLIENTS ON CLAIM FORM.                    F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.

                                                153 Entity's id number                                                   C&E Recommendation


                                                                                                                                   Page 46 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                              NOTES
      EACH CLAIM IS LIMITED TO 66 OR
      LESS DETAILS AND MUST INCLUDE A
      TOTAL BILLED AMOUNT. PLEASE
      RESUBMIT FOLLOWING THESE
00314 GUIDELINES.                             F20 FNL/Denied: Claim/line has been denied.
                                              121 Service line number greater than maximum allowable for payer.

      CLIENT MAY NOT SIGN AS PERSON
00315 OBTAINING CONSENT.                      F20 FNL/Denied: Claim/line has been denied.
                                              466 Entities Original Signature


      DATED SIGNATURE OF PERSON
      OBTAINING CONSENT WAS PRIOR TO
00316 DATE CLIENT SIGNED THE CONSENT.         F20 FNL/Denied: Claim/line has been denied.
                                              395 Date entity signed certification/recertification


      LAB AND RADIOLOGY
      INTERPRETATIONS ARE CONSIDERED
      PART OF THE PROFESSIONAL CARE
00317 OF THE CLIENT.                          F20 FNL/Denied: Claim/line has been denied.
                                                9 No payment will be made for this claim.

      EXCEEDS NUMBER OF
      VISITS/SUPPLIES AUTHORIZED FOR
00318 THIS CERTIFICATION PERIOD.              F20 FNL/Denied: Claim/line has been denied.
                                              483 Maximum coverage amount met or exceeded for benefit period.

      EACH CLAIM IS LIMITED TO 26 OR
      LESS DETAILS AND MUST INCLUDE A
      TOTAL BILLED AMOUNT. PLEASE
      RESUBMIT FOLLOWING THESE
00319 GUIDELINES.                             F20 FNL/Denied: Claim/line has been denied.
                                              121 Service line number greater than maximum allowable for payer.




                                                                                                                          Page 47 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                             NOTES

      CONSULTATION SERVICES ARE ONLY
      PAYABLE TO THE DENTIST/PHYSICIAN
00320 NOT PERFORMING THE TREATMENT.            F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      SERVICE NOT A BENEFIT OF
      MEDICARE. PLEASE REFILE THIS
      SERVICE WITH MEDICAID ON THE
      CORRECT CLAIM FORM & INCLUDE
      THE MEDICARE REMITTANCE ADVICE
00322 OR NOTICE.                                F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                275 Claim                                         C&E Recommendation


      DOCUMENTATION SUBMITTED WITH
      CLAIM FOR CCP SERVICES DOES NOT
      JUSTIFY PAYMENT. PLEASE REVIEW
      DOCUMENTATION CRITERIA AND
00323 APPEAL WITH MORE INFORMATION.             F20 FNL/Denied: Claim/line has been denied.
                                                294 Supporting documentation.


      ANESTHESIA SERVICES MUST BE
      REPORTED WITH CPT-4 ANESTHESIA
      CODES. PLEASE RESUBMIT CLAIM
      WITH APPROPRIATE PROCEDURE
00324 CODES.                                    F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.




                                                                                                            Page 48 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                       NOTES

      FOR INPATIENT SERVICES, PAID AMT
      REDUCED BY 20% EFF 9/1/1994. FOR
      OUTPATIENT SVCS, PAID AMT
      REDUCED BY 17.3% EFF 9/1/1999 OR
00325 20% EFF 9/1/1994-8/31/1999.               F104 FNL/Payment: Payment reflects plan provisions.
                                                 104 Processed according to plan provisions.

      DATES OF SERVICE OVER ONE YEAR
      FROM PROCESS DATE ARE NOT
00327 PAYABLE.                                   F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.

      PSYCHOTHERAPY WHEN BILLED WITH
      ELECTROSHOCK IS NOT A COVERED
00329 BENEFIT.                                   F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.                                 C&E Recommended
                                                 106 This amount is not entity's responsibility.                             C&E Recommended


      THIS PAYMENT IS DUE TO A REFUND
00330 MADE IN ERROR BY YOUR OFFICE.             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      INITIAL HOSPITAL VISIT WITHIN 30
      DAYS OF AN INITIAL HOSPITAL VISIT
      FOR SAME/RELATED CONDITION
      PAYABLE AS A FOLLOW-UP HOSPITAL
00331 VISIT.                                     F10 FNL/Payment: Claim/line has been paid.
                                                  15 One or more originally submitted procedure code have been modified.

      THIS DETAIL DENIED DUE TO
      INSUFFICIENT INFORMATION. PLEASE
      RESUBMIT WITH NAMES OF ALL
      TESTS INCLUDED IN THIS
00332 PANEL/SERIES.                              F20 FNL/Denied: Claim/line has been denied.
                                                 419 Individual test(s) comprising the panel and the charges for each test

                                                                                                                                      Page 49 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                      NOTES

      PAYMENT IS WITHHELD DUE TO AN
      IRS NOTICE OF LEVY-YOUR 1099 WILL
      NOT BE AFFECTED BY THIS WITHHELD
00333 AMOUNT.                                    F00 Finalized: Claim/encounter has been processed.
                                                   9 No payment will be made for this claim.

      NON-EMERGENCY AMBULANCE
      TRANSFERS TO A DOCTOR'S OFFICE
      REQUIRE NAME & ADDRESS OF
      DOCTOR & MUST STATE THE
      DIAGNOSIS & TREATMENT RENDERED
00334 AT TIME OF VISIT.                          F20 FNL/Denied: Claim/line has been denied.
                                                 428 Reason for transport by ambulance

      THIS CLAIM WAS RECEIVED
      ORIGINALLY FROM ANOTHER
      INSURANCE CARRIER AND IS NOW
00335 PAST THE 95 DAY FILING DEADLINE.           F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.


      THIS RECOUPMENT IS THE RESULT
      OF AN ERROR IN PROCESSING
      MEDICARE CLAIMS. MEDICAID DOES
00338 NOT PAY MEDICARE DENIED DETAILS.          F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                   9 No payment will be made for this claim.                                C&E Recommendation
                                                 101 Claim was processed as adjustment to previous claim.

      APPEAL RECEIVED PAST THE 180 DAY
      FILING DEADLINE. THE ORIGINAL
      PAYMENT OR DENIAL HAS NOT BEEN                 FNL/Adj Complt: Claim/encounter has been adjudicated. No payment
00339 AFFECTED.                                  F40 forthcoming.
                                                   9 No payment will be made for this claim.




                                                                                                                                      Page 50 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      THIS ADJUSTMENT IS A RESULT OF
      THE RESOLUTION OF YOUR WRITTEN
      CASE APPEAL COMPLAINT BY TDH
      MEDICAL APPEALS & PROVIDER
00340 RESOLUTION DIVISION.                     F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS ADJUSTMENT IS A RESULT OF
      YOUR TDH MEDICAL APPEALS &
      PROVIDER RESOLUTION DIVISION
00341 ORAL APPEAL.                             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      SUBSEQUENT SERVICES TO A
      THSTEPS SCREENING VISIT ARE
      PAYABLE AS A FOLLOW-UP
00347 SCREENING VISIT.                          F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.



      THESE SERVICES ARE NOT PAYABLE
      FOR CLIENTS DETERMINED TO BE
      PRESUMPTIVELY ELIGIBLE. REFER TO
00349 PROVIDER PROCEDURE MANUAL.                F20 FNL/Denied: Claim/line has been denied.
                                                 91 Entity not eligible/not approved for dates of service.

      EYEGLASS PROGRAM SERVICES ARE
      NOT A BENEFIT FOR APHAKIA.
      PLEASE USE CODES FOR
00350 PROSTHETIC EYEWEAR.                       F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.




                                                                                                                                   Page 51 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                     NOTES

      A NEW PATIENT VISIT IS PAYABLE AS
      AN ESTABLISHED PATIENT VISIT
      WHEN A CONSULT, MEDICAL, OR
      SURGICAL SERVICE HAS PREVIOUSLY
00352 BEEN PAID TO THE SAME PROVIDER.             F10 FNL/Payment: Claim/line has been paid.
                                                   15 One or more originally submitted procedure code have been modified.

      THIS CHARGE IS INCLUDED IN ROOM
00353 RATE BILLED ON THE SAME DAY.                F20 FNL/Denied: Claim/line has been denied.
                                                  483 Maximum coverage amount met or exceeded for benefit period.

      CONSULTATION SERVICES FOR THIS
      PROVIDER SPECIALTY ARE PAYABLE
      ONLY AS AN INITIAL OFFICE/HOSPITAL
00354 VISIT.                                      F20 FNL/Denied: Claim/line has been denied.
                                                    9 No payment will be made for this claim.

      NHIC MUST HAVE A VALID CONSENT
      FORM ON FILE FOR PAYMENT OF
      STERILIZATION PROCEDURES.REFER
      TO PROVIDER PROCEDURES MANUAL
      FOR INFORMATION ON CONSENT
00356 FORMS.                                      F20 FNL/Denied: Claim/line has been denied.
                                                   21 Missing or invalid information.

      INITIAL HOSPITAL CARE WITHIN 30
      DAYS OF A CONSULT PAYABLE AS A
00357 FOLLOW-UP CONSULT.                          F10 FNL/Payment: Claim/line has been paid.
                                                   15 One or more originally submitted procedure code have been modified.


      EARLY REMOVAL MAY ONLY BE USED
      WHEN THE APPLIANCES WERE
      PLACED BY AN UNAFFILIATED
      PROVIDER. AUTHORIZATION IS
00358 REQUIRED PRIOR TO REMOVAL.                 F209 FNL/Denied: Service not authorized.

                                                                                                                                    Page 52 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                       NOTES
                                                 84 Service not authorized.


      THIS SERVICE HAS BEEN PROCESSED
      BY MEDICAID, NO FURTHER
      CONSIDERATION OF PAYMENT BY
      CIDC, DUE TO CLIENT AGE AND
00359 MEDICAID PROGRAM TYPE.                    F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      CLAIM DENIED. TRANSPORT DOES
      NOT MEET NON-EMERGENCY
      GUIDELINES. PLEASE REFER TO
      PROVIDER PROCEDURE MANUAL
00360 WHEN APPEALING CLAIM.                      F20 FNL/Denied: Claim/line has been denied.
                                                 428 Reason for transport by ambulance


      PROVIDER CERTIFIED FOR MEDICARE-
      MEDICAID CROSSOVER CLAIMS ONLY.
      CONTACT CUSTOMER SERVICE FOR
00361 MEDICAID CERTIFICATION.                  F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                 132 Entity's Medicaid provider id.

      APPEALS/CLAIMS MUST BE
      SUBMITTED WITHIN 95 DAYS OF DATE
      OF PRIVATE INSURANCE EOB OR
      MEDICARE REMITTANCE ADVICE OR
00362 NOTICE.                                    F20 FNL/Denied: Claim/line has been denied.
                                                   9 No payment will be made for this claim.

      DOCUMENTATION INSUFFICIENT TO
      DETERMINE EMERGENCY TRANSFER.
      RESUBMIT WITH ER RECORDS,
      FACILITY TRANSFER RECORDS &/OR
00363 L&D RECORDS.                               F20 FNL/Denied: Claim/line has been denied.


                                                                                                                                    Page 53 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                 NOTES

                                                299 Emergency room notes/report.                                       C&E Recommendation
                                                427 Emergency care provided during transport

      CONTINUED PAYMENT FOR
      PT/OT/SPEECH THERAPY REQUIRES
      DOCUMENTATION OF MARKED
      IMPROVEMENT WITHIN 2 MONTHS OF
00364 ONSET OF INJURY/ILLNESS.                  F20 FNL/Denied: Claim/line has been denied.
                                                404 Specific findings, complaints, or symptoms necessitating service


      AUTHORIZATION DENIED. RESUBMIT
      WITH ADMIT AND DISCHARGE
      RECORDS, PHYSICIAN LETTER OF
      MEDICAL NECESSITY, H&P, OR HOME
00365 HEALTH/NURSING HOME CARE PLAN.            F20 FNL/Denied: Claim/line has been denied.
                                                431 Provide condition/functional status at time of service


      CLAIM DENIED DUE TO INCORRECT
      ADDRESS. PLEASE SUBMIT ADDRESS
      CHANGE IN WRITING ON LETTER -
      HEAD TO NHIC TO THE ATTENTION OF
00366 THE PROVIDER ENROLLMENT DEPT.             F20 FNL/Denied: Claim/line has been denied.
                                                126 Entity's address.

      CLAIMS FOR CLIENTS WITH
      RETROACTIVE ELIGIBILITY MUST BE
      RECEIVED WITHIN 95 DAYS OF NHIC'S
      RECEIPT OF CLIENT'S ELIGIBILITY
00367 FROM DHS.                                 F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.




                                                                                                                                 Page 54 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                       NOTES
      IF YOU ARE HAVING DIFFICULTY
      FILING YOUR APPEAL, PLEASE
      CONTACT NHIC CUSTOMER SERVICE
00368 AT 1-800-925-9126.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      SERVICES EXCEED 180 DAY THERAPY
      LIMIT. NOT PAYABLE FOR CHRONIC
      CONDITION. MAY APPEAL WITH
      SUPPORTING MEDICAL
00371 DOCUMENTATION.                             F20 FNL/Denied: Claim/line has been denied.
                                                 310 Progress notes for the six months prior to statement date.

      GUIDELINES FOR PAYMENT OF
      PT/OT/SPEECH THERAPY ARE LIMITED
      AND SPECIFIC AS TO TYPE OF INJURY
00372 AND OR ILLNESS.                            F20 FNL/Denied: Claim/line has been denied.
                                                 442 Modalities of service

      PLEASE REFILE YOUR ADJUSTMENT
      REQUEST WITH A STATEMENT OF THE                FNL/Adj Complt: Claim/encounter has been adjudicated. No payment
00373 NATURE OF YOUR APPEAL.                     F40 forthcoming.
                                                 294 Supporting documentation.

      PROCEDURE DENIED DUE TO LACK
      OF PRIOR AUTHORIZATION. APPEAL
      TO TDH CSHCN, 1100 WEST 49TH ST.,
      AUSTIN, TX 78756-3179 WITHIN 30
00374 DAYS OF NHIC'S DISPOSITION.               F209 FNL/Denied: Service not authorized.
                                                  84 Service not authorized.

      CLAIM MUST BE ADJUSTED BY
      MEDICARE PRIOR TO PAYMENT BY
00375 MEDICAID.                                F2010 FNL/Denied: Payer not primary.
                                                  85 Entity not primary.

                                                 171 Other insurance coverage information (health, liability, auto, etc.).   C&E Recommendation

                                                                                                                                       Page 55 of 378
                                                              EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES

      A VALID DIAGNOSIS CODE IS
      REQUIRED FOR PROCESSING. REFILE
      CLAIM WITH A VALID DIAGNOSIS
      CODE. NARRATIVE DESCRIPTIONS
00376 ARE NOT ACCEPTABLE.                      F20 FNL/Denied: Claim/line has been denied.
                                               255 Diagnosis code.

      OTHER INSURANCE AMOUNT IS
      GREATER THAN TOTAL BILLED.
      PLEASE RESUBMIT WITH TOTAL
00377 CHARGES.                                 F00 Finalized: Claim/encounter has been processed.
                                               400 Claim is out of balance


      PLEASE SUBMIT TO OTHER INSURER
      AND ALLOW 110 DAYS FOR
      RESPONSE BEFORE APPEALING TO
      NHIC. DOCUMENT DATE OTHER
00378 INSURANCE WAS BILLED.                  F2010 FNL/Denied: Payer not primary.

                                                 7 Claim may be reconsidered at a future date.                            C&E Recommendation
                                                85 Entity not primary.

      OUR REVIEW INDICATES PREVIOUS
      CLAIM WAS PROCESSED CORRECTLY.
      PLEASE CONTACT THE TEXAS
      HEALTH NETWORK FOR MORE
00379 INFORMATION. 1-888-834-7226.            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      SERVICES DENIED AS A RESULT OF
      UTILIZATION REIVEW. PLEASE
      CONTACT THE TEXAS HEALTH
00380 NETWORK. 1-888-834-7226.                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.


                                                                                                                                    Page 56 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                      NOTES

      A VALID SHARS PROVIDER NUMBER IS
      REQUIRED IN BLOCK 32 OF THE HCFA
      1500. PLEASE RESUBMIT CLAIM WITH
00381 A VALID SHARS PROVIDER NUMBER.           F20 FNL/Denied: Claim/line has been denied.
                                               132 Entity's Medicaid provider id.

      MEDICATION CHARGES MUST
      INDICATE THE NAME OF THE DRUG,
      ROUTE OF ADMINISTRATION AND THE
00384 DOSAGE.                                  F20 FNL/Denied: Claim/line has been denied.
                                               217 Drug name, strength and dosage form.


      A PROCEDURE CODE CANNOT BE
      ASSIGNED BY THE DESCRIPTION
      SUBMITTED. PLEASE ASSIGN A
      PROCEDURE CODE OR CLARIFY THE
00385 DESCRIPTION ON THE CLAIM FORM.           F20 FNL/Denied: Claim/line has been denied.
                                               454 Procedure code for services rendered.


      CLAIMS FOR HOSPITAL TO HOSPITAL
      OR NH TO NH TRANSFERS MUST
      STATE THE SPECIFIC
      FACILITIES/SERVICES UNAVAILABLE
      AT THE HOSPTIAL/NURSING HOME OF
00387 ORIGIN.                                  F20 FNL/Denied: Claim/line has been denied.

                                               266 Facility point of origin and destination - ambulance.   C&E Recommendation
                                               428 Reason for transport by ambulance




                                                                                                                     Page 57 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      PREVIOUS PROCESSING OF CLAIM
      HAS BEEN REVIEWED AND
      DETERMINED TO BE CORRECT.
      CONTACT CUSTOMER SERVICE IF
      YOU NEED CLARIFICATION OF PRIOR
00388 DISPOSITION.                             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      YOUR CLAIM HAS BEEN REVIEWED
      AND PROCESSED. YOU WILL RECEIVE
      CLARIFICATION IN WRITTEN
00389 CORRESPONDENCE.                           F00 Finalized: Claim/encounter has been processed.
                                                  2 More detailed information in letter.

      PAYMENT FOR HOME HEALTH
      SERVICES CANNOT BE MADE WHEN
      THE PHYSICIAN WHO SIGNS THE PLAN
      OF CARE IS OWNER/PARTNER
00390 AND/OR MEMBER OF THE BOARD.               F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.


      CLIENT IS ELIGIBLE FOR MULTIPLE
      PROGRAMS (MEDICAID, CSHCN,
      MANAGED CARE, FP) FOR THE DATES
      OF SERVICE. YOUR CLAIM WAS SPLIT
      TO FACILITATE PROCESSING. TOTAL
      CHARGES WILL FINALIZE AS
      SEPARATE CLAIMS ON THE PROGRAM
00391 SPECIFIC R&S REPORT(S).                  F107 FNL/Payment: Claim contains split payment.
                                                 72 Claim contains split payment.

      LOCK-IN PHYSICIAN'S PROVIDER
00392 NUMBER MUST BE ON THE CLAIM.              F20 FNL/Denied: Claim/line has been denied.
                                                 93 Entity is not selected primary care provider.




                                                                                                                                   Page 58 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      FINANCIAL ACTION DUE TO TDH
00393 DIRECTIVE.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      PROVIDER DOES NOT HAVE BRC
      CERTIFICATION ON FILE TO PERFORM
      MAMMOGRAPHY PROCEDURE BILLED.
      PLEASE CONTACT CUSTOMER
00394 SERVICE ABOUT BRC CERTIFICATION.          F20 FNL/Denied: Claim/line has been denied.
                                                142 Entity's license/certification number.


      SERVICES DENIED. PLEASE CONTACT
      THE TEXAS HEALTH NETWORK FOR
      INFORMATION REGARDING THIS
00396 CLAIM. 1-888-834-7226.                    F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      WHEN MULTIPLES OF THE SAME
      CHARGES ARE PERFORMED ON THE
      SAME DAY, SEPARATE THE DETAILS
      AND DOCUMENT TIMES FOR EACH
00397 ADDITIONAL CHARGE.                        F20 FNL/Denied: Claim/line has been denied.
                                                300 Lab/test report/notes/results.

      THE CLAIM DETAILS EXCEED OUR 28
      LIMIT. PLEASE COMBINE LIKE
      REVENUE CODES OR SEND MULTIPLE
00398 CLAIMS.                                   F20 FNL/Denied: Claim/line has been denied.
                                                121 Service line number greater than maximum allowable for payer.

      THIS ADJUSTMENT IS THE RESULT OF
      YOUR FACILITY'S RECENT ANCILLARY
      REVIEW VISIT; THESE SERVICES DO
      NOT MEET MEDICAID CRITERIA FOR
00399 REIMBURSEMENT.                           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                                                                                                   Page 59 of 378
                                                                    EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                      NOTES
                                                 101 Claim was processed as adjustment to previous claim.

      DRG NOT PAYABLE FOR THIS AGE
      GROUP; RESUBMIT WITH CORRECTED
      DIAGNOSIS CODE FOR VALID DRG
00400 ASSIGNMENT.                                  F20 FNL/Denied: Claim/line has been denied.
                                                   256 DRG code(s).

      TEFRA 82 PROHIBITS PAYMENT FOR
      SURGICAL ASSISTANCE PROVIDED IN
      A FACILITY WITH A TEACHING
      PROGRAM IN THE ASSISTANT'S
00402 SPECIALTY.                                  F203 FNL/Denied: Denied due to plan provisions.
                                                   104 Processed according to plan provisions.

      SERVICES PROVIDED OUTSIDE YOUR
      OFFICE REQUIRE FACILITY NAME AND
      ADDRESS OR 9 DIGIT FACILITY
00403 PROVIDER NUMBER.                             F20 FNL/Denied: Claim/line has been denied.

                                                   132 Entity's Medicaid provider id.                       C&E Recommendation
                                                   179 Outside lab charges.

      LAB OR XRAY SERVICES NOT
      INCLUDED IN FACILITY SERVICE MUST
      BE BILLED SEPARATELY USING THE
      PHYSICIAN OR LABORATORY
00404 PROVIDER NUMBER                              F20 FNL/Denied: Claim/line has been denied.

                                                   132 Entity's Medicaid provider id.                       C&E Recommendation
                                                   179 Outside lab charges.

      BASE UNITS FOR ANESTHESIA WHEN
      MULTIPLE PROCEDURES ARE
      PERFORMED REPRESENT THE
      PROCEDURE WITH THE HIGHEST UNIT
00405 VALUE.                                       F10 FNL/Payment: Claim/line has been paid.

                                                                                                                      Page 60 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
                                                251 Total anesthesia minutes.


      THE MEDICARE REMITTANCE ADVICE
      OR NOTICE DOESN'T MATCH THE
      INFORMATION ON YOUR CLAIM.
00406 PLEASE RECONCILE AND RESUBMIT.             F20 FNL/Denied: Claim/line has been denied.
                                                 286 Other payer's Explanation of Benefits/payment information.


      HIC NO. OR SUFFIX ON MEDICARE RA
      OR NOTICE DOES NOT MATCH FILE.
      RESUBMIT SERVICES TO MEDICARE
      USING CORRECT HIC NO. SHOWN ON
00407 CLIENT MEDICAL ID CARD.                    F20 FNL/Denied: Claim/line has been denied.
                                                 284 Copy of Medicare ID card.

      EYEGLASS PROGRAM BENEFITS ARE
      NOT AVAILABLE TO CLIENTS
      PREVIOUSLY FURNISHED WITH
00408 PROSTHETIC EYEWEAR.                        F20 FNL/Denied: Claim/line has been denied.
                                                 483 Maximum coverage amount met or exceeded for benefit period.


      YOU MAY RECEIVE PAYMENT UNDER
      THIS PROCEDURE CODE FOR NO
      MORE THAN TWO CASE DENIALS OUT
      OF EVERY TEN CASES SUBMITTED
00409 FOR AUTHORIZATION.                         F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.


      REPEAT INITIAL ICU-CCU VISIT OR
      RESPIRATORY CARE WITHIN 10 DAYS
00410 IS PAYABLE AS SUBSEQUENT CARE.             F10 FNL/Payment: Claim/line has been paid.
                                                  15 One or more originally submitted procedure code have been modified.


                                                                                                                                   Page 61 of 378
                                                                     EOB CSI ANALYSIS

                                             X-WALK
CURR                                         HIPAA
NHIC                                         FINAL
EOB                                          CSCC/CSC
CODE MESSAGE NARRATIVE                       CODE        MESSAGE NARRATIVE                                                     NOTES
      OUR RECORDS INDICATE THE
      BILLING/PERFORMING OR REFERRING
      PROVIDER HAS BEEN SANCTIONED,
      EXCLUDED OR TERMINATED FROM
00411 THIS PROGRAM.                               F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                     91 Entity not eligible/not approved for dates of service.

      THE CLAIM FORM SUBMITTED IS
      LACKING ALL OR MOST OF THE
      REQUIRED INFORMATION. PLEASE
      RESUBMIT A COMPLETED CLAIM
00412 FORM.                                         F20 FNL/Denied: Claim/line has been denied.
                                                    122 Missing/invalid data prevents payer from processing claim.


      CLAIMS WITH PARTIAL NONCOVERED
      AMOUNTS CANNOT BE PROCESSED.
      PLEASE INDICATE WHAT CHARGES
      ARE BEING NONCOVERED AND
00413 RESUBMIT CLAIM.                               F20 FNL/Denied: Claim/line has been denied.
                                                    425 Itemize non-covered services

      THE "FROM" DATE OF SERVICE MUST
      MATCH THE ADMIT DATE OF SERVICE
      FOR TYPE OF BILL 111, 112, 115, 121,
      122, AND 125. PLEASE CORRECT AND
00414 RESUBMIT CLAIM.                               F20 FNL/Denied: Claim/line has been denied.
                                                    187 Date(s) of service.

                                                    188 Statement from-through dates.                                          C&E Recommendation

      PROFESSIONAL COMP HAS
      PREVIOUSLY BEEN BILLED/PAID AND
      CONSIDERED PART OF THE
      COMBINED PROCEDURE. IF
      APPROPRIATE RESUBMIT CLAIM FOR
00415 TECHNICAL COMPONENT.                          F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                         Page 62 of 378
                                                              EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                        NOTES

                                              104 Processed according to plan provisions.   C&E Recommendation
                                              250 Type of service.

      MEDICARE ELIGIBILITY IS BEING
      INVESTIGATED BY DHS. PLEASE
      REAPPEAL AFTER 120 DAYS, BUT
00416 WITHIN 180 DAYS OF THIS R&S.            F20 FNL/Denied: Claim/line has been denied.
                                              198 Medicare effective date.

      TECHNICAL COMP HAS PREVIOUSLY
      BEEN BILLED/PAID AND CONSIDERED
      PART OF THE COMBINED
      PROCEDURE. IF APPROPRIATE
      RESUBMIT CLAIM FOR PROFESSIONAL
00417 COMPONENT.                              F20 FNL/Denied: Claim/line has been denied.

                                              104 Processed according to plan provisions.   C&E Recommendation
                                              250 Type of service.

      THE ELECTRONIC CLAIM REJECTION
      REPORT DOES NOT MATCH THE
      INFORMATION ON YOUR PAPER
      CLAIM. PLEASE CORRECT AND
00418 RESUBMIT.                               F20 FNL/Denied: Claim/line has been denied.
                                               21 Missing or invalid information.

      A SEPARATE CLAIM FORM IS
      REQUIRED FOR EACH DATE OF
      AMBULANCE SERVICES. PLEASE
      RECONCILE AND RESUBMIT WITH
      SIGNED CLAIM COPIES FOR EACH
00419 DATE OF SERVICE.                        F20 FNL/Denied: Claim/line has been denied.
                                              481 Claim/submission format is invalid.




                                                                                                      Page 63 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                                     NOTES

      OUR RECORDS INDICATE PROVIDER
      IS NOT ENROLLED IN THIS PROGRAM.
00420 CONTACT NHIC CUSTOMER SERVICE.            F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  132 Entity's Medicaid provider id.


      DETAIL PERFORMING PROVIDER
      NUMBER NOT ON PROVIDER FILE.
      NOTE: AS OF 4/7/2002, OLD MEDICAID
      PROVIDER NUMBERS ARE NO
      LONGER ACCEPTED, PLEASE SUBMIT
00421 A VALID TPI FOR THIS SERVICE.             F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  132 Entity's Medicaid provider id.

      TAKE HOME DRUGS/FLOURIDE ARE
      NOT A BENEFIT. THESE REQUIRE A
      PRESCRIPTION, PAYABLE THROUGH
00422 THE VENDOR DRUG PROGRAM.                    F20 FNL/Denied: Claim/line has been denied.

                                                    9 No payment will be made for this claim                                 C&E Recommendation
                                                  216 Drug information.

      DENTAL BEHAVIORAL MANAGEMENT
      REQUIRES 2 COMPONENTS - THE
      SPECIFIC BEHAVIOR AND THE
      TECHNIQUE USED. PLEASE APPEAL
      CLAIM WITH APPROPRIATE
00423 DOCUMENTATION.                              F20 FNL/Denied: Claim/line has been denied.
                                                  407 Complications/mitigating circumstances


      THIS PROCEDURE REQUIRES
      MODIFIER(S). PLEASE APPEAL CLAIM
00424 WITH APPROPRIATE MODIFIER(S).               F20 FNL/Denied: Claim/line has been denied.
                                                  453 Procedure Code Modifier(s) for Service(s) Rendered


                                                                                                                                       Page 64 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE        MESSAGE NARRATIVE                                                     NOTES

      THIS RECOUPMENT IS NECESSARY TO
      PROCESS YOUR SPLIT CLAIMS FOR
      OUTLIER CONSIDERATION. NO
      ACTION ON YOUR PART IS
00425 NECESSARY. REFER TO FUTURE R&S.         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      A CORRECTED CLAIM FORM MUST
      ACCOMPANY THE R&S. PLEASE
      REFER TO THE INSTRUCTIONS ON
      YOUR R&S FOR RESUBMITTING
00426 INCOMPLETE CLAIMS.                       F20 FNL/Denied: Claim/line has been denied.
                                               275 Claim.

      DATE(S) OF SERVICE ON CLAIM OR
      ATTACHMENT ARE PRIOR TO THE
      ADMIT DATE. PLEASE RECONCILE
      AND RESUBMIT WITH SIGNED CLAIM
00427 COPY.                                    F20 FNL/Denied: Claim/line has been denied.
                                               187 Date(s) of service.
                                               230 Hospital admission hour.

                                                                                                                          C&E Recommendation
      PROVIDER NOT ELIGIBLE FOR CO-
      INSURANCE OR DEDUCTABLE
      PAYMENT. CONTACT NHIC CUSTOMER
00428 SERVICE.                               F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                91 Entity not eligible/not approved for dates of service.

      THIS SURGERY/SERVICE/SITUATION
      DESCRIBED IS NOT ON THE
      AUTHORIZATION LETTER AND IS NOT
00429 PAYABLE.                                F209 FNL/Denied: Service not authorized.
                                                84 Service not authorized.




                                                                                                                                    Page 65 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                             NOTES
      THIRTY DAYS OF INPATIENT HOSPITAL
      CONFINEMENT HAVE BEEN UTILIZED.
      NO PAYMENT MADE FOR CO-INS
      AND/OR DEDUCTIBLES, IF
00431 APPLICABLE.                                F20 FNL/Denied: Claim/line has been denied.
                                                 483 Maximum coverage amount met or exceeded for benefit period.

      TO APPEAL MULTIPLE HOSPITAL
      CLAIMS FOR POTENTIAL OUTLIER
      PAYMENT, RESUBMIT ONE CLAIM
00432 WITH COMBINED TOTAL CHARGES.               F20 FNL/Denied: Claim/line has been denied.
                                                   7 Claim may be reconsidered at a future date.

                                                 275 Claim                                                         C&E Recommendation


      ADD'L INFO NEEDED TO PROCESS
      CLAIM FOR EPOETIN ALFA. PLEASE
      RESUBMIT SIGNED CLAIM COPY, R&S
      COPY & TOTAL UNITS ADMIN W/CODE
00433 Q9920-Q9940 (BASED ON HCT).                F20 FNL/Denied: Claim/line has been denied.
                                                 216 Drug information.

                                                 217 Drug name, strength and dosage form.                          C&E Recommendation

      DATES OF SERVICE HAVE BEEN
      PREVIOUSLY PAID ON A DIFFERENT
      CLAIM. FOR MEDICAID INFORMATION
      CALL 1-800-925-9126. FOR CIDC
00434 INFORMATION CALL 1-800-568-2413.          F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                  54 Duplicate of a previously processed claim/line.

      REJECTED CLAIMS MUST BE FILED ON
      THE CORRECT CLAIM FORM WITH A
      TEXMEDNET REJECTION REPORT
      WHICH INCLUDES THE NHIC
00435 ASSIGNED TRANSMISSION NUMBER.              F20 FNL/Denied: Claim/line has been denied.

                                                                                                                             Page 66 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                      NOTES
                                                  275 Claim.

      FOR DATES OF SERVICE ON/AFTER
      6/10/91, PROC. MUST BE BILLED AS A
      WEEKLY SERVICE. PLEASE RESUBMIT
      CLAIM COPY, R&S, AND APPROPRIATE
00437 PROCEDURE CODE.                             F20 FNL/Denied: Claim/line has been denied.
                                                  454 Procedure code for services rendered.

      RESIDENTIAL TREATMENT SERVICES
      PAYABLE ONLY FOR PERSONS
      ELIGIBLE FOR CHILD PROTECTIVE
      SERVICES (CLIENT TYPE PROGRAM 8,
00439 9, OR 10).                                  F20 FNL/Denied: Claim/line has been denied.
                                                  109 Entity not eligible.

      RECOUPMENT DUE TO DHS
      DIRECTIVE. SERVICES FOR THIS
      CLIENT ARE PAID BY HOME AND
      COMMUNITY BASED SERVICES
00442 WAIVER.                                    F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      THIS SERVICE EXCEEDS BENEFIT
      LIMITATIONS BUT MAY BE PAID WITH
      MEDICAL NECESSITY
      DOCUMENTATION. PLEASE APPEAL
      WITH APPROPRIATE
00443 DOCUMENTATION.                              F20 FNL/Denied: Claim/line has been denied.
                                                  294 Supporting documentation.

      REQUEST FOR CHANGE OF
      INCORRECT PROVIDER NUMBER
      MUST BE PROCESSED AND
      CORRECTED BY MEDICARE PRIOR TO
00445 MEDICAID ADJUSTMENT.                      F2010 FNL/Denied: Payer not primary.
                                                  286 Other payer's Explanation of Benefits/payment information.

                                                                                                                                     Page 67 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                         NOTES

      THE NAME AND ADDRESS OR NINE
      DIGIT PROVIDER NUMBER OF THE
      PERFORMING LAB MUST BE
      INDICATED ON THE CLAIM WHEN
00448 BILLING A LAB HANDLING FEE.                F20 FNL/Denied: Claim/line has been denied.
                                                 179 Outside lab charges.


      INFORMATION FROM THE OTHER
      INSURANCE COMPANY HAS BEEN
      RECEIVED. CLIENT HAS MORE THAN
      ONE INSURANCE COMPANY. PLEASE
00450 CONTACT CUSTOMER SERVICE.                F2010 FNL/Denied: Payer not primary.
                                                 116 Claim submitted to incorrect payer.

      AMBULANCE TRANSFER DOES NOT
      MEET EMERGENCY/NON-EMERGENCY
      CRITERIA. REFER TO PROVIDER
      PROCEDURES MANUAL FOR APPEAL
00451 GUIDELINES.                                F20 FNL/Denied: Claim/line has been denied.
                                                 337 Ambulance certification/documentation.


      PROCEDURE CODE 1-4600Z IS NOT
      PAYABLE PRIOR TO 6-1-95 FOR THE
      TEXAS MEDICAID PROGRAM. 1-4600Z
00452 IS NOT A BENEFIT OF CIDC PROGRAM.          N/A Per FMT this EOB should be discontinued.

      SERVICE DENIED BY ASSOCIATE
      DENTAL DIRECTOR. X-RAY
      UNREADABLE/UNMARKED RT/LT. A
      COMPLETE DESCRIPTION OF
      PROCEDURE TOOTH ID, AND CLEAR X-
00453 RAY IS REQUIRED.                           F20 FNL/Denied: Claim/line has been denied.
                                                 318 X-rays.


                                                                                                        Page 68 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
      OUR RECORDS INDICATE THAT THE
      REFERRING/ORDERING PROVIDER
      HAS BEEN SANCTIONED, EXCLUDED
      OR TERMINATED FROM THIS
00454 PROGRAM.                                 F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  24 Entity not approved as an electronic submitter.

      MEDICAL CARE ID FORM 3087 OR
      MEDICAID VERIFICATION FORM 1027
      IS THE ONLY ACCEPTABLE MEDICAID
      CLIENT ELIGIBILITY VERIFICATION
00456 DOCUMENTS.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 153 Entity's id number.

      SERVICES PROVIDED IN AN
      INSTITUTION FOR MENTAL DISEASE
      FOR PERSONS BETWEEN THE AGES
      OF 21 AND 65 YEARS ARE NOT A
      BENEFIT OF THE TEXAS MEDICAID
00457 PROGRAM.                                   F20 FNL/Denied: Claim/line has been denied.

                                                 104 Processed according to plan provisions.                                C&E Recommendation
                                                 475 Procedure code not valid for patient age

      DRG CANNOT BE ASSIGNED. CLIENT
      SEX ON FILE IS INVALID TO
      PROCEDURE OR DIAGNOSIS BILLED.
      ELIGIBILITY REFERRAL SENT TO DHS.
00458 REAPPEAL WITHIN 180 DAYS.                  F20 FNL/Denied: Claim/line has been denied.
                                                  86 Diagnosis and patient gender mismatch.

      PROCEDURE DENIED. MAY BE
      CONSIDERED UNDER THE THSTEPS-
      CCP PROGRAM. PLEASE APPEAL
      WITH \DOCUMENTATION TO SUPPORT
      THE MEDICAL
00459 NECESSITY/APPROPRIATENESS.                 F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                      Page 69 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                           NOTES
                                                 287 Medical necessity for service.

      REQUESTED DOCUMENTATION
      RECEIVED. HOWEVER THE DATE(S)
      AND/OR CONTENT DO NOT DEFINE
      CLIENT'S "SEVERELY DISABLED"
00460 CONDITION AT TIME OF TRANSPORT.              F20 FNL/Denied: Claim/line has been denied.
                                                   472 Ambulance Run Sheet

      CLAIM MUST STATE THAT STAFF ARE
      ON AN "ON CALL" BASIS ONLY
      BETWEEN 8:00 PM AND 8:00 AM AND
      MUST INCLUDE EXACT TIME OF
      AMBULANCE TRANSFER FOR
00461 PAYMENT.                                     F20 FNL/Denied: Claim/line has been denied.
                                                   472 Ambulance Run Sheet


      MEDICAID REIMBURSEMENT FOR
      AMBULANCE SVCS IS LIMITED TO
      BASIC LIFE SUPPORT (BLS). PLEASE
      RESUBMIT ADVANCED LIFE SUPPORT
00462 (ALS) SVCS AS BLS PROC W/ A9 MOD.            F20 FNL/Denied: Claim/line has been denied.
                                                   472 Ambulance Run Sheet

      PLEASE PROVIDE THE COMPLETE 9-
      DIGIT CIDC PERFORMING PROVIDER
      NUMBER OR NAME OF THE
      PERFORMING PROVIDER. A MEDICAID
      PROVIDER NUMBER IS NOT VALID FOR
00463 CIDC.                                        F20 FNL/Denied: Claim/line has been denied.
                                                   153 Entity's id number.




                                                                                                         Page 70 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                         NOTES
      CLAIM DENIED DUE TO CLIENT OR
      PROVIDER INELIGIBILITY. CLIENTS
      MUST BE UNDER AGE 21 AND
      PROVIDERS MUST BE ENROLLED FOR
00464 THIS CCP DATE OF SERVICE.                F20 FNL/Denied: Claim/line has been denied.
                                               475 Procedure code not valid for patient age

      THSTEPS-CCP SERVICES ARE
      PAYABLE FOR CLIENTS UNDER THE
      AGE OF 21.THESE SERVICES HAVE
      BEEN CUTBACK/DENIED FOR DATES
      OF SERVICE ON/AFTER THE 21ST
00465 BIRTHDAY.                                F20 FNL/Denied: Claim/line has been denied.
                                               475 Procedure code not valid for patient age

      SURGICAL PROC PERFORMED IN
      HASC MUST BE BILLED USING THE
      HOSPITAL AMBULATORY SURGICAL
      CENTER PROV. NUMBER THAT WAS
00466 ISSUED.                                  F20 FNL/Denied: Claim/line has been denied.
                                               132 Entity's Medicaid provider id.

      RESUBMIT WITH PHYSICIAN'S LETTER
      STATING HOW THE PATIENT WILL
      MEDICALLY BENEFIT FROM A
      NURSING HOME TO NURSING HOME
00467 TRANSFER.                                F20 FNL/Denied: Claim/line has been denied.
                                               428 Reason for transport by ambulance

      THIS AUTHORIZATION NUMBER IS
      NULL AND VOID DUE TO HOSPITAL
      FAILURE TO SUBMIT REQUESTED
      DOCUMENTATION. APPEAL WITH
00468 ADMIT AND DISCHARGE RECORDS.             F20 FNL/Denied: Claim/line has been denied.
                                               297 Medical notes/report.




                                                                                                      Page 71 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                     NOTES

      CLAIM/PROCEDURE WAS
      REFERENCED TO A MISSING/INVALID
      DIAGNOSIS CODE. PLEASE REFILE
00469 WITH A CORRECT DIAGNOSIS CODE.             F20 FNL/Denied: Claim/line has been denied.
                                                 255 Diagnosis code.


      INITIAL HOSPITAL CARE BILLED ON
      THE SAME DAY AS NEWBORN
      RESUSCITATION OR CRITICAL CARE IS
00470 PAYABLE AS A SUBSEQUENT VISIT.             F20 FNL/Denied: Claim/line has been denied.
                                                  15 One or more originally submitted procedure code have been modified.

      EACH CLAIM IS LIMITED TO 27 OR
      LESS DETAILS AND MUST INCLUDE A
      TOTAL BILLED AMOUNT. PLEASE
      RESUBMIT FOLLOWING THESE
00472 GUIDELINES.                                F20 FNL/Denied: Claim/line has been denied.
                                                 121 Service line number greater than maximum allowable for payer.

      THIS SERVICE REQUIRES PRIOR
      AUTHORIZATION. PAPER APPEAL
      WITH R&S, CLAIM COPY AND
      REQUIRED DOCUMENTATION AS
      DEFINED IN THE PROVIDER
00473 PROCEDURE MANUAL.                         F209 FNL/Denied: Service not authorized.
                                                  84 Service not authorized.


      THESE TESTS SHOULD BE COMBINED
      & BILLED AS 1 CHARGE. RESUBMIT
      W/SIGNED CLAIM COPY, R&S, AND
00474 APPROPRIATE TEST CODE.                     F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.




                                                                                                                                   Page 72 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                         NOTES
      PAID ACCORDING TO THE TEXAS
      MEDICAID REIMBURSEMENT
      METHODOLOGY-TMRM (RELATIVE
      VALUE UNIT TIMES STATEWIDE
00475 CONVERSION FACTOR)                       F102 FNL/Payment: Payment made in full.
                                                 67 Payment made in full.

      THESE SERVICES FOR NURSING
      FACILITY CLIENTS MUST BE
      COORDINATED WITH THE NURSING
      FACILITY PRIOR TO CONTACTING
00477 TDHS REHAB SVCS PROGRAM.                  F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.


      SERVICE DENIED BY THE ASSOCIATE
      MEDICAL DIRECTOR. AIR TRANSFER
      NOT NECESSARY, SERVICE
00480 AVAILABLE AT ORIGINAL FACILITY.           F20 FNL/Denied: Claim/line has been denied.
                                                430 Nearest appropriate facility

      BASED ON ALL DOCUMENTATION
      RECEIVED, AMBULANCE TRANSFER
      DOES NOT MEET EMERGENCY
      CRITERIA. THEREFORE, IT IS NOT A
00481 BENEFIT.                                  F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

                                                104 Processed according to plan provisions.   C&E Recommendation

      EVALUATION AND MANAGEMENT
      CODES ARE NOT PAYABLE ON AN
      OUTPATIENT CLAIM. REFER TO
00483 PROVIDER PROCEDURE MANUAL.                F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.




                                                                                                        Page 73 of 378
                                                                 EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                           NOTES
      AIR TRANSFER IS DENIED. TO
      CONSIDER CLAIM FOR PAYMENT
      SUBMIT YOUR FLIGHT RECORDS,
      HOSPITAL ADMIT / DISCHARGE
      RECORDS AND HISTORY AND
00486 PHYSICAL.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 297 Medical notes/report.

      DIAGNOSIS CODES BEGINNING WITH
      E OR M ARE NOT VALID AS A PRIMARY
      DIAGNOSIS. PLEASE REFILE YOUR
      CLAIM WITH A VALID PRIMARY
00487 DIAGNOSIS CODE.                            F20 FNL/Denied: Claim/line has been denied.
                                                 254 Primary diagnosis code.

      OUR RECORDS INDICATE THAT
      THERE IS NO CLIA NUMBER ON FILE
      FOR THIS PROVIDER NUMBER OR THE
      CLIA IS NOT VALID FOR THE DATES OF
00488 SERVICE ON THE CLAIM.                      F20 FNL/Denied: Claim/line has been denied.
                                                 142 Entity's license/certification number.


      CLIENT ENROLLED IN THE TEXAS
      HEALTH NETWORK FOR DATE(S) OF
      SERVICE. ELIG. SERVICES WILL BE
      PROCESSED ON SEPARATE CLAIM. NO
00489 ACTION ON YOUR PARTNECESSARY.              F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.

      REQUIRED INFORMATION ON
      PHYSICIAN'S AUTHORIZATION IS
      MISSING/INCOMPLETE. PLEASE
      REFER TO PROVIDER PROCEDURES
00490 MANUAL.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 122 Missing/invalid data prevents payer from processing claim.


                                                                                                                          Page 74 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES

      ADM. DENIED BY UR. SERVICES
      PROVIDED IN OBSERVATION MAY BE
      APPEALED TO NHIC ADJUSTMENTS
      ON A REVISED OUTPATIENT CLAIM AS
00491 SPECIFIED IN HHSC DENIAL LETTER.          F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      PROCESSING DETERMINED TO BE
      CORRECT. IF YOU FIND NHIC DID NOT
      PROVIDE FULL APPEAL
      CONSIDERATION, YOU MAY FILE A
      COMPLAINT WITH TDH WITHIN 60
00493 CALENDAR DAYS.                            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      THIS SERVICE WAS PAID TO AN
      INDEPENDENT LAB. IF SERVICE
      PERFORMED IN YOUR OFFICE,
      PLEASE APPEAL WITH TEST RESULT
      AND NECESSITY FOR REPEAT
00494 PROCEDURE.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 300 Lab/test report/notes/results.

      REQUIRED TEFRA INFORMATION
      INCOMPLETE. PLEASE RESUBMIT
      WITH THE APPROPRIATE MODIFIER
00498 AND TOTAL TIME IN MINUTES.                 F20 FNL/Denied: Claim/line has been denied.
                                                 251 Total anesthesia minutes.

      CLIENT IS ELIGIBLE FOR MEDICARE.
      BILL MEDICARE FIRST. MEDICARE
00499 NUMBER: %1.                              F2010 FNL/Denied: Payer not primary.
                                                 116 Claim submitted to incorrect payer.




                                                                                                                                    Page 75 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                     NOTES

      DOCUMENTATION OF CLIENT'S
      DISABILITY INSUFFICIENT. RESUBMIT
      WITH CLARIFICATION OF CLIENT'S
      CONDITION REQUIRING A STRETCHER
00500 AND/OR MEDICAL MONITORING.                 F20 FNL/Denied: Claim/line has been denied.
                                                 472 Ambulance Run Sheet


      PAYMENT FOR MILEAGE IS NOT MADE
      PRIOR TO PICK UP OR AFTER
00501 COMPLETION OF PATIENT TRANSFER.            F20 FNL/Denied: Claim/line has been denied.
                                                 104 Processed according to plan provisions.

      NEWBORN SERVICES DENIED ON
      MOTHER'S CLAIM. PLEASE RESUBMIT
      NEWBORN SERVICE ON A SEPARATE
00502 NEWBORN CLAIM.                             F20 FNL/Denied: Claim/line has been denied.
                                                 238 Separate claim for mother/baby charges.

      REVENUE CODE INVALID OR NOT
00503 USED BY THIS PROGRAM.                      F20 FNL/Denied: Claim/line has been denied.
                                                 455 Revenue code for services rendered.

      REDUCED DUE TO CLIENT'S
      MEDICALLY NEEDY SPENDDOWN. FOR
      INFORMATION, PLEASE CALL
00504 CUSTOMER SERVICE.                         F103 FNL/Payment: Partial payment made for this claim.
                                                  68 Partial payment made for this claim.

      WHEN A CONSULTING PHYSICIAN
      INSTITUTES TREATMENT AND
      FOLLOWS THE CLIENT, THE
      CONSULTATION IS PAYABLE AS
00507 PHYSICIAN VISITS.                          F10 FNL/Payment: Claim/line has been paid.
                                                  15 One or more originally submitted procedure code have been modified.


                                                                                                                                   Page 76 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                             NOTES

      INTERIM BILLING, LATE CHARGES NOT
      PAYABLE UNDER LONESTAR SELECT II
      PERDIEM PRICING METHOD. PLEASE
      RESUBMIT ONE CLAIM WITH
00508 COMBINED FINAL CHARGES.                    F20 FNL/Denied: Claim/line has been denied.
                                                   7 Claim may be reconsidered at a future date.

      CLAIM DENIED. CLIENT HAS MET THE
      30 ENCOUNTER LIMITATION. PRIOR
      AUTHORIZATION IS REQUIRED FOR
      ADDITIONAL SERVICES IN THE
00510 CURRENT CALENDAR YEAR.                    F209 FNL/Denied: Service not authorized.
                                                  84 Service not authorized.

      APPEAL TO TDH W/MEDICAL
      RECORDS AND AFFIDAVIT. INPATIENT
      HOSPITAL STAY W/IN 24 HRS OF AN
      OUTPATIENT SURGICAL STAY
      REQUIRES DOCUMENTATION OF
00511 COMPLICATION.                              F20 FNL/Denied: Claim/line has been denied.
                                                 407 Complications/mitigating circumstances

      SERVICES NOT MEDICALLY
      NECESSARY AS RELATED TO
      COUNSELING AND SELECTION OF A
      CONTRACEPTIVE METHOD ARE NOT
      PAYABLE TO A FAMILY PLANNING
00512 AGENCY.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 287 Medical necessity for service.


      ELECTRONIC BILLING OF EMERGENCY
      TRANSFERS REQUIRE A NARRATIVE
      DESCRIPTION OF CLIENT'S
      CONDITION AND VITAL SIGNS TO BE
00513 INCLUDED IN THE COMMENT FIELD.             F20 FNL/Denied: Claim/line has been denied.

                                                                                                           Page 77 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                     NOTES
                                                  472 Ambulance Run Sheet

      HOSPITAL SUBSEQUENT CARE IS NOT
      PAYABLE TO REFERRING PHYSICIAN
      ONCE CONSULTANT ASSUMES CARE
00514 OF THE CLIENT.                             F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      AN INITIAL CARE VISIT WITHIN ONE
      YEAR OF ANOTHER INITIAL CARE
      VISIT IN THE SKILLED NURSING
      FACILITY IS PAYABLE AS A
00515 SUBSEQUENT CARE VISIT                       F10 FNL/Payment: Claim/line has been paid.
                                                   15 One or more originally submitted procedure code have been modified.

      IF EYEWEAR IS BEYOND PROGRAM
      BENEFITS, CIRCLE ITEM A IN BLOCK 7
      AND HAVE THE CLIENT SIGN BLOCK 11
00516 OF THE CLAIM FORM.                          F20 FNL/Denied: Claim/line has been denied.
                                                  466 Entities Original Signature

      A NEW PATIENT VISIT WITHIN ONE
      YEAR OF A CONSULT IS PAYABLE AS
00517 AN ESTABLISHED PATIENT VISIT.               F10 FNL/Payment: Claim/line has been paid.
                                                   15 One or more originally submitted procedure code have been modified.

      THE AT MODIFIER CANNOT BE USED
      WITH A PAN. PLEASE RESUBMIT
      CORRECTED CLAIM WITH R&S AND
      INDICATE ACUTE OR CHRONIC
00518 CONDITION.                                  F20 FNL/Denied: Claim/line has been denied.
                                                  293 Reason for physical therapy.

      THE COMBINATION OF MODIFIER
      DESCRIPTION AND TYPE OF SERVICE
00519 IS INVALID.                                 F20 FNL/Denied: Claim/line has been denied.
                                                  453 Procedure Code Modifier(s) for Service(s) Rendered

                                                                                                                                    Page 78 of 378
                                                             EOB CSI ANALYSIS

                                       X-WALK
CURR                                   HIPAA
NHIC                                   FINAL
EOB                                    CSCC/CSC
CODE MESSAGE NARRATIVE                 CODE       MESSAGE NARRATIVE                                               NOTES

      CLIENT MUST BE SEEN BY A
      PHYSICIAN WITHIN A SIX MONTH
      PERIOD IN ORDER TO QUALIFY FOR
00520 HOME HEALTH BENEFITS.                  F20 FNL/Denied: Claim/line has been denied.
                                             310 Progress notes for the six months prior to statement date.

      REQUIRED TEFRA INFORMATION
      INCOMPLETE. PLEASE RESUBMIT
      WITH NUMBER OF CONCURRENT
00525 PROCEDURES SUPERVISED.                 F20 FNL/Denied: Claim/line has been denied.
                                             262 Type of surgery/service for which anesthesia was administered.

      SERVICES AVAILABLE THROUGH
      TEXAS DEPARTMENT OF HEALTH ARE
00526 NOT A BENEFIT.                         F20 FNL/Denied: Claim/line has been denied.
                                               9 No payment will be made for this claim.

      CLINICAL LABORATORY
      CONSULTATIONS PAYABLE ONLY
      WITH NAME OF REQUESTING
      PHYSICIAN, PATIENT DIAGNOSIS,
      CLINICAL TEST RESULTS, AND
00529 WRITTEN NARRATIVE REPORT.              F20 FNL/Denied: Claim/line has been denied.
                                             300 Lab/test report/notes/results.

      LAB HANDLING CHARGE PAYABLE
      ONLY WHEN SPECIMEN IS
      COLLECTED BY VENIPUNCTURE OR
      CATHETERIZATION AND TEST IS
      PERFORMED OUTSIDE PHYSICIANS
00532 OFFICE.                                F20 FNL/Denied: Claim/line has been denied.
                                             179 Outside lab charges.




                                                                                                                          Page 79 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      CLAIM DENIED DUE TO INTERIM
      BILLING. PLEASE REFILE CLAIM
      AFTER DISCHARGE OR 30 DAYS
00533 CONTINUOUS HOSPITALIZATION.               F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

      THIS CLAIM/APPEAL CANNOT BE
      PROCESSED CORRECTLY DUE TO
      ILLEGIBLE INFORMATION. PLEASE
      RESUBMIT WITH LEGIBLE
00534 CLAIM/DOCUMENTATION.                      F20 FNL/Denied: Claim/line has been denied.
                                                122 Missing/invalid data prevents payer from processing claim.

      AS OF 010198 THE DMEH PROVIDER
      NUMBER MUST BE USED ON HCFA
      1500 WHEN BILLING HOME HEALTH
      DME/MEDICAL SUPPLIES. REFILE
      CORRECT CLAIM FOR THIS DETAIL
00535 W/R&S.                                    F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.


      FOR PAYMENT OF CONCURRENT
      CARE, APPEAL MUST BE SUBMITTED
      WITH HISTORY/PHYSICAL, ALL
      CONSULT REPORTS, AND ALL
00536 PHYSICIAN PROGRESS REPORTS.               F20 FNL/Denied: Claim/line has been denied.
                                                297 Medical notes/report.

      HHSC/OIE HAS REQUESTED THIS ITEM
      BE RECOUPED. APPEALS MUST BE
      FORWARDED TO THE OIE/MPI
00537 DIVISION OF HHSC.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.




                                                                                                                                   Page 80 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                           NOTES
      DOCUMENTATION INSUFFICIENT TO
      VERIFY MEDICAL NECESSITY. PLEASE
      RESUBMIT WITH SIGNED CLAIM COPY,
      R&S COPY, AND COMPLETE
      DOCUMENTATION OF MEDICAL
00543 NECESSITY.                               F20 FNL/Denied: Claim/line has been denied.
                                               287 Medical necessity for service.

      ADDITIONAL INFO NEEDED TO
      PROCESS CLAIM. PLEASE RESUBMIT
      WITH SIGNED CLAIM COPY, R&S
      COPY, AND DATE OF ONSET OF
00544 DIALYSIS TREATMENTS.                     F20 FNL/Denied: Claim/line has been denied.
                                               213 Date of first routine dialysis.


      ADD'L INFO NEEDED TO PROCESS
      CLAIM. RESUBMIT SIGNED CLAIM
      COPY, R&S COPY, ITEMIZED CHARGES
      ALL THERAPY PROGRESS NOTES AND
00545 DATE OF ONSET OF INJURY/ILLNESS.         F20 FNL/Denied: Claim/line has been denied.
                                               310 Progress notes for the six months prior to statement date.

      PROCEDURE/SERVICE EXCEEDS THE
      BENEFIT LIMITATION OF 12
      CHIROPRACTIC VISITS FOR A 12
00546 MONTH PERIOD.                            F20 FNL/Denied: Claim/line has been denied.
                                               348 Chiropractic treatment plan.

      SUBMISSION OF FRONT AND BACK OF
      CONSENT FORM IS REQUIRED.
      PLEASE RESUBMIT WITH SIGNED
      CLAIM COPY, R&S COPY, AND COPY
00547 OF CORRECTED CONSENT FORM.               F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.




                                                                                                                        Page 81 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      YOUR MOST RECENT APPEAL HAS
      BEEN REVIEWED AND FURTHER
      CLARIFICATION IS NEEDED. IT HAS
      BEEN REFERRED TO PROVIDER
      RELATIONS AND SOMEONE WILL
00548 CONTACT YOU.                              F00 Finalized: Claim/encounter has been processed.
                                                  0 Cannot provide further status electronically.

      THIS ADJUSTMENT IS THE RESULT OF
      REQUIRED INTERNAL PROCESSING.
      NO ACTION ON YOUR PART IS
00549 REQUIRED.                                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS EQUIPMENT/SUPPLY/SERVICE IS
      CONSIDERED PART OF, DUPLICATE
      OF, OR AN UNNEEDED EXTENSION OF
      ANOTHER PIECE OF
00550 EQUIPMENT/SUPPLY/SERVICE.                 F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      TECHNICAL CLAIM DENIAL DUE TO
      LACK OF COMPLETE MED RECORD.
      RESUBMISSION MUST BE WITHIN 30
00552 DAYS TO BE RECONSIDERED.                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      ADDITIONAL INFO NEEDED TO
      PROCESS CLAIM. PLEASE RESUBMIT
      WITH SIGNED CLAIM COPY, R&S
      COPY, SEPARATE DATES AND
00553 CHARGES FOR SERVICES.                     F20 FNL/Denied: Claim/line has been denied.
                                                 84 Service not authorized.




                                                                                                                                   Page 82 of 378
                                                               EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                               NOTES
      YOUR REQUEST FOR DX/PROC.
      CODE/DRG CHANGE CANNOT BE
      ACCOMPLISHED UNTIL AFTER YOUR
      RETROSPECTIVE REVIEW IS
00556 COMPLETED.                                F00 Finalized: Claim/encounter has been processed.
                                                 46 Internal review/audit.


      YOUR CLAIMS HAVE BEEN DENIED IN
      ORDER TO BE COMBINED FOR
      CORRECT DRG PAYMENT. NO ACTION
00557 ON YOUR PART IS NECESSARY.                F20 FNL/Denied: Claim/line has been denied.
                                                103 Claim combined with other claim(s).


      THESE COMPONENTS SHOULD BE
      COMBINED & BILLED AS A
      URINALYSIS. PLEASE RESUBMIT
      SIGNED CLAIM COPY, R&S COPY, AND
00558 APPROPRIATE URINALYSIS CODE.              F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


      THESE TESTS SHOULD BE COMBINED
      & BILLED AS A CBC/PANEL. PLEASE
      RESUBMIT WITH SIGNED CLAIM COPY,
      R&S COPY, & APPROPRIATE CODE
00559 (X7619, 85021-85027, 85031).              F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.

      THIS SERVICE DETERMINED NOT
      MEDICALLY NECESSARY BY THE
      MEDICAL DIRECTOR. IF YOU FIND YOU
      DID NOT RECEIVE ADEQUATE
      REVIEW, YOU MAY FILE A COMPLAINT
00560 W/TDH.                                    F20 FNL/Denied: Claim/line has been denied.


                                                                                                             Page 83 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                          NOTES

                                                  9 No payment will be made for this claim      C&E Recommendation
                                                287 Medical necessity for service.

      ADDITIONAL INFORMATION NEEDED
      TO PROCESS CLAIM. PLEASE
      RESUBMIT WITH SIGNED CLAIM COPY,
      R&S COPY, NEW, AND OLD
00561 PRESCRIPTION.                             F20 FNL/Denied: Claim/line has been denied.
                                                282 Copy of prescription.
                                                403 Entity referral notes/orders/prescription
      CLAIM HAS BEEN DENIED AS THE
      PATIENT LIABILITY IS GREATER THAN
      THE DRG PAYABLE AMOUNT. FOR
      MORE INFORMATION, CONTACT NHIC
00562 CUSTOMER SERVICE.                         F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      ADDITIONAL INFORMATION NEEDED
      TO PROCESS CLAIM. PLEASE
      RESUBMIT WITH SIGNED CLAIM COPY,
      R&S COPY AND COMPLETE
00563 DOCUMENTATION OF ER VISIT.                F20 FNL/Denied: Claim/line has been denied.
                                                299 Emergency room notes/report.

      RECEIVED PAST 95 DAY FILING
      DEADLINE. REFER TO CLAIMS FILING
      DEADLINE SECTION OF PROVIDER
      PROCEDURES MANUAL FOR
00565 INSTRUCTIONS.                             F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.




                                                                                                          Page 84 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      CLAIM INDICATES REPLACING
      EYEWEAR BUT PROC CODE
      INDICATES NEW EYEWEAR. PLEASE
      RESUBMIT WITH SIGNED CLAIM COPY,
      R&S COPY, & APPROPRIATE
00566 EYEWEAR CODES(S).                         F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


      THESE LAB TESTS SHOULD BE BILLED
      AS A PANEL. PLEASE COMBINE THE
      CHARGES AND RESUBMIT WITH THE
00567 APPROPRIATE PANEL CODE.                   F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


      THIS SERVICE IS CONSIDERED PART
      OF AN INCLUSIVE PAYMENT MADE ON
      ANOTHER SERVICE OR ITEM THAT
00568 HAS ALREADY BEEN PROVIDED.                F20 FNL/Denied: Claim/line has been denied.
                                                483 Maximum coverage amount met or exceeded for benefit period.

      THIS CLAIM REPROCESSED FOR NHIC
      INTERNAL REPORTING PURPOSES
      ONLY. NO ACTION ON YOUR PART IS
00569 NECESSARY.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      THE STERILIZATION CONSENT FORM
      MUST BE SIGNED AT LEAST 30 DAYS
      PRIOR TO THE DAY OF SURGERY OR
00570 THE EXPECTED DATE OF DELIVERY.            F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature
                                                468 Patient Signature Source


                                                                                                                                   Page 85 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                     NOTES
      DATE OF SURGERY ON CLAIM &
      CONSENT FORM DO NOT MATCH.
      RESUBMIT W/ SIGNED CLAIM COPY,
      VALID CONSENT FORM, R&S COPY &
      OP REPORT TO DOCUMENT DATE OF
00571 SURGERY.                                  F20 FNL/Denied: Claim/line has been denied.
                                                298 Operative report.

                                                466 Entities original signature.                                           C&E Recommendation

      IT IS MANDATORY THAT
      AUTHORIZATION BE OBTAINED. DUE
      TO THE LACK OF APPROVAL, THE
00572 SERVICE IS NON-PAYABLE.                  F209 FNL/Denied: Service not authorized.
                                                 84 Service not authorized.

      THE PLACE OF SERVICE IS UNCLEAR.
      PLEASE SPECIFY INPATIENT OR
      OUTPATIENT FOR HOSPITAL
00573 SERVICES.                                 F20 FNL/Denied: Claim/line has been denied.
                                                249 Place of service.


      SERVICES ARE COVERED BY HOSPICE
      PROGRAM ADMINISTERED BY THE
      DEPARTMENT OF HUMAN SERVICES.
      PLEASE REFER TO YOUR PROVIDER
00574 PROCEDURE MANUAL.                       F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.


      AN ELIGIBILITY UPDATE ON THIS
      CLIENT HAS BEEN SENT TO DHS.                  FNL/Denied: Patient not eligible for benefits for submitted dates of
00576 PLEASE REAPPEAL WITHIN 180 DAYS.        F2013 service.
                                                  7 Claim may be reconsidered at a future date.




                                                                                                                                     Page 86 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                            NOTES
      TO REIMBURSE ORAL/TOPICAL
      MEDICATION CHARGES "OH DRUG" OR
      MODIFIER "SH" MUST BE INDICATED
00578 ON THE UB92.                               F20 FNL/Denied: Claim/line has been denied.
                                                 453 Procedure Code Modifier(s) for Service(s) Rendered

      THIS IS AN INFORMATIONAL APPEAL
      TO DOCUMENT YOUR TELEPHONE
      APPEAL ATTEMPT. RESUBMIT YOUR
      APPEAL TO NHIC WITH THE REQUIRED
00579 DOCUMENTATION.                             F20 FNL/Denied: Claim/line has been denied.
                                                 294 Supporting documentation.

      IN ACCORDANCE WITH OBRA
      (OMNIBUS BUDGET RECONCILIATION
      ACT) OF 1987, THE COST OF THE IOL
      IS INCLUDED IN THE FACILITY
00580 PAYMENT.                                 F1010 FNL/Payment: Payment made to facility.
                                                   9 No payment will be made for this claim.

      ADDITIONAL INFO NEEDED TO
      PROCESS CLAIM. PLEASE RESUBMIT
      WITH SIGNED CLAIM COPY. R&S
      COPY, AND INVOICE SHOWING
      ACQUISITION COST OF INTRAOCULAR
00581 LENS.                                      F20 FNL/Denied: Claim/line has been denied.
                                                 110 Claim requires pricing information.

      CLIENT STATEMENT OF NO OTHER
      INSURANCE IS NOT SUFFICIENT
      DOCUMENTATION. PLEASE RESUBMIT
      WITH DISPOSITION FROM THE
00582 INSURANCE COMPANY.                       F2010 FNL/Denied: Payer not primary.
                                                 286 Other payer's Explanation of Benefits/payment information.




                                                                                                                          Page 87 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                    NOTES
      MEDICARE-ONLY PROC CODE.
      PLEASE RESUBMIT WITH R&S COPY,
      SIGNED CLAIM COPY AND
      APPROPRIATE CPT, HCFA, MEDICAID                                                                                     Revise 583 description
      LOCAL CODE OR COMPLETE                                                                                              to exclude reference to
00583 DESCRIPTION OF SVC.                       F20 FNL/Denied: Claim/line has been denied.                               local code.
                                                454 Procedure code for services rendered.

      CLAIM DENIED DUE TO INCOMPLETE
      SCREEN. PLEASE REFER TO
      PROVIDER PROCEDURES MANUAL
00584 FOR SCREEN REQUIREMENTS.                  F20 FNL/Denied: Claim/line has been denied.
                                                476 Missing or invalid units of service

      INITIAL HOSPITAL VISIT OR PSYCH
      EXAM WITHIN 30 DAYS OF CONSULT
      CUTBACK TO SUBSEQUENT CARE
00586 VISIT.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 15 One or more originally submitted procedure code have been modified.

                                                104 Processed according to plan provisions                                C&E Recommendation

      YOUR INPATIENT CLAIM HAS BEEN
      DENIED. IT WILL BE REPROCESSED AS
      AN OUTPATIENT CLAIM. NO FURTHER
      ACTION ON YOUR PART IS
00588 NECESSARY.                                F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.


      THIS CPT-4 ANESTHESIA CODE IS NOT
      PAYABLE FOR DOS BEFORE 1-1-91.
      PLEASE RESUBMIT SIGNED CLAIM
      COPY, R&S COPY, AND APPROPRIATE
00589 CPT-4 SURGICAL CODE.                      F20 FNL/Denied: Claim/line has been denied.
                                                454 Procedure code for services rendered.


                                                                                                                                      Page 88 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                      NOTES
      RESUBMIT W/SIGNED CLAIM COPY,
      R&S COPY, MEDICARE REMITTANCE
      ADVICE OR NOTICE, & INDICATE
      WHETHER MEDICAID ASSIGNMENT IS
00590 ACCEPTED.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 358 Does provider accept assignment of benefits?


      PROCEDURE REQUIRES A VALID
      HYSTERECTOMY/STERILIZATION/ABO
      RTION MODIFIER. PLEASE RESUBMIT
      WITH AN APPROPRIATE MODIFIER
00591 AND A SIGNED CLAIM COPY.                   F20 FNL/Denied: Claim/line has been denied.
                                                 453 Procedure Code Modifier(s) for Service(s) Rendered

      IT IS NOT ANATOMICALLY POSSIBLE
      TO PERFORM THIS PROCEDURE ON
      THIS CLIENT. PLEASE CORRECT
      CLIENT AND/OR PROCEDURE
00593 INFORMATION AND RESUBMIT.                  F20 FNL/Denied: Claim/line has been denied.
                                                 474 Procedure code and patient gender mismatch

      CLIENT IS COVERED BY LIABILITY
      INSURANCE, WHICH MUST BE BILLED
      PRIOR TO THIS PROGRAM. PLEASE
      REFER TO RESPONSIBLE PARTY
00594 INFORMATION.                             F2010 FNL/Denied: Payer not primary.
                                                 171 Other insurance coverage information (health, liability, auto, etc.).

      THIS CLIENT HAS RECENTLY
      RECEIVED MEDICAID ELIGIBILITY FOR
      THESE DATES OF SERVICE. PLEASE
00598 BILL MEDICAID FIRST.                     F2010 FNL/Denied: Payer not primary.
                                                 116 Claim submitted to incorrect payer.




                                                                                                                                     Page 89 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
      THE QUANTITY BILLED SHOULD
      REFLECT THE TOTAL VOLUME (IN
      CC'S) CONTAINED IN THE VIAL OF
00600 ALLERGY VACCINE                           F20 FNL/Denied: Claim/line has been denied.

                                                222 Drug dispensing units and average wholesale price (AWP).               C&E Recommendation
                                                258 Days/units for procedure/revenue code.

      A RECEIVABLE HAS BEEN
      ESTABLISHED IN THE AMOUNT OF THE
      ORIGINAL PAYMENT: %1. FUTURE
      PAYMENTS WILL BE REDUCED OR
      WITHHELD UNTIL SUCH AMOUNT IS
00601 PAID IN FULL.                            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      ORIGINAL PROCESSING REVIEWED
      AND DETERMINED TO BE CORRECT.
      SUBMIT APPEAL TO TX DEPT OF
      HEALTH - CIDC APPEALS 1100 WEST
00602 49TH ST. AUSTIN TX. 78756-3179.          F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      PLEASE RESUBMIT WITH
      HYSTERECTOMY
      ACKNOWLEDGEMENT OR PHYSICIAN
      SIGNED/DATED STATEMENT IF CLIENT
      IS POST MENOPAUSAL OR HAS BEEN
00604 SURGICALLY STERILIZED.                    F20 FNL/Denied: Claim/line has been denied.
                                                294 Supporting documentation.

                                                466 Entity's original signature.                                           C&E Recommendation




                                                                                                                                     Page 90 of 378
                                                                 EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                        NOTES

      REQUEST FOR DRG CHANGE CANNOT
      BE ACCOMPLISHED WITHOUT THE
      ORIGINAL AND REVISED UB92S AND
      COMPLETE MEDICAL RECORDS.
00605 PLEASE RESUBMIT.                           F20 FNL/Denied: Claim/line has been denied.

                                                 275 Claim                                     C&E Recommendation
                                                 297 Medical notes/report.

      WELL CHILD SERVICES ARE NOT
      PAYABLE ON THIS CLAIM. WELL CHILD
      SERVICES ARE COVERED UNDER THE
      THSTEPS PROGRAM TO THSTEPS
00606 PROVIDERS.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      DOCUMENTATION DOES NOT
      INDICATE A SUFFICIENT CHANGE IN
      PRESCRIPTION ACCORDING TO
00609 MEDICAID GUIDELINES.                       F20 FNL/Denied: Claim/line has been denied.
                                                 294 Supporting documentation.


      IF EYEWEAR IS LOST OR DESTROYED,
      CIRCLE ITEM B IN BLOCK 7 AND HAVE
      THE CLIENT SIGN IN BLOCK 11 OF THE
00610 CLAIM FORM.                                F20 FNL/Denied: Claim/line has been denied.
                                                 466 Entities Original Signature

      PLEASE RESUBMIT ROUTINE
      NEWBORN CARE WITH SIGNED CLAIM
      COPY, R&S COPY, INDIVIDUAL DATES
      & CHARGES FOR EACH DAY OF
      ROUTINE CARE USING CODES 90225 &
00611 90282.                                     F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

                                                                                                         Page 91 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                     NOTES


      THIS CLAIM HAS BEEN REPROCESSED
      AFTER RETROSPECTIVE REVIEW.
      PLEASE REFER TO FOLLOW-UP
00612 LETTER FOR DETAILED EXPLANATION.         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  2 More detailed information in letter.

      DENIED. INCOMPLETE CLAIM
      RECEIVED PAST 95 DAY FILING
      DEADLINE. RESUBMIT CORRECTED
      CLAIM FORM, ALL PREVIOUS R&S
      REPORTS, IF CLAIM WAS FILED W/IN
00613 DEADLINE.                                 F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

      MEDICARE PD AMT IS LESS THAN
      MEDICAID PD AMT. CO-INS AND/OR
      DED GREATER THAN THE
      DIFFERENCE BETWEEN MEDICARE PD
      & MEDICAID PD. MEDICAID PAYS THE
00614 DIFF.                                     F10 FNL/Payment: Claim/line has been paid.
                                                 65 Claim/line has been paid.

      SHARS SERVICES MUST BE BILLED TO
      OTHER INSURANCE PRIOR TO BILLING
      MEDICAID. PLEASE REFER TO SHARS
      SECTION OF THE PROVIDER
00615 PROCEDURES MANUAL.                      F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.

      MEDICARE PD AMT IS LESS THAN
      MEDICAID PD AMT. THE DIFF. IS
      EQUAL TO OR GREATER THAN THE
      CO-INS AND/OR DED. MEDICAID PAYS
00617 THE CO-INS AND/OR DED.                    F10 FNL/Payment: Claim/line has been paid.
                                                 65 Claim/line has been paid.

                                                                                                                                   Page 92 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                     NOTES

      YOUR CLAIM IS BEING ROUTED
      WITHIN NHIC FOR CORRECT
      PROCESSING. NO ACTION REQUIRED
00618 ON YOUR PART.                               F00 Finalized: Claim/encounter has been processed.
                                                    1 For more detailed information, see remittance advice.

      SURGICAL PROCEDURE AND/OR
      DIAGNOSIS WAS DISALLOWED FROM
      DRG ASSIGNMENT DUE TO INELIGIBLE
00620 DATES.                                     F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.


      DIAGNOSIS SEQUENCE HAS BEEN
      CHANGED AND SURGICAL
      PROCEDURE HAS BEEN CHANGED OR
00622 EXCLUDED FOR DRG ASSIGNMENT.                F10 FNL/Payment: Claim/line has been paid.
                                                   15 One or more originally submitted procedure code have been modified.

      THIS PAYMENT IS DUE TO ADDITIONAL
      REIMBURSEMENT TO
      DISPROPORTIONATE SHARE
00623 HOSPITALS.                                 F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THE COINSURANCE PAYMENT FOR
      THIS SERVICE IS LIMITED TO MQMB
      AND QMB CLIENTS. CHECK THE
      MEDICAID ID TO VERIFY THE CLIENT'S
00625 PROGRAM TYPE.                               F10 FNL/Payment: Claim/line has been paid.
                                                   65 Claim/line has been paid.




                                                                                                                                    Page 93 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                      NOTES

      APPEALS FOR CHANGING
      DRG/DIAGNOSES/PROCEDURE CODES
      FOR YOUR HOSPITAL CAN ONLY BE
00626 ACCOMPLISHED THROUGH TDH.                  F20 FNL/Denied: Claim/line has been denied.
                                                   7 Claim may be reconsidered at a future date.

      YOUR CLAIM HAS BEEN SPLIT TO
      FACILITATE PROCESSING OF OTHER
      INSURANCE. NO ACTION ON YOUR
00628 PART IS NECESSARY.                        F107 FNL/Payment: Claim contains split payment.
                                                  72 Claim contains split payment.

      THIS SERVICE MUST BE BILLED USING
      A CCP PROCEDURE CODE. PLEASE
      RESUBMIT USING THE CORRECT
00629 CODE.                                      F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      ADJUSTMENT HAS BEEN INITIATED
      FOR RECOUPMENT OF PHYSICIAN
      SERVICES EXCEEDING 30 DAY
      INPATIENT LIMITATION. (EFFECTIVE
00630 SEPTEMBER 1, 1986)                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      NHIC WILL NOT KEY CLAIM DATA
      FROM AN ATTACHMENT/SUPERBILL,
00631 OR CHARGE TICKETS.                         F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.
                                                 455 Revenue code for services rendered.

      MEDICARE DENIAL INSUFFICIENT TO
      CONSIDER PAYMENT OF CLAIM.
      APPEAL TO THE MEDICARE RELATED
00632 HMO                                      F2010 FNL/Denied: Payer not primary.
                                                 115 Cannot process HMO claims

                                                                                                                                    Page 94 of 378
                                                                EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                   NOTES

      MODIFIER 7A, 7C, 7D, AJ, AL, OR AN
      MUST BE USED TO IDENTIFY THE
      PROFESSIONAL PERFORMING THIS
00633 SERVICE.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 453 Procedure Code Modifier(s) for Service(s) Rendered

      MISSING/INVALID/FUTURE DATE OF
      SERVICE HAS BEEN REPLACED WITH
      DATE OF RECEIPT TO ALLOW FOR
      PROCESSING. PLEASE RESUBMIT
      CLAIM WITH CORRECT DATE OF
00634 SERVICE.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 187 Date(s) of service.

      TWO MODIFIERS ARE REQUIRED ON
      THIS DETAIL. ONE IDENTIFYING THE
      CASE MANAGER AND ONE
      IDENTIFYING THE SERVICE
00636 PERFORMED.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 453 Procedure Code Modifier(s) for Service(s) Rendered

      EFFECTIVE DATE OF SERVICE 10-01-
      92 CLIENTS UNDER 1 YEAR OLD
      REQUIRE EMERGENCY OR
      EXCEPTION TO PERIODICITY
      INDICATOR FOR THSTEPS DENTAL
00639 SERVICES.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 471 Were services related to an emergency?

      DIAGNOSIS CODE DOES NOT MEET
      THERAPY GUIDELINES OF A
      MUSCULOSKELETAL CONDITION. IF
      APPLICABLE, PLEASE RESUBMIT WITH
00641 ADDITIONAL DIAGNOSIS CODE.                 F20 FNL/Denied: Claim/line has been denied.
                                                 255 Diagnosis code.


                                                                                                                  Page 95 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                      NOTES
      DECISION DETERMINED TO BE
      CORRECT. IF YOU FIND NHIC DID NOT
      PROVIDE FULL APPEAL
      CONSIDERATION, YOU MAY FILE A
      COMPLAINT WITH TDH WITHIN 60
00642 CALENDAR DAYS.                            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      CLAIM INDICATES OUTPATIENT
      CHARGES IN EXCESS OF 23 HOURS.
      RESUBMIT CLAIM WITH CHARGES FOR
00643 THE INITIAL 23 HOURS ONLY.                 F20 FNL/Denied: Claim/line has been denied.
                                                   7 Claim may be reconsidered at a future date.

      PROCEDURE REQUIRES ADDITIONAL
      CIDC SPECIALTY TEAM/CENTER
      PROVIDER ENROLLMENT. CONTACT
      TDH/CIDC FOR MORE INFORMATION, 1-
00645 800-252-8023.                              F20 FNL/Denied: Claim/line has been denied.
                                                 145 Entity's specialty code.

      ON OR AFTER 10-01-92 PROVIDERS
      MUST STATE ON THEIR CLAIMS, OR
      BY ATTACHED INVOICE, THE RETAIL
      PRICE OF THE EQUIPMENT BEING
00646 BILLED.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 110 Claim requires pricing information.

      AN INTERNAL REVIEW FOUND THIS
      FAMILY PLANNING CLAIM WAS SPLIT
      IN ERROR. CLAIM WILL BE
      REPROCESSED; NO ACTION ON YOUR
00647 PART IS NECESSARY.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.




                                                                                                                                    Page 96 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                            NOTES
      XRAY DENIED - THE NECESSITY OF
      THIS XRAY IN AN EMERGENCY
      SITUATION NOT DOCUMENTED BY
00648 PROVIDER.                                 F20 FNL/Denied: Claim/line has been denied.
                                                294 Supporting documentation.


      THE MEDICAL PORTION OF THIS
      SERVICE HAS BEEN PROCESSED ON
      THIS CLAIM. THE FAMILY PLANNING
      PORTION WILL BE PROCESSED ON A
00649 SEPARATE CLAIM.                          F107 FNL/Payment: Claim contains split payment.
                                                 72 Claim contains split payment.


      THIS PROCEDURE NOT COMPATIBLE
      WITH TOOTH ID SUBMITTED.
      PROPER TOOTH ID IS REQUIRED
00650 FOR THIS PROCEDURE.                       F20 FNL/Denied: Claim/line has been denied.
                                                240 Tooth surface(s) involved.

      THIS PROCEDURE IS LIMITED IN THE
      THSTEPS DENTAL PROGAM. IT IS
      PAYABLE ONLY ON EMERGENCY
00651 CLAIMS.                                   F20 FNL/Denied: Claim/line has been denied.
                                                471 Were services related to an emergency?

      PROVIDER NOT CERTIFIED TO
      PERFORM THIS TYPE OF
00652 LABORATORY SERVICE.                       F20 FNL/Denied: Claim/line has been denied.
                                                142 Entity's license/certification number.

      PAYMENT FOR THIS SERVICE IS
      DENIED - DOCUMENTATION DOES
      NOT SUPPORT THE NECESSITY FOR
      THIS PROCEDURE ON AN
00653 EMERGENCY CLAIM.                          F20 FNL/Denied: Claim/line has been denied.

                                                                                                         Page 97 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                  NOTES
                                                287 Medical necessity for service.

      THE CLIENT'S AGE DOES NOT FALL
      WITHIN THE AGE SPAN FOR THIS
00654 PROCEDURE.                                  F20 FNL/Denied: Claim/line has been denied.
                                                  475 Procedure code not valid for patient age


      PARTIAL DENTURES ARE LIMITED TO
      MISSING ANTERIOR TEETH OR EIGHT
00655 OCCLUDING POSTERIOR TEETH.                  F00 Finalized: Claim/encounter has been processed.
                                                  104 Processed according to plan provisions.

      THE COMBINATION OF THE
      PROCEDURE CODE, THE TOOTH ID
      AND THE SURFACE ID SUBMITTED
00656 ARE INCOMPATIBLE.                           F20 FNL/Denied: Claim/line has been denied.
                                                  240 Tooth surface(s) involved.

      SURFACE ID IS BLANK OR INVALID.
00657 PLEASE CORRECT AND RESUBMIT.                F20 FNL/Denied: Claim/line has been denied.
                                                  240 Tooth surface(s) involved.

      TEMPORARY FILLING/SEALANTS NOT
      PAYABLE WITH CROWN OR
      RESTORATION. INCISION AND
      DRAINAGE OF ABSCESS NOT                                                                          Revise 658 description
      PAYABLE SAME DATE AS                                                                             to correct spelling of
00658 EXTRACITON.                                F203 FNL/Denied: Denied due to plan provisions.       extraction.
                                                  104 Processed according to plan provisions.

      LIMITATIONS PREVENT PAYMENT OF A
      PULPOTOMY AND A ROOT CANAL ON
00659 THE SAME TOOTH ID.                         F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.




                                                                                                                   Page 98 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                            NOTES

      PAYMENT FOR THIS PROCEDURE NOT
      ALLOWED WHEN ANOTHER EXAM/X-
00660 RAY ALLOWED ON THE SAME CLAIM.           F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS TID HAS BEEN EXTRACTED.
00661 APPEAL WITH X-RAY                         F20 FNL/Denied: Claim/line has been denied.
                                                318 X-rays.


      IV OR IM MEDICATION FOR SEDATION
      IS NOT PAYABLE ON THE SAME DAY
00662 AS GENERAL ANESTHESIA.                   F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.


      OUR RECORDS INDICATE THIS TOOTH
      ID WAS PREVIOUSLY CROWNED. THIS
00663 PROCEDURE IS DENIED.                     F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS PROCEDURE NOT PAYABLE -
      PAYMENT INCLUDED IN THE FEE
      PREVIOUSLY BILLED FOR THE CROWN
00664 ON SAME TOOTH.                           F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      PROCEDURES/SERVICE LIMITED TO
      ONCE PER 6 MONTH PERIOD
      CALCULATED FROM LAST DATE OF
00665 SERVICE.                                 F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS PROCEDURE IS LIMITED. IT IS
      PAYABLE ONLY ONCE EVERY THIRTY-
00666 SIX MONTHS.                              F203 FNL/Denied: Denied due to plan provisions.

                                                                                                         Page 99 of 378
                                                                    EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                  NOTES
                                                  104 Processed according to plan provisions.

      THIS PROCEDURE DENIED OR
      CUTBACK - CLAIM EXCEEDS TOTAL
      AMOUNT PAYABLE FOR X-RAYS PER
00668 CASE.                                         F00 Finalized: Claim/encounter has been processed.
                                                    104 Processed according to plan provisions.

      THIS PROCEDURE DENIED OR
      CUTBACK. SERVICES EXCEED TOTAL
      PAYABLE AMOUNT FOR
      RESTORATIVE/CROWN PROCEDURES
00669 ON EACH TOOTH.                                F00 Finalized: Claim/encounter has been processed.
                                                    104 Processed according to plan provisions.

      PROVIDERS MANUFACTURING DME
      EQUIPMENT ON SITE MUST BE
      REGISTERED WITH APPROPRIATE
00671 STATE/FEDERAL AGENCIES.                       F20 FNL/Denied: Claim/line has been denied.
                                                    335 Durable medical equipment certification.

      ALLOWED AMT FOR THIS OUTPATIENT
      SERVICE IS REDUCED BY 22.4% FOR
      SFY '98, &'99, 19.7 % FOR 2000 AND
00672 BEYOND.                                      F104 FNL/Payment: Payment reflects plan provisions.
                                                    104 Processed according to plan provisions.

      DOCUMENTATION OF NECESSITY OF
      SERVICE AND/OR XRAYS MUST BE
      SUBMITTED FOR CONSIDERATION OF
00673 PAYMENT.                                      F20 FNL/Denied: Claim/line has been denied.
                                                    287 Medical necessity for service.

      PALLIATIVE AND
      SEDATIVE/TEMPORARY FILLINGS ARE
      NOT BOTH PAYABLE ON THE SAME
00674 DATE OF SERVICE.                              F00 Finalized: Claim/encounter has been processed.

                                                                                                                 Page 100 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               104 Processed according to plan provisions.

      PROVIDERS MAY NOT BE
      REIMBURSED FOR IMMUNIZATIONS
      THAT MAY BE OBTAINED AT NO
      CHARGE FROM THE TEXAS DEPT. OF
00677 HEALTH.                                    F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.

      PAYMENT RECOUPED FROM
      OUTPATIENT PROVIDER NUMBER.
      RESUBMIT FOR ELECTIVE/NON-
      EMERGENCY DAY SURGERY USING
      CORRECT PROVIDER NUMBER. HASC-
00678 MEDICAID, IPS-CIDC.                       F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                   7 Claim may be reconsidered at a future date.

      DRUGS/SUPPLIES COVERED
      THROUGH THE VENDOR DRUG
      PROGRAM CANNOT BE PAID BY
      THSTEPS/CCP/HOME HEALTH.
      PLEASE BILL THE VENDOR DRUG
00679 PROGRAM.                                F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.


      OUR RECORDS INDICATE THIS
      PATIENT IS ENROLLED WITH
      MEDICAID. PLEASE BILL MEDICAID
      FIRST. CIDC DOES NOT SUPPLEMENT
00680 MEDICAID REIMBURSEMENT.                 F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.




                                                                                                                                    Page 101 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
      RESUBMIT ANTEPARTUM SERVICE
      W/SIGNED CLAIM COPY, R&S COPY,
      INDIVIDUAL DATES AND CHARGES
      USING THE APPROPRIATE
00682 PROCEDURE CODES.                           F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      DOCUMENTATION OF SURGERY
      PERFORMED WITHIN 6 WEEKS OF THE
      DATE OF SERVICE IS REQUIRED FOR
00686 THIS DIAGNOSIS.                            F20 FNL/Denied: Claim/line has been denied.
                                                 298 Operative report.

      MEDICAID RECOUPMENT DUE TO
      RETRO MEDICARE ELIGIBILITY. TO
      BILL MEDICARE INCLUDE THIS
      MESSAGE IN COMMENT/REMARK
      FIELD FOR EMC OR ATTACH FOR
00688 PAPER CLAIM.                              F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 116 Claim submitted to incorrect payer.

      PAYMENT REDUCED DUE TO NON-
      RECEIPT OF THE IRS W-9/IRS LETTER
      147C PREVIOUSLY SENT TO YOUR
00689 FACILITY/OFFICE.                          F103 FNL/Payment: Partial payment made for this claim.
                                                  68 Partial payment made for this claim.

      CHARGES FOR TAKE HOME DRUGS
      MUST BE SUBMITTED TO THE
00690 VENDOR DRUG PROGRAM                      F2010 FNL/Denied: Payer not primary.
                                                 116 Claim submitted to incorrect payer.

      ELECTIVE ABORTIONS ARE NOT A
      BENEFIT OF MEDICAID UNLESS THE
      PREGNANCY ENDANGERS THE LIFE
      OF THE MOTHER OR IS THE RESULT
00691 OF RAPE OR INCEST.                         F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                    Page 102 of 378
                                                                    EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                        NOTES
                                                 287 Medical necessity for service.

      TEXAS MEDICAID PLAN OF CARE
      REQUIRES PHYSICIAN SIGNATURE
      AND/OR DATE. RESUBMIT WITH A
      CORRECTED PLAN OF CARE, R & S,
00694 AND A SIGNED CLAIM COPY.                     F20 FNL/Denied: Claim/line has been denied.
                                                   295 Attending physician report.


      PLEASE RESUBMIT WITH R&S, SIGNED
      CLAIM COPY, AND ANESTHESIA
      RECORD DOCUMENTING PROCEDURE
      LENGTH/TIME, SIGNED BY THE
00697 PHYSICIAN/CRNA.                              F20 FNL/Denied: Claim/line has been denied.
                                                   251 Total anesthesia minutes.

      ATTENDING PHYSICIAN AND
      SURGEON MUST BE ENROLLED IN
      THIS PROGRAM FOR CONSIDERATION
00698 OF PAYMENT.                                F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                   109 Entity not eligible.


      THE SUBSTITUTE PROVIDER
      MODIFIER "Q" INDICATED ON YOUR
      CLAIM IS INVALID. PLEASE REFER TO
00699 PROVIDER PROCEDURES MANUAL.                  F20 FNL/Denied: Claim/line has been denied.
                                                   453 Procedure Code Modifier(s) for Service(s) Rendered


      SERVICE(S) REQUIRE REFERRING
      PROVIDER NAME/NUMBER FOR
      PROCESSING. REFERRING PROVIDER
      CANNOT BE THE SAME PROVIDER
00701 WHO RENDERED THESE SERVICE(S).               F20 FNL/Denied: Claim/line has been denied.
                                                   132 Entity's Medicaid provider id.

                                                                                                                                      Page 103 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                   NOTES

      IN HOUSE TRANSFERS ARE NOT
      ELIGIBLE FOR BOTH DRG AND A PER
      DIEM PAYMENT. RESUBMIT ENTIRE
      LENGTH OF STAY ON ONE CLAIM
00702 FORM                                      F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

      THE CLIENT'S CONDITION DOES NOT
      MEET THE "SEVERELY DISABLED"
      CRITERIA, THEREFORE, IT IS NOT A
00703 BENEFIT.                                  F20 FNL/Denied: Claim/line has been denied.
                                                  9 No payment will be made for this claim.

      PLEASE RESUBMIT WITH
      APPROPRIATE MODIFIER TO INDICATE
      NUMBER OF CONCURRENT
      ANESTHESIA PROCEDURES
00704 SUPERVISED.                               F20 FNL/Denied: Claim/line has been denied.
                                                453 Procedure Code Modifier(s) for Service(s) Rendered


      ADMINISTRATION OF IMMUNIZATIONS
      IS NOT A PAYABLE SERVICE PRIOR TO
      7-1-93 OR FOR CLIENTS 21 YEARS OF
00705 AGE OR OLDER.                             F20 FNL/Denied: Claim/line has been denied.
                                                475 Procedure code not valid for patient age

      THE CHARGES AND/OR DATES OF
      SERVICE ON THE CLAIM DO NOT
      MATCH THOSE ON YOUR R&S
      STATEMENT. PLEASE RESUBMIT WITH
      MATCHING CHARGES AND DATES OF
00706 SERVICE.                                  F20 FNL/Denied: Claim/line has been denied.
                                                187 Date(s) of service.




                                                                                                                 Page 104 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                  NOTES
      BLOCK 24K PERFORMING PROVIDER
      NUMBER IS MISSING OR INVALID OR
      DOESN'T CORRESPOND TO A GROUP
00707 BILLING NUMBER.                           F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.


      THE CLIENT'S NAME IN THE CONSENT
      TO STERILIZATION DOES NOT MATCH
      THE CLIENT'S NAME IN THE
      PHYSICIAN'S STATEMENT PART OF
00708 THE STERILIZATION CONSENT FORM.           F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.

      TYPED/STAMPED SIGNATURES ARE
      NOT ACCEPTABLE FOR THE PERSON
      OBTAINING CONSENT OR PHYSICIAN
      STATEMENT. RESUBMIT WITH
      APPLICABLE HANDWRITTEN
00709 SIGNATURE(S).                             F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature

      PLEASE RESUBMIT A COPY OF THE
      CONSENT FORM WITH TIME OF DAY
      THE CLIENT SIGNED THE CONSENT
      TO STERILIZATION AND TIME OF DAY
00710 THE SURGERY WAS PERFORMED.                F20 FNL/Denied: Claim/line has been denied.

                                                 21 Missing or invalid information.                    C&E Recommendation
                                                294 Supporting documentation.

      CLAIM DENIED. INPATIENT HOSPITAL
      STAYS FOR NON-EMERGENCY
      DIAGNOSES ARE NOT COVERED IN
00713 NON-CONTRACTED HOSPITALS.                F204 FNL/Denied: Denied due to contract provisions.
                                                107 Processed according to contract/plan provisions.


                                                                                                                Page 105 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE         MESSAGE NARRATIVE                           NOTES
      THIS SERVICE/SITUATION/SURGERY
      DOES NOT MEET AUTHORIZATION
      CRITERIA. PLEASE APPEAL WITH
      COMPLETE MEDICAL RECORD FOR
00714 EXTENDED LENGTH OF STAY.                  F20 FNL/Denied: Claim/line has been denied.
                                                317 Patient's medical records.


      CLAIM DENIED. INPATIENT STAYS
      LONGER THAN 3 DAYS REQUIRE
      AUTHORIZATION. PLEASE APPEAL
      WITH COMPLETE MEDICAL RECORDS
00715 TO DETERMINE STABILIZATION DATE.          F20 FNL/Denied: Claim/line has been denied.
                                                317 Patient's medical records.

      ADOLESCENT PREVENTIVE VISIT
      MUST BE BILLED IN ACCORDANCE
      W/THE PERIODICITY SCHEDULE.
      REFER TO PROVIDER PROCEDURE
00716 MANUAL.                                  F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      HEARING AID PURCHASES ARE
      LIMITED TO ONCE EVERY 6 YEARS
      EXCEPT FOR PERSONS UNDER 21
00717 YEARS OF AGE.                            F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      OBSERVATION/OUTPATIENT
      CHARGES RELATED TO OR WITHIN
      ONE DAY OF INPATIENT STAY MUST
      BE BILLED ON THE INPATIENT CLAIM
00718 FORM.                                     F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                    9 No payment will be made for this claim      C&E Recommendation


                                                                                                           Page 106 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

                                                103 Claim combined with other claim(s).                                    C&E Recommendation

                                                107 Processed according to contract/plan provisions.                       C&E Recommendation

      FAMILY PLANNING SERVICES
      PROVIDED BY THE FQHC MUST BE
      FILED WITH THE APPROPRIATE
      FAMILY PLANNING PROCEDURE CODE
00720 ON THE CLAIM FORM.                        F20 FNL/Denied: Claim/line has been denied.

                                                275 Claim                                                                  C&E Recommendation
                                                454 Procedure code for services rendered.

      THIS RECOUPMENT IS THE RESULT
      OF THE UTILIZATION REVIEW
      PROCESS. PLEASE REFER TO
      WRITTEN CORRESPONDENCE FOR
00721 MORE INFORMATION.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                  2 More detailed information in letter.                                   C&E Recommendation
                                                101 Claim was processed as adjustment to previous claim.


      ITEM(S) DENIED AS PART OF RENTAL
      FEE. APPEAL MUST INCLUDE
      STATEMENT INDICATING CLIENT
      OWNS EQUIPMENT AND REASON(S)
00723 WHY REPLACEMENT IS NEEDED.                F20 FNL/Denied: Claim/line has been denied.

                                                186 Purchase and rental price of durable medical equipment.                C&E Recommendation
                                                294 Supporting documentation.




                                                                                                                                    Page 107 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
                                                                                                                            Per FMT need to
      TB SKIN TEST CODE MUST BE ON THE                                                                                      revise description of
      CLAIM. SUBMIT ONLY 2500Y, 2503Y,                                                                                      EOB 00724 to exclude
      AND 2506Y. REFER TO THE PROVIDER                                                                                      reference to local
00724 PROCEDURES MANUAL.                         F20 FNL/Denied: Claim/line has been denied.                                codes.
                                                 454 Procedure code for services rendered.


      IMMUNIZATION/NON-IMMUNIZATION
      CODE MUST BE ON CLAIM. REFER TO
00725 THE PROVIDER PROCEDURE MANUAL.             F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      SUPPLIES AND/OR DURABLE MEDICAL
      EQUIPMENT ARE NOW PAYABLE TO
      DME/DMEH AND VP PROVIDER
00727 NUMBERS ONLY.                            F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                  25 Entity not approved.

      PLEASE FURNISH LICENSE NUMBER IN
      A VALID FORMAT. EXAMPLE: TXBL1234
      FOR ADMITTING/ATTENDING
00728 PHYSICIAN.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 143 Entity's state license number.

      NORPLANT REIMBURSEMENT IS NOT
      INCLUDED IN THE DRG PAYMENT.
      REFILE FOR NORPLANT ON AN
00730 OUTPATIENT CLAIM.                          F20 FNL/Denied: Claim/line has been denied.
                                                   7 Claim may be reconsidered at a future date.


      ONLY CLAIMS WITH AN APPROVED
      EMERGENCY DIAGNOSIS ARE
      PAYABLE. REFER TO YOUR FACILITY'S
00731 PREPAYMENT REVIEW GUIDELINES.              F20 FNL/Denied: Claim/line has been denied.
                                                 471 Were services related to an emergency?

                                                                                                                                       Page 108 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE        MESSAGE NARRATIVE                                                     NOTES


      THIS PROCEDURE IS NOT PAYABLE                                                                                        Per FMT need to
      FOR NON-ACUTE DX FOR YOUR                                                                                            revise description of
      PROVIDER TYPE. PLEASE RESUBMIT                                                                                       EOB 00732 to exclude
      WITH NEW CCP CODES LISTED IN                                                                                         reference to local
00732 9/12/94 LETTER FROM NHIC.                 F20 FNL/Denied: Claim/line has been denied.                                codes.
                                                454 Procedure code for services rendered.

      THESE SERVICES BILLED WITHOUT A
      FAMILY PLANNING DIAGNOSIS MUST
      BE BILLED AS AN ENCOUNTER BY THE
00733 FQHC.                                     F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                454 Procedure code for services rendered.                                  C&E Recommendation

      CLAIM/PROCEDURE NOT PAYABLE BY
      NHIC. RESUBMIT CLAIM TO CIDC
      CENTRAL OFFICE, 1100 WEST 49TH
00736 ST, AUSTIN TEXAS, 78756-3179            F2010 FNL/Denied: Payer not primary.
                                                116 Claim submitted to incorrect payer.

      INPATIENT ADMISSION DENIED AS A
      RESULT OF RETROSPECTIVE
00738 UTILIZATION REVIEW.                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      DX/PROCEDURE CODE SEQUENCING
      CHANGE FOR APPROPRIATE DRG
      ASSIGNMENT AS A RESULT OF
      RETROSPECTIVE UTILIZATION
      REVIEW OR TO CORRECT CODING
00739 ERROR.                                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.




                                                                                                                                      Page 109 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                   NOTES
      THIS CASE INVOLVED A PATIENT
      TRANSFER. PAYMENT CALCULATED
00740 ON A PER DIEM BASIS.                     F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      THIS IS THE MAXIMUM PAYMENT FOR
      AN INPATIENT STAY ACCORDING TO
      YOUR FACILITY'S REIMBURSEMENT
00741 METHODOLOGY.                             F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      FOR INFORMATIONAL PURPOSES
      ONLY -- THIS CASE CONSIDERED FOR
00742 PAYMENT ON ANOTHER CLAIM.                 F00 Finalized: Claim/encounter has been processed.
                                                103 Claim combined with other claim(s).


      CLAIM HAS BEEN REDUCED DUE TO
      MEDICALLY NEEDY SPENDDOWN. FOR
      PATIENT LIABILITY INFORMATION,
00743 PLEASE CALL CUSTOMER SERVICE.            F103 FNL/Payment: Partial payment made for this claim.
                                                 68 Partial payment made for this claim.

                                                104 Processed according to plan provisions.             C&E Recommendation

      MAXIMUM PAYMENT FOR
      TRANSPLANT HOSPITAL STAY
      ACCORDING TO DRG
00745 REIMBURSEMENT METHOD.                    F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.


      DRG ASSIGNMENT BASED ONLY ON
      COMPLICATION REQUIRING
      INPATIENT ADMISSION OR
      READMISSION; RESUBMIT SURGICAL
00747 PROCEDURES ON HASC CLAIM.                 F20 FNL/Denied: Claim/line has been denied.

                                                                                                                 Page 110 of 378
                                                                    EOB CSI ANALYSIS

                                            X-WALK
CURR                                        HIPAA
NHIC                                        FINAL
EOB                                         CSCC/CSC
CODE MESSAGE NARRATIVE                      CODE         MESSAGE NARRATIVE                              NOTES
                                                       7 Claim may be reconsidered at a future date.

                                                   132 Entity's Medicaid provider id.                   C&E Recommendation

                                                   189 Hospital admission date.                         C&E Recommendation

      SECOND NEWBORN HERE/METABOLIC
      TEST CODE MUST BE ON THE CLAIM.
      REFER TO PROVIDER PROCEDURE
      MANUAL OR CONTACT CUSTOMER
00748 SERVICE.                                     F20 FNL/Denied: Claim/line has been denied.
                                                   454 Procedure code for services rendered.


      ACCORDING TO STATE DIRECTION A
      SHARS OR ECI PROVIDER MUST
      OBTAIN PARENTAL CONSENT BEFORE
00749 FILING WITH PRIVATE INSURANCE.               F00 Finalized: Claim/encounter has been processed.
                                                   104 Processed according to plan provisions.


      INFORMATION NOT RECEIVED WITHIN
00750 60 DAYS: TECHNICAL DENIAL IS FINAL.         F203 FNL/Denied: Denied due to plan provisions.
                                                   104 Processed according to plan provisions.

      EXTRA CHARGE FOR NIGHT CALL
      BILLED WITH NON-EMERGENCY
00752 TRANSPORT ARE NOT PAYABLE.                   F20 FNL/Denied: Claim/line has been denied.
                                                     9 No payment will be made for this claim.

      PRECISE LEVEL OF SUBLUXATION
      MUST BE INDICATED ON CLAIM FOR
00753 CONSIDERATION OF PAYMENT.                    F20 FNL/Denied: Claim/line has been denied.
                                                   270 Subluxation location.




                                                                                                                 Page 111 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                      NOTES
      ATTACHMENTS TO YOUR CLAIM DID
      NOT SUPPORT OR AGREE WITH
00754 SERVICES BILLED.                          F20 FNL/Denied: Claim/line has been denied.
                                                421 Medical review attachment/information for service(s)


      PROCEDURE PAYMENT DETERMINED
      BY PROGRAM/BENEFIT PLAN,
      REIMBURSEMENT METHODOLOGY,
      DATE OF SERVICE AND/OR TEFRA
      GUIDELINES AS DESCRIBED IN
00755 PROVIDER PROCEDURES MANUAL.              F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.


      SERVICE PROCESSED ACCORDING TO
      TEFRA GUIDELINES DESCRIBED IN
00756 PROVIDER PROCEDURES MANUAL.              F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      PROCEDURE PAYMENT BASED ON
      PROGRAM/BENEFIT PLAN, DATE OF
      SERVICE AND IS CALCULATED AT THE
00757 DETAIL BILLED AMOUNT.                    F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      THESE SERVICES ARE NOT PAYABLE
      FOR CHRONIC/LONG-TERM
00759 CONDITIONS.                              F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      TOTAL BILLED HAS BEEN CHANGED
00760 TO REFLECT INVOICE COST.                  F10 FNL/Payment: Claim/line has been paid.
                                                178 Submitted charges.




                                                                                                                   Page 112 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE       MESSAGE NARRATIVE                                                      NOTES

      CLINICAL LABORATORY PROCEDURE
      PAYMENT BASED ON NATIONAL FEE
      SCHEDULE, PROGRAM/BENEFIT PLAN
00761 AND DATE OF SERVICE.                       F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THIS CHARGE IS CONSIDERED PART
      OF DAILY ROOM/RATE AND/OR
00762 NURSING CARE.                              F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      PAYMENT RECOUPED/DENIED PER
00763 PROVIDER REQUEST.                          F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.


      PAYMENT FOR REPEAT LASER
      TREATMENT WITHIN 6 MONTHS IS
00764 INCLUDED IN INITIAL LASER PAYMENT.         F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      SERVICE FILED ON AN INCORRECT
      CLAIM FORM. PLEASE REFILE ON
00765 HCFA 1500.                                  F20 FNL/Denied: Claim/line has been denied.
                                                  275 Claim.

      ITEMIZED CHARGES FOR THESE
      SERVICES ARE NEEDED BEFORE
00766 PAYMENT CAN BE CONSIDERED.                  F20 FNL/Denied: Claim/line has been denied.
                                                  279 Itemized claim.


      DAILY RENTAL CHARGES FOR
      EQUIPMENT ARE NOT PAYABLE IN
00767 ADDITION TO INITIAL EQUIPMENT FEE.         F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

                                                                                                                                     Page 113 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                     NOTES

      A NARRATIVE DESCRIPTION OF THE
      CLIENT'S CONDITION AND/OR
00770 SYMPTOMS IS REQUIRED.                     F20 FNL/Denied: Claim/line has been denied.
                                                431 Provide condition/functional status at time of service

      INITIAL CONSULT WITHIN 12 MONTHS
      OF ANY OTHER CONSULT CUTBACK
00772 TO FOLLOW-UP CONSULT.                     F10 FNL/Payment: Claim/line has been paid.
                                                 15 One or more originally submitted procedure code have been modified.

      PHYSICIAN'S NAME MUST BE AT THE
      TOP OF THE CONSENT FORM AND
00774 AFTER "TO BE STERILIZED BY".              F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature

      REPEAT INITIAL HOSPITAL CARE
      WITHIN 30 DAYS PAYABLE AS
00775 SUBSEQUENT CARE VISIT.                    F10 FNL/Payment: Claim/line has been paid.
                                                 15 One or more originally submitted procedure code have been modified.


      SUBSEQUENT HOSPITAL CARE NOT
00776 PAYABLE TO CONSULTING PHYSICIAN.         F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      FOLLOW-UP CONSULTATIONS ARE
00778 LIMITED TO ONE PER WEEK.                  F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      INITIAL CONSULT ON ESTABLISHED
      PATIENT CUTBACK TO FOLLOW-UP
00779 CONSULT.                                  F10 FNL/Payment: Claim/line has been paid.
                                                 15 One or more originally submitted procedure code have been modified.




                                                                                                                                  Page 114 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                     NOTES

      PLEASE SUBMIT ONE R&S COPY WITH
      EACH CORRECTED CLAIM/APPEAL,
00780 REFER TO PROVIDER MANUAL.                 F00 Finalized: Claim/encounter has been processed.
                                                  7 Claim may be reconsidered at a future date.

                                                275 Claim                                                                 C&E Recommendation

                                                280 Itemized claim by provider                                            C&E Recommendation

                                                285 Vouchers/explanation of benefits (EOB)                                C&E Recommendation

      THIS CLAIM HAS BEEN ADJUSTED TO
      PAY AT YOUR SELECTIVELY
00783 CONTRACTED RATE.                         F105 FNL/Payment: Payment reflects contract provisions.
                                                107 Processed according to contract/plan provisions.

      PLEASE RESUBMIT FACILITY
      SERVICES WITH THE APPROPRIATE
00784 PROVIDER NUMBER.                          F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.

      REQUIRED INVOICE INSUFFICIENT OR
      MISSING. RESUBMIT WITH
00785 CORRECTED INVOICE.                        F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                 21 Missing or invalid information.                                       C&E Recommendation

      THIS DETAIL HAS BEEN DIVIDED TO
      REFLECT A ROOM ACCOMODATION
00787 FOR THE DATE OF SERVICE.                  F10 FNL/Payment: Claim/line has been paid.
                                                 15 One or more originally submitted procedure code have been modified.

      RADIATION THERAPY FACILITY
      TECHNICAL SERVICES ARE NOT
00788 PAYABLE TO PHYSICIANS.                   F203 FNL/Denied: Denied due to plan provisions.

                                                                                                                                   Page 115 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                              NOTES
                                                107 Processed according to contract/plan provisions.

      THIS VISIT DENIED AS INCLUDED IN
00791 PAYMENT FOR ANTEPARTUM CARE.               F203 FNL/Denied: Denied due to plan provisions.
                                                  107 Processed according to contract/plan provisions.

      INCORRECT DIAGNOSIS/MISSING INFO
      PREVENTS DRG ASSIGNMENT.
00792 PLEASE CORRECT AND RESUBMIT.                F20 FNL/Denied: Claim/line has been denied.
                                                  255 Diagnosis code.

00793 DRG CODE INVALID/NOT ON FILE.               F20 FNL/Denied: Claim/line has been denied.

                                                   21 Missing or invalid information                               C&E Recommendation
                                                  256 DRG code(s).

      ASSIGNMENT ACCEPTANCE IS
00794 REQUIRED FOR CLAIM PAYMENT.                 F20 FNL/Denied: Claim/line has been denied.
                                                  358 Does provider accept assignment of benefits?

      THESE SERVICES DENIED DUE TO
      FAILURE TO SUBMIT REQUESTED
00795 INFORMATION.                              F2024 FNL/Denied: Requested additional information not received.
                                                   95 Requested additional information not received.

      EXCESSIVE SUPPLIES BILLED AS
      HOME HEALTH SERVICES HAVE BEEN
00797 CUTBACK/REDUCED.                           F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      CATARACT GLASSES OR LENS
      SERVICES REQUIRE THE DATE OF
00799 THE RELATED CATARACT SURGERY.               F20 FNL/Denied: Claim/line has been denied.

                                                  187 Date(s) of service                                           C&E Recommendation
                                                  297 Medical notes/report.


                                                                                                                            Page 116 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                     NOTES

                                                298 Operative report.                                                     C&E Recommendation

                                                374 Is prescribed lenses a result of cataract surgery?                    C&E Recommendation

                                                486 Principle Procedure Date                                              C&E Recommendation

      PROCEDURE PENDING FURTHER
      REVIEW. PLEASE APPEAL WITHIN THE
00800 FILING DEADLINES.                         N/A Per FMT this EOB should be discontinued.


      SECOND OPINIONS ARE PAYABLE AS
      THE APPROPRIATE EVALUATION AND
00802 MANAGEMENT CODE.                          F10 FNL/Payment: Claim/line has been paid.
                                                 15 One or more originally submitted procedure code have been modified.

      MRI NOT PAYABLE WHEN
      PERFORMED ON SAME DAY OR
      WITHIN 7 DAYS AFTER CT SCAN OF
00803 SAME AREA.                               F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      CT SCAN NOT PAYABLE WHEN
      PERFORMED WITHIN 7 DAYS AFTER
00804 MRI OF SAME AREA.                        F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS PROCEDURE IS DENIED, NOT
00805 MEDICALLY NECESSARY.                      F20 FNL/Denied: Claim/line has been denied.

                                                  9 No payment will be made for this claim                                C&E Recommendation
                                                287 Medical necessity for service.

      MORE THAN ONE RESTORATION ON A
      SINGLE SURFACE IS CONSIDERED A
00806 SINGLE RESTORATION.                      F203 FNL/Denied: Denied due to plan provisions.

                                                                                                                                   Page 117 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                              NOTES
                                                104 Processed according to plan provisions.

      THE PROVIDER WHO PERFORMED
      THIS SERVICE MUST BILL UNDER
00807 HIS/HER OWN PROVIDER NUMBER.                F20 FNL/Denied: Claim/line has been denied.
                                                  132 Entity's Medicaid provider id.

      THIS SERVICE IS NOT A BENEFIT
      MORE THAN ONCE IN A 6-YEAR
00808 PERIOD.                                    F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      DOCUMENTATION INDICATES
      SERVICES WERE AVAILABLE AT THE
00809 FACILITY OF ORIGIN.                         F20 FNL/Denied: Claim/line has been denied.
                                                  430 Nearest appropriate facility


      PLEASE PROVIDE/EXPLAIN
00810 DIAGNOSIS/REASON FOR SERVICES.              F20 FNL/Denied: Claim/line has been denied.
                                                  287 Medical necessity for service.


      AUTHORIZATION MUST BE OBTAINED
      BEFORE DISPENSING CONTACT LENS,
00811 W/EXCEPTION OF DX-APHAKIA.                 F209 FNL/Denied: Service not authorized.
                                                   84 Service not authorized.

      OBSERVATION ROOM AND RELATED
      SERVICES PROVIDED IN EXCESS OF
00812 23 HOURS ARE NOT PAYABLE.                  F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.


      THIS PROCEDURE/SERVICE IS
      CONSIDERED BILATERAL AND
00813 INCLUDES THE UNILATERAL SERVICE.           F203 FNL/Denied: Denied due to plan provisions.

                                                                                                           Page 118 of 378
                                                                 EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               104 Processed according to plan provisions.

      ANESTHESIOLOGIST ASSISTANT
00814 INFORMATIONAL DETAIL ONLY.                 F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.

      ACCOMMODATION IS PAID TO THE
      FACILITY WHO HAD THE CLIENT AT
00816 MIDNIGHT THE DAY OF TRANSFER.             F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      EMERGENCY ROOM CHARGE NOT
      PAYABLE ON THE SAME DAY AS AN
00818 OBSERVATION ROOM CHARGE.                  F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      PLEASE VERIFY THE YEAR OF
      SERVICE INDICATED ON YOUR CLAIM
00820 AND RESUBMIT.                              F20 FNL/Denied: Claim/line has been denied.
                                                 482 Date Error, Century Missing

      GROUP BILLING PROVIDER NUMBER
      NEEDED FOR CLAIM TO BE
00821 PROCESSED.                                 F20 FNL/Denied: Claim/line has been denied.
                                                 132 Entity's Medicaid provider id.

      THIS SERVICE IS DENIED. ONSET
      DATE MUST BE PRIOR TO THE DATE
00822 OF SERVICE.                                F20 FNL/Denied: Claim/line has been denied.
                                                 397 Date of onset/exacerbation of illness/condition

      COMPLETE MEDICAL RECORD WAS
      NOT RECEIVED WITHIN 30 DAYS;
00824 TECHNICAL DENIAL IS FINAL.                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                   9 No payment will be made for this claim.                                C&E Recommendation
                                                 101 Claim was processed as adjustment to previous claim.

                                                                                                                                     Page 119 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      OUR REVIEW INDICATES THE
      DESIGNATED LOCK-IN PROVIDER
      NAME/NUMBER FURNISHED IS
00825 INCORRECT.                                F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.


      CLAIM DENIED. PATIENT TRANSFERS
      WITHIN THE SAME FACILITY RECEIVE
00826 ONLY ONE DRG PAYMENT.                    F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS ADJUSTMENT IS NOT THE
      RESULT OF THE UTILIZATION REVIEW
00827 PROCESS.                                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      YOUR APPEAL HAS BEEN REVIEWED.
      PAID AMOUNT REFLECTS AN
00828 ADJUSTMENT.                              F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      YOUR CLAIM HAS BEEN REVIEWED BY
      THE PHYSICIANS & HAS BEEN
00829 ADJUSTED ACCORDINGLY.                     F00 Finalized: Claim/encounter has been processed.
                                                 46 Internal review/audit.


      PLEASE RESUBMIT YOUR CLAIM WITH
      RADIOLOGY NOTES DESCRIBING
00830 AREA OF BODY SCANNED.                     F20 FNL/Denied: Claim/line has been denied.
                                                297 Medical notes/report.

      YOUR PAYMENT REFLECTS MARCH 1,
00831 1988, SDA/PDI UPDATE.                    F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

                                                                                                                                   Page 120 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                         NOTES

      THE D&C IS CONSIDERED PART OF
00832 THIS TUBAL LIGATION PROCEDURE.            F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      PROVIDER NOT CERTIFIED FOR THIS
00834 DATE OF SERVICE.                           F20 FNL/Denied: Claim/line has been denied.
                                                 142 Entity's license/certification number.

      MEDICARE REMITTANCE ADVICE OR
      NOTICE MUST BE SUBMITTED WITH A
00836 COMPLETED CLAIM FORM.                      F20 FNL/Denied: Claim/line has been denied.
                                                 286 Other payer's Explanation of Benefits/payment information.

      THIS CLIENT IS ELIGIBLE FOR
00837 EMERGENCY SERVICES ONLY.                   F20 FNL/Denied: Claim/line has been denied.

                                                  90 Entity not eligible for medical benefits for submitted dates of service.   C&E Recommendation
                                                 471 Were services related to an emergency?

      CLIENT IS NOT ELIGIBLE FOR FAMILY
      PLANNING SERVICES UNDER TITLE                  FNL/Denied: Patient not eligible for benefits for submitted dates of
00838 XIX.                                     F2013 service.
                                                  88 Entity not eligible for benefits for submitted dates of service.


      THE MAXIMUM NUMBER OF
      ALLOWABLE ORTHODONTIC
00840 ADJUSTMENTS HAS BEEN EXCEEDED.             F20 FNL/Denied: Claim/line has been denied.
                                                 483 Maximum coverage amount met or exceeded for benefit period.

      ORTHODONTIC ADJUSTMENTS ARE
      NOT A BENEFIT ONCE BOTH
00841 RETAINERS HAVE BEEN APPLIED.               F20 FNL/Denied: Claim/line has been denied.
                                                 483 Maximum coverage amount met or exceeded for benefit period.




                                                                                                                                         Page 121 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                     NOTES

      INITIAL VISIT NOT PAYABLE WITH
00842 OTHER ORTHODONTIC PROCEDURES.           F203 FNL/Denied: Denied due to plan provisions.
                                               104 Processed according to plan provisions.

      PROCEDURE CODE HAS BEEN
      CHANGED IN ACCORDANCE WITH
00843 THSTEPS DENTAL GUIDELINES.               F00 Finalized: Claim/encounter has been processed.
                                                15 One or more originally submitted procedure code have been modified.

      CLAIMS SUBMITTED FOR NON-
      RENDERED SERVICES ARE NOT
00844 REQUIRED.                                F00 Finalized: Claim/encounter has been processed.
                                                 9 No payment will be made for this claim.

      INFORMATION ON CLAIM DOES NOT
00846 MATCH WHAT WAS AUTHORIZED.              F209 FNL/Denied: Service not authorized.
                                                84 Service not authorized.

      PART A CHARGES MUST BE
      PROCESSED BY MEDICARE PRIOR TO
00847 SUBMITTING TO MEDICAID.                F2010 FNL/Denied: Payer not primary.
                                                85 Entity not primary.

      PLEASE CLARIFY TYPE OF
      TRANSPORT. EMERGENCY/NON-
      EMERGENCY/AIR. CHANGE CODES
00848 ACCORDINGLY.                             F20 FNL/Denied: Claim/line has been denied.
                                               428 Reason for transport by ambulance

      THIS SERVICE WAS CHANGED AND/OR
      NOT APPROVED BY THE ASSOCIATE
00849 DENTAL DIRECTOR.                         F00 Finalized: Claim/encounter has been processed.
                                                46 Internal review/audit.




                                                                                                                                 Page 122 of 378
                                                              EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES

      MAXIMUM PAYMENT FOR INPATIENT
      STAY BASED ON LONESTAR SELECTII
00852 PERDIEM REIMBURSEMENT METHOD.           F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      PRIMARY DX/SEQUENCING CHANGED
      BY NHIC PHYSICIAN FOR
00854 APPROPRIATE DRG ASSIGNMENT.             F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      PAYMENT FOR THESE ITEMS IS
00855 INCLUDED IN THE BASE RATE.              F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      ACCOMMODATIONS/ANCILLARY
      SERVICES DENIED AS A RESULT OF
00856 RETROSPECTIVE REVIEW.                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      DRG ASSIGNMENT EXCLUDED
      SURGICAL PROCEDURE UNRELATED
00857 TO PRINCIPAL DIAGNOSIS.                 F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.


      SERVICES PROVIDED OUTSIDE THE
      STATE OF TEXAS ARE PAYABLE ONLY
00858 FOR EMERGENCY SITUATIONS.                F20 FNL/Denied: Claim/line has been denied.
                                               471 Were services related to an emergency?

      ONE OR MORE OF THE DIAGNOSES
      REQUIRE 4TH OR 5TH DIGIT
00859 SPECIFICITY.                             F00 Finalized: Claim/encounter has been processed.
                                               426 All current diagnoses




                                                                                                                                  Page 123 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES
      MEDICAID CANNOT PAY FOR
      SERVICES DENIED BY MEDICARE DUE
      TO ENROLLMENT IN A HOSPICE
00860 PROGRAM.                               F2010 FNL/Denied: Payer not primary.
                                                85 Entity not primary.

      OTHER INSURANCE PAYMENT IS
00861 GREATER THAN DRG PAYABLE.                F00 Finalized: Claim/encounter has been processed.
                                                 9 No payment will be made for this claim.

      APPEAL REVIEWED BY MED
      DIRECTOR/ASSOCIATE MED.
      DIRECTOR & ADJUSTED PER
00862 INSTRUCTIONS.                           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.


      PLEASE REFILE A CORRECTED CLAIM
      FORM, INCLUDING THE AMBULANCE
00866 BASE RATE PROCEDURE CODE.                F00 Finalized: Claim/encounter has been processed.
                                                 7 Claim may be reconsidered at a future date.


      YOUR APPEAL HAS BEEN REVIEWED
      AND THIS SERVICE REMAINS DENIED
00868 AS NOT A BENEFIT.                       F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                 9 No payment will be made for this claim.                                C&E Recommendation
                                               101 Claim was processed as adjustment to previous claim.

      PROCEDURE/SERVICE LIMITED TO
      ONCE PER 12 MONTHS FROM LAST
00870 DATE OF SERVICE.                        F203 FNL/Denied: Denied due to plan provisions.
                                               104 Processed according to plan provisions.

                                               483 Maximum coverage amount met or exceeded for benefit period.            C&E Recommendation


                                                                                                                                   Page 124 of 378
                                                               EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                        NOTES
      INDICATE THE AMOUNT OF
      TIME/HOURS INVOLVED IN
00871 PSYCHOLOGICAL TESTING.                    F20 FNL/Denied: Claim/line has been denied.
                                                263 Length of time for services rendered.

      DIAGNOSIS CODE FOR DELIVERY IS
00872 MISSING.                                  F20 FNL/Denied: Claim/line has been denied.
                                                254 Primary diagnosis code.


      THE DIAGNOSIS AND/OR PROCEDURE
      CODE SUBMITTED DOES NOT
00873 CORRESPOND TO CLIENT'S AGE/SEX.           F20 FNL/Denied: Claim/line has been denied.
                                                157 Entity's Gender


00874 PLACE OF SERVICE MISSING/INVALID.         F20 FNL/Denied: Claim/line has been denied.
                                                249 Place of service.

      THE REMITTANCE ADVICE OR
      NOTICE/R&S MUST INDICATE
      CORRECT NAME/PCN OF CLIENT
00877 BEING BILLED.                             F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.
                                                153 Entity's id number.

      DATE AND TIME OF DEATH MUST BE
      PROVIDED TO PROCESS. REFILE
      CLAIM WITH REQUIRED
00878 INFORMATION.                              F20 FNL/Denied: Claim/line has been denied.
                                                159 Entity's date of death

      PHYSICIAN SIGNATURE AND DATE OF
      SERVICE REQUIRED ON EXAM
00879 REPORT.                                   F20 FNL/Denied: Claim/line has been denied.
                                                466 Entities Original Signature


                                                                                                      Page 125 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                NOTES
      THIS DETAIL IS FOR INFORMATIONAL
00880 PURPOSES ONLY.                            F00 Finalized: Claim/encounter has been processed.
                                                247 Line information.

      IDENTITY OF THE WITNESS MISSING
      ON PATIENT CERTIFICATION
00882 STATEMENT.                                F20 FNL/Denied: Claim/line has been denied.

                                                 21 Missing or invalid information.                  C&E Recommendation
                                                408 Initial certification

      PATIENT CERTIFICATION MISSING OR
00883 NOT SIGNED.                               F20 FNL/Denied: Claim/line has been denied.

                                                 21 Missing or invalid information                   C&E Recommendation
                                                408 Initial certification

      THSTEPS MEDICAL INFORMATIONAL
00884 DETAIL ONLY.                              F00 Finalized: Claim/encounter has been processed.
                                                247 Line information.

      CLAIM DENIED BECAUSE ITEM 3 ON
      PHYSICIAN EXAM REPORT CHECKED
00885 YES.                                     F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      CLAIM DENIED BECAUSE OF NO
      RECOMMENDED HEARING AID OR
      COST OF HEARING AID ON EVAL
00886 REPORT.                                  F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      DATE OF CALIBRATION REQUIRED ON
00887 HEARING AID EVAL FORM.                   F203 FNL/Denied: Denied due to plan provisions.

                                                 21 Missing or invalid information                   C&E Recommendation
                                                104 Processed according to plan provisions.

                                                                                                              Page 126 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                            NOTES

                                                 187 Date(s) of service.                          C&E Recommendation

      CLAIM DENIED DUE TO INCONSISTENT
      TEST SCORES IN SOUND FIELD TEST
00888 RESULTS.                                  F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      SIGNATURE OF DESIGNATED
      FITTER/DISPENSER REQUIRED ON
00889 EVALUATION REPORT (FORM 3503).            F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

                                                 466 Entities Original Signature                  C&E Recommendation

      CLAIM DENIED FOR LACK OF A SERIAL
00890 NUMBER ON THE INVOICE.                    F203 FNL/Denied: Denied due to plan provisions.

                                                  21 Missing or invalid information               C&E Recommendation
                                                 104 Processed according to plan provisions.


      PHYSICIAN'S ADDRESS IS REQUIRED
00891 ON PHYSICIAN EXAM REPORT.                  F20 FNL/Denied: Claim/line has been denied.
                                                 126 Entity's address.

      PHYSICIAN'S NAME MUST BE PRINTED
      OR TYPED ON PHYSICIAN EXAM
00892 REPORT.                                    F20 FNL/Denied: Claim/line has been denied.
                                                 125 Entity's name.

      PROVIDER SIGNATURE MISSING ON
00893 HEARING AID EVAL FORM.                     F20 FNL/Denied: Claim/line has been denied.
                                                 466 Entities Original Signature

      CLAIM DENIED DUE TO INCOMPLETE
00894 TESTING.                                   F20 FNL/Denied: Claim/line has been denied.

                                                                                                           Page 127 of 378
                                                                    EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                             NOTES
                                                417 Prior testing, including result(s) and date(s) as related to service(s)


      CLAIM DENIED FOR LACK OF PATIENT
      CERTIFICATION STATEMENT FOR
00895 COST OVER ALLOWABLE.                         F20 FNL/Denied: Claim/line has been denied.
                                                   408 Initial certification

      ROUTINE DENTAL EMERGENT AND
      ORTHODONTIC SERVICES MUST BE
00896 BILLED ON SEPERATE CLAIMS.                 F103 FNL/Payment: Partial payment made for this claim.
                                                    7 Claim may be reconsidered at a future date.

                                                    21 Missing or invalid information                                             C&E Recommendation
                                                       Total orthodontic service, initial appliance fee, monthly fee, length of
                                                   246 service                                                                    C&E Recommendation

                                                   275 Claim                                                                      C&E Recommendation

      CLIENT NOT ELIGIBLE FOR THSTEPS
      DENTAL SERVICE. ONLY CLIENTS
00897 UNDER 21 OR ICF-MR.                          F20 FNL/Denied: Claim/line has been denied.
                                                   475 Procedure code not valid for patient age


      SURGICAL DATE AND/OR PROCEDURE
      REQUIRED FOR PROCESSING. REFILE
00898 CORRECTED CLAIM.                             F20 FNL/Denied: Claim/line has been denied.
                                                     7 Claim may be reconsidered at a future date.

                                                   454 Procedure code for services rendered.                                      C&E Recommendation

      EYEGLASS LENSES REQUIRE A
00899 PRESCRIPTION IN BLOCK 13.                    F20 FNL/Denied: Claim/line has been denied.

                                                    21 Missing or invalid information.                                            C&E Recommendation
                                                   403 Entity referral notes/orders/prescription

                                                                                                                                           Page 128 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                 NOTES

      TYPED OR HANDWRITTEN
      INFORMATION MUST HAVE MEDICAL
      CARRIER VERIFICATION TO BE
00900 PROCESSED.                               F20 FNL/Denied: Claim/line has been denied.
                                               286 Other payer's Explanation of Benefits/payment information.

      THIS LAB SVC IS PART OF A PANEL
      CODE AND WILL NOT BE PAID
00902 SEPERATELY.                              F20 FNL/Denied: Claim/line has been denied.
                                               454 Procedure code for services rendered.

      TYPE OF BILL INVALID, MISSING OR
      INCOMPATIBLE WITH PROVIDER TYPE
00903 OR SERVICES BILLED.                      F20 FNL/Denied: Claim/line has been denied.
                                               228 Type of bill for UB-92 claim.

      DATE OF ADMISSION REQUIRED IN
00904 BLOCK 17 FOR PROCESSING.                 F20 FNL/Denied: Claim/line has been denied.
                                               189 Hospital admission date.

      DISCHARGE PATIENT STATUS
00905 MISSING OR INVALID.                      F20 FNL/Denied: Claim/line has been denied.

                                                21 Missing or invalid information.                                    C&E Recommendation
                                               234 Patient discharge status.

      REFILE CLAIM WITH MEDICAL
00906 RECORD NUMBER.                           F20 FNL/Denied: Claim/line has been denied.
                                               478 Claim submitter's identifier (patient account number) is missing

      FORM 3503 IS MISSING. RESUBMIT
      CLAIM WITH FORM 3503 SIGNED BY
00908 THE DESIGNATED PROVIDER.                 F20 FNL/Denied: Claim/line has been denied.
                                                21 Missing or invalid information.

                                               466 Entities Original Signature                                        C&E Recommendation

                                                                                                                               Page 129 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                             NOTES

      TOTAL NUMBER OF CC'S PER
      ANTIGEN VIAL IS NEEDED FOR
      FURTHER PROCESSING OF THIS
00909 CLAIM.                                    F20 FNL/Denied: Claim/line has been denied.
                                                258 Days/units for procedure/revenue code.

      RESUBMIT YOUR CLAIM WITH THE
      NAME OF THE MOTHER OF THIS
00911 NEWBORN.                                  F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.

      PLEASE PROVIDE THE NUMBER OF
00913 COVERED DAYS.                             F20 FNL/Denied: Claim/line has been denied.
                                                456 Covered Day(s)


      TYPE AND SOURCE OF ADMIT
00914 MISSING/INVALID. PLEASE RESUBMIT.         F20 FNL/Denied: Claim/line has been denied.

                                                 21 Missing or invalid information                 C&E Recommendation
                                                229 Hospital admission source.
                                                231 Hospital admission type.


      INFORMATION IN FORM LOCATOR 63,
00915 79, OR 86 IS MISSING OR INVALID.          F20 FNL/Denied: Claim/line has been denied.
                                                 21 Missing or invalid information.

                                                187 Date(s) of service.                            C&E Recommendation

      DIAGNOSIS REFERENCE NUMBER
00916 REQUIRED IN FORM LOCATOR 43.              F20 FNL/Denied: Claim/line has been denied.
                                                477 Diagnosis code pointer is missing or invalid




                                                                                                            Page 130 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                      NOTES
      BILL ONLY DATES OF SERVICE
      APPLICABLE TO PAN NUMBER IN
00917 FORM LOCATOR 63.                           F20 FNL/Denied: Claim/line has been denied.
                                                  48 Referral/authorization.

      START OF CARE DATE IS MISSING OR
00918 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 192 Date of first service for current series/symptom/illness.

      CLIENT HAS TWO PCN'S. DHS HAS
      BEEN NOTIFIED TO MERGE PCN'S.
00920 PLEASE REAPPEAL IN 180 DAYS.               F20 FNL/Denied: Claim/line has been denied.

                                                   7 Claim may be reconsidered at a future date.                            C&E Recommendation
                                                  56 Awaiting eligibility determination.

      DRG CHANGE DUE TO HOSPITALS
      REQUEST TO CORRECT A
      DIAGNOSIS/PROCEDURE CODING
00922 ERROR.                                    F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      CLAIM DENIAL: BLOCK 12A OR 12B IS
00923 MISSING.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 480 Other Carrier Claim filing indicator is missing or invalid

      THE DATE OF X-RAY MUST BE PRIOR
      TO THE SUBLUXATION
00924 MANIPULATION.                              F20 FNL/Denied: Claim/line has been denied.
                                                 210 Date of the last x-ray.


      CLIENT'S FULL NAME, CLIENT
      NUMBER, SEX & CORRECT DOB MUST
00925 BE ON CLAIM FOR PROCESSING.                F20 FNL/Denied: Claim/line has been denied.

                                                  21 Missing or invalid information.                                        C&E Recommendation

                                                                                                                                     Page 131 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE      MESSAGE NARRATIVE                                                      NOTES
                                                    Entity's name, address, phone, gender, DOB, marital status, employment
                                                173 status and relation to subscriber.


      CLAIMS THAT HAVE CREDIT/NEGATIVE
      AMOUNTS CANNOT BE PROCESSED.
00926 PLEASE CORRECT AND RESUBMIT.              F20 FNL/Denied: Claim/line has been denied.
                                                402 Amount must be greater than zero


      DATE OF SURGERY (FL 80) IS PRIOR
      TO ADMISSION DATE (FL 17). PLEASE
00927 RECONCILE AND RESUBMIT.                   F20 FNL/Denied: Claim/line has been denied.
                                                486 Principle Procedure Date

      TOTAL CLAIM CHARGE DOES NOT
00928 MATCH ATTACHMENT CHARGES.                 F20 FNL/Denied: Claim/line has been denied.
                                                178 Submitted charges.

      ACCOMMODATION CHARGES MUST
00929 INCLUDE THE RATE PER DAY.                 F20 FNL/Denied: Claim/line has been denied.
                                                181 Hospital s room rate.

      SURGERY DATE MUST FALL WITHIN
      SPAN DATES (BLOCK 6). PLEASE
00930 REFILE CORRECTED CLAIM.                   F20 FNL/Denied: Claim/line has been denied.
                                                486 Principle Procedure Date

      PLEASE PROVIDE THE ORIGIN AND/OR
      DESTINATION OF AMBULANCE
00931 SERVICE.                                  F20 FNL/Denied: Claim/line has been denied.
                                                266 Facility point of origin and destination - ambulance.

      NUMBER OF MILES AND CHARGE PER
      MILE MUST EQUAL THE TOTAL
00932 MILEAGE CHARGE.                           F20 FNL/Denied: Claim/line has been denied.
                                                178 Submitted charges.

                                                                                                                                   Page 132 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                         NOTES
                                                267 Number of miles patient was transported.

                                                                                                                              C&E Recommendation

      THIS ADJUSTMENT IS DUE TO A
      PATIENT TRANSFER. PAYMENT IS
00933 CALCULATED ON A PER DIEM BASIS.            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      THIS IS A DUPLICATE ADJUSTMENT
      REQUEST. PLEASE DO NOT FILE
00934 DUPLICATES.                                F202 FNL/Denied: Duplicate of an existing claim/line, awaiting processing.
                                                   78 Duplicate of an existing claim/line, awaiting processing.

      MEDICARE ATTACHMENT IS NOT A
      MEDICARE REMITTANCE ADVICE OR
00935 NOTICE.                                  F2010 FNL/Denied: Payer not primary.
                                                 286 Other payer's Explanation of Benefits/payment information.

      THESE SERVICES PAID IN
      ACCORDANCE WITH THE FEDERAL
00936 MATCHING FUND RATE.                        F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      SNF MEDICARE PART A
      COINSURANCE AND DEDUCTIBLES
00937 ARE PROCESSED BY DHS.                    F2010 FNL/Denied: Payer not primary.
                                                 116 Claim submitted to incorrect payer.

      HOSPICE INFORMATION MUST BE
      SENT TO DHS. REAPPEAL WITHIN 180
00938 DAYS.                                    F2010 FNL/Denied: Payer not primary.
                                                  85 Entity not primary.

      THIS PROCEDURE NOT COVERED FOR
00940 THIS PROVIDER SPECIALTY.                    F20 FNL/Denied: Claim/line has been denied.
                                                  145 Entity's specialty code.

                                                                                                                                       Page 133 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                      NOTES

      THIS CLAIM HAS BEEN READJUSTED
00941 AT THE REQUEST OF HHSC.                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      PAID UNDER THSTEPS
00942 COMPREHENSIVE CARE PROGRAM.               F104 FNL/Payment: Payment reflects plan provisions.
                                                 104 Processed according to plan provisions.

      ADMITTING DIAGNOSIS CODE IS
      REQUIRED IN FORM LOCATOR 76.
      PLEASE RESUBMIT WITH A VALID
00944 CODE.                                      F20 FNL/Denied: Claim/line has been denied.
                                                 232 Admitting diagnosis.

      RESUBMIT CORRECTED CLAIM WITH
      DATE AND PROCEDURE CODE FOR
00946 STERILIZATION.                             F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      RESUBMIT CORRECTED CLAIM WITH
      DATE AND PROCEDURE CODE FOR
00947 DELIVERY.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 454 Procedure code for services rendered.

      CLAIM DOCUMENTATION DOES NOT
      SUPPORT REQUESTED
00948 DIAGNOSIS/DRG CHANGE.                      F20 FNL/Denied: Claim/line has been denied.
                                                 294 Supporting documentation.


      MEDICAID CONSIDERS CASTING,
      STRAPPING, & SPLINTING TO BE PART
00949 OF THE GLOBAL SURGICAL FEE.               F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.




                                                                                                                                    Page 134 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                                     NOTES

      THIS CLIENT DOESN'T HAVE THSTEPS
      ELIGIBILITY AND DOESN'T QUALIFY                 FNL/Denied: Patient not eligible for benefits for submitted dates of
00951 FOR THSTEPS-CCP SERVICES.                 F2013 service.
                                                   88 Entity not eligible for benefits for submitted dates of service.

      THE AUTHORIZATION NUMBER USED
00953 ON THIS CLAIM IS INVALID.                   F20 FNL/Denied: Claim/line has been denied.

                                                   21 Missing or invalid information                                         C&E Recommendation
                                                  252 Authorization/certification number.

      THE AUTHORIZATION NUMBER USED
      ON THIS CLAIM IS NOT VALID FOR THE
00954 DATE OF SERVICE.                            F20 FNL/Denied: Claim/line has been denied.
                                                  252 Authorization/certification number.


      THIS IS NOT A VALID PROC CODE FOR
      THIS DATE OF SERVICE. RESUBMIT
00958 WITH A VALID PROC CODE.                     F20 FNL/Denied: Claim/line has been denied.
                                                  454 Procedure code for services rendered.

      PAID ACCORDING TO CO-
      SURGEON/TEAM SURGEON
00959 GUIDELINES.                                F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      EKG INTERPRETATIONS ARE NOT
      SEPARATELY PAYABLE UNDER TEXAS
00960 MEDICAID.                                  F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      SERVICE DENIED SINCE IT IS
      INCLUDED IN THE PAYMENT FOR
00962 EVALUATION OF THE CLIENT.                 F1011 FNL/Payment: Payment made professional.
                                                  104 Processed according to plan provisions.

                                                                                                                                      Page 135 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                               NOTES

      PAID ACCORDING TO THE
      ACCOMMODATION CODE PER DIEM
00965 PRICING METHODOLOGY.                     F104 FNL/Payment: Payment reflects plan provisions.
                                                104 Processed according to plan provisions.

      THE DETAIL(S) QUANTITY WAS
      CHANGED TO MATCH WHAT THE
00966 PROVIDER DESCRIBED.                        F3 Finalized/Revised - Adjudication information has been changed
                                                258 Days/units for procedure/revenue code.

      THE DETAIL(S) PLACE OF SERVICE
      WAS CHANGED TO MATCH WHAT THE
00967 PROVIDER DESCRIBED.                        F3 Finalized/Revised - Adjudication information has been changed
                                                249 Place of service.

      THE TOTAL MEDICARE PAID IS EQUAL
      TO OR GREATER THAN YOUR
00968 ENCOUNTER RATE.                           F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      COMBINED TOTAL OF MEDICARE AND
      MEDICAID PAYMENT EQUALS YOUR
00969 ENCOUNTER RATE.                           F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      THIS IS A DUPLICATE SERVICE THAT
      WAS PAID TO THIS PROVIDER UNDER
00970 A DIFFERENT NUMBER.                      F201 FNL/Denied: Duplicate of a previously processed claim/line.
                                                 54 Duplicate of a previously processed claim/line.


      THE COST OF FREIGHT FROM
      MANUFACTURER TO VENDOR IS NOT
00971 PAYABLE AFTER OCTOBER 1, 1992.           F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.


                                                                                                                            Page 136 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                     NOTES
      LABOR FEE (TECHNICIAN FITTING AND
      MEASURING FEE) NOT PAYABLE
00972 AFTER OCTOBER 1, 1992.                    F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      SERVICE BILLED IS CONSIDERED
      PART OF APPROPRIATE STANDARD
      OF CARE & NOT PAYABLE
00973 SEPARATELY.                               F203 FNL/Denied: Denied due to plan provisions.
                                                 104 Processed according to plan provisions.

      HOUR OF ADMISSION REQUIRED FOR
00974 PROCESSING.                                F20 FNL/Denied: Claim/line has been denied.

                                                  21 Missing or invalid information                                         C&E Recommendation
                                                 230 Hospital admission hour.

      PLEASE RESUBMIT USING
      APPROPRIATE HCPC/CCP
00976 PROCEDURE CODE.                            F20 FNL/Denied: Claim/line has been denied.

                                                  21 Missing or invalid information                                         C&E Recommendation
                                                 454 Procedure code for services rendered.

      IN ORDER TO FACILITATE
      PROCESSING LIKE REVENUE CODES
00980 HAVE BEEN COMBINED.                        F00 Finalized: Claim/encounter has been processed.
                                                  15 One or more originally submitted procedure code have been modified.

      MEDICATIONS PAID UNDER THSTEPS-
      CCP MUST BE BILLED BY ENROLLED
00982 VP PROVIDER.                             F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                 132 Entity's Medicaid provider id.

      USED DME IS NOT A BENEFIT OF CCP.
      PLEASE APPEAL WITH CORRECT TYPE
00983 OF SERVICE.                                F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                     Page 137 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES
                                                250 Type of service.

      PLEASE FURNISH THE SURGEON'S
      LICENSE NUMBER IN A VALID FORMAT
00984 (EXAMPLE: TXBL1234).                      F20 FNL/Denied: Claim/line has been denied.
                                                143 Entity's state license number.

      CLAIM DENIED DUE TO
      RETROSPECTIVE UTILIZATION
      REVIEW PROCESS. PLEASE APPEAL
00985 TO TDH.                                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      THE ADMIT AND/OR DISCHARGE DATE
      DOES NOT MATCH THE SERVICE DATE
00986 ON ONE OR MORE DETAILS.                   F20 FNL/Denied: Claim/line has been denied.
                                                187 Date(s) of service.

                                                189 Hospital admission date.                                               C&E Recommendation

                                                190 Hospital discharge date.                                               C&E Recommendation

      ALLERGY VIAL DENIED. PAYMENT OF
      ALLERGY INJECTION INCLUDES THE
00987 COST OF THE EXTRACT.                     F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      THIS SERVICE(S) INCLUDED IN THE
      REIMBURSEMENT FOR CUSTOMIZED
00988 EQUIPMENT.                               F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      DOCUMENTATION FOR
      AUTHORIZATION REQUEST OR
      EXTENSION NOT RECEIVED WITHIN
00989 TIME LIMITS.                              F20 FNL/Denied: Claim/line has been denied.

                                                                                                                                    Page 138 of 378
                                                                   EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                                       NOTES
                                                 294 Supporting documentation.

      NHIC RECEIVED AN ELECTRONICALLY
      SUBMITTED MCARE CLAIM
      CORRECTION FROM YOUR
      INTERMEDIARY. NHIC DOES NOT
      PROCESS MCARE CORRECTIONS
      ELECTRONICALLY. PLEASE RESUBMIT
      THE ORIGINAL CLAIM AND THE
      CORRECTED CLAIM WITH APPLICABLE
00990 MRANS.                                      F20 FNL/Denied: Claim/line has been denied.
                                                  286 Other payer's Explanation of Benefits/payment information.

      DENIED DUE TO HMO REQUIREMENTS
00991 NOT BEING MET.                              F20 FNL/Denied: Claim/line has been denied.
                                                  115 Cannot process HMO claims

      MEDICAID R&S AND CIDC CLAIM DO
      NOT MATCH. RESUBMIT WITH EXACT
00992 MATCHING R&S AND CLAIM.                     F20 FNL/Denied: Claim/line has been denied.
                                                    7 Claim may be reconsidered at a future date.

00993 CIDC DEFAULT.                               N/A Per FMT this EOB should be discontinued.

      OUR RECORDS INDICATE THIS CLIENT
      IS NOT ELIGIBLE FOR THIS                        FNL/Denied: Patient not eligible for benefits for submitted dates of
00994 DIAGNOSIS.                                F2013 service.
                                                  255 Diagnosis code.


      THIS SERVICE SHOULD BE APPEALED
00995 TO MEDICAID BEFORE BILLING CIDC.          F2010 FNL/Denied: Payer not primary.
                                                  116 Claim submitted to incorrect payer.

      THIS SERVICE HAS BEEN PAID/DENIED
      BY MEDICAID. NO FURTHER PAYMENT
00996 BY CIDC.                                   F203 FNL/Denied: Denied due to plan provisions.

                                                                                                                                     Page 139 of 378
                                                                  EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                       NOTES
                                                104 Processed according to plan provisions.


      OUR RECORDS INDICATE THIS CLIENT
      IS ENROLLED WITH MEDICAID.                     FNL/Denied: Patient not eligible for benefits for submitted dates of
00997 PLEASE BILL MEDICAID FIRST.              F2013 service.
                                                  88 Entity not eligible for benefits for submitted dates of service.


      WE ARE UNABLE TO PROCESS YOUR
      ELECTRONIC APPEAL. PLEASE
      RESUBMIT YOUR APPEAL AND APPLY
      CHANGES TO THE CORRESPONDING
      DETAIL # YOU ARE APPEALING FROM
      THE PREVIOUS CLAIM. CONTACT THE
      EDI HELP DESK FOR MORE
01000 INFORMATION 888-863-3638.                   F20 FNL/Denied: Claim/line has been denied.
                                                    7 Claim may be reconsidered at a future date.

      THIS PAYMENT WAS INCREASED BY
      1.9% PER THE 77TH LEGISLATURE
      FUNDING FOR MEDICAID
01001 PROFESSIONAL SERVICES SFY02                F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THIS PAYMENT WAS INCREASED BY
      6.1% PER THE 77TH LEGISLATURE
      FUNDING FOR MEDICAID
01002 PROFESSIONAL SERVICES SFY02                F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THIS PAYMENT WAS INCREASED BY
      3.7% PER THE 77TH LEGISLATURE
      FUNDING FOR MEDICAID DENTAL
01003 SERVICES SFY02                             F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.


                                                                                                                                    Page 140 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                             NOTES
      FAMILY PLANNING SERVICES MUST BE
      BILLED ON THE FAMILY PLANNING
      2017 CLAIM FORM. PLEASE RESUBMIT
      YOUR CLAIM ON THE APPROPRIATE
01007 FORM.                                     F20 FNL/Denied: Claim/line has been denied.
                                                  7 Claim may be reconsidered at a future date.

                                                 21 Missing or invalid information.               C&E Recommendation

                                                275 Claim                                         C&E Recommendation

      CLAIM DIAGNOSIS IS INVALID TO
01008 CLIENT'S SEX.                             F20 FNL/Denied: Claim/line has been denied.
                                                 86 Diagnosis and patient gender mismatch.

      PROCEDURE CODE AND/OR
      DIAGNOSIS ARE NOT PART OF THIS
01009 BENEFIT PLAN.                            F203 FNL/Denied: Denied due to plan provisions.
                                                104 Processed according to plan provisions.

      BILLING PROVIDER NUMBER FORMAT
01010 IS INVALID.                               F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.

      REFERRING PROVIDER NUMBER
01013 FORMAT IS INVALID.                        F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.

      PROCEDURE IS NOT ALLOWED TO
      SPAN DATES OF SERVICE, OR
      QUANTITY BILLED IS NOT EVENLY
      DIVISIBLE BY NUMBER OF DAYS, OR
01015 CLAIM HAS MORE THAN 28 DETIALS.           F20 FNL/Denied: Claim/line has been denied.

                                                 21 Missing or invalid information                C&E Recommendation
                                                187 Date(s) of service.


                                                                                                           Page 141 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                        NOTES
      OTHER PROVIDER NUMBER FORMAT
01017 INVALID.                                  F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.

      OPERATING PROVIDER NUMBER
01018 FORMAT INVALID.                           F20 FNL/Denied: Claim/line has been denied.
                                                132 Entity's Medicaid provider id.

      LAB NAME AND ADDRESS ARE
      REQUIRED WHEN BILLING LAB
01019 HANDLING FEE.                             F20 FNL/Denied: Claim/line has been denied.
                                                125 Entity's name.

                                                126 Entity's address.                         C&E Recommendation

      FACILITY PROVIDER STATE
01021 ABBREVIATION IS INVALID.                  F20 FNL/Denied: Claim/line has been denied.
                                                 21 Missing or invalid information.

      FACILITY PROVIDER ZIP MUST BE A 5
01022 OR 9 DIGIT NUMBER.                        F20 FNL/Denied: Claim/line has been denied.
                                                126 Entity's address.
                                                132 Entity's Medicaid provider id.

      BILLING PROVIDER TAX ID MUST BE
01024 NUMERIC.                                  F20 FNL/Denied: Claim/line has been denied.
                                                128 Entity's tax id.

      PROVIDER TPI-PRACTICE LOCATION
01025 IS IN PENDING STATUS.                     F20 FNL/Denied: Claim/line has been denied.
                                                 44 Charges pending provider audit.

      A VALID CLIENT DATE OF BIRTH IS
      REQUIRED AND CANNOT BE IN THE
01026 FUTURE.                                   F20 FNL/Denied: Claim/line has been denied.
                                                158 Entity's date of birth


                                                                                                       Page 142 of 378
                                                                  EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE        MESSAGE NARRATIVE                                                      NOTES

      A VALID DATE OF DEATH IS REQUIRED
01027 AND CANNOT BE IN THE FUTURE.               F20 FNL/Denied: Claim/line has been denied.
                                                 159 Entity's date of death

      CLAIM INDICATES CLIENT HAS OTHER
      INSURANCE. ALL OR PART OF THE
      REQUIRED INFORMATION IS MISSING.
      SEE PROVIDER MANUAL FOR
      REQUIRED OTHER INSURANCE
01028 INFORMATION.                               F20 FNL/Denied: Claim/line has been denied.
                                                 171 Other insurance coverage information (health, liability, auto, etc.).

      TOTAL CLAIM CHARGES IS A
01035 REQUIRED NUMERIC FIELD.                    F20 FNL/Denied: Claim/line has been denied.
                                                 178 Submitted charges.

      INCOMPLETE PROVIDER ELIGIBILITY,
01046 CONTACT PROVIDER ENROLLMENT.             F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                 109 Entity not eligible.

      SOURCE OF PAYMENT MUST BE A
01054 VALID VALUE.                               F20 FNL/Denied: Claim/line has been denied.
                                                 401 Source of payment is not valid

      CURR-SOURCE OF PAYMENT IS
01058 REQUIRED.                                  F20 FNL/Denied: Claim/line has been denied.
                                                 401 Source of payment is not valid

      AUTO ACCIDENT INDICATOR IS
01062 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 366 Is injury due to auto accident?

      EMPLOYMENT RELATED INDICATOR IS
01063 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 364 Is accident/illness/condition employment related?


                                                                                                                                     Page 143 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                            NOTES
01071 COVERED DAYS IS REQUIRED.                F20 FNL/Denied: Claim/line has been denied.
                                               456 Covered Day(s)

      OCCURRENCE SPAN FROM DATE IS
      REQUIRED AND CANNOT BE A
01074 FUTURE DATE.                               F20 FNL/Denied: Claim/line has been denied.
                                                 462 NUBC Occurrence Span Code(s) and Date(s)

      OCCURRENCE SPAN TO DATE IS
      REQUIRED AND CANNOT BE A
01075 FUTURE DATE.                               F20 FNL/Denied: Claim/line has been denied.
                                                 462 NUBC Occurrence Span Code(s) and Date(s)

      OCCURRENCE CODE MUST BE
01076 NUMERIC.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 461 NUBC Occurrence Code(s) and Date(s)

01077 OCCURRENCE DATE IS REQUIRED.               F20 FNL/Denied: Claim/line has been denied.
                                                 461 NUBC Occurrence Code(s) and Date(s)

      EYEGLASS PRESCRIPTION
01078 REPLACEMENT CODE IS INVALID.               F20 FNL/Denied: Claim/line has been denied.
                                                 219 Prescription number.


01079 CONDITION CODE MUST BE NUMERIC.            F20 FNL/Denied: Claim/line has been denied.
                                                 460 NUBC Condition Code(s)

      THSTEPS REFERRAL INDICATOR IS
01081 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                  48 Referral/authorization.

      DENTAL EXCEPTION TO PERIODICITY
01082 INVALID.                                   F20 FNL/Denied: Claim/line has been denied.
                                                 239 Dental information.




                                                                                                        Page 144 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                     NOTES
      DENTAL EMERGENCY INDICATOR IS
01083 INVALID.                                 F20 FNL/Denied: Claim/line has been denied.
                                               239 Dental information.

                                               471 Were services related to an emergency                  C&E Recommendation

01084 ORTHO INDICATOR IS INVALID.              F20 FNL/Denied: Claim/line has been denied.
                                               239 Dental information.

      QUANTITY BILLED GREATER THAN 999
01088 IS INVALID. PLEASE RESUBMIT.             F20 FNL/Denied: Claim/line has been denied.
                                                 7 Claim may be reconsidered at a future date.

01093 BILLED AMOUNT IS REQUIRED.               F20 FNL/Denied: Claim/line has been denied.
                                               178 Submitted charges.

      CSHCN (CIDC) EOB MUST BE
01100 NUMERIC.                                 F20 FNL/Denied: Claim/line has been denied.
                                                21 Missing or invalid information.

      CSHCN DURABLE MEDICAL
      EQUIPMENT AND PARTS MUST BE
      NEW, NOT USED, RECONDITIONED OR
01101 DAMAGED                                  F20 FNL/Denied: Claim/line has been denied.
                                               377 Was durable medical equipment purchased new or used?

      FUNDING SOURCE MUST BE
01105 INDICATED.                               F20 FNL/Denied: Claim/line has been denied.
                                               401 Source of payment is not valid

      PAYMENT CODE INDICATED IS
01106 INVALID.                                 F20 FNL/Denied: Claim/line has been denied.
                                               401 Source of payment is not valid

01107 CLIENT LAST NAME IS BLANK.               F20 FNL/Denied: Claim/line has been denied.
                                               125 Entity's name.


                                                                                                                   Page 145 of 378
                                                                   EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                                              NOTES
01108 CLIENT FIRST NAME IS BLANK.                F20 FNL/Denied: Claim/line has been denied.
                                                 125 Entity's name.

      NO ATTACHMENTS ON AN
01111 AMBULANCE CLAIM.                             F20 FNL/Denied: Claim/line has been denied.
                                                   472 Ambulance Run Sheet

01112 DATE OF DEATH IS INVALID.                    F20 FNL/Denied: Claim/line has been denied.
                                                   159 Entity's date of death

01114 CLIENT SIGNATURE IS MISSING.                 F20 FNL/Denied: Claim/line has been denied.
                                                   466 Entities Original Signature

      PLEASE ENTER THE CORRECT FP
01116 TITLE BEING BILLED.                        F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      PLEASE INDICATE WHETHER THIS IS A
01117 NEW OR EXISTING PATIENT.                     F20 FNL/Denied: Claim/line has been denied.
                                                   387 Date patient last examined by entity

      PLEASE INDICATE THE PATIENT'S
01118 RACE.                                        F20 FNL/Denied: Claim/line has been denied.
                                                   122 Missing/invalid data prevents payer from processing claim.

      PLEASE INDICATE THE PATIENT'S
01119 ETHNICITY.                                   F20 FNL/Denied: Claim/line has been denied.
                                                   122 Missing/invalid data prevents payer from processing claim.

01120 PLEASE ENTER FAMILY INCOME.                  F20 FNL/Denied: Claim/line has been denied.
                                                   122 Missing/invalid data prevents payer from processing claim.

      PLEASE ENTER THE TOTAL NUMBER
      OF PEOPLE SUPPORTED BY THE
01121 FAMILY INCOME.                               F20 FNL/Denied: Claim/line has been denied.
                                                   122 Missing/invalid data prevents payer from processing claim.


                                                                                                                            Page 146 of 378
                                                                EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                           NOTES
      PLEASE ENTER THE NUMBER OF
      TIMES THE PATIENT HAS BEEN
01122 PREGNANT.                                F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

      PLEASE ENTER THE NUMBER OF LIVE
01123 BIRTHS FOR THE PATIENT.                  F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

      PLEASE ENTER THE NUMBER OF
01124 LIVING CHILDREN THE PATIENT HAS.         F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

01128 ENTER THE LEVEL OF PRACTIONER.           F20 FNL/Denied: Claim/line has been denied.
                                               147 Entity's qualification degree/designation (e.g. RN,PhD,MD)


      ENTER THE DATE OF OCCURRENCE IF
      BILLING FOR COMPLICATIONS
      RELATED TO STERILIZATIONS,
01130 CONTRACEPTIVE IMPLANTS OR IUDS.          F20 FNL/Denied: Claim/line has been denied.

                                               122 Missing/invalid data prevents payer from processing claim.   C&E Recommendation
                                               461 NUBC Occurrence Code(s) and Date(s)

01132 TYPE OF SERVICE IS INVALID.              F20 FNL/Denied: Claim/line has been denied.
                                               250 Type of service.

01133 DIAGNOSIS REFERENCE IS INVALID.          F20 FNL/Denied: Claim/line has been denied.
                                               477 Diagnosis code pointer is missing or invalid

      ATTACHMENT/OI DISPOSITION CODE
01138 IS INVALID.                              F20 FNL/Denied: Claim/line has been denied.
                                               480 Other Carrier Claim filing indicator is missing or invalid

01139 ATTACHMENT INDICATOR IS INVALID.         F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

                                                                                                                         Page 147 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                                     NOTES

      UNABLE TO ASSIGN
      PROGRAM/BENEFIT PLAN. PLEASE
      REFILE CLAIM WITH CORRECTED
      CLIENT/PROVIDER INFORMATION.
      NOTE: FP TITLE V, X, AND XX CLAIMS
      AND ENCOUNTERS WITH DATES OF
      SERVICE PRIOR TO 09/01/2001
      SHOULD BE SUBMITTED TO STATE
01140 AGENCY.                                    F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

                                                  116 Claim submitted to incorrect payer.                                    C&E Recommendation

      THIS DETAIL CANNOT BE PROCESSED
      UNDER THE CURRENT PROGRAM.
      PLEASE APPEAL UNDER THE
01141 PREVIOUS PROGRAM.                          F203 FNL/Denied: Denied due to plan provisions.
                                                  104 Processed according to plan provisions.

      PRIMARY BIRTH CONTROL METHOD
      AT END OF VISIT IS 'NO METHOD'.
      PLEASE SUPPLY REASON NO METHOD
01142 USED FIELD.                                 F20 FNL/Denied: Claim/line has been denied.
                                                  294 Supporting documentation.

      SURGERY DATE IS MISSING OR
01143 INVALID                                     F20 FNL/Denied: Claim/line has been denied.
                                                  390 Date of most recent medical event necessitating service(s)

      SERVICE FILED ON AN INCORRECT
      FORM. PROVIDER ELIGIBLE FOR
      COINSURANCE OR DEDUCTIBLE
      PAYMENT ONLY. CONTACT NHIC
01144 CUSTOMER SERVICE.                         F2016 FNL/Denied: Provider not eligible/not approved for dates of service.
                                                   91 Entity not eligible/not approved for dates of service.


                                                                                                                                      Page 148 of 378
                                                                  EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE        MESSAGE NARRATIVE                                      NOTES
      CLAIM FORM NOT ALLOWED FOR THIS
01145 PROGRAM.                                    F20 FNL/Denied: Claim/line has been denied.
                                                  275 Claim.

      CLAIM/PROCEDURE NOT PAYABLE BY
      NHIC PRIOR TO 08/06/2001. RESUBMIT
      CLAIM TO CIDC CENTRAL OFFICE,
      1100 WEST 49TH ST, AUSTIN TEXAS,
01146 78756-3179                                F2010 FNL/Denied: Payer not primary.
                                                  116 Claim submitted to incorrect payer.


      PLEASE REFER TO OTHER EOB
      MESSAGES ASSIGNED TO THIS CLAIM
01147 FOR PAYMENT/DENIAL INFORMATION.             F00 Finalized: Claim/encounter has been processed.
                                                    1 For more detailed information, see remittance advice.

      HMO COPAY DETERMINED BY TDH,
      DATE OF SERVICE AND
01500 PROGRAM/BENEFIT PLAN.                       F00 Finalized: Claim/encounter has been processed.
                                                  104 Processed according to plan provisions.


      IMMUNIZATION PROCEDURE
      PAYMENT DETERMINED BY
      PROGRAM/BENEFIT PLAN, DATE OF
      SERVICE, BILLED AMOUNT AND IS SET
01501 AT A MAXIMUM ALLOWABLE RATE.                F00 Finalized: Claim/encounter has been processed.
                                                  104 Processed according to plan provisions.

      FAMILY PLANNING TITLE V, X
      PROCEDURE PAYMENT DETERMINED
      BY TDH, DATE OF SERVICE AND
01502 BILLED AMOUNT.                              F00 Finalized: Claim/encounter has been processed.
                                                  104 Processed according to plan provisions.




                                                                                                                      Page 149 of 378
                                                              EOB CSI ANALYSIS

                                       X-WALK
CURR                                   HIPAA
NHIC                                   FINAL
EOB                                    CSCC/CSC
CODE MESSAGE NARRATIVE                 CODE       MESSAGE NARRATIVE                                                      NOTES
      PROCEDURE PAYMENT BASED ON
      TDH MANDATED ASC/HASC GROUP
      RATES, PROGRAM/BENEFIT PLAN,
      LOCALITY/SPECIALTY, BILLED
01503 AMOUNT AND DATE OF SERVICE.             F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      DRG CLAIM DENIED; SEE SEPARATE
01504 EOB FOR FUTHER EXPLANATION.             F00 Finalized: Claim/encounter has been processed.
                                                1 For more detailed information, see remittance advice.

      MEDICAID PAYS THE DEDUCTIBLE
      AND CO-INSURANCE ONLY FOR
01505 SERVICES PAID BY MEDICARE.              F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      YOUR ADJUSTMENT IS BEING
      RESEARCHED. NO ACTION ON YOUR
05001 PART IS NECESSARY.                     F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                              101 Claim was processed as adjustment to previous claim.


      THANK YOU FOR YOUR REFUND OF
      THE GRADUATE MEDICAL EDUCATION
      COST AUDIT SETTLEMENT. YOUR
06000 1099 WILL BE CREDITED.                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                              101 Claim was processed as adjustment to previous claim.

      THANK YOU FOR YOUR REFUND OF
      THE THIRD PARTY REIMBURSEMENT
      AUDIT. YOUR 1099 WILL BE
06001 CREDITED.                              F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                              101 Claim was processed as adjustment to previous claim.




                                                                                                                                 Page 150 of 378
                                                               EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES
      THANK YOU FOR YOUR REFUND OF
      THE FQHC OR PSYCH COST AUDIT
      SETTLEMENT. YOUR 1099 WILL BE
06002 CREDITED.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      THANK YOU FOR YOUR REFUND OF
      THE FQHC INTERIM SETTLEMENT.
06003 YOUR 1099 WILL BE CREDITED.             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      THANK YOU FOR YOUR REFUND OF
      THE RHC INTERIM SETTLEMENT.
      YOUR 1099 LIABILITY WILL BE
06004 CREDITED.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PAYMENT IS THE RESULT OF A COST
06005 AUDIT SETTLEMENT.                       F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      ADDITIONAL INFORMATION IS
      REQUIRED TO IDENTIFY THE CLIENT
06006 AND /OR DOS.                             F20 FNL/Denied: Claim/line has been denied.
                                               122 Missing/invalid data prevents payer from processing claim.

                                               125 Entity's name.                                                         C&E Recommendation

                                               187 Date(s) of service.                                                    C&E Recommendation

      THIS PAYMENT IS THE RESULT OF A
      GRADUATE MEDICAL EDUCATION
06007 COST AUDIT SETTLEMENT.                  F104 FNL/Payment: Payment reflects plan provisions.
                                               104 Processed according to plan provisions.

      RELEASE OF FUNDS HELD AT THE
06008 REQUEST OF THE STATE.                    F00 Finalized: Claim/encounter has been processed.

                                                                                                                                   Page 151 of 378
                                                                   EOB CSI ANALYSIS

                                           X-WALK
CURR                                       HIPAA
NHIC                                       FINAL
EOB                                        CSCC/CSC
CODE MESSAGE NARRATIVE                     CODE         MESSAGE NARRATIVE                                                    NOTES
                                                      9 No payment will be made for this claim.

      THIS IS A REFUND OF A BACK-UP
06009 WITHHOLDING PENALTY.                       F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      PAYMENT IS A RESULT OF FQHC
06010 INTERIM SETTLEMENT.                        F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      PAYMENT IS A RESULT OF RHC
06011 INTERIM SETTLEMENT.                        F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      THIS PAYMENT IS A REPAYMENT OF
06012 MONIES WITHHELD.                           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      REFUND IS DUE TO THE RELEASE OF
06013 AN IRS LEVY.                               F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      PAYMENT FOR FQHC OR PSYCH COST
06014 AUDIT SETTLEMENT.                          F104 FNL/Payment: Payment reflects plan provisions.
                                                  104 Processed according to plan provisions.

      A CHECK HAS BEEN SENT
      SEPARATELY AS PAYMENT FOR THIS
      ITEM. YOUR 1099 LIABILITY HAS BEEN
06015 INCREASED.                                  F00 Finalized: Claim/encounter has been processed.
                                                    1 For more detailed information, see remittance advice.

      THIS IS A RECOUPMENT OF AN
06017 ADVANCE.                                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.




                                                                                                                                     Page 152 of 378
                                                              EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                      NOTES
      THIS RECOUPMENT IS THE RESULT
      OF NON-RECEIPT OF THE COST
06018 REPORT.                                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.


      THIS RECOUPMENT IS THE RESULT
      OF DELINQUENT PAYMENT REQUIRED
06019 FOR A COST AUDIT SETTLEMENT.            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      THIS RECOUPMENT IS THE RESULT
      OF DELINQUENT PAYMENT REQUIRED
      FOR A GRADUATE MEDICAL
      EDUCATION COST AUDIT
06020 SETTLEMENT.                             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD AT THE
06022 DIRECTION OF HHSC MPI.                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD AT THE
      DIRECTION OF SYSTEM RESOURCES
06023 MFADS.                                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD DUE TO A CIVIL
06024 MONETARY PENALTY.                       F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD DUE TO A
06025 DELINQUENT STUDENT LOAN.                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                               101 Claim was processed as adjustment to previous claim.


06026 PAYMENT WITHHELD DUE TO SURS.           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                                                                                                  Page 153 of 378
                                                                 EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                        NOTES
                                                101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD DUE TO
06027 INVESTIGATIVE COSTS .                      F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHTHELD DUE TO OTHER
06028 RECOUPMENTS.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      PAYMENT WITHHELD DUE TO
06029 MEDICARE.                                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.


06030 PAYMENT WITHHELD DUE TO WAGES.             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      FINANCIAL ACTION DUE TO TDH
06031 DIRECTIVE.                                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      THIS RECOUPMENT IS THE RESULT
      OF A COST AUDIT SETTLEMENT TO AN
06032 OLD OWNER.                                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.


      THIS RECOUPMENT IS THE RESULT
      OF DELINQUENT PAYMENT REQUIRED
06033 FOR AN FQHC INTERIM SETTLEMENT.            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                  101 Claim was processed as adjustment to previous claim.

      RECOUPMENT IS RESULT OF
      DELINQUENT PAYMENT REQUIRED
      FOR AN FQHC OR PSYCH COST AUDIT
06034 SETTLEMENT.                                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.

                                                                                                                                     Page 154 of 378
                                                                EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                                                        NOTES
                                               101 Claim was processed as adjustment to previous claim.

      RECOUPMENT IS RESULT OF
      DELINQUENT PAYMENT REQUIRED
06035 FOR AN RHC INTERIM SETTLEMENT.            F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM HHSC-
06036 MPI.                                       F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.


      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM HHSC-MPI
06038 DUE TO CIVIL MONETARY PENALTY.             F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.


      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM HHSC-MPI
06041 DUE TO INVESTIGATIVE COSTS.                F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.


      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM HHSC-MPI
06042 DUE TO OTHER RECOUPMENTS.                  F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.




                                                                                                                                    Page 155 of 378
                                                             EOB CSI ANALYSIS

                                        X-WALK
CURR                                    HIPAA
NHIC                                    FINAL
EOB                                     CSCC/CSC
CODE MESSAGE NARRATIVE                  CODE       MESSAGE NARRATIVE                               NOTES

      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM HHSC-MPI
06043 DUE TO MEDICARE.                        F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.


      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM TEXAS
06045 DEPARTMENT OF HEALTH .                  F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM
      DIRECTION FROM TDH DUE TO CHILD
06046 SUPPORT.                                F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.


      YOUR PAYMENT FOR THE AMOUNT %1
      WAS HELD FOR THE FOLLOWING
      REASON: DIRECTION FROM OFFICE
06047 OF ATTORNEY GENERAL.                    F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      THIS IS AN ADVANCE OF FUTURE
06048 NURSING FACILITY PAYMENTS.              F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      THIS IS AN ADVANCE OF FUTURE
06049 PAYMENTS.                               F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.




                                                                                                           Page 156 of 378
                                                                 EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE           MESSAGE NARRATIVE                                                  NOTES
      THIS IS A RECOUPMENT OF A
06050 NURSING FACILITIES ADVANCE.               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      RECOUPMENT IS DUE TO TITLE XIX
06051 RETRO-ELIGIBILITY.                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      RECOUPMENT IS DUE TO AN
06052 ADVANCE PREVIOUSLY RECEIVED.              F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      NO EOB PRINTS ON THE R&S. THE
06053 EOB CODE IS FOR THE ER&S.                      ?
                                                     ?

      RECOUPMENT IS DUE TO RHC
      HOSPITAL BASED INTERIM
06056 SETTLEMENT.                               F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

      YOUR PAYMENT IN THE AMOUNT %1
      WAS HELD AT THE DIRECTION OF THE
06057 STATE MEDICAID AGENCY.                     F00 Finalized: Claim/encounter has been processed.
                                                 104 Processed according to plan provisions.

      THANK YOU FOR YOUR REFUND OF
      THE RHC HOSPITAL BASED INTERIM
      SETTLEMENT. YOUR 1099 LIABILITY
06058 WILL BE CREDITED.                         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.


      THANK YOU FOR YOUR REFUND OF
      THE COST AUDIT SETTLEMENT. YOUR
06059 1099 LIABILITY HAS BEEN CREDITED.         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                 101 Claim was processed as adjustment to previous claim.

                                                                                                                                    Page 157 of 378
                                                             EOB CSI ANALYSIS

                                       X-WALK
CURR                                   HIPAA
NHIC                                   FINAL
EOB                                    CSCC/CSC
CODE MESSAGE NARRATIVE                 CODE       MESSAGE NARRATIVE                                                      NOTES

      PAYMENT IS FOR RHC HOSPITAL
06060 BASED INTERIM SETTLEMENT.               F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      OVERPAYMENT MADE TO NHIC BY
06061 THE THIRD PARTY CARRIER.                F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      PAYMENT IS FOR CASE MANAGEMENT
06062 FEES.                                   F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      RECOUPMENT IS DUE TO
      OVERPAYMENT OF CASE
06063 MANAGEMENT FEES.                       F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                              101 Claim was processed as adjustment to previous claim.

      CONTACT CUSTOMER SERVICE AT 1-
      800-925-9126 FOR ADDITIONAL
06064 INFORMATION.                            F00 Finalized: Claim/encounter has been processed.
                                                0 Cannot provide further status electronically.

      ACCOUNT RECEIVABLE IS DUE TO
      THE ADJUSTED CLAIM LISTED. FOR
      DETAILS, REFER TO YOUR R&S FOR
      THE DATE LISTED WITHIN THE
06065 ORIGINAL DATE FIELD.                   F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                              101 Claim was processed as adjustment to previous claim.

      CASH RECEIPT APPLIED TO AN
06066 ACCOUNT RECEIVABLE.                     F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

      CASH RECEIPT APPLIED TO A
06067 PAYOUT.                                 F00 Finalized: Claim/encounter has been processed.
                                              104 Processed according to plan provisions.

                                                                                                                                 Page 158 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      MONEY WAS WITHHELD BY NHIC AT
06068 THE PROVIDER'S REQUEST.                  F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      MONEY REFUNDED BY YOUR OFFICE
      WAS INSUFFICIENT FOR THE AMOUNT
06069 DUE NHIC.                                F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      MONEY WAS WITHHELD DUE TO AN
      NHIC PAYMENT ERROR. CONTACT
      CUSTOMER SERVICE AT 1-800-925-
06070 9126 FOR ADDITIONAL INFORMATION.         F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      MONEY WAS WITHHELD DUE TO AN
      NHIC NON-PAYMENT ERROR.
      CONTACT CUSTOMER SERVICE AT 1-
      800-925-9126 FOR ADDITIONAL
06071 INFORMATION.                             F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.


      THANK YOU FOR YOUR REFUND OF
06072 THE OLD OWNER COST SETTLEMENT.           F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THANK YOU FOR YOUR REFUND OF
06073 THE CASE MANAGEMENT FEE.                 F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      PAYMENT DUE TO DUPLICATE
      RECOVERY BY REFUND AND
06135 RECOUPMENT.                              F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

                                                                                                                                   Page 159 of 378
                                                               EOB CSI ANALYSIS

                                         X-WALK
CURR                                     HIPAA
NHIC                                     FINAL
EOB                                      CSCC/CSC
CODE MESSAGE NARRATIVE                   CODE       MESSAGE NARRATIVE                                                      NOTES

      APPROVED TO PAY - 'FUNDS GONE'.
      THE BILLING PROVIDER'S FISCAL
      YEAR BUDGET CEILING HAS BEEN
      EXCEEDED. IF FUNDS BECOME
      AVAILABLE IN THE FUTURE, THIS
      CLAIM WILL BE REPROCESSED FOR
30000 PAYMENT.                                  F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      PROCEDURE PAYMENT FOR FAMILY
      PLANNING TEEN GROUP COUNSELING
      IS BASED ON A MINIMUM OR MAXIMUM
      FEE DETERMINED BY QUANTITY
30001 BILLED.                                   F00 Finalized: Claim/encounter has been processed.
                                                104 Processed according to plan provisions.

      ADJUSTMENT TO THIS CLAIM/DETAIL
30002 INITIATED BY NHIC                        F405 FNL/Adj Complt: Claim was processed as adjustment to previous claim.
                                                101 Claim was processed as adjustment to previous claim.

      THIS CLAIM WAS MANUALLY
90000 REVIEWED.                                 F00 Finalized: Claim/encounter has been processed.
                                                 46 Internal review/audit.

      TOTAL BILLED OUT OF BALANCE OR
90013 INVALID FORMAT                            F20 FNL/Denied: Claim/line has been denied.
                                                178 Submitted charges.

      NET BILLED OUT OF BALANCE TO
90016 TOTAL BILLED AMOUNT                       F20 FNL/Denied: Claim/line has been denied.
                                                178 Submitted charges.

      ADMISSION DATE NOT ENTERED ON
90052 INPATIENT CLAIMS                          F20 FNL/Denied: Claim/line has been denied.
                                                189 Hospital admission date.


                                                                                                                                   Page 160 of 378
                                                                EOB CSI ANALYSIS

                                          X-WALK
CURR                                      HIPAA
NHIC                                      FINAL
EOB                                       CSCC/CSC
CODE MESSAGE NARRATIVE                    CODE       MESSAGE NARRATIVE                             NOTES
      DISCHARGE DATE INVALID TO
90054 PATIENT STATUS OR DOS                     F20 FNL/Denied: Claim/line has been denied.
                                                190 Hospital discharge date.

90056 HEADER FROM DATE OF SERVICE               F20 FNL/Denied: Claim/line has been denied.
                                                194 Confinement dates.

90057 HEADER TO DATES OF SERVICE                F20 FNL/Denied: Claim/line has been denied.
                                                194 Confinement dates.

      DISCHARGE DIAGNOSIS INVALID
90060 FORMAT                                    F20 FNL/Denied: Claim/line has been denied.
                                                254 Primary diagnosis code.

      ADMITTING DIAGNOSIS IS AN INVALID
90080 FORMAT                                    F20 FNL/Denied: Claim/line has been denied.
                                                232 Admitting diagnosis.

90089 OCCURRENCE SPAN CODE INVALID              F20 FNL/Denied: Claim/line has been denied.
                                                462 NUBC Occurrence Span Code(s) and Date(s)

      TYPE OF ADMISSION CODE IS INVALID
90091 TO CLIENT'S AGE                           F20 FNL/Denied: Claim/line has been denied.
                                                231 Hospital admission type.

      DETAIL SURGERY DATE OUTSIDE
      HEADER DATES OF SERVICE ON
90165 INPATIENT CLAIMS                          F20 FNL/Denied: Claim/line has been denied.
                                                187 Date(s) of service.

      CLAIM DIAGNOSIS REFERENCE
90174 INVALID FORMAT                            F20 FNL/Denied: Claim/line has been denied.
                                                477 Diagnosis code pointer is missing or invalid




                                                                                                           Page 161 of 378
                                                          EOB CSI ANALYSIS

                                     X-WALK
CURR                                 HIPAA
NHIC                                 FINAL
EOB                                  CSCC/CSC
CODE MESSAGE NARRATIVE               CODE       MESSAGE NARRATIVE                        NOTES
      THE NUMBER OF DETAILS IN THE
      HEADER DOES NOT MATCH THE
      ACTUAL NUMBER OF DETAILS
91816 SUBMITTED ON THE CLAIM               F20 FNL/Denied: Claim/line has been denied.
                                           481 Claim/submission format is invalid.

     *** END OF REPORT ***




                                                                                                 Page 162 of 378
                                                                      39337c9a-a58d-4821-8d8b-90dd110df8e3.xls

EOB - Explanation of Benefits
CSCC - Claim Status Category Code
CSC - Claim Status Code

EOB codes crosswalked to their corresponding HIPAA codes as they would appear on the Claim Status Inquiry (CSI).
EFFECTIVE
FROM             EFFECTIVE TO EOB                                                   CSCC                                                                        CSC
DATE             DATE         CODE        EOB NARRATIVE                             CODE      CSCC NARRATIVE                                                   CODE
                                          MILEAGE/PAYMENT REDUCED TO
    01/01/1977       12/31/3999   00001   NEAREST APPROPRIATE FACILITY                F1      Finalized/Payment-The claim/line has been paid.                  430


                                          THIS SERVICE HAS BEEN RECOUPED AS                   Finalized/Adjudication Complete - No payment forthcoming-The
                                          A RESULT OF THE ER RETROSPECTIVE                    claim/encounter has been adjudicated and no further payment is
    01/01/1977       12/31/3999   00002   REVIEW PROCESS.                             F4      forthcoming.                                                     101


                                          A PROPHYLAXIS WITHIN 90 DAYS OF A
                                          PERIODONTAL SCALING OR ROOT
    01/01/1977       12/31/3999   00003   PLANING IS NOT PAYABLE.                     F2      Finalized/Denial - The claim/line has been denied.               104


                                          FAMILY PLANNING PROGRAM
    01/01/1977       12/31/3999   00004   DESIGNATION REQUIRED.                       F2      Finalized/Denial - The claim/line has been denied.               104


                                          THIS SERVICE DENIED/RECOUPED
                                          BECAUSE PCP CONTACT IS REQUIRED
    01/01/1977       12/31/3999   00005   PRIOR TO CLIENT TREATMENT                   F2      Finalized/Denial - The claim/line has been denied.                9


                                          THIS SERVICE DENIED AS A RESULT OF                  Finalized/Adjudication Complete - No payment forthcoming - The
                                          THE ER RETROSPECTIVE REVIEW                         claim/encounter has been adjudicated and no further payment is
    01/01/1977       12/31/3999   00006   PROCESS.                                    F4      forthcoming.                                                     101


                                          CIDC PCN/PROVIDER NUMBER(S) ARE
    01/01/1977       12/31/3999   00007   NOT VALID ON A MEDICAID CLAIM               F2      Finalized/Denial - The claim/line has been denied.                21



                                          TITLE X PROVIDERS MUST PROVIDE
    01/01/1977       12/31/3999   00008   LEVEL OF PRACTITIONER INFORMATION.          F2      Finalized/Denial - The claim/line has been denied.               147


                                          THIS SERVICE DENIED/RECOUPED
                                          BECAUSE CLIENT LEFT FACILITY PRIOR
    01/01/1977       12/31/3999   00009   TO TREATMENT                                F2      Finalized/Denial - The claim/line has been denied.               234


                                                                                  Page 163 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


                                  THESE SERVICES DENIED/RECOUPED
                                  DUE TO INAPPROPRIATE REFERRAL BY
01/01/1977   12/31/3999   00010   PCP TO THE EMERGENCY ROOM                  F2      Finalized/Denial - The claim/line has been denied.               48



                                  INFORMATIONAL PROCEDURE TO
                                  INDICATE DENTAL SERVICE PERFORMED
01/01/1977   12/31/3999   00011   UNDER GENERAL ANESTHESIA.                  F2      Finalized/Denial - The claim/line has been denied.               239


                                  FREQUENCY OF VISITS BILLED DOES
                                  NOT MATCH VISITS AUTHORIZED
01/01/1977   12/31/3999   00012   THROUGH HOME HEALTH UNIT                   F2      Finalized/Denial - The claim/line has been denied.               259


                                  THIS SERVICE NOT ALLOWED FOR THIS
01/01/1977   12/31/3999   00013   DIAGNOSIS.                                 F2      Finalized/Denial - The claim/line has been denied.               255


                                  DUE TO INPATIENT UTILIZATION REVIEW                Finalized/Adjudication Complete - No payment forthcoming - The
                                  DENIAL, ALL RELATED SERVICES ARE                   claim/encounter has been adjudicated an no further payment is
01/01/1977   12/31/3999   00014   DENIED/RECOUPED.                           F4      forthcoming.                                                     101


                                  CONSULT CODE FOR ESTABLISHED
                                  PATIENT CHANGED TO FOLLOW-UP
01/01/1977   12/31/3999   00015   OFFICE VISIT/HOSPITAL VISIT.               F1      Finalized/Payment - The claim/line has been paid.                104



                                  MEDICAID DOES NOT PAY FOR THESE
01/01/1977   12/31/3999   00016   SERVICES NOT COVERED BY MEDICARE.          F2      Finalized/Denial - The claim/line has been denied.               9


                                  CLIENT IN OVER AGE 65 AND IS NOT                   Finalized/Adjudication Complete - No payment forthcoming-The
                                  ELIGIBLE FOR SERVICES THROUGH THIS                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00017   PROGRAM TYPE.                              F4      forthcoming.                                                     88


                                  MEDICAID ALLOWANCE LIMITED TO THE
                                  MEDICARE DEDUCTIBLE AND/OR
01/01/1977   12/31/3999   00018   COINSURANCE                                F1      Finalized/Payment-The claim/line has been paid.                  182


                                  MEDICARE PAID THE TOTAL ALLOWABLE
01/01/1977   12/31/3999   00019   FOR THE SERVICE.                           F2      Finalized/Denial - The claim/line has been denied.               9




                                                                         Page 164 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls

                                  EXAM WITHIN 180 DAYS OF INITIAL EXAM
01/01/1977   12/31/3999   00020   PAID AS FOLLOW UP EXAM                      F1      Finalized/Payment-The claim/line has been paid.      104


                                  APPEAL FOR TITLE V OR XX FAMILY
                                  PLANNING SERVICES RECEIVED PAST
01/01/1977   12/31/3999   00021   180 DAY FILING DEADLINE.                    F2      Finalized/Denial - The claim/line has been denied.    9


                                  THE NUMBER OF ACCOMMODATIONS
                                  BILLED DOES NOT AGREE WITH THE
01/01/1977   12/31/3999   00022   DATES OF SERVICE.                           F2      Finalized/Denial - The claim/line has been denied.   187


                                  MULTIPLE SURGICAL PROCEDURES
                                  PROCESSED ACCORDING TO SURGERY
01/01/1977   12/31/3999   00023   GUIDELINES.                                 F1      Finalized/Payment - The claim/line has been paid.    104


                                  ADDITIONAL LENGTH OF STAY NOT
01/01/1977   12/31/3999   00024   MEDICALLY DOCUMENTED.                       F2      Finalized/Denial - The claim/line has been denied.   260


                                  REQUESTED INFORMATION NOT
                                  RECEIVED WITHIN 30 DAYS, DENIAL IS
01/01/1977   12/31/3999   00025   FINAL.                                      F2      Finalized/Denial - The claim/line has been denied.    9


                                  CLIENT IS ELIGIBLE FOR MEDICARE, BILL
01/01/1977   12/31/3999   00026   MEDICARE FIRST.                             F2      Finalized/Denial - The claim/line has been denied.   171



                                  ALLOWED AMOUNT REFLECTS OTHER
                                  INSURANCE PAYMENT THAT MAY EQUAL
01/01/1977   12/31/3999   00027   OR EXCEED PROGRAM LIABILITY                 F2      Finalized/Denial - The claim/line has been denied.   182


                                  CLAIM ADJUSTED TO MATCH
01/01/1977   12/31/3999   00028   AUTHORIZATION.                              F1      Finalized/Payment - The Claim/line has been paid.    48


                                  CLIENT MUST BE 21 YEARS OF AGE ON
01/01/1977   12/31/3999   00029   THE DATE CONSENT WAS SIGNED.                F2      Finalized/Denial - The claim/line has been denied.   104


                                  CLIENT NAME IS MISSING. PLEASE
01/01/1977   12/31/3999   00030   CORRECT AND RESUBMIT YOUR CLAIM.            F2      Finalized/Denial - The claim/line has been denied.   125




                                                                          Page 165 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


                                  FACILITY PROVIDER NUMBER REQUIRED
01/01/1977   12/31/3999   00031   ON THE HCFA 1500 CLAIM FORM.              F2      Finalized/Denial - The claim/line has been denied.   122


                                  CLIENT'S COUNTY OF RESIDENCE CODE
01/01/1977   12/31/3999   00032   REQUIRED.                                 F2      Finalized/Denial - The claim/line has been denied.   153


                                  BILLING PROVIDER NUMBER NOT
                                  AUTHORIZED FOR ELECTRONIC BILLING.
01/01/1977   12/31/3999   00033   PLEASE CONTACT NHIC.                      F2      Finalized/Denial - The claim/line has been denied.   24


                                  PROCEDURE NOT A BENEFIT MORE
01/01/1977   12/31/3999   00034   THAN ONCE IN A LIFETIME.                  F2      Finalized/Denial - The claim/line has been denied.   483


                                  PROCEDURE NOT A BENEFIT MORE
01/01/1977   12/31/3999   00035   THAN TWICE IN A LIFETIME.                 F2      Finalized/Denial - The claim/line has been denied.   483


                                  ALL APPLICABLE BLANKS ON CONSENT
                                  FORM NOT COMPLETED. REFER TO
01/01/1977   12/31/3999   00036   PROVIDER PROCEDURE MANUAL.                F2      Finalized/Denial - The claim/line has been denied.   122


                                  PLEASE DOCUMENT SOURCE OF CREDIT
                                  AMOUNT INDICATED. REFILE
01/01/1977   12/31/3999   00037   CORRECTED CLAIM.                          F2      Finalized/Denial - The claim/line has been denied.   401


                                  MEDICAID/MEDICARE DOES NOT PAY
                                  FOR SERVICES WHEN PAID/DENIED BY
01/01/1977   12/31/3999   00038   THE CLIENT SELECTED HMO.                  F2      Finalized/Denial - The claim/line has been denied.   115


                                  THSTEPS-CCP SERVICES ARE NOT
                                  PAYABLE FOR DATES OF SERVICE PRIOR
01/01/1977   12/31/3999   00039   TO 040190.                                F2      Finalized/Denial - The claim/line has been denied.   483


                                  DUPLICATE ITEM OF A CLAIM BEING
                                  PROCESSED. PLEASE DO NOT FILE A
01/01/1977   12/31/3999   00040   DUPLICATE CLAIM.                          F2      Finalized/Denial - The claim/line has been denied.   54


                                  THESE CHARGES ARE INCLUDED IN THE
                                  GLOBAL AMBULATORY SURGICAL
01/01/1977   12/31/3999   00041   FACILITY PAYMENT.                         F2      Finalized/Denial - The claim/line has been denied.   104


                                                                        Page 166 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




                                  THIS IS A DUPLICATE SERVICE THAT HAS
01/01/1977   12/31/3999   00042   BEEN PAID TO ANOTHER PROVIDER.              F2      Finalized/Denial - The claim/line has been denied.               54


                                  THIS SERVICE WAS PREVIOUSLY PAID
01/01/1977   12/31/3999   00043   TO PROVIDER/SUPPLIER.                       F2      Finalized/Denial - The claim/line has been denied.               54


                                  PAYMENT BY AGENCIES IDENTIFIED AS
                                  SECONDARY TO THIS PROGRAM MUST
01/01/1977   12/31/3999   00044   BE REFUNDED TO THE AGENCY.                  F1      Finalized/Payment - The claim/line has been paid.                171


01/01/1977   12/31/3999   00045   DENIED ON CLAIM %1 ON %2.                   F2      Finalized/Denial - The claim/line has been denied.               54


                                  DATE OF BIRTH IN FIELD MISSING OR
01/01/1977   12/31/3999   00046   INVALID.                                    F2      Finalized/Denial - The claim/line has been denied.               158


                                  PROFESSIONAL OR TECHNICAL
                                  COMPONENT FEE INCLUDED IN
01/01/1977   12/31/3999   00047   COMBINED PROCEDURE.                         F2      Finalized/Denial - The claim/line has been denied.               9


                                  CLIENT HAS NOT BEEN ELIGIBLE FOR AT
                                  LEAST TWO YEARS / REMOVED FROM
01/01/1977   12/31/3999   00048   DHS FILE.                                   F2      Finalized/Denial - The claim/line has been denied.               88


                                  DIAGNOSIS DOES NOT INDICATE
                                  MEDICAL NECESSITY FOR SERVICE(S) TO
01/01/1977   12/31/3999   00049   BE REPEATED.                                F2      Finalized/Denial - The claim/line has been denied.               255


                                  PATIENT SOCIAL SECURITY NUMBER
01/01/1977   12/31/3999   00050   REQUIRED.                                   F2      Finalized/Denial - The claim/line has been denied.               148


                                  THIS ADJUSTMENT IS A RESULT OF A                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  RETROSPECTIVE REVIEW OF                             claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00051   READMISSIONS AND TRANSFERS.                 F4      forthcoming.                                                     46


01/01/1977   12/31/3999   00052   SEX OF PATIENT MUST BE INDICATED.           F2      Finalized/Denial - The claim/line has been denied.               157




                                                                          Page 167 of 378
                                                                39337c9a-a58d-4821-8d8b-90dd110df8e3.xls

                                  THE PHYSICIAN ASSIST-CERT NAME AND
                                  LICENSE NUMBER NEEDS TO BE
01/01/1977   12/31/3999   00053   INCLUDED ON THE CLAIM.                        F2      Finalized/Denial - The claim/line has been denied.               142


                                                                                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS RECOUPMENT IS A REISSUE OF                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00054   PREVIOUS RECOUPMENT.                          F4      forthcoming                                                      101


01/01/1977   12/31/3999   00055   CLIENT NOT ICF-MR ELIGIBLE.                   F2      Finalized/Denial - The claim/line has been denied.               109


                                  TAKE HOME DRUGS AND SUPPLIES ARE
01/01/1977   12/31/3999   00056   NOT A BENEFIT.                                F2      Finalized/Denial - The claim/line has been denied.               9


                                  ACCORDING TO HCFA REGULATIONS
                                  PAYMENT REDUCED AS THIS TEST IS
01/01/1977   12/31/3999   00057   PART OF AN AUTOMATED GROUP.                   F1      Finalized/Payment - The claim/line has been paid.                68


                                  PROCEDURE PAYMENT DETERMINED BY
                                  PROGRAM/BENEFIT PLAN,
                                  LOCALITY/SPECIALTY, DATE OF SERVICE
01/01/1977   12/31/3999   00058   AND BILLED AMOUNT.                            F1      Finalized/Payment - The claim/line has been paid.                104


                                  ADDITIONAL PAYMENT FOR INCIDENTAL
01/01/1977   12/31/3999   00059   SURGERY IS NOT A BENEFIT.                     F2      Finalized/Denial - The claim/line has been denied.               483


                                  PURCHASE PRICE HAS BEEN REACHED.
                                  RENTAL FEE IS NO LONGER PAYABLE
01/01/1977   12/31/3999   00060   FOR THIS EQUIPMENT.                           F2      Finalized/Denial - The claim/line has been denied.               184


                                  A PHYSICIAN'S PRESCRIPTION FOR THIS
01/01/1977   12/31/3999   00061   EQUIPMENT IS REQUIRED.                        F2      Finalized/Denial - The claim/line has been denied.               219


                                  CLAIM DENIED. PHYSICIAN
                                  CERTIFICATION STATEMENT NOT
01/01/1977   12/31/3999   00062   SUBMITTED.                                    F2      Finalized/Denial - The claim/line has been denied.               332


                                  RESUBMIT RUN SHEET WITH A
                                  NARRATIVE DESCRIPTION OF CLIENT'S
01/01/1977   12/31/3999   00063   CONDITION AND VITAL SIGNS.                    F2      Finalized/Denial - The claim/line has been denied.               472



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                                  SCREEN EXCEEDS PERIODICITY
01/01/1977   12/31/3999   00064   SCHEDULE.                                     F2      Finalized/Denial - The claim/line has been denied.                     483


                                  VALID PRIMARY BIRTH CONTROL
01/01/1977   12/31/3999   00065   METHOD REQUIRED.                              F2      Finalized/Denial - The claim/line has been denied.                     122


                                  SERVICES FOR LOCK-IN CLIENT
                                  PAYABLE ONLY TO DESIGNATED LOCK-IN
01/01/1977   12/31/3999   00066   PROVIDER.                                     F2      Finalized/Denial - The claim/line has been denied.                     93


                                  PROCEDURE/SERVICE LIMITED TO ONCE
01/01/1977   12/31/3999   00067   PER CALENDER MONTH.                           F2      Finalized/Denial - The claim/line has been denied.                     483


                                                                                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS PAYOUT IS A REISSUE OF                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00068   PREVIOUS PAYOUT.                              F4      forthcoming.                                                           101


                                  CONCURRENT CARE DETERMINED NOT
01/01/1977   12/31/3999   00069   MEDICALLY NECESSARY.                          F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PROCEDURE BILLED IS NOT A BENEFIT
01/01/1977   12/31/3999   00070   OF THIS FAMILY PLANNING PROGRAM.              F2      Finalized/Denial - The claim/line has been denied.                     104


                                  DOCUMENTATION NOT RECEIVED WITHIN
01/01/1977   12/31/3999   00071   TIME LIMIT.                                   F2      Finalized/Denial - The claim/line has been denied.                      9


                                  SERVICES CONSIDERED EXPERIMENTAL
                                  OR INVESTIGATIONAL ARE NOT A
01/01/1977   12/31/3999   00072   BENEFIT.                                      F2      Finalized/Denial - The claim/line has been denied.                     9


                                                                                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00073   INPATIENT DEDUCTIBLE HAS BEEN MET.            F0      and no more action will be taken.                                      98



                                  INFORMATIONAL CODE FOR MEDICAL                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00074   TRANSPORTATION PROGRAM USE ONLY.              F0      and no more action will be taken.                                       9




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                                  MISSING, INVALID OR FUTURE DATES OF
01/01/1977   12/31/3999   00075   SERVICE.                                   F2      Finalized/Denial - The claim/line has been denied.                    187



01/01/1977   12/31/3999   00076   MISSING OR INVALID TYPE OF SERVICE.        F2      Finalized/Denial - The claim/line has been denied.                    250


                                  THIS PROCEDURE NOT PAYABLE IN THIS
01/01/1977   12/31/3999   00077   PLACE OF SERVICE.                          F2      Finalized/Denial - The claim/line has been denied.                    249


                                  MISSING OR INVALID PROCEDURE CODE
01/01/1977   12/31/3999   00078   OR DESCRIPTION OF SERVICE.                 F2      Finalized/Denial - The claim/line has been denied.                    454


                                  REFERRING PROVIDER WAS NOT THE
01/01/1977   12/31/3999   00079   PCP ON THE DATE OF SERVICE.                F2      Finalized/Denial - The claim/line has been denied.                    93


01/01/1977   12/31/3999   00080   VALID PATIENT CO-PAY IS REQUIRED.          F2      Finalized/Denial - The claim/line has been denied.                    122


                                  CLAIM BILLED TO NHIC IN ERROR. BILL
                                  HMO. IF CLIENT IS A STAR+PLUS MQMB
01/01/1977   12/31/3999   00081   FILE APPEAL TO NHIC.                       F2      Finalized/Denial - The claim/line has been denied.                    115


                                  EMERGENCY TRANSFERS CANNOT BE
                                  APPEALED AS A NON-EMERGENCY
01/01/1977   12/31/3999   00082   TRANSFER.                                  F2      Finalized/Denial - The claim/line has been denied.                    9


                                  SERVICES BILLED TO NHIC IN ERROR.
01/01/1977   12/31/3999   00083   BILL VISTA.                                F2      Finalized/Denial - The claim/line has been denied.                    115


                                  X-RAY WITHIN LAST 12 MONTHS
                                  REQUIRED FOR CHIROPRACTIC
01/01/1977   12/31/3999   00084   TREATMENT OF CHRONIC CONDITION.            F2      Finalized/Denial - The claim/line has been denied.                    318


                                  PROVIDER NOT ENROLLED FOR DATES
                                  OF SERVICE. CONTACT NHIC CUSTOMER
01/01/1977   12/31/3999   00085   SERVICE.                                   F2      Finalized/Denial - The claim/line has been denied.                    132


                                  REQUEST FOR EXTENDED PAN HAS
                                  BEEN DENIED. YOUR CLAIM IS BEING                   Finalized - The claim/encounter has completed the adjudiction cycle
01/01/1977   12/31/3999   00086   PROCESSED WITH ROUTINE PAN.                F0      and no more action will be taken.                                     48


                                                                         Page 170 of 378
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01/01/1977   12/31/3999   00087   MARITAL STATUS MUST BE ENTERED.            F2      Finalized/Denial - The claim/line has been denied.               160


                                  CONSULTS NOT APPROVED BY
01/01/1977   12/31/3999   00088   MEMBER'S PCP.                              F2      Finalized/Denial - The claim/line has been denied.               25


                                  AIR TRANSFER HAS BEEN APPROVED AT
                                  NON-EMERGENCY GROUND RATE;
01/01/1977   12/31/3999   00089   PAYMENT REDUCED.                           F1      Finalized/E303Payment - The claim/line has been paid.            104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS ACTION IS THE RESULT OF A                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00090   MEDICARE ADJUSTMENT.                       F4      forthcoming.                                                     101


                                  ADULT PHYSICAL EXAMS MUST BE
01/01/1977   12/31/3999   00091   PERFORMED BY MEMBER'S PCP.                 F2      Finalized/Denial - The claim/line has been denied.               85


                                  THIS IS NOT A VALID PROCEDURE FOR
                                  DATE OF SERVICE, RESUBMIT USING
01/01/1977   12/31/3999   00092   THE AUTOMATED TEST CODE.                   F2      Finalized/Denial - The claim/line has been denied.               454


                                  ONLY 2 PELVIC ULTRASOUNDS ALLOWED
01/01/1977   12/31/3999   00093   PER PREGNANCY.                             F2      Finalized/Denial - The claim/line has been denied.               483



                                  ALLOWED DISCOUNT FACTOR FOR THIS
                                  OUTPATIENT SERVICE IS INCREASED BY
                                  5.2% FOR SFY 2000-2001 AND SFY 2002-
                                  2003. THE PREVIOUS RATE OF 80.30%
                                  HAS BEEN INCREASED TO 84.48% FOR
10/01/2001   12/31/3999   00094   DATES OF SERVICE 10/01/01 AND AFTER        F1      Finalized/Payment - The claim/line has been paid.                67


                                  ALLOWED AMT FOR THIS OUTPATIENT
                                  SERVICE IS INCREASED BY 5.2% FOR
10/14/2001   12/31/3999   00095   SFY 2000-2001 AND 2002-2003                F1      Finalized/Payment - The claim/line has been paid.                67


                                  AIR TRANSFER HAS BEEN APPROVED AT
                                  EMERGENCY GROUND RATE; PAYMENT
01/01/1977   12/31/3999   00096   REDUCED.                                   F1      Finalized/Payment - The claim/line has been paid.                104



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                                  PAYMENT ADJUSTED ON THE                            Finalized/Adjudication Complete - No payment forthcoming - The
                                  FOLLOWING CLIENT: %1; DATE OF                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00097   SERVICE %2; AND ICN %3.                    F4      forthcoming.                                                           101


                                  NEWBORN CHARGES PENDING
                                  AWAITING ELIGIBILITY STATUS FROM                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00098   DHS-NO FURTHER ACTION REQUIRED.            F0      and no more action will be taken.                                      56


01/01/1977   12/31/3999   00099   PAID AT THE ENCOUNTER RATE.                F1      Finalized/Payment - The claim/line has been paid.                      67


                                  A CHARGE WAS NOT NOTED FOR THIS                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00100   SERVICE.                                   F0      and no more action will be taken.                                      110


                                  THIS IS A RECOUPMENT OF INDIVIDUAL                 Finalized/Adjudication Complete - No payment forthcoming - The
                                  PROCEDURE CODES THAT WERE                          claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00101   INCORRECTLY PAID.                          F4      forthcoming.                                                           101


                                  THIS IS A DELETED PROCEDURE THAT IS
01/01/1977   12/31/3999   00102   A NONCOVERED SERVICE.                      F2      Finalized/Denial - The claim/line has been denied.                     9


                                  SERVICES EXCEED ALLOWED BENEFIT
01/01/1977   12/31/3999   00103   LIMITATIONS.                               F2      Finalized/Denial - The claim/line has been denied.                     483


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                                                                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00104   ADJUSTMENT REFLECTS CORRECT SDA.           F4      forthcoming.                                                           101


                                  THIS PROCEDURE IS NOT AUTHORIZED.
01/01/1977   12/31/3999   00105   PROCEDURE DENIED.                          F2      Finalized/Denial - The claim/line has been denied.                     84


                                  PERFORMING PROVIDER NOT
                                  CERTIFIED. CONTACT NHIC CUSTOMER
01/01/1977   12/31/3999   00106   SERVICE.                                   F2      Finalized/Denial - The claim/line has been denied.                     142


                                  MEDICAID PCN/PROVIDER NUMBER(S) IS
01/01/1977   12/31/3999   00107   NOT VALID ON A CIDC CLAIM.                 F2      Finalized/Denial - The claim/line has been denied.                     132


01/01/1977   12/31/3999   00108   FACILITY PROVIDER IS NOT CERTIFIED.        F2      Finalized/Denial - The claim/line has been denied.                     142


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                                  CHIROPRACTIC SERVICES REQUIRE THE
01/01/1977   12/31/3999   00109   RELATED X-RAY DATE.                        F2      Finalized/Denial - The claim/line has been denied.   210


                                  PERFORMING PROVIDER NUMBER NOT
                                  IDENTIFIED AS PART OF THE GROUP
01/01/1977   12/31/3999   00110   BILLING NUMBER.                            F2      Finalized/Denial - The claim/line has been denied.   132



                                  MORE THAN ONE ASSISTANT SURGEON
01/01/1977   12/31/3999   00111   NOT PAYABLE FOR THIS PROCEDURE.            F1      Finalized/Payment - The claim/line has been paid.    104


                                  MORE THAN TWO ASSISTANT
                                  SURGEONS NOT PAYABLE FOR THIS
01/01/1977   12/31/3999   00112   PROCEDURE.                                 F1      Finalized/Payment - The claim/line has been paid.    104


                                  FURNISH THE MEDICARE REMITTANCE
                                  ADVICE OR NOTICE FOR OUR
01/01/1977   12/31/3999   00113   PROCESSING.                                F2      Finalized/Denial - The claim/line has been denied.   286


                                  PROCEDURE CODE IS INVALID OR THE
                                  COMBINATION OF PROCEDURE CODE
01/01/1977   12/31/3999   00114   AND TYPE OF SERVICE IS INVALID.            F2      Finalized/Denial - The claim/line has been denied.   454



                                  THIS SERVICE DENIED AS A DUPLICATE
01/01/1977   12/31/3999   00115   OF ANOTHER ITEM ON THE SAME CLAIM.         F2      Finalized/Denial - The claim/line has been denied.   54


                                  SERVICES BILLED TO NHIC IN ERROR.
01/01/1977   12/31/3999   00116   BILL PHP.                                  F2      Finalized/Denial - The claim/line has been denied.   115


                                  THIS PROCEDURE IS PART OF ANOTHER
                                  PROCEDURE/SERVICE BILLED ON SAME
01/01/1977   12/31/3999   00117   DAY.                                       F2      Finalized/Denial - The claim/line has been denied.   106


                                  SERVICE(S) REQUIRE PERFORMING
                                  PROVIDER NAME/NUMBER FOR
01/01/1977   12/31/3999   00118   PAYMENT.                                   F2      Finalized/Denial - The claim/line has been denied.   132




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                                  A QUANTITY FOR THIS BILLED AMOUNT
01/01/1977   12/31/3999   00119   IS NEEDED FOR PROCESSING.                  F2      Finalized/Denial - The claim/line has been denied.               476


                                  PROCEDURE PAYMENT DETERMINED BY
                                  PROGRAM/BENEFIT PLAN, DATE OF
                                  SERVICE AND IS CALCULATED ON AN
01/01/1977   12/31/3999   00120   INDIVIDUAL BASIS BY NHIC.                  F1      Finalized/Payment - The claim/line has been paid.                104


                                  SUBSTITUTE PHYSICIAN'S NAME AND
                                  PROVIDER NUMBER MUST BE IN BLOCKS
01/01/1977   12/31/3999   00121   17A AND 17B.                               F2      Finalized/Denial - The claim/line has been denied.               21


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS CLAIM IS REISSUE OF PREVIOUS                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00122   CLAIM.                                     F4      forthcoming.                                                     101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS IS AN ADJUSTMENT TO PREVIOUS                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00123   CLAIM %1, WHICH APPEARS ON R&S %2.         F4      forthcoming.                                                     101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THANK YOU FOR YOUR REFUND, YOUR                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00124   1099 LIABILITY HAS BEEN CREDITED.          F4      forthcoming.                                                     101


                                  CHIROPRACTIC TREATMENT OF AN
                                  ACUTE CONDITION REQUIRES A
01/01/1977   12/31/3999   00125   RELATED X-RAY EVERY 3 MONTHS.              F2      Finalized/Denial - The claim/line has been denied.               318


                                  PAYMENT WAS REDUCED BY %1 DUE TO
                                  MEDICALLY NEEDY SPEND DOWN
01/01/1977   12/31/3999   00126   PAYMENT                                    F1      Finalized/Payment - The claim/line has been paid.                104


01/01/1977   12/31/3999   00127   PAID ON CLAIM %1 ON %2.                    F2      Finalized/Denial - The claim/line has been denied.               54


                                  THIS DATE OF SERVICE NOT
                                  AUTHORIZED DURING THE INPATIENT
01/01/1977   12/31/3999   00128   CONCURRENT REVIEW PROCESS.                 F2      Finalized/Denial - The claim/line has been denied.               84


                                  PAYMENT REDUCED BY MEDICAL
01/01/1977   12/31/3999   00129   REVIEWER.                                  F1      Finalized/Payment - The claim/line has been paid.                47


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                                  MEDICARE DENIAL INSUFFICIENT TO
                                  CONSIDER PAYMENT OF CLAIM.
01/01/1977   12/31/3999   00130   APPEAL/REAPPEAL TO MEDICARE.              F2      Finalized/Denial - The claim/line has been denied.                     171


                                  CLAIM DENIED DUE TO INVALID
                                  AUTHORIZATION NUMBER. CONTACT
01/01/1977   12/31/3999   00131   CLIENT'S HMO TO APPEAL.                   F2      Finalized/Denial - The claim/line has been denied.                     252


                                  EXCEEDS THE LIMIT OF 24
                                  CHIROPRACTIC VISITS FOR A 12 MONTH
01/01/1977   12/31/3999   00132   PERIOD.                                   F2      Finalized/Denial - The claim/line has been denied.                     483


                                  THIS PAYMENT IS THE RESULT OF A
01/01/1977   12/31/3999   00133   COST AUDIT SETTLEMENT.                    F1      Finalized/Payment - The claim/line has been paid                       46


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  VOIDED CLAIMS-THIS AMOUNT HAS BEEN                claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00134   CREDITED TO YOUR NET IRS LIABILITY.       F4      forthcoming.                                                           101


                                  DRG BILLED DOES NOT MATCH DRG
                                  AUTHORIZED. CLAIM PROCESSED
01/01/1977   12/31/3999   00135   ACCORDING TO AUTHORIZED DRG.              F1      Finalized/Payment - The claim/line has been paid                       48


                                  PARTIAL PAYMENT WITHHELD DUE TO A                 Finalized - The claim/encounter has completed the adjudictaion cycle
01/01/1977   12/31/3999   00136   PREVIOUS OVERPAYMENT.                     F0      and no more action will be taken.                                      483


                                  TOTAL BILLED CHANGED TO REFLECT
                                  THE TOTAL DETAIL CHARGES AND/OR                   Finalized - The claim/encounter has completed the adjudictaion cycle
01/01/1977   12/31/3999   00137   THE COMBINATION OF CLAIMS.                F0      and no more action will be taken.                                      103


                                  THESE PSYCHIATRIC SERVICES ARE
01/01/1977   12/31/3999   00138   PAID AT 62.5% OF ALLOWED AMOUNT.          F1      Finalized/Payment - The claim/line has been paid                       104


                                  PAYMENT WAS REDUCED BY %1 DUE TO
01/01/1977   12/31/3999   00139   OTHER INSURANCE PAYMENTS                  F1      Finalized/Payment - The claim/line has been paid                       286




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                                  PROLONGED PHYSICIAN SERVICES
                                  WITHOUT "FACE TO FACE" PATIENT
01/01/1977   12/31/3999   00140   CONTACT ARE NOT PAYABLE.                  F2      Finalized/Denial - The claim/line has been denied.   104


                                  CLAIM DENIED DUE TO LACK OF
                                  NOTIFICATION WITHIN 24 HOURS OF
01/01/1977   12/31/3999   00141   ADMISSION.                                F2      Finalized/Denial - The claim/line has been denied.   84


                                  HOSPITAL ADMISSION DENIED.
                                  CERTIFICATION FOR OBSERVATION
01/01/1977   12/31/3999   00142   ONLY. REFILE AS OUTPATIENT CLAIM.         F2      Finalized/Denial - The claim/line has been denied.   7


                                  MEDICARE ENROLLMENT COMPLETED-
                                  PLEASE FILE THIS AND FUTURE
01/01/1977   12/31/3999   00143   SERVICES TO MEDICARE.                     F2      Finalized/Denial - The claim/line has been denied.   85


                                  THIS PROCEDURE NOT COVERED FOR
01/01/1977   12/31/3999   00144   THIS PROVIDER TYPE.                       F2      Finalized/Denial - The claim/line has been denied.   9


                                  CONSULTATIONS BETWEEN PHYSICIANS
01/01/1977   12/31/3999   00145   ARE NOT COVERED.                          F2      Finalized/Denial - The claim/line has been denied.   9


                                  THIS SURGICAL PROCEDURE DOES NOT
                                  REQUIRE THE SERVICES OF AN
01/01/1977   12/31/3999   00146   ASSISTANT.                                F2      Finalized/Denial - The claim/line has been denied.   104


                                  AN ANESTHESIOLOGIST IS NOT A
                                  COVERED BENEFIT FOR THIS
01/01/1977   12/31/3999   00147   PROCEDURE.                                F2      Finalized/Denial - The claim/line has been denied.   104


                                  G0168-NOT IMPLEMENTED BY TX MCD.
                                  RESUBMIT WITH APPROPRIATE CPT
01/01/1977   12/31/3999   00148   REPAIR/SURGICAL CODE.                     F2      Finalized/Denial - The claim/line has been denied.   454


                                  PROCEDURE PAYMENT BASED ON
                                  PROGRAM/BENEFIT PLAN, DATE OF
                                  SERVICE AND A MAXIMUM PAYMENT
01/01/1977   12/31/3999   00149   AMOUNT SET BY HCFA OR TDH.                F1      Finalized/Payment - The claim/line has been paid.    104




                                                                        Page 176 of 378
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                                  PAID IN ACCORDANCE WITH MEDICAID
01/01/1977   12/31/3999   00150   GUIDELINES.                                  F1      Finalized/Payment - The claim/line has been paid.                      104


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS SERVICE RECOUPED AT THE                         claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00151   REQUEST OF THE CLIENTS MCO.                  F4      forthcoming.                                                           101


                                  THIRTY DAYS OF INPATIENT HOSPITAL                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00152   CONFINEMENT HAVE BEEN UTILIZED.              F0      and no more action will be taken.                                      483


                                  CAPPED SERVICES - HMO NOT PAYOR
01/01/1977   12/31/3999   00153   (HMO).                                       F2      Finalized/Denial - The claim/line has been denied.                     105


                                  HMO NOT PAYOR - SUBMIT CHARGES TO
01/01/1977   12/31/3999   00154   NHIC (HMO).                                  F2      Finalized/Denial - The claim/line has been denied.                     116


01/01/1977   12/31/3999   00155   SSI CLIENT - SUBMIT TO NHIC (HMO).           F2      Finalized/Denial - The claim/line has been denied.                     116


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS RECOUPMENT RESULTS FROM AN                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00156   INCORRECT PAYMENT.                           F4      forthcoming.                                                           101


                                  SERVICES OUTSIDE THE UNITED STATES
01/01/1977   12/31/3999   00157   ARE NOT A BENEFIT.                           F2      Finalized/Denial - The claim/line has been denied.                     9


                                  SERVICES RELATED TO DENTAL CARE
01/01/1977   12/31/3999   00158   ARE NOT A BENEFIT.                           F2      Finalized/Denial - The claim/line has been denied.                     89


                                  PLEASE REFILE USING APPROPRIATE
                                  CPT PROCEDURE CODE UNDER DOD
01/01/1977   12/31/3999   00159   PROVIDER NUMBER.                             F2      Finalized/Denial - The claim/line has been denied.                     132


                                  CLAIM DENIED BASED ON FINAL                          Acknowledgement/Receipt-The claim/encounter has been received.
                                  ELIGIBILITY DETERMINATION. ADVISE                    This does not mean that the claim has been accepted for
                                  PATIENT TO CONTACT DHS                               adjudication.
01/01/1977   12/31/3999   00160   CASEWORKER.                                  A1                                                                             88




                                                                           Page 177 of 378
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                                  OUTLIER PMT ADJUSTED AS RESULT OF                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  RETROSPECTIVE REVIEW BY HHSC                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00161   UTILIZATION REVIEW.                        F4      forthcoming.                                                           101


                                  OUTLIER PAYMENT DENIED AS A RESULT                 Finalized/Adjudication Complete - No payment forthcoming - The
                                  OF RETROSPECTIVE REVIEW BY HHSC -                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00162   UTILIZATION REVIEW.                        F4      forthcoming.                                                           101


                                  %1 OF THE TOTAL PAYMENT IS THE
01/01/1977   12/31/3999   00163   OUTLIER PAYMENT                            F1      Finalized/Payment - The claim/line has been paid.                      65


                                  THESE SERVICES ARE NOT IN
01/01/1977   12/31/3999   00164   ACCORDANCE WITH MEDICAL POLICY.            F2      Finalized/Denial - The claim/line has been denied.                     9


                                  PROCEDURE CODE CHANGED TO MATCH                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00165   PROVIDER'S DESCRIPTION.                    F0      and no more action will be taken.                                      15


                                  PROCEDURE CODE CHANGED IN
                                  ACCORDANCE WITH PREPAYMENT                         Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00166   REVIEW GUIDELINES.                         F0      and no more action will be taken.                                      15


                                  CLAIM WAS NOT RECEIVED W/IN 95
                                  DAYS. APPEAL W/PREVIOUS R&S
01/01/1977   12/31/3999   00167   REPORTS IF CLAIM WAS ON TIME.              F2      Finalized/Denial - The claim/line has been denied.                     9


01/01/1977   12/31/3999   00168   PAID AT COST REIMBURSEMENT RATE.           F1      Finalized/Payment - The claim/line has been paid.                      104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS ADJUSTMENT IS THE RESULT OF A                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00169   NHIC DESK REVIEW.                          F4      forthcoming.                                                           101


                                  RECEIVED PAST 95 DAY FILING
                                  DEADLINE. EXCEPTIONS NOTED IN
01/01/1977   12/31/3999   00170   PROVIDER PROCEDURE MANUAL.                 F2      Finalized/Denial - The claim/line has been denied.                     9


                                  THIS CHARGE IS INCLUDED IN THE
01/01/1977   12/31/3999   00172   SURGICAL/ANESTHESIA FEE.                   F2      Finalized/Denial - The claim/line has been denied.                     104




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                                  SERVICES INCLUDED IN TOTAL
01/01/1977   12/31/3999   00173   MATERNITY CHARGE.                            F2      Finalized/Denial - The claim/line has been denied.   104


                                  THIS PROVIDER NUMBER IS NOT
                                  ASSIGNED TO THIS AUTHORIZATION
01/01/1977   12/31/3999   00174   NUMBER.                                      F2      Finalized/Denial - The claim/line has been denied.   25



                                  ROUTINE FAMILY PLANNING PHYSICAL
01/01/1977   12/31/3999   00175   EXAMS ARE LIMITED TO ONE PER YEAR.           F2      Finalized/Denial - The claim/line has been denied.   483


                                  OBSERVATION ROOM/ER CHARGES ON
                                  DAY OF ADMISSION MUST BE BILLED ON
01/01/1977   12/31/3999   00176   INPATIENT CLAIM FORM.                        F2      Finalized/Denial - The claim/line has been denied.   228


                                  OUR RECORDS INDICATE THAT THE
                                  CLIENT WAS DECEASED AT THE TIME OF
01/01/1977   12/31/3999   00177   SERVICE.                                     F2      Finalized/Denial - The claim/line has been denied.   9


                                  AS OF 4/7/02 THE TEXAS PROVIDER
                                  IDENTIFIER (TPI) REPLACES THE
                                  MEDICAID PROVIDER NUMBER. THIS
                                  CLAIM WAS BILLED WITH THE OLD
                                  PROVIDER NUMBER. PLEASE SUBMIT
                                  THIS AND FUTURE CLAIMS USING YOUR
                                  TPI. SEE MEDICAID BULLETIN 161
01/01/1977   12/31/3999   00179   MARCH/APRIL 2002.                            F2      Finalized/Denial - The claim/line has been denied.   132


                                  CLIENT NUMBER INVALID. PLEASE
                                  RESUBMIT WITH ACCURATE CLIENT
01/01/1977   12/31/3999   00180   INFORMATION.                                 F2      Finalized/Denial - The claim/line has been denied.   153


                                  CLIENT'S FULL NAME, CLIENT NUMBER,
                                  SEX & DATE OF BIRTH DO NOT MATCH
01/01/1977   12/31/3999   00181   INFORMATION ON FILE.                         F2      Finalized/Denial - The claim/line has been denied.   125


                                  OUR RECORDS INDICATE CLIENT IS NOT
                                  ELIGIBLE FOR BENEFITS FOR THIS DATE
01/01/1977   12/31/3999   00182   OF SERVICE.                                  F2      Finalized/Denial - The claim/line has been denied.   88




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                                  SERVICES RELATED TO AN
                                  UNAUTHORIZED ORGAN TRANSPLANT
01/01/1977   12/31/3999   00183   ARE NOT PAYABLE.                            F2      Finalized/Denial - The claim/line has been denied.                     84


                                  THIS SERVICE PAYABLE AS AN
                                  INPATIENT SERVICE ONLY, INCLUDED IN
01/01/1977   12/31/3999   00184   DRG.                                        F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS PROCEDURE DENIED/CUTBACK.
                                  EXCEEDS TOTAL ALLOWED OF $24.38
01/01/1977   12/31/3999   00185   PER QUADRANT.                               F1      Finalized/Payment - The claim/line has been paid.                      68



                                  THIS DETAIL/CLAIM CANNOT BE PRICED                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00186   BASED ON THE INFORMATION PROVIDED           F0      and no more action will be taken.                                      110


                                  CONSENT DOES NOT COMPLY WITH
                                  HEALTH AND HUMAN SERVICES
01/01/1977   12/31/3999   00187   GUIDELINES.                                 F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PROCEDURE CODE IS NO LONGER
                                  VALID. RESUBMIT USING EMERGENCY
01/01/1977   12/31/3999   00189   ROOM AND ANCILLARY CODES.                   F2      Finalized/Denial - The claim/line has been denied.                     454


                                  CLAIM BILLED TO NHIC IN ERROR. BILL
                                  TO BHO (VALUE OPTIONS @ 888-800-
01/01/1977   12/31/3999   00190   6799)                                       F2      Finalized/Denial - The claim/line has been denied.                     115


                                  OUR RECORDS INDICATE THAT THE
                                  NEWBORN IS NOT AND WILL NOT BE
01/01/1977   12/31/3999   00192   ELIGIBLE FOR THESE DATES.                   F2      Finalized/Denial - The claim/line has been denied.                     88


                                  DENTAL CARIES (52100) IS NOT A
                                  PAYABLE DIAGNOSIS FOR CLIENTS AGE
01/01/1977   12/31/3999   00193   21 AND OVER.                                F2      Finalized/Denial - The claim/line has been denied.                     475


                                  THESE SERVICES ARE NOT PAYABLE
                                  FOR CLIENTS RESIDING IN A NURSING
01/01/1977   12/31/3999   00194   HOME.                                       F2      Finalized/Denial - The claim/line has been denied.                     104




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                                  PAYMENT FOR REPEAT LASER
                                  TREATMENT WITHIN 90 DAYS IS
01/01/1977   12/31/3999   00195   INCLUDED IN INITIAL LASER PAYMENT.          F2      Finalized/Denial - The claim/line has been denied.   104


                                  LOCAL MODIFIERS ARE NOT VALID FOR
                                  DATES OF SERVICE ON OR AFTER
01/01/1977   12/31/3999   00196   10/16/2003.                                 F2      Finalized/Denial - The claim/line has been denied.   122


                                  ORTHODONTIA RELATED PROCEDURE
                                  CODES D0330, D0340, D0350, D0470 ARE
                                  REQUIRED TO BE SUBMITTED ON THE
                                  SAME DATES OF SERVICE AND SAME
                                  CLAIM WITH THE ORTHODONTIA
                                  INDICATOR TO BE CONSIDERED FOR
01/01/1977   12/31/3999   00197   REIMBURSEMENT.                              F2      Finalized/Denial - The claim/line has been denied.   454


                                  STERILIZATIONS PERFORMED ON
                                  CLIENTS UNDER AGE 21 ARE NOT A
01/01/1977   12/31/3999   00198   BENEFIT OF THE MEDICAID PROGRAM.            F2      Finalized/Denial - The claim/line has been denied.   475


                                  DOCUMENTATION DOES NOT SUPPORT
                                  HOMEBOUND CRITERIA FOR HOME
01/01/1977   12/31/3999   00199   HEALTH SERVICES.                            F2      Finalized/Denial - The claim/line has been denied.   422


                                  EXCEEDS THE 50 VISITS PER CLIENT PER
                                  YEAR LIMITATION FOR HOME HEALTH
01/01/1977   12/31/3999   00200   SERVICES.                                   F2      Finalized/Denial - The claim/line has been denied.   483


                                  VALID HOUR OF DISCHARGE REQUIRED
01/01/1977   12/31/3999   00201   FOR PROCESSING.                             F2      Finalized/Denial - The claim/line has been denied.   233


                                  THIS IS NOT A BENEFIT.
                                  DOCUMENTATION INDICATES TRANSFER
01/01/1977   12/31/3999   00202   OF CONVENIENCE.                             F2      Finalized/Denial - The claim/line has been denied.   428


                                  MEDICARE DRG CODE MISSING ON
                                  MEDICARE REMITTANCE ADVICE OR
01/01/1977   12/31/3999   00203   NOTICE.                                     F2      Finalized/Denial - The claim/line has been denied.   122




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                                  THIS SERVICE HAS BEEN PREVIOUSLY
                                  PROCESSED UNDER ANOTHER
                                  PROGRAM (MEDICAID, MANAGED CARE,
08/01/2002   12/31/3999   00204   CSHCN, FP).                                 F2      Finalized/Denial - The claim/line has been denied.   104


                                  DOCUMENTATION DOES NOT JUSTIFY AN
                                  ADDITIONAL ATTENDANT OR
01/01/1977   12/31/3999   00205   REGISTERED NURSE.                           F2      Finalized/Denial - The claim/line has been denied.   414


01/01/1977   12/31/3999   00207   SERVICE NOT A BENEFIT.                      F2      Finalized/Denial - The claim/line has been denied.   9


                                  THIS RECOUPMENT IS DUE TO A
                                  DUPLICATE PAYMENT TO YOUR
01/01/1977   12/31/3999   00208   PROVIDER NUMBER.                            F2      Finalized/Denial - The claim/line has been denied.   54


                                  PROCEDURE AND/OR PLACE OF SERVICE
01/01/1977   12/31/3999   00209   CODE MISSING.                               F2      Finalized/Denial - The claim/line has been denied.   454


                                  MEDICARE PAYMENT INFORMATION
                                  MISSING. PLEASE RESUBMIT WITH
01/01/1977   12/31/3999   00210   MEDICARE RA OR NOTICE.                      F2      Finalized/Denial - The claim/line has been denied.   286


                                  INJECTIONS WHEN ALTERNATE DRUG
                                  OR ROUTE IS POSSIBLE REQUIRE
01/01/1977   12/31/3999   00211   MODIFIER.                                   F2      Finalized/Denial - The claim/line has been denied.   453


                                  WAITING TIME MUST BE WELL
                                  DOCUMENTED FOR CONSIDERATION OF
01/01/1977   12/31/3999   00212   PAYMENT.                                    F2      Finalized/Denial - The claim/line has been denied.   337


                                  THIS AUTHORIZATION FOR
01/01/1977   12/31/3999   00213   ORTHODONTICS HAS EXPIRED.                   F2      Finalized/Denial - The claim/line has been denied.   252


                                  NON-FAMILY PLANNING SERVICES WILL
                                  BE PROCESSED ON ANOTHER
01/01/1977   12/31/3999   00214   REMITTANCE AND STATUS REPORT.               F1      Finalized/Payment - The claim/line has been paid.    72


                                  POST-OP VISITS ARE INCLUSIVE TO THE
01/01/1977   12/31/3999   00215   SURGERY FEE.                                F2      Finalized/Denial - The claim/line has been denied.   483



                                                                          Page 182 of 378
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                                  LAB OR X-RAY PERFORMED OUTSIDE
                                  YOUR OFFICE MUST BE BILLED BY THE
01/01/1977   12/31/3999   00216   PERFORMING FACILITY.                      F2      Finalized/Denial - The claim/line has been denied.                     179


                                  PAYMENT REDUCED THROUGH                           Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00217   HOSPITAL ACTION.                          F0      and no more action will be taken.                                      425


                                  INVALID REFERRING PROVIDER.
                                  CONSULTATION HAS BEEN CHANGED TO                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00218   CORRESPONDING VISIT.                      F0      and no more action will be taken.                                      15


                                  DOCUMENTATION DOES NOT MEET
                                  EMERGENCY STERILIZATION
01/01/1977   12/31/3999   00219   REQUIREMENTS.                             F2      Finalized/Denial - The claim/line has been denied.                     104


                                  EMERGENCY ABDOMINAL SURGERY
                                  MUST HAVE DESCRIPTION OF
                                  CIRCUMSTANCES AND MEDICAL
01/01/1977   12/31/3999   00220   NECESSITY.                                F2      Finalized/Denial - The claim/line has been denied.                     298


                                  ACKNOWLEDGEMENT CONSENT DOES
                                  NOT COMPLY WITH HEALTH AND HUMAN
01/01/1977   12/31/3999   00221   SERVICES GUIDELINES.                      F2      Finalized/Denial - The claim/line has been denied.                     104


                                  DATED SIGNATURE DID NOT APPEAR
                                  BELOW HYSTERECTOMY
01/01/1977   12/31/3999   00222   ACKNOWLEDGEMENT.                          F2      Finalized/Denial - The claim/line has been denied.                     466


                                  CO-INSURANCE NOT APPLICABLE FOR
01/01/1977   12/31/3999   00223   THIS DATE OF SERVICE.                     F2      Finalized/Denial - The claim/line has been denied.                     9


                                  ADDITIONAL AUTHORIZATION FOR
                                  REPLACEMENT RETAINERS IS REQUIRED
01/01/1977   12/31/3999   00224   PRIOR TO BILLING.                         F2      Finalized/Denial - The claim/line has been denied.                     202


                                  THIS NON-ROUTINE SERVICE IS DENIED
01/01/1977   12/31/3999   00225   DUE TO LACK OF AUTHORIZATION.             F2      Finalized/Denial - The claim/line has been denied.                     48




                                                                        Page 183 of 378
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                                  SERVICE DENIED. LACK OF
                                  AUTHORIZATION, NOTIFICATION OF
01/01/1977   12/31/3999   00226   ADMISSION, OR CONCURRENT REVIEW.           F2      Finalized/Denial - The claim/line has been denied.                     48


                                  CLAIM NOT PAYABLE DUE TO DENIED
01/01/1977   12/31/3999   00227   AUTHORIZATION.                             F2      Finalized/Denial - The claim/line has been denied.                     48


                                  YOUR CLAIM IS PENDING AND WILL BE
                                  PROCESSED SHORTLY. NO ACTION ON                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00229   YOUR PART IS NECESSARY.                    P0      and no more action will be taken.                                      38


                                  LACK OF TRANSPORTATION DOES NOT
                                  JUSTIFY EMERGENCY/NON-EMERGENCY
01/01/1977   12/31/3999   00231   TRANSFER.                                  F2      Finalized/Denial - The claim/line has been denied.                     104


                                  SEALANTS NOT PAYABLE ON SURFACES
                                  THAT HAVE BEEN PREVIOUSLY
01/01/1977   12/31/3999   00232   RESTORED.                                  F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THE AUTHORIZATION NUMBER USED IS
01/01/1977   12/31/3999   00233   FOR ANOTHER CLIENT/PROVIDER.               F2      Finalized/Denial - The claim/line has been denied.                     48


                                  PAYMENT REDUCED FOR MULTIPLE
                                  TRANSFER; REFER TO PROVIDER
01/01/1977   12/31/3999   00234   PROCEDURE MANUAL.                          F1      Finalized/Payment - The claim/line has been paid.                      68


                                  CLIENT IS NOT A TEXAS RESIDENT.
                                  PLEASE FILE IN THE CLIENT'S HOME
01/01/1977   12/31/3999   00235   STATE.                                     F2      Finalized/Denial - The claim/line has been denied.                     9


                                  THIS SERVICE MUST BE SUBMITTED
                                  WITH A PHYSICIAN PROVIDER NUMBER
01/01/1977   12/31/3999   00236   ON A HCFA 1500 CLAIM FORM.                 F2      Finalized/Denial - The claim/line has been denied.                     275



                                  BENEFIT ONLY AVAILABLE TO
                                  PROVIDERS CONTRACTED WITH DHS,
01/01/1977   12/31/3999   00237   TDH, OR TDPRS; NOT PAYABLE BY NHIC.        F2      Finalized/Denial - The claim/line has been denied.                     116




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                                  MEDICARE PAID EQUAL TO OR GREATER
                                  THAN MEDICAID PAID, NO FURTHER                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00238   PAYMENT.                                   F0      and no more action will be taken.                                      182


                                  THIS PROCEDURE IS NOT PAYABLE AS A
                                  TOTAL COMPONENT. USE PROC CODES
01/01/1977   12/31/3999   00239   T-93005 OR T-93041.                        F2      Finalized/Denial - The claim/line has been denied.                     454


                                  ALL BLANKS ON THE PHYSICIANS
                                  STATEMENT OF THE CONSENT FORM
01/01/1977   12/31/3999   00240   MUST BE COMPLETED.                         F2      Finalized/Denial - The claim/line has been denied.                     21


                                  PAYMENTS MADE BY CLIENT FOR
                                  MEDICAID COVERED SERVICES MUST BE
01/01/1977   12/31/3999   00241   REFUNDED TO THE CLIENT.                    F1      Finalized/Payment - The claim/line has been paid.                      106


                                  CONSENT TO STERILIZATION INVALID 180
                                  DAYS AFTER DATE OF CLIENT
01/01/1977   12/31/3999   00242   SIGNATURE.                                 F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS IS A DUPLICATE SERVICE THAT
                                  WAS ALREADY PAID TO A PHYSICIAN
01/01/1977   12/31/3999   00243   WITHIN YOUR GROUP.                         F2      Finalized/Denial - The claim/line has been denied.                     54


                                  REFERRAL CODE 02-11 NOT INDICATED
                                  BUT IS REQUIRED WHEN CONDITION
01/01/1977   12/31/3999   00244   CODE IS PRESENT.                           F2      Finalized/Denial - The claim/line has been denied.                     48


                                  PLEASE RESUBMIT CLAIM WITH COPY OF
01/01/1977   12/31/3999   00246   THE PAID/DENIED R&S.                       F2      Finalized/Denial - The claim/line has been denied.                     7


                                  HOSPITAL ADMISSION WITHIN 30 DAYS
                                  OF CONSULT FOR SAME CONDITION
01/01/1977   12/31/3999   00247   PAYABLE AS HOSPITAL VISIT.                 F1      Finalized/Payment - The claim/line has been paid.                      104


                                  A PHYSICIAN CERTIFICATION
                                  STATEMENT MUST ACCOMPANY ALL
01/01/1977   12/31/3999   00248   CLAIMS FOR ABORTION SERVICES.              F2      Finalized/Denial - The claim/line has been denied.                     291




                                                                         Page 185 of 378
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                                  DOCUMENTATION DOES NOT
                                  SUBSTANTIATE THE NEED FOR PRIVATE
01/01/1977   12/31/3999   00250   ROOM.                                      F2      Finalized/Denial - The claim/line has been denied.   9


                                  DOCUMENTATION DOES NOT
                                  SUBSTANTIATE NEED FOR LATE
01/01/1977   12/31/3999   00251   DISCHARGE.                                 F2      Finalized/Denial - The claim/line has been denied.   9


                                  PROCEDURE/SERVICE LIMITED TO ONE
                                  EVERY 24 MONTHS CALCULATED FROM
01/01/1977   12/31/3999   00252   LAST DATE OF SERVICE.                      F2      Finalized/Denial - The claim/line has been denied.   104


                                  THIS IS NOT PAYABLE AS A ROUTINE
                                  OFFICE VISIT. NARRATIVE FOR
01/01/1977   12/31/3999   00253   OBSERVATION IS REQUIRED.                   F2      Finalized/Denial - The claim/line has been denied.   297


                                  EXPECTED DATE OF DELIVERY IS
                                  NEEDED ON CONSENT TO VERIFY 30
01/01/1977   12/31/3999   00254   DAYS FROM CLIENT'S SIGN DATE.              F2      Finalized/Denial - The claim/line has been denied.   199


                                  RESUBMIT TO NHIC WITH COMPLETE
                                  OTHER INSURANCE INFO AND
01/01/1977   12/31/3999   00255   DOCUMENT PAYMENT OR DENIAL.                F2      Finalized/Denial - The claim/line has been denied.   286


                                  PROCEDURE NOT PAYABLE TO THIS
                                  PROVIDER TYPE/SPECIALTY FOR
01/01/1977   12/31/3999   00256   CLIENTS OVER 21 YEARS.                     F2      Finalized/Denial - The claim/line has been denied.   475


                                  MEDICARE DEDUCTIBLES, CO-
                                  INSURANCE, NON-COVERED CHARGES
                                  AND PAYABLES DO NOT BALANCE.
                                  PLEASE RESUBMIT WITH MEDICARE
01/01/1977   12/31/3999   00257   REMITTANCE ADVICE OR NOTICE.               F2      Finalized/Denial - The claim/line has been denied.   400


                                  CLAIM DENIED PENDING ELIGIBILITY
                                  REDETERMINATION. PLEASE ADVISE
                                  CLIENT TO CONTACT THEIR
01/01/1977   12/31/3999   00258   CASEWORKER.                                F2      Finalized/Denial - The claim/line has been denied.   56




                                                                         Page 186 of 378
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                                  PROCEDURES/SERVICES DENIED NOT AS
                                  A BENEFIT CANNOT BE COMBINED AS
01/01/1977   12/31/3999   00259   PART OF ANOTHER PROCEDURE.                   F2      Finalized/Denial - The claim/line has been denied.                     483


                                  CLIENT IS COVERED BY OTHER
                                  INSURANCE WHICH MUST BE BILLED
                                  PRIOR TO THIS PROGRAM - SEE
                                  "PRIVATE INSURANCE INFORMATION"
01/01/1977   12/31/3999   00260   BELOW OR ON FOLLOWING PAGE.                  F2      Finalized/Denial - The claim/line has been denied.                     286


                                  PRIMARY BIRTH CONTROL METHOD AT
                                  END OF VISIT MUST BE CONSISTENT
                                  WITH THE FAMILY PLANNING
                                  PROCEDURE BILLED. PLEASE CORRECT
01/01/1977   12/31/3999   00261   AND RESUBMIT CLAIM.                          F2      Finalized/Denial - The claim/line has been denied.                     454


                                  SIGNATURE OF THE EMERGENCY
                                  MEDICAL TECHNICIAN (EMT)
                                  TRANSPORTING THE CLIENT IS
                                  REQUIRED ON MEDICAL NECESSITY
01/01/1977   12/31/3999   00262   DOCUMENTATION.                               F2      Finalized/Denial - The claim/line has been denied.                     466


                                  INITIAL HOSPITAL CARE WITHIN 3 DAYS
                                  OF A NEW PATIENT VISIT IS PAYABLE AS                 Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00263   A SUBSEQUENT CARE VISIT.                     F0      and no more action will be taken.                                      15


                                  INITIAL OFFICE VISIT WITHIN 30 DAYS OF
                                  AN INITIAL OFFICE VISIT FOR
                                  SAME/RELATED CONDITION PAYABLE AS                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00264   FOLLOW-UP VISIT.                             F0      and no more action will be taken.                                      15



                                  EXCEEDS ALLOWED BENEFIT
                                  LIMITATION. PROCEDURE LIMITED TO
01/01/1977   12/31/3999   00266   ONE PER FISCAL YEAR. (SEPT. 1-AUG. 31)       F2      Finalized/Denial - The claim/line has been denied.                     483


                                  YOUR CLAIM INDICATES
                                  DOCUMENTATION WAS ATTACHED BUT
                                  NONE WAS RECEIVED. PLEASE
                                  RESUBMIT DOCUMENTATION AND COPY
01/01/1977   12/31/3999   00267   OF R&S.                                      F2      Finalized/Denial - The claim/line has been denied.                     294




                                                                           Page 187 of 378
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                                  INITIAL OFFICE VISIT WITHIN 3 DAYS OF
                                  E.R. VISIT FOR SAME/RELATED                          Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00268   DIAGNOSIS PAID AS FOLLOW-UP VISIT.           F0      and no more action will be taken.                                      15


                                  STERILIZATION PROC CONSENTED TO BY
                                  CLIENT DOES NOT MATCH PROC ON
                                  PHYS STATEMENT AND/OR CLAIM.
                                  PLEASE RESUBMIT ALL FORMS WITH
01/01/1977   12/31/3999   00269   CORRECTED INFORMATION.                       F2      Finalized/Denial - The claim/line has been denied.                     454


                                  HYSTERECTOMY CLAIMS REQUIRE
                                  ACKNOWLEDGMENT SIGNED/DATED
                                  PRIOR TO SURGERY OR PHYSICIAN
                                  CERTIFICATION FOR EXCEPTIONS.
                                  REFER TO PROVIDER PROCEDURE
01/01/1977   12/31/3999   00270   MANUAL.                                      F2      Finalized/Denial - The claim/line has been denied.                     466


                                  CLAIM DENIED DUE TO INACCURATE
                                  CLIENT INFORMATION. PLEASE CONTACT
                                  MEDICARE TO VERIFY CLIENT
01/01/1977   12/31/3999   00271   ELIGIBILITY INFORMATION.                     F2      Finalized/Denial - The claim/line has been denied.                     198


                                  UNABLE TO PROCESS. SUBMIT AS A
                                  PAPER CLAIM W/THE APPROPRIATE
01/01/1977   12/31/3999   00272   DOCUMENTS.                                   F2      Finalized/Denial - The claim/line has been denied.                     294



                                  MEDICAL NECESSITY OF THIS
                                  PROCEDURE MUST BE VERIFIED.
                                  PLEASE SUBMIT A SIGNED CLAIM, R&S
                                  COPY, HISTORY, PHYSICAL, PATHOLOGY
01/01/1977   12/31/3999   00274   AND/OR OPERATIVE REPORT.                     F2      Finalized/Denial - The claim/line has been denied.                     294


                                  THIS CLAIM HAS BEEN DENIED AND WILL
                                  BE RETURNED FOR ADDITIONAL
                                  INFORMATION. REFILE ORIGINAL CLAIM
                                  WITH INVOICE FOR PAYMENT OF THIS
01/01/1977   12/31/3999   00275   SERVICE.                                     F2      Finalized/Denial - The claim/line has been denied.                     285




                                                                           Page 188 of 378
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                                  CLIENT NOT ENROLLED IN STAR FOR
                                  THE DATE(S) OF SERVICE. MEDICAID
                                  ELIGIBLE SERVICES WILL BE
                                  PROCESSED ON SEPARATE CLAIM. NO                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00276   ACTION ON YOUR PART IS NECESSARY.         F0      and no more action will be taken.                                      104


                                  CLAIM DENIED BECAUSE BILLED
                                  SERVICES ARE PRIOR TO DATE OF
                                  BIRTH. PLEASE RESUBMIT WITH SIGNED
                                  CLAIM COPY, R&S COPY AND
01/01/1977   12/31/3999   00277   CORRECTED DATES.                          F2      Finalized/Denial - The claim/line has been denied.                     158


                                  THE DOCUMENTATION REQUESTED HAS
                                  BEEN RECEIVED BUT IT IS FOR THE
                                  WRONG CLIENT/DATE OF SERVICE/ETC.
                                  PLEASE RESUBMIT WITH APPROPRIATE
01/01/1977   12/31/3999   00278   DOCUMENTATION.                            F2      Finalized/Denial - The claim/line has been denied.                     125


                                  MEDICARE ELIGIBILITY HAS NOT BEEN
                                  ESTABLISHED. CLIENT MAY BE
                                  DETERMINED MEDICARE ELIGIBLE AT A
01/01/1977   12/31/3999   00279   LATER DATE.                               F2      Finalized/Denial - The claim/line has been denied.                     284


                                  CLAIM DENIED DUE TO INCOMPLETE
                                  PHYSICIAN CERTIFICATION STATEMENT.
                                  RESUBMIT WITH COMPLETED
01/01/1977   12/31/3999   00280   CERTIFICATION                             F2      Finalized/Denial - The claim/line has been denied.                     332


                                  NO VALID CONTRACT FOR TITLE V OR XX
                                  FAMILY PLANNING IS ASSOCIATED WITH
                                  THIS PROVIDER FOR THE DATES OF
01/01/1977   12/31/3999   00281   SERVICE BILLED.                           F2      Finalized/Denial - The claim/line has been denied.                     107


                                  THIS RECOUPMENT RESULTS FROM
                                  PAYMENT TO AN INCORRECT CLIENT
                                  NUMBER. THE CLAIM WILL BE                         Finalized/Adjudication Complete - No payment forthcoming - The
                                  REPROCESSED TO THE CORRECT                        claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00282   CLIENT NUMBER.                            F4      forthcoming.                                                           101




                                                                        Page 189 of 378
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                                  THIS RECOUPMENT RESULTS FROM
                                  PAYMENT MADE INCORRECTLY TO YOUR
                                  PROVIDER NUMBER. THIS CLAIM WILL BE                Finalized/Adjudication Complete - No payment forthcoming - The
                                  PROCESSED TO THE CORRECT                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00283   PROVDER.                                   F4      forthcoming.                                                     101


                                  THIS RECOUPMENT RESULTS FROM AN
                                  INCORRECT MEDICAID PAYMENT. THE                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  CLIENT IS ELIGIBLE FOR MEDICARE FOR                claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00284   THESE SERVICES.                            F4      forthcoming.                                                     101



                                  THIS RECOUPMENT RESULTS FROM AN
                                  INCORRECT PAYMENT. THIRTY BENEFIT                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  DAYS OF HOSPITAL CONFINEMENT HAVE                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00285   BEEN USED IN FACILITY/FACILITIES.          F4      forthcoming.                                                     101


                                  THIS RECOUPMENT RESULTS FROM AN
                                  INCORRECT PAYMENT. THE FULL                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  ALLOWABLE FOR THIS CLAIM WAS PAID                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00286   PREVIOUSLY.                                F4      forthcoming.                                                     101


                                  THIS RECOUPMENT RESULTS FROM AN
                                  INCORRECT PAYMENT. THE CLIENT'S
                                  PRIVATE INSURANCE HAS PAID THE                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  TOTAL MEDICAID ALLOWABLE FOR THE                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00287   SERVICE(S).                                F4      forthcoming.                                                     101


                                  PROCEDURES/SERVICES LIMITED TO
                                  TWICE PER 12 MONTH PERIOD
                                  CALCULATED FROM THE FIRST DATE OF
01/01/1977   12/31/3999   00289   SERVICE.                                   F2      Finalized/Denial - The claim/line has been denied.               483


                                  DATED SIGNATURE OF PHYSICIAN ON OR
                                  AFTER DAY OF SURGERY IS REQUIRED
                                  ON LAST SECTION OF CONSENT FORM.
                                  PLEASE REFER TO PROVIDER
01/01/1977   12/31/3999   00290   PROCEDURES MANUAL.                         F2      Finalized/Denial - The claim/line has been denied.               466




                                                                         Page 190 of 378
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                                  PERSON OBTAINING CONSENT MUST
                                  COMPLETE ALL BLANKS OF
                                  APPROPRIATE STATEMENT. PLEASE
                                  REFER TO PROVIDER PROCEDURES
01/01/1977   12/31/3999   00291   MANUAL.                                    F2      Finalized/Denial - The claim/line has been denied.   122


                                  THE INDICATED SERVICE(S) DO NOT
                                  DIVIDE EVENLY INTO THE QUANTITY
                                  BILLED. RESUBMIT WITH CORRECT
01/01/1977   12/31/3999   00292   QUANTITY BILLED.                           F2      Finalized/Denial - The claim/line has been denied.   476


                                  THSTEPS MEDICAL CHECKUPS AND
                                  ACUTE CARE TREATMENT SERVICES
                                  MUST BE BILLED ON SEPARATE CLAIM
01/01/1977   12/31/3999   00293   FORMS.                                     F1      Finalized/Payment - The claim/line has been paid.    7


                                  PROCEDURE PAYMENT DETERMINED BY
                                  PROGRAM/BENEFIT PLAN, DATE OF
                                  SERVICE, BILLED AMOUNT AND
                                  PROVIDER'S CUSTOMARY RATE. THE
                                  PREVAILING 50TH PERCENTILE BASED
                                  ON PROVIDER'S LOCALITY/SPECIALTY
                                  WILL BE USED IF NO CUSTOMARY
01/01/1977   12/31/3999   00294   EXISTS.                                    F1      Finalized/Payment - The claim/line has been paid.    66


                                  TITLE V AND XX FAMILY PLANNING
                                  CLAIMS MUST BE FILED W/IN 120 DAYS
                                  OF DOS EXCEPT AS NOTED IN THE
                                  FAMILY PLANNING SECTION OF THE
01/01/1977   12/31/3999   00295   PROVIDER PROCEDURE MANUAL.                 F2      Finalized/Denial - The claim/line has been denied.   9


                                  VALID PROVIDER NUMBER REQUIRED.
01/01/1977   12/31/3999   00296   PLEASE CORRECT AND RESUBMIT.               F2      Finalized/Denial - The claim/line has been denied.   132


                                  THIS SURGERY DOES NOT MEET THE
                                  CRITERIA FOR FUNCTIONAL DISABILITY
                                  AS DETERMINED BY PROGRAM
01/01/1977   12/31/3999   00297   GUIDELINES.                                F2      Finalized/Denial - The claim/line has been denied.   104


                                  ELIGIBILITY DATE MUST NOT BE BLANK,
                                  INVALID, OR MORE THAN 365 DAYS
01/01/1977   12/31/3999   00298   BEFORE DATE OF SERVICE.                    F2      Finalized/Denial - The claim/line has been denied.   9



                                                                         Page 191 of 378
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                                  PHYSICIAN/SUPPLIER SIGNATURE
                                  MISSING OR NOT IN CORRECT BLOCK ON
                                  CLAIM. REFILE WITH SIGNATURE IN
01/01/1977   12/31/3999   00299   CORRECT BLOCK.                           F2      Finalized/Denial - The claim/line has been denied.                     466


                                  CLAIMS FOR TEEN GROUP COUNSELING
                                  MUST FOLLOW PROGRAM GUIDELINES.
                                  PLEASE CORRECT AND RESUBMIT                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00300   CLAIM.                                   F0      and no more action will be taken.                                      104


                                  CLIENT SIGNATURE IS REQUIRED IN
                                  BLOCK 11 WHEN BILLING FOR EYEWEAR
                                  BEYOND PROGRAM SPECIFICATIONS
                                  AND/OR LOST OR DESTROYED
01/01/1977   12/31/3999   00301   EYEWEAR.                                 F2      Finalized/Denial - The claim/line has been denied.                     466



                                  SERVICE PAYABLE ONLY TO PROVIDERS
                                  WHO ARE APPROVED AS TARGETED
                                  CASE MANAGEMENT PROVIDERS. APPLY
                                  TO TDH BUREAU OF COMMUNITY
01/01/1977   12/31/3999   00302   ORIENTED PRIMARY CARE.                   F2      Finalized/Denial - The claim/line has been denied.                     116


                                  PER HCFA MANDATE, PAYMENT IS
                                  REDUCED OR DENIED BECAUSE
                                  AUTOMATED TESTS WERE PAID FOR THE
                                  SAME DATE OF SERVICE ON THIS CLAIM               Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00303   OR ON A PREVIOUS CLAIM(S).               F0      and no more action will be taken.                                      104


                                  TEMPORARY LENSES NOT ALLOWED
                                  AFTER CONVALESCENT PERIOD (4
                                  MONTHS AFTER CATARACT SURGERY).
                                  PROCEDURE CODE CHANGED TO
01/01/1977   12/31/3999   00304   PERMANENT LENS PROCEDURE CODE.           F2      Finalized/Denial - The claim/line has been denied.                     483


                                  THE ADDED DETAIL WAS NOT ON THE
                                  ORIGINAL CLAIM. NEW DAY DETAILS
                                  MUST BE SUBMITTED ON A CLAIM FORM
01/01/1977   12/31/3999   00307   AS A NEW DAY CLAIM.                      F2      Finalized/Denial - The claim/line has been denied.                     7




                                                                       Page 192 of 378
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                                  YOUR 2017 CLAIM FORM IS MISSING
                                  REQUIRED INFORMATION. PLEASE
                                  REFER TO 2017 GUIDELINES AND
01/01/1977   12/31/3999   00308   RESUBMIT CORRECTED CLAIM.                   F2      Finalized/Denial - The claim/line has been denied.   275


                                  YOUR FAMILY PLANNING CLAIM SPANS
                                  DIFFERENT FISCAL YEARS. PLEASE
                                  RESUBMIT SEPARATE CLAIMS FOR
                                  SERVICES PERFORMED DURING
01/01/1977   12/31/3999   00309   DIFFERENT FISCAL YEARS.                     F2      Finalized/Denial - The claim/line has been denied.   187


                                  SERVICE(S) FILED ON AN INCORRECT
                                  CLAIM FORM. REFER TO PROVIDER
                                  PROCEDURES MANUAL AND REFILE AS
01/01/1977   12/31/3999   00310   AN ORIGINAL CLAIM.                          F2      Finalized/Denial - The claim/line has been denied.   275


                                  THIS SERVICE DENIED/RECOUPED
                                  BECAUSE PCP CONTACT IS REQUIRED
                                  PRIOR TO TREATMENT OF CLIENT
01/01/1977   12/31/3999   00312   DURING REGULAR OFFICE HOURS.                F2      Finalized/Denial - The claim/line has been denied.   94


                                  CLAIM INDICATES MULTIPLE
                                  TRANSPORT. PLEASE PROVIDE NAMES
                                  AND PCNS OF ADDITIONAL CLIENTS ON
01/01/1977   12/31/3999   00313   CLAIM FORM.                                 F2      Finalized/Denial - The claim/line has been denied.   153


                                  EACH CLAIM IS LIMITED TO 66 OR LESS
                                  DETAILS AND MUST INCLUDE A TOTAL
                                  BILLED AMOUNT. PLEASE RESUBMIT
01/01/1977   12/31/3999   00314   FOLLOWING THESE GUIDELINES.                 F2      Finalized/Denial - The claim/line has been denied.   121


                                  CLIENT MAY NOT SIGN AS PERSON
01/01/1977   12/31/3999   00315   OBTAINING CONSENT.                          F2      Finalized/Denial - The claim/line has been denied.   466


                                  DATED SIGNATURE OF PERSON
                                  OBTAINING CONSENT WAS PRIOR TO
01/01/1977   12/31/3999   00316   DATE CLIENT SIGNED THE CONSENT.             F2      Finalized/Denial - The claim/line has been denied.   395



                                  LAB AND RADIOLOGY INTERPRETATIONS
                                  ARE CONSIDERED PART OF THE
01/01/1977   12/31/3999   00317   PROFESSIONAL CARE OF THE CLIENT.            F2      Finalized/Denial - The claim/line has been denied.   9


                                                                          Page 193 of 378
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                                  EXCEEDS NUMBER OF VISITS/SUPPLIES
                                  AUTHORIZED FOR THIS CERTIFICATION
01/01/1977   12/31/3999   00318   PERIOD.                                     F2      Finalized/Denial - The claim/line has been denied.   483


                                  EACH CLAIM IS LIMITED TO 26 OR LESS
                                  DETAILS AND MUST INCLUDE A TOTAL
                                  BILLED AMOUNT. PLEASE RESUBMIT
01/01/1977   12/31/3999   00319   FOLLOWING THESE GUIDELINES.                 F2      Finalized/Denial - The claim/line has been denied.   121


                                  CONSULTATION SERVICES ARE ONLY
                                  PAYABLE TO THE DENTIST/PHYSICIAN
01/01/1977   12/31/3999   00320   NOT PERFORMING THE TREATMENT.               F2      Finalized/Denial - The claim/line has been denied.   104



                                  SERVICE NOT A BENEFIT OF MEDICARE.
                                  PLEASE REFILE THIS SERVICE WITH
                                  MEDICAID ON THE CORRECT CLAIM
                                  FORM & INCLUDE THE MEDICARE
01/01/1977   12/31/3999   00322   REMITTANCE ADVICE OR NOTICE.                F2      Finalized/Denial - The claim/line has been denied.   275


                                  DOCUMENTATION SUBMITTED WITH
                                  CLAIM FOR CCP SERVICES DOES NOT
                                  JUSTIFY PAYMENT. PLEASE REVIEW
                                  DOCUMENTATION CRITERIA AND
01/01/1977   12/31/3999   00323   APPEAL WITH MORE INFORMATION.               F2      Finalized/Denial - The claim/line has been denied.   294



                                  ANESTHESIA SERVICES MUST BE
                                  REPORTED WITH CPT-4 ANESTHESIA
                                  CODES. PLEASE RESUBMIT CLAIM WITH
01/01/1977   12/31/3999   00324   APPROPRIATE PROCEDURE CODES.                F2      Finalized/Denial - The claim/line has been denied.   454


                                  FOR INPATIENT SERVICES, PAID AMT
                                  REDUCED BY 20% EFF 9/1/1994. FOR
                                  OUTPATIENT SVCS, PAID AMT REDUCED
                                  BY 17.3% EFF 9/1/1999 OR 20% EFF
01/01/1977   12/31/3999   00325   9/1/1994-8/31/1999.                         F1      Finalized/Payment - The claim/line has been paid.    104


                                  DATES OF SERVICE OVER ONE YEAR
                                  FROM PROCESS DATE ARE NOT
01/01/1977   12/31/3999   00327   PAYABLE.                                    F2      Finalized/Denial - The claim/line has been denied.   9


                                                                          Page 194 of 378
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                                  PSYCHOTHERAPY WHEN BILLED WITH
                                  ELECTROSHOCK IS NOT A COVERED
01/01/1977   12/31/3999   00329   BENEFIT.                                    F2      Finalized/Denial - The claim/line has been denied.                     106


                                                                                      Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS PAYMENT IS DUE TO A REFUND                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00330   MADE IN ERROR BY YOUR OFFICE.               F4      forthcoming.                                                           101


                                  INITIAL HOSPITAL VISIT WITHIN 30 DAYS
                                  OF AN INITIAL HOSPITAL VISIT FOR
                                  SAME/RELATED CONDITION PAYABLE AS
01/01/1977   12/31/3999   00331   A FOLLOW-UP HOSPITAL VISIT.                 F1      Finalized/Payment - The claim/line has been paid.                      15


                                  THIS DETAIL DENIED DUE TO
                                  INSUFFICIENT INFORMATION. PLEASE
                                  RESUBMIT WITH NAMES OF ALL TESTS
01/01/1977   12/31/3999   00332   INCLUDED IN THIS PANEL/SERIES.              F2      Finalized/Denial - The claim/line has been denied.                     419


                                  PAYMENT IS WITHHELD DUE TO AN IRS
                                  NOTICE OF LEVY-YOUR 1099 WILL NOT
                                  BE AFFECTED BY THIS WITHHELD                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00333   AMOUNT.                                     F0      and no more action will be taken.                                      9


                                  NON-EMERGENCY AMBULANCE
                                  TRANSFERS TO A DOCTOR'S OFFICE
                                  REQUIRE NAME & ADDRESS OF DOCTOR
                                  & MUST STATE THE DIAGNOSIS &
                                  TREATMENT RENDERED AT TIME OF
01/01/1977   12/31/3999   00334   VISIT.                                      F2      Finalized/Denial - The claim/line has been denied.                     428


                                  THIS CLAIM WAS RECEIVED ORIGINALLY
                                  FROM ANOTHER INSURANCE CARRIER
                                  AND IS NOW PAST THE 95 DAY FILING
01/01/1977   12/31/3999   00335   DEADLINE.                                   F2      Finalized/Denial - The claim/line has been denied.                     9


                                  THIS RECOUPMENT IS THE RESULT OF
                                  AN ERROR IN PROCESSING MEDICARE                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  CLAIMS. MEDICAID DOES NOT PAY                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00338   MEDICARE DENIED DETAILS.                    F4      forthcoming.                                                           9




                                                                          Page 195 of 378
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                                  APPEAL RECEIVED PAST THE 180 DAY
                                  FILING DEADLINE. THE ORIGINAL                      Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT OR DENIAL HAS NOT BEEN                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00339   AFFECTED.                                  F4      forthcoming.                                                     9


                                  THIS ADJUSTMENT IS A RESULT OF THE
                                  RESOLUTION OF YOUR WRITTEN CASE
                                  APPEAL COMPLAINT BY TDH MEDICAL                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  APPEALS & PROVIDER RESOLUTION                      claim/encounter has been adjudicated and no further payment is
08/01/2002   12/31/3999   00340   DIVISION.                                  F4      forthcoming.                                                     101


                                  THIS ADJUSTMENT IS A RESULT OF
                                  YOUR TDH MEDICAL APPEALS &                         Finalized/Adjudication Complete - No payment forthcoming - The
                                  PROVIDER RESOLUTION DIVISION ORAL                  claim/encounter has been adjudicated and no further payment is
08/01/2002   12/31/3999   00341   APPEAL.                                    F4      forthcoming.                                                     101



                                  SUBSEQUENT SERVICES TO A THSTEPS
                                  SCREENING VISIT ARE PAYABLE AS A
01/01/1977   12/31/3999   00347   FOLLOW-UP SCREENING VISIT.                 F2      Finalized/Denial - The claim/line has been denied.               9


                                  THESE SERVICES ARE NOT PAYABLE
                                  FOR CLIENTS DETERMINED TO BE
                                  PRESUMPTIVELY ELIGIBLE. REFER TO
01/01/1977   12/31/3999   00349   PROVIDER PROCEDURE MANUAL.                 F2      Finalized/Denial - The claim/line has been denied.               91


                                  EYEGLASS PROGRAM SERVICES ARE
                                  NOT A BENEFIT FOR APHAKIA. PLEASE
                                  USE CODES FOR PROSTHETIC
01/01/1977   12/31/3999   00350   EYEWEAR.                                   F2      Finalized/Denial - The claim/line has been denied.               454


                                  A NEW PATIENT VISIT IS PAYABLE AS AN
                                  ESTABLISHED PATIENT VISIT WHEN A
                                  CONSULT, MEDICAL, OR SURGICAL
                                  SERVICE HAS PREVIOUSLY BEEN PAID
01/01/1977   12/31/3999   00352   TO THE SAME PROVIDER.                      F1      Finalized/Payment - The claim/line has been paid.                15


                                  THIS CHARGE IS INCLUDED IN ROOM
01/01/1977   12/31/3999   00353   RATE BILLED ON THE SAME DAY.               F2      Finalized/Denial - The claim/line has been denied.               483




                                                                         Page 196 of 378
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                                  CONSULTATION SERVICES FOR THIS
                                  PROVIDER SPECIALTY ARE PAYABLE
                                  ONLY AS AN INITIAL OFFICE/HOSPITAL
01/01/1977   12/31/3999   00354   VISIT.                                     F2      Finalized/Denial - The claim/line has been denied.   9



                                  NHIC MUST HAVE A VALID CONSENT
                                  FORM ON FILE FOR PAYMENT OF
                                  STERILIZATION PROCEDURES.REFER TO
                                  PROVIDER PROCEDURES MANUAL FOR
01/01/1977   12/31/3999   00356   INFORMATION ON CONSENT FORMS.              F2      Finalized/Denial - The claim/line has been denied.   21


                                  INITIAL HOSPITAL CARE WITHIN 30 DAYS
                                  OF A CONSULT PAYABLE AS A FOLLOW-
01/01/1977   12/31/3999   00357   UP CONSULT.                                F1      Finalized/Payment - The claim/line has been paid.    15


                                  EARLY REMOVAL MAY ONLY BE USED
                                  WHEN THE APPLIANCES WERE PLACED
                                  BY AN UNAFFILIATED PROVIDER.
                                  AUTHORIZATION IS REQUIRED PRIOR TO
01/01/1977   12/31/3999   00358   REMOVAL.                                   F2      Finalized/Denial - The claim/line has been denied.   84


                                  THIS SERVICE HAS BEEN PROCESSED
                                  BY MEDICAID, NO FURTHER
                                  CONSIDERATION OF PAYMENT BY CIDC,
                                  DUE TO CLIENT AGE AND MEDICAID
01/01/1977   12/31/3999   00359   PROGRAM TYPE.                              F2      Finalized/Denial - The claim/line has been denied.   104


                                  CLAIM DENIED. TRANSPORT DOES NOT
                                  MEET NON-EMERGENCY GUIDELINES.
                                  PLEASE REFER TO PROVIDER
                                  PROCEDURE MANUAL WHEN APPEALING
01/01/1977   12/31/3999   00360   CLAIM.                                     F2      Finalized/Denial - The claim/line has been denied.   428


                                  PROVIDER CERTIFIED FOR MEDICARE-
                                  MEDICAID CROSSOVER CLAIMS ONLY.
                                  CONTACT CUSTOMER SERVICE FOR
01/01/1977   12/31/3999   00361   MEDICAID CERTIFICATION.                    F2      Finalized/Denial - The claim/line has been denied.   132


                                  APPEALS/CLAIMS MUST BE SUBMITTED
                                  WITHIN 95 DAYS OF DATE OF PRIVATE
                                  INSURANCE EOB OR MEDICARE
01/01/1977   12/31/3999   00362   REMITTANCE ADVICE OR NOTICE.               F2      Finalized/Denial - The claim/line has been denied.   9


                                                                         Page 197 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



                                  DOCUMENTATION INSUFFICIENT TO
                                  DETERMINE EMERGENCY TRANSFER.
                                  RESUBMIT WITH ER RECORDS, FACILITY
                                  TRANSFER RECORDS &/OR L&D
01/01/1977   12/31/3999   00363   RECORDS.                                   F2      Finalized/Denial - The claim/line has been denied.               299


                                  CONTINUED PAYMENT FOR
                                  PT/OT/SPEECH THERAPY REQUIRES
                                  DOCUMENTATION OF MARKED
                                  IMPROVEMENT WITHIN 2 MONTHS OF
01/01/1977   12/31/3999   00364   ONSET OF INJURY/ILLNESS.                   F2      Finalized/Denial - The claim/line has been denied.               404


                                  AUTHORIZATION DENIED. RESUBMIT
                                  WITH ADMIT AND DISCHARGE RECORDS,
                                  PHYSICIAN LETTER OF MEDICAL
                                  NECESSITY, H&P, OR HOME
01/01/1977   12/31/3999   00365   HEALTH/NURSING HOME CARE PLAN.             F2      Finalized/Denial - The claim/line has been denied.               431


                                  CLAIM DENIED DUE TO INCORRECT
                                  ADDRESS. PLEASE SUBMIT ADDRESS
                                  CHANGE IN WRITING ON LETTER - HEAD
                                  TO NHIC TO THE ATTENTION OF THE
01/01/1977   12/31/3999   00366   PROVIDER ENROLLMENT DEPT.                  F2      Finalized/Denial - The claim/line has been denied.               126


                                  CLAIMS FOR CLIENTS WITH
                                  RETROACTIVE ELIGIBILITY MUST BE
                                  RECEIVED WITHIN 95 DAYS OF NHIC'S
                                  RECEIPT OF CLIENT'S ELIGIBILITY FROM
01/01/1977   12/31/3999   00367   DHS.                                       F2      Finalized/Denial - The claim/line has been denied.                9


                                  IF YOU ARE HAVING DIFFICULTY FILING                Finalized/Adjudication Complete - No payment forthcoming - The
                                  YOUR APPEAL, PLEASE CONTACT NHIC                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00368   CUSTOMER SERVICE AT 1-800-925-9126.        F4      forthcoming.                                                     101


                                  SERVICES EXCEED 180 DAY THERAPY
                                  LIMIT. NOT PAYABLE FOR CHRONIC
                                  CONDITION. MAY APPEAL WITH
                                  SUPPORTING MEDICAL
01/01/1977   12/31/3999   00371   DOCUMENTATION.                             F2      Finalized/Denial - The claim/line has been denied.               310




                                                                         Page 198 of 378
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                                  GUIDELINES FOR PAYMENT OF
                                  PT/OT/SPEECH THERAPY ARE LIMITED
                                  AND SPECIFIC AS TO TYPE OF INJURY
01/01/1977   12/31/3999   00372   AND OR ILLNESS.                             F2      Finalized/Denial - The claim/line has been denied.                     442


                                  PLEASE REFILE YOUR ADJUSTMENT                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  REQUEST WITH A STATEMENT OF THE                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00373   NATURE OF YOUR APPEAL.                      F4      forthcoming.                                                           294


                                  PROCEDURE DENIED DUE TO LACK OF
                                  PRIOR AUTHORIZATION. APPEAL TO TDH
                                  CSHCN, 1100 WEST 49TH ST., AUSTIN, TX
                                  78756-3179 WITHIN 30 DAYS OF NHIC'S
08/06/2001   12/31/3999   00374   DISPOSITION.                                F2      Finalized/Denial - The claim/line has been denied.                     84


                                  CLAIM MUST BE ADJUSTED BY
                                  MEDICARE PRIOR TO PAYMENT BY
01/01/1977   12/31/3999   00375   MEDICAID.                                   F2      Finalized/Denial - The claim/line has been denied.                     171



                                  A VALID DIAGNOSIS CODE IS REQUIRED
                                  FOR PROCESSING. REFILE CLAIM WITH A
                                  VALID DIAGNOSIS CODE. NARRATIVE
01/01/1977   12/31/3999   00376   DESCRIPTIONS ARE NOT ACCEPTABLE.            F2      Finalized/Denial - The claim/line has been denied.                     255



                                  OTHER INSURANCE AMOUNT IS
                                  GREATER THAN TOTAL BILLED. PLEASE                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00377   RESUBMIT WITH TOTAL CHARGES.                F0      and no more action will be taken.                                      400


                                  PLEASE SUBMIT TO OTHER INSURER
                                  AND ALLOW 110 DAYS FOR RESPONSE
                                  BEFORE APPEALING TO NHIC.
                                  DOCUMENT DATE OTHER INSURANCE
01/01/1977   12/31/3999   00378   WAS BILLED.                                 F2      Finalized/Denial - The claim/line has been denied.                     7


                                  OUR REVIEW INDICATES PREVIOUS
                                  CLAIM WAS PROCESSED CORRECTLY.
                                  PLEASE CONTACT THE TEXAS HEALTH                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  NETWORK FOR MORE INFORMATION. 1-                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00379   888-834-7226.                               F4      forthcoming.                                                           101




                                                                          Page 199 of 378
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                                  SERVICES DENIED AS A RESULT OF
                                  UTILIZATION REIVEW. PLEASE CONTACT                 Finalized/Adjudication Complete - No payment forthcoming - The
                                  THE TEXAS HEALTH NETWORK. 1-888-                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00380   834-7226.                                  F4      forthcoming.                                                           101


                                  A VALID SHARS PROVIDER NUMBER IS
                                  REQUIRED IN BLOCK 32 OF THE HCFA
                                  1500. PLEASE RESUBMIT CLAIM WITH A
01/01/1977   12/31/3999   00381   VALID SHARS PROVIDER NUMBER.               F2      Finalized/Denial - The claim/line has been denied.                     132


                                  MEDICATION CHARGES MUST INDICATE
                                  THE NAME OF THE DRUG, ROUTE OF
01/01/1977   12/31/3999   00384   ADMINISTRATION AND THE DOSAGE.             F2      Finalized/Denial - The claim/line has been denied.                     217


                                  A PROCEDURE CODE CANNOT BE
                                  ASSIGNED BY THE DESCRIPTION
                                  SUBMITTED. PLEASE ASSIGN A
                                  PROCEDURE CODE OR CLARIFY THE
01/01/1977   12/31/3999   00385   DESCRIPTION ON THE CLAIM FORM.             F2      Finalized/Denial - The claim/line has been denied.                     454


                                  CLAIMS FOR HOSPITAL TO HOSPITAL OR
                                  NH TO NH TRANSFERS MUST STATE THE
                                  SPECIFIC FACILITIES/SERVICES
                                  UNAVAILABLE AT THE
01/01/1977   12/31/3999   00387   HOSPTIAL/NURSING HOME OF ORIGIN.           F2      Finalized/Denial - The claim/line has been denied.                     266



                                  PREVIOUS PROCESSING OF CLAIM HAS
                                  BEEN REVIEWED AND DETERMINED TO
                                  BE CORRECT. CONTACT CUSTOMER                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  SERVICE IF YOU NEED CLARIFICATION                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00388   OF PRIOR DISPOSITION.                      F4      forthcoming.                                                           101


                                  YOUR CLAIM HAS BEEN REVIEWED AND
                                  PROCESSED. YOU WILL RECEIVE
                                  CLARIFICATION IN WRITTEN                           Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00389   CORRESPONDENCE.                            F0      and no more action will be taken.                                       2


                                  PAYMENT FOR HOME HEALTH SERVICES
                                  CANNOT BE MADE WHEN THE PHYSICIAN
                                  WHO SIGNS THE PLAN OF CARE IS
                                  OWNER/PARTNER AND/OR MEMBER OF
01/01/1977   12/31/3999   00390   THE BOARD.                                 F2      Finalized/Denial - The claim/line has been denied.                      9


                                                                         Page 200 of 378
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                                  CLIENT IS ELIGIBLE FOR MULTIPLE
                                  PROGRAMS (MEDICAID, CSHCN,
                                  MANAGED CARE, FP) FOR THE DATES OF
                                  SERVICE. YOUR CLAIM WAS SPLIT TO
                                  FACILITATE PROCESSING. TOTAL
                                  CHARGES WILL FINALIZE AS SEPARATE
                                  CLAIMS ON THE PROGRAM SPECIFIC R&S
01/01/1977   12/31/3999   00391   REPORT(S).                                F1      Finalized/Payment - The claim/line has been paid.               72


                                  LOCK-IN PHYSICIAN'S PROVIDER
01/01/1977   12/31/3999   00392   NUMBER MUST BE ON THE CLAIM.              F2      Finalized/Denial - The claim/line has been denied.              93


                                  FINANCIAL ACTION DUE TO TDH                       FNL/Adj Complt: Claim was processed as adjustment to previous
08/01/2002   12/31/3999   00393   DIRECTIVE.                                F4      claim.                                                          101


                                  PROVIDER DOES NOT HAVE BRC
                                  CERTIFICATION ON FILE TO PERFORM
                                  MAMMOGRAPHY PROCEDURE BILLED.
                                  PLEASE CONTACT CUSTOMER SERVICE
01/01/1977   12/31/3999   00394   ABOUT BRC CERTIFICATION.                  F2      Finalized/Denial - The claim/line has been denied.              142


                                  SERVICES DENIED. PLEASE CONTACT
                                  THE TEXAS HEALTH NETWORK FOR
                                  INFORMATION REGARDING THIS CLAIM.
01/01/1977   12/31/3999   00396   1-888-834-7226.                           F2      Finalized/Denial - The claim/line has been denied.              9


                                  WHEN MULTIPLES OF THE SAME
                                  CHARGES ARE PERFORMED ON THE
                                  SAME DAY, SEPARATE THE DETAILS AND
                                  DOCUMENT TIMES FOR EACH
01/01/1977   12/31/3999   00397   ADDITIONAL CHARGE.                        F2      Finalized/Denial - The claim/line has been denied.              300



                                  THE CLAIM DETAILS EXCEED OUR 28
                                  LIMIT. PLEASE COMBINE LIKE REVENUE
01/01/1977   12/31/3999   00398   CODES OR SEND MULTIPLE CLAIMS.            F2      Finalized/Denial - The claim/line has been denied.              121




                                                                        Page 201 of 378
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                                  THIS ADJUSTMENT IS THE RESULT OF
                                  YOUR FACILITY'S RECENT ANCILLARY
                                  REVIEW VISIT; THESE SERVICES DO NOT               Finalized/Adjudication Complete - No payment forthcoming - The
                                  MEET MEDICAID CRITERIA FOR                        claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00399   REIMBURSEMENT.                            F4      forthcoming.                                                     101


                                  DRG NOT PAYABLE FOR THIS AGE
                                  GROUP; RESUBMIT WITH CORRECTED
                                  DIAGNOSIS CODE FOR VALID DRG
01/01/1977   12/31/3999   00400   ASSIGNMENT.                               F2      Finalized/Denial - The claim/line has been denied.               256


                                  TEFRA 82 PROHIBITS PAYMENT FOR
                                  SURGICAL ASSISTANCE PROVIDED IN A
                                  FACILITY WITH A TEACHING PROGRAM IN
01/01/1977   12/31/3999   00402   THE ASSISTANT'S SPECIALTY.                F2      Finalized/Denial - The claim/line has been denied.               104


                                  SERVICES PROVIDED OUTSIDE YOUR
                                  OFFICE REQUIRE FACILITY NAME AND
01/01/1977   12/31/3999   00403   ADDRESS AND PROVIDER IDENTIFIER.          F2      Finalized/Denial - The claim/line has been denied.               132



                                  LAB OR XRAY SERVICES NOT INCLUDED
                                  IN FACILITY SERVICE MUST BE BILLED
                                  SEPARATELY USING THE PHYSICIAN OR
01/01/1977   12/31/3999   00404   LABORATORY PROVIDER NUMBER                F2      Finalized/Denial - The claim/line has been denied.               132


                                  BASE UNITS FOR ANESTHESIA WHEN
                                  MULTIPLE PROCEDURES ARE
                                  PERFORMED REPRESENT THE
                                  PROCEDURE WITH THE HIGHEST UNIT
01/01/1977   12/31/3999   00405   VALUE.                                    F1      Finalized/Payment - The claim/line has been paid.                251


                                  THE MEDICARE REMITTANCE ADVICE OR
                                  NOTICE DOESN'T MATCH THE
                                  INFORMATION ON YOUR CLAIM. PLEASE
01/01/1977   12/31/3999   00406   RECONCILE AND RESUBMIT.                   F2      Finalized/Denial - The claim/line has been denied.               286


                                  HIC NO. OR SUFFIX ON MEDICARE RA OR
                                  NOTICE DOES NOT MATCH FILE.
                                  RESUBMIT SERVICES TO MEDICARE
                                  USING CORRECT HIC NO. SHOWN ON
01/01/1977   12/31/3999   00407   CLIENT MEDICAL ID CARD.                   F2      Finalized/Denial - The claim/line has been denied.               284



                                                                        Page 202 of 378
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                                  EYEGLASS PROGRAM BENEFITS ARE
                                  NOT AVAILABLE TO CLIENTS
                                  PREVIOUSLY FURNISHED WITH
01/01/1977   12/31/3999   00408   PROSTHETIC EYEWEAR.                            F2       Finalized/Denial - The claim/line has been denied.                     483


                                  YOU MAY RECEIVE PAYMENT UNDER
                                  THIS PROCEDURE CODE FOR NO MORE
                                  THAN TWO CASE DENIALS OUT OF
                                  EVERY TEN CASES SUBMITTED FOR                           Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00409   AUTHORIZATION.                                 F0       and no more action will be taken.                                      104


                                  REPEAT INITIAL ICU-CCU VISIT OR
                                  RESPIRATORY CARE WITHIN 10 DAYS IS
01/01/1977   12/31/3999   00410   PAYABLE AS SUBSEQUENT CARE.                    F1       Finalized/Payment - The claim/line has been paid.                      15


                                  OUR RECORDS INDICATE THE
                                  BILLING/PERFORMING OR REFERRING
                                  PROVIDER HAS BEEN SANCTIONED,
                                  EXCLUDED OR TERMINATED FROM THIS
01/01/1977   12/31/3999   00411   PROGRAM.                                       F2       Finalized/Denial - The claim/line has been denied.                     91


                                  THE CLAIM FORM SUBMITTED IS
                                  LACKING ALL OR MOST OF THE
                                  REQUIRED INFORMATION. PLEASE
01/01/1977   12/31/3999   00412   RESUBMIT A COMPLETED CLAIM FORM.               F2       Finalized/Denial - The claim/line has been denied.                     122


                                  CLAIMS WITH PARTIAL NONCOVERED
                                  AMOUNTS CANNOT BE PROCESSED.
                                  PLEASE INDICATE WHAT CHARGES ARE
                                  BEING NONCOVERED AND RESUBMIT
01/01/1977   12/31/3999   00413   CLAIM.                                         F2       Finalized/Denial - The claim/line has been denied.                     425


                                  THE "FROM" DATE OF SERVICE MUST
                                  MATCH THE ADMIT DATE OF SERVICE
                                  FOR TYPE OF BILL 111, 112, 115, 121, 122,
                                  AND 125. PLEASE CORRECT AND
01/01/1977   12/31/3999   00414   RESUBMIT CLAIM.                                F2       Finalized/Denial - The claim/line has been denied.                     188




                                                                              Page 203 of 378
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                                  PROFESSIONAL COMP HAS PREVIOUSLY
                                  BEEN BILLED/PAID AND CONSIDERED
                                  PART OF THE COMBINED PROCEDURE. IF
                                  APPROPRIATE RESUBMIT CLAIM FOR
01/01/1977   12/31/3999   00415   TECHNICAL COMPONENT.                       F2       Finalized/Denial - The claim/line has been denied.   104


                                  MEDICARE ELIGIBILITY IS BEING
                                  INVESTIGATED BY DHS. PLEASE
                                  REAPPEAL AFTER 120 DAYS, BUT WITHIN
01/01/1977   12/31/3999   00416   180 DAYS OF THIS R&S.                      F2       Finalized/Denial - The claim/line has been denied.   198


                                  TECHNICAL COMP HAS PREVIOUSLY
                                  BEEN BILLED/PAID AND CONSIDERED
                                  PART OF THE COMBINED PROCEDURE. IF
                                  APPROPRIATE RESUBMIT CLAIM FOR
01/01/1977   12/31/3999   00417   PROFESSIONAL COMPONENT.                    F2       Finalized/Denial - The claim/line has been denied.   104


                                  THE ELECTRONIC CLAIM REJECTION
                                  REPORT DOES NOT MATCH THE
                                  INFORMATION ON YOUR PAPER CLAIM.
01/01/1977   12/31/3999   00418   PLEASE CORRECT AND RESUBMIT.               F2       Finalized/Denial - The claim/line has been denied.   21



                                  A SEPARATE CLAIM FORM IS REQUIRED
                                  FOR EACH DATE OF AMBULANCE
                                  SERVICES. PLEASE RECONCILE AND
                                  RESUBMIT WITH SIGNED CLAIM COPIES
01/01/1977   12/31/3999   00419   FOR EACH DATE OF SERVICE.                  F2       Finalized/Denial - The claim/line has been denied.   481


                                  OUR RECORDS INDICATE PROVIDER IS
                                  NOT ENROLLED IN THIS PROGRAM.
01/01/1977   12/31/3999   00420   CONTACT TMHP CUSTOMER SERVICE.             F2       Finalized/Denial - The claim/line has been denied.   132


                                  DETAIL PERFORMING PROVIDER
                                  NUMBER NOT ON PROVIDER FILE. NOTE:
                                  AS OF 4/7/2002, OLD MEDICAID PROVIDER
                                  NUMBERS ARE NO LONGER ACCEPTED,
                                  PLEASE SUBMIT A VALID TPI FOR THIS
01/01/1977   12/31/3999   00421   SERVICE.                                   F2       Finalized/Denial - The claim/line has been denied.   132




                                                                          Page 204 of 378
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                                  TAKE HOME DRUGS/FLOURIDE ARE NOT
                                  A BENEFIT. THESE REQUIRE A
                                  PRESCRIPTION, PAYABLE THROUGH THE
01/01/1977   12/31/3999   00422   VENDOR DRUG PROGRAM.                       F2      Finalized/Denial - The claim/line has been denied.               9


                                  DENTAL BEHAVIORAL MANAGEMENT
                                  REQUIRES 2 COMPONENTS - THE
                                  SPECIFIC BEHAVIOR AND THE
                                  TECHNIQUE USED. PLEASE APPEAL
                                  CLAIM WITH APPROPRIATE
01/01/1977   12/31/3999   00423   DOCUMENTATION.                             F2      Finalized/Denial - The claim/line has been denied.               407


                                  THIS PROCEDURE REQUIRES
                                  MODIFIER(S). PLEASE APPEAL CLAIM
01/01/1977   12/31/3999   00424   WITH APPROPRIATE MODIFIER(S).              F2      Finalized/Denial - The claim/line has been denied.               453


                                  THIS RECOUPMENT IS NECESSARY TO
                                  PROCESS YOUR SPLIT CLAIMS FOR
                                  OUTLIER CONSIDERATION. NO ACTION                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  ON YOUR PART IS NECESSARY. REFER                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00425   TO FUTURE R&S.                             F4      forthcoming.                                                     101


                                  A CORRECTED CLAIM FORM MUST
                                  ACCOMPANY THE R&S. PLEASE REFER
                                  TO THE INSTRUCTIONS ON YOUR R&S
                                  FOR RESUBMITTING INCOMPLETE
01/01/1977   12/31/3999   00426   CLAIMS.                                    F2      Finalized/Denial - The claim/line has been denied.               275


                                  DATE(S) OF SERVICE ON CLAIM OR
                                  ATTACHMENT ARE PRIOR TO THE ADMIT
                                  DATE. PLEASE RECONCILE AND
01/01/1977   12/31/3999   00427   RESUBMIT WITH SIGNED CLAIM COPY.           F2      Finalized/Denial - The claim/line has been denied.               230



                                  PROVIDER NOT ELIGIBLE FOR CO-
                                  INSURANCE OR DEDUCTABLE PAYMENT.
01/01/1977   12/31/3999   00428   CONTACT NHIC CUSTOMER SERVICE.             F2      Finalized/Denial - The claim/line has been denied.               91


                                  THIS SURGERY/SERVICE/SITUATION
                                  DESCRIBED IS NOT ON THE
                                  AUTHORIZATION LETTER AND IS NOT
01/01/1977   12/31/3999   00429   PAYABLE.                                   F2      Finalized/Denial - The claim/line has been denied.               84



                                                                         Page 205 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


                                  THIRTY DAYS OF INPATIENT HOSPITAL
                                  CONFINEMENT HAVE BEEN UTILIZED. NO
                                  PAYMENT MADE FOR CO-INS AND/OR
01/01/1977   12/31/3999   00431   DEDUCTIBLES, IF APPLICABLE.                F2      Finalized/Denial - The claim/line has been denied.   483


                                  TO APPEAL MULTIPLE HOSPITAL CLAIMS
                                  FOR POTENTIAL OUTLIER PAYMENT,
                                  RESUBMIT ONE CLAIM WITH COMBINED
01/01/1977   12/31/3999   00432   TOTAL CHARGES.                             F2      Finalized/Denial - The claim/line has been denied.   275


                                  ADD'L INFO NEEDED TO PROCESS CLAIM
                                  FOR EPOETIN ALFA. PLEASE RESUBMIT
                                  SIGNED CLAIM COPY, R&S COPY &
                                  TOTAL UNITS ADMIN W/CODE Q9920-
01/01/1977   12/31/3999   00433   Q9940 (BASED ON HCT).                      F2      Finalized/Denial - The claim/line has been denied.   217


                                  DATES OF SERVICE HAVE BEEN
                                  PREVIOUSLY PAID ON A DIFFERENT
                                  CLAIM. FOR MEDICAID INFORMATION
                                  CALL 1-800-925-9126. FOR CIDC
01/01/1977   12/31/3999   00434   INFORMATION CALL 1-800-568-2413.           F2      Finalized/Denial - The claim/line has been denied.   54


                                  REJECTED CLAIMS MUST BE FILED ON
                                  THE CORRECT CLAIM FORM WITH A
                                  TEXMEDNET REJECTION REPORT WHICH
                                  INCLUDES THE NHIC ASSIGNED
01/01/1977   12/31/3999   00435   TRANSMISSION NUMBER.                       F2      Finalized/Denial - The claim/line has been denied.   275


                                  FOR DATES OF SERVICE ON/AFTER
                                  6/10/91, PROC. MUST BE BILLED AS A
                                  WEEKLY SERVICE. PLEASE RESUBMIT
                                  CLAIM COPY, R&S, AND APPROPRIATE
01/01/1977   12/31/3999   00437   PROCEDURE CODE.                            F2      Finalized/Denial - The claim/line has been denied.   454



                                  RESIDENTIAL TREATMENT SERVICES
                                  PAYABLE ONLY FOR PERSONS ELIGIBLE
                                  FOR CHILD PROTECTIVE SERVICES
01/01/1977   12/31/3999   00439   (CLIENT TYPE PROGRAM 8, 9, OR 10).         F2      Finalized/Denial - The claim/line has been denied.   109




                                                                         Page 206 of 378
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                                  RECOUPMENT DUE TO DHS DIRECTIVE.
                                  SERVICES FOR THIS CLIENT ARE PAID BY               Finalized/Adjudication Complete - No payment forthcoming - The
                                  HOME AND COMMUNITY BASED                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00442   SERVICES WAIVER.                           F4      forthcoming.                                                     101


                                  THIS SERVICE EXCEEDS BENEFIT
                                  LIMITATIONS BUT MAY BE PAID WITH
                                  MEDICAL NECESSITY DOCUMENTATION.
                                  PLEASE APPEAL WITH APPROPRIATE
01/01/1977   12/31/3999   00443   DOCUMENTATION.                             F2      Finalized/Denial - The claim/line has been denied.               294


                                  REQUEST FOR CHANGE OF INCORRECT
                                  PROVIDER NUMBER MUST BE
                                  PROCESSED AND CORRECTED BY
                                  MEDICARE PRIOR TO MEDICAID
01/01/1977   12/31/3999   00445   ADJUSTMENT.                                F2      Finalized/Denial - The claim/line has been denied.               286


                                  THE NAME AND ADDRESS OR NINE DIGIT
                                  PROVIDER NUMBER OF THE
                                  PERFORMING LAB MUST BE INDICATED
                                  ON THE CLAIM WHEN BILLING A LAB
01/01/1977   12/31/3999   00448   HANDLING FEE.                              F2      Finalized/Denial - The claim/line has been denied.               179


                                  INFORMATION FROM THE OTHER
                                  INSURANCE COMPANY HAS BEEN
                                  RECEIVED. CLIENT HAS MORE THAN ONE
                                  INSURANCE COMPANY. PLEASE
01/01/1977   12/31/3999   00450   CONTACT CUSTOMER SERVICE.                  F2      Finalized/Denial - The claim/line has been denied.               116


                                  AMBULANCE TRANSFER DOES NOT MEET
                                  EMERGENCY/NON-EMERGENCY
                                  CRITERIA. REFER TO PROVIDER
                                  PROCEDURES MANUAL FOR APPEAL
01/01/1977   12/31/3999   00451   GUIDELINES.                                F2      Finalized/Denial - The claim/line has been denied.               337


                                  SERVICE DENIED BY ASSOCIATE DENTAL
                                  DIRECTOR. X-RAY
                                  UNREADABLE/UNMARKED RT/LT. A
                                  COMPLETE DESCRIPTION OF
                                  PROCEDURE TOOTH ID, AND CLEAR X-
01/01/1977   12/31/3999   00453   RAY IS REQUIRED.                           F2      Finalized/Denial - The claim/line has been denied.               318




                                                                         Page 207 of 378
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                                  OUR RECORDS INDICATE THAT THE
                                  REFERRING/ORDERING PROVIDER HAS
                                  BEEN SANCTIONED, EXCLUDED OR
01/01/1977   12/31/3999   00454   TERMINATED FROM THIS PROGRAM.              F2      Finalized/Denial - The claim/line has been denied.   24


                                  MEDICAL CARE ID FORM 3087 OR
                                  MEDICAID VERIFICATION FORM 1027 IS
                                  THE ONLY ACCEPTABLE MEDICAID
                                  CLIENT ELIGIBILITY VERIFICATION
01/01/1977   12/31/3999   00456   DOCUMENTS.                                 F2      Finalized/Denial - The claim/line has been denied.   153



                                  SERVICES PROVIDED IN AN INSTITUTION
                                  FOR MENTAL DISEASE FOR PERSONS
                                  BETWEEN THE AGES OF 21 AND 65
                                  YEARS ARE NOT A BENEFIT OF THE
01/01/1977   12/31/3999   00457   TEXAS MEDICAID PROGRAM.                    F2      Finalized/Denial - The claim/line has been denied.   104


                                  DRG CANNOT BE ASSIGNED. CLIENT SEX
                                  ON FILE IS INVALID TO PROCEDURE OR
                                  DIAGNOSIS BILLED. ELIGIBILITY
                                  REFERRAL SENT TO DHS. REAPPEAL
01/01/1977   12/31/3999   00458   WITHIN 180 DAYS.                           F2      Finalized/Denial - The claim/line has been denied.   86


                                  PROCEDURE DENIED. MAY BE
                                  CONSIDERED UNDER THE THSTEPS-CCP
                                  PROGRAM. PLEASE APPEAL WITH
                                  \DOCUMENTATION TO SUPPORT THE
                                  MEDICAL
01/01/1977   12/31/3999   00459   NECESSITY/APPROPRIATENESS.                 F2      Finalized/Denial - The claim/line has been denied.   287


                                  REQUESTED DOCUMENTATION
                                  RECEIVED. HOWEVER THE DATE(S)
                                  AND/OR CONTENT DO NOT DEFINE
                                  CLIENT'S "SEVERELY DISABLED"
01/01/1977   12/31/3999   00460   CONDITION AT TIME OF TRANSPORT.            F2      Finalized/Denial - The claim/line has been denied.   472



                                  CLAIM MUST STATE THAT STAFF ARE ON
                                  AN "ON CALL" BASIS ONLY BETWEEN 8:00
                                  PM AND 8:00 AM AND MUST INCLUDE
                                  EXACT TIME OF AMBULANCE TRANSFER
01/01/1977   12/31/3999   00461   FOR PAYMENT.                               F2      Finalized/Denial - The claim/line has been denied.   472



                                                                         Page 208 of 378
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                                  MEDICAID REIMBURSEMENT FOR
                                  AMBULANCE SVCS IS LIMITED TO BASIC
                                  LIFE SUPPORT (BLS). PLEASE RESUBMIT
                                  ADVANCED LIFE SUPPORT (ALS) SVCS
01/01/1977   12/31/3999   00462   AS BLS PROC W/ A9 MOD.                     F2      Finalized/Denial - The claim/line has been denied.   472



                                  PLEASE PROVIDE THE COMPLETE 9-
                                  DIGIT CIDC PERFORMING PROVIDER
                                  NUMBER OR NAME OF THE PERFORMING
                                  PROVIDER. A MEDICAID PROVIDER
01/01/1977   12/31/3999   00463   NUMBER IS NOT VALID FOR CIDC.              F2      Finalized/Denial - The claim/line has been denied.   153


                                  CLAIM DENIED DUE TO CLIENT OR
                                  PROVIDER INELIGIBILITY. CLIENTS MUST
                                  BE UNDER AGE 21 AND PROVIDERS
                                  MUST BE ENROLLED FOR THIS CCP DATE
01/01/1977   12/31/3999   00464   OF SERVICE.                                F2      Finalized/Denial - The claim/line has been denied.   475



                                  THSTEPS-CCP SERVICES ARE PAYABLE
                                  FOR CLIENTS UNDER THE AGE OF
                                  21.THESE SERVICES HAVE BEEN
                                  CUTBACK/DENIED FOR DATES OF
01/01/1977   12/31/3999   00465   SERVICE ON/AFTER THE 21ST BIRTHDAY.        F2      Finalized/Denial - The claim/line has been denied.   475


                                  SURGICAL PROC PERFORMED IN HASC
                                  MUST BE BILLED USING THE HOSPITAL
                                  AMBULATORY SURGICAL CENTER PROV.
01/01/1977   12/31/3999   00466   NUMBER THAT WAS ISSUED.                    F2      Finalized/Denial - The claim/line has been denied.   132


                                  RESUBMIT WITH PHYSICIAN'S LETTER
                                  STATING HOW THE PATIENT WILL
                                  MEDICALLY BENEFIT FROM A NURSING
01/01/1977   12/31/3999   00467   HOME TO NURSING HOME TRANSFER.             F2      Finalized/Denial - The claim/line has been denied.   428


                                  THIS AUTHORIZATION NUMBER IS NULL
                                  AND VOID DUE TO HOSPITAL FAILURE TO
                                  SUBMIT REQUESTED DOCUMENTATION.
                                  APPEAL WITH ADMIT AND DISCHARGE
01/01/1977   12/31/3999   00468   RECORDS.                                   F2      Finalized/Denial - The claim/line has been denied.   297




                                                                         Page 209 of 378
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                                  CLAIM/PROCEDURE WAS REFERENCED
                                  TO A MISSING/INVALID DIAGNOSIS CODE.
                                  PLEASE REFILE WITH A CORRECT
01/01/1977   12/31/3999   00469   DIAGNOSIS CODE.                             F2      Finalized/Denial - The claim/line has been denied.   255


                                  INITIAL HOSPITAL CARE BILLED ON THE
                                  SAME DAY AS NEWBORN
                                  RESUSCITATION OR CRITICAL CARE IS
01/01/1977   12/31/3999   00470   PAYABLE AS A SUBSEQUENT VISIT.              F2      Finalized/Denial - The claim/line has been denied.   15


                                  EACH CLAIM IS LIMITED TO 27 OR LESS
                                  DETAILS AND MUST INCLUDE A TOTAL
                                  BILLED AMOUNT. PLEASE RESUBMIT
01/01/1977   12/31/3999   00472   FOLLOWING THESE GUIDELINES.                 F2      Finalized/Denial - The claim/line has been denied.   121


                                  THIS SERVICE REQUIRES PRIOR
                                  AUTHORIZATION. PAPER APPEAL WITH
                                  R&S, CLAIM COPY AND REQUIRED
                                  DOCUMENTATION AS DEFINED IN THE
01/01/1977   12/31/3999   00473   PROVIDER PROCEDURE MANUAL.                  F2      Finalized/Denial - The claim/line has been denied.   84


                                  THESE TESTS SHOULD BE COMBINED &
                                  BILLED AS 1 CHARGE. RESUBMIT
                                  W/SIGNED CLAIM COPY, R&S, AND
01/01/1977   12/31/3999   00474   APPROPRIATE TEST CODE.                      F2      Finalized/Denial - The claim/line has been denied.   454


                                  PAID ACCORDING TO THE TEXAS
                                  MEDICAID REIMBURSEMENT
                                  METHODOLOGY-TMRM (RELATIVE VALUE
                                  UNIT TIMES STATEWIDE CONVERSION
01/01/1977   12/31/3999   00475   FACTOR)                                     F1      Finalized/Payment - The claim/line has been paid.    67


                                  THESE SERVICES FOR NURSING
                                  FACILITY CLIENTS MUST BE
                                  COORDINATED WITH THE NURSING
                                  FACILITY PRIOR TO CONTACTING TDHS
01/01/1977   12/31/3999   00477   REHAB SVCS PROGRAM.                         F2      Finalized/Denial - The claim/line has been denied.   9


                                  SERVICE DENIED BY THE ASSOCIATE
                                  MEDICAL DIRECTOR. AIR TRANSFER NOT
                                  NECESSARY, SERVICE AVAILABLE AT
01/01/1977   12/31/3999   00480   ORIGINAL FACILITY.                          F2      Finalized/Denial - The claim/line has been denied.   430



                                                                          Page 210 of 378
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                                  BASED ON ALL DOCUMENTATION
                                  RECEIVED, AMBULANCE TRANSFER
                                  DOES NOT MEET EMERGENCY CRITERIA.
01/01/1977   12/31/3999   00481   THEREFORE, IT IS NOT A BENEFIT.           F2      Finalized/Denial - The claim/line has been denied.                     104


                                  EVALUATION AND MANAGEMENT CODES
                                  ARE NOT PAYABLE ON AN OUTPATIENT
                                  CLAIM. REFER TO PROVIDER
01/01/1977   12/31/3999   00483   PROCEDURE MANUAL.                         F2      Finalized/Denial - The claim/line has been denied.                     454



                                  AIR TRANSFER IS DENIED. TO CONSIDER
                                  CLAIM FOR PAYMENT SUBMIT YOUR
                                  FLIGHT RECORDS, HOSPITAL ADMIT /
                                  DISCHARGE RECORDS AND HISTORY
01/01/1977   12/31/3999   00486   AND PHYSICAL.                             F2      Finalized/Denial - The claim/line has been denied.                     297


                                  DIAGNOSIS CODES BEGINNING WITH E
                                  OR M ARE NOT VALID AS A PRIMARY
                                  DIAGNOSIS. PLEASE REFILE YOUR
                                  CLAIM WITH A VALID PRIMARY
01/01/1977   12/31/3999   00487   DIAGNOSIS CODE.                           F2      Finalized/Denial - The claim/line has been denied.                     254


                                  OUR RECORDS INDICATE THAT THERE IS
                                  NO CLIA NUMBER ON FILE FOR THIS
                                  PROVIDER NUMBER OR THE CLIA IS NOT
                                  VALID FOR THE DATES OF SERVICE ON
01/01/1977   12/31/3999   00488   THE CLAIM.                                F2      Finalized/Denial - The claim/line has been denied.                     142


                                  CLIENT ENROLLED IN THE TEXAS
                                  HEALTH NETWORK FOR DATE(S) OF
                                  SERVICE. ELIG. SERVICES WILL BE
                                  PROCESSED ON SEPARATE CLAIM. NO                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00489   ACTION ON YOUR PARTNECESSARY.             F0      and no more action will be taken.                                      104


                                  REQUIRED INFORMATION ON
                                  PHYSICIAN'S AUTHORIZATION IS
                                  MISSING/INCOMPLETE. PLEASE REFER
01/01/1977   12/31/3999   00490   TO PROVIDER PROCEDURES MANUAL.            F2      Finalized/Denial - The claim/line has been denied.                     122




                                                                        Page 211 of 378
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                                  ADM. DENIED BY UR. SERVICES
                                  PROVIDED IN OBSERVATION MAY BE
                                  APPEALED TO NHIC ADJUSTMENTS ON A                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  REVISED OUTPATIENT CLAIM AS                         claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00491   SPECIFIED IN HHSC DENIAL LETTER.            F4      forthcoming.                                                     101



                                  PROCESSING DETERMINED TO BE
                                  CORRECT. IF YOU FIND NHIC DID NOT
                                  PROVIDE FULL APPEAL CONSIDERATION,                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  YOU MAY FILE A COMPLAINT WITH TDH                   claim/encounter has been adjudicated and no further payment is
08/01/2002   12/31/3999   00493   WITHIN 60 CALENDAR DAYS.                    F4      forthcoming.                                                     101


                                  THIS SERVICE WAS PAID TO AN
                                  INDEPENDENT LAB. IF SERVICE
                                  PERFORMED IN YOUR OFFICE, PLEASE
                                  APPEAL WITH TEST RESULT AND
01/01/1977   12/31/3999   00494   NECESSITY FOR REPEAT PROCEDURE.             F2      Finalized/Denial - The claim/line has been denied.               300


                                  REQUIRED TEFRA INFORMATION
                                  INCOMPLETE. PLEASE RESUBMIT WITH
                                  THE APPROPRIATE MODIFIER AND TOTAL
01/01/1977   12/31/3999   00498   TIME IN MINUTES.                            F2      Finalized/Denial - The claim/line has been denied.               251


                                  CLIENT IS ELIGIBLE FOR MEDICARE. BILL
                                  MEDICARE FIRST. MEDICARE NUMBER:
01/01/1977   12/31/3999   00499   %1.                                         F2      Finalized/Denial - The claim/line has been denied.               116


                                  DOCUMENTATION OF CLIENT'S
                                  DISABILITY INSUFFICIENT. RESUBMIT
                                  WITH CLARIFICATION OF CLIENT'S
                                  CONDITION REQUIRING A STRETCHER
01/01/1977   12/31/3999   00500   AND/OR MEDICAL MONITORING.                  F2      Finalized/Denial - The claim/line has been denied.               472


                                  PAYMENT FOR MILEAGE IS NOT MADE
                                  PRIOR TO PICK UP OR AFTER
01/01/1977   12/31/3999   00501   COMPLETION OF PATIENT TRANSFER.             F2      Finalized/Denial - The claim/line has been denied.               104


                                  NEWBORN SERVICES DENIED ON
                                  MOTHER'S CLAIM. PLEASE RESUBMIT
                                  NEWBORN SERVICE ON A SEPARATE
01/01/1977   12/31/3999   00502   NEWBORN CLAIM.                              F2      Finalized/Denial - The claim/line has been denied.               238



                                                                          Page 212 of 378
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                                  REVENUE CODE INVALID OR NOT USED
01/01/1977   12/31/3999   00503   BY THIS PROGRAM.                          F2      Finalized/Denial - The claim/line has been denied.   455


                                  REDUCED DUE TO CLIENT'S MEDICALLY
                                  NEEDY SPENDDOWN. FOR
                                  INFORMATION, PLEASE CALL CUSTOMER
01/01/1977   12/31/3999   00504   SERVICE.                                  F1      Finalized/Payment - The claim/line has been paid.    68


                                  WHEN A CONSULTING PHYSICIAN
                                  INSTITUTES TREATMENT AND FOLLOWS
                                  THE CLIENT, THE CONSULTATION IS
01/01/1977   12/31/3999   00507   PAYABLE AS PHYSICIAN VISITS.              F1      Finalized/Payment - The claim/line has been paid.    15


                                  INTERIM BILLING, LATE CHARGES NOT
                                  PAYABLE UNDER LONESTAR SELECT II
                                  PERDIEM PRICING METHOD. PLEASE
                                  RESUBMIT ONE CLAIM WITH COMBINED
01/01/1977   12/31/3999   00508   FINAL CHARGES.                            F2      Finalized/Denial - The claim/line has been denied.   7


                                  CLAIM DENIED. CLIENT HAS MET THE 30
                                  ENCOUNTER LIMITATION. PRIOR
                                  AUTHORIZATION IS REQUIRED FOR
                                  ADDITIONAL SERVICES IN THE CURRENT
01/01/1977   12/31/3999   00510   CALENDAR YEAR.                            F2      Finalized/Denial - The claim/line has been denied.   84


                                  APPEAL TO TDH W/MEDICAL RECORDS
                                  AND AFFIDAVIT. INPATIENT HOSPITAL
                                  STAY W/IN 24 HRS OF AN OUTPATIENT
                                  SURGICAL STAY REQUIRES
08/01/2002   12/31/3999   00511   DOCUMENTATION OF COMPLICATION.            F2      Finalized/Denial - The claim/line has been denied.   407



                                  SERVICES NOT MEDICALLY NECESSARY
                                  AS RELATED TO COUNSELING AND
                                  SELECTION OF A CONTRACEPTIVE
                                  METHOD ARE NOT PAYABLE TO A FAMILY
01/01/1977   12/31/3999   00512   PLANNING AGENCY.                          F2      Finalized/Denial - The claim/line has been denied.   287




                                                                        Page 213 of 378
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                                  ELECTRONIC BILLING OF EMERGENCY
                                  TRANSFERS REQUIRE A NARRATIVE
                                  DESCRIPTION OF CLIENT'S CONDITION
                                  AND VITAL SIGNS TO BE INCLUDED IN
01/01/1977   12/31/3999   00513   THE COMMENT FIELD.                          F2      Finalized/Denial - The claim/line has been denied.   472


                                  HOSPITAL SUBSEQUENT CARE IS NOT
                                  PAYABLE TO REFERRING PHYSICIAN
                                  ONCE CONSULTANT ASSUMES CARE OF
01/01/1977   12/31/3999   00514   THE CLIENT.                                 F2      Finalized/Denial - The claim/line has been denied.   104



                                  AN INITIAL CARE VISIT WITHIN ONE YEAR
                                  OF ANOTHER INITIAL CARE VISIT IN THE
                                  SKILLED NURSING FACILITY IS PAYABLE
01/01/1977   12/31/3999   00515   AS A SUBSEQUENT CARE VISIT                  F1      Finalized/Payment - The claim/line has been paid.    15


                                  IF EYEWEAR IS BEYOND PROGRAM
                                  BENEFITS, CIRCLE ITEM A IN BLOCK 7
                                  AND HAVE THE CLIENT SIGN BLOCK 11
01/01/1977   12/31/3999   00516   OF THE CLAIM FORM.                          F2      Finalized/Denial - The claim/line has been denied.   466


                                  A NEW PATIENT VISIT WITHIN ONE YEAR
                                  OF A CONSULT IS PAYABLE AS AN
01/01/1977   12/31/3999   00517   ESTABLISHED PATIENT VISIT.                  F1      Finalized/Payment - The claim/line has been paid.    15


                                  THE AT MODIFIER CANNOT BE USED
                                  WITH A PAN. PLEASE RESUBMIT
                                  CORRECTED CLAIM WITH R&S AND
                                  INDICATE ACUTE OR CHRONIC
01/01/1977   12/31/3999   00518   CONDITION.                                  F2      Finalized/Denial - The claim/line has been denied.   293


                                  THE COMBINATION OF MODIFIER
                                  DESCRIPTION AND TYPE OF SERVICE IS
01/01/1977   12/31/3999   00519   INVALID.                                    F2      Finalized/Denial - The claim/line has been denied.   453


                                  CLIENT MUST BE SEEN BY A PHYSICIAN
                                  WITHIN A SIX MONTH PERIOD IN ORDER
                                  TO QUALIFY FOR HOME HEALTH
01/01/1977   12/31/3999   00520   BENEFITS.                                   F2      Finalized/Denial - The claim/line has been denied.   310




                                                                          Page 214 of 378
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                                  REQUIRED TEFRA INFORMATION
                                  INCOMPLETE. PLEASE RESUBMIT WITH
                                  NUMBER OF CONCURRENT
01/01/1977   12/31/3999   00525   PROCEDURES SUPERVISED.                     F2      Finalized/Denial - The claim/line has been denied.                262


                                  SERVICES AVAILABLE THROUGH TEXAS
                                  DEPARTMENT OF HEALTH ARE NOT A
01/01/1977   12/31/3999   00526   BENEFIT.                                   F2      Finalized/Denial - The claim/line has been denied.                9



                                  CLINICAL LABORATORY CONSULTATIONS
                                  PAYABLE ONLY WITH NAME OF
                                  REQUESTING PHYSICIAN, PATIENT
                                  DIAGNOSIS, CLINICAL TEST RESULTS,
01/01/1977   12/31/3999   00529   AND WRITTEN NARRATIVE REPORT.              F2      Finalized/Denial - The claim/line has been denied.                300



                                  LAB HANDLING CHARGE PAYABLE ONLY
                                  WHEN SPECIMEN IS COLLECTED BY
                                  VENIPUNCTURE OR CATHETERIZATION
                                  AND TEST IS PERFORMED OUTSIDE                      Acknowledgement/Acceptance into adjudication system-The
01/01/1977   12/31/3999   00531   PHYSICIANS OFFICE.                         A2      claim/encounter has been accepted into the adjudication system.   107



                                  LAB HANDLING CHARGE PAYABLE ONLY
                                  WHEN SPECIMEN IS COLLECTED BY
                                  VENIPUNCTURE OR CATHETERIZATION
                                  AND TEST IS PERFORMED OUTSIDE
01/01/1977   12/31/3999   00532   PHYSICIANS OFFICE.                         F2      Finalized/Denial - The claim/line has been denied.                179


                                  CLAIM DENIED DUE TO INTERIM BILLING.
                                  PLEASE REFILE CLAIM AFTER
                                  DISCHARGE OR 30 DAYS CONTINUOUS
01/01/1977   12/31/3999   00533   HOSPITALIZATION.                           F2      Finalized/Denial - The claim/line has been denied.                7


                                  THIS CLAIM/APPEAL CANNOT BE
                                  PROCESSED CORRECTLY DUE TO
                                  ILLEGIBLE INFORMATION. PLEASE
                                  RESUBMIT WITH LEGIBLE
01/01/1977   12/31/3999   00534   CLAIM/DOCUMENTATION.                       F2      Finalized/Denial - The claim/line has been denied.                122




                                                                         Page 215 of 378
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                                  AS OF 010198 THE DMEH PROVIDER
                                  NUMBER MUST BE USED ON HCFA 1500
                                  WHEN BILLING HOME HEALTH
                                  DME/MEDICAL SUPPLIES. REFILE
                                  CORRECT CLAIM FOR THIS DETAIL
01/01/1977   12/31/3999   00535   W/R&S.                                    F2      Finalized/Denial - The claim/line has been denied.               132


                                  FOR PAYMENT OF CONCURRENT CARE,
                                  APPEAL MUST BE SUBMITTED WITH
                                  HISTORY/PHYSICAL, ALL CONSULT
                                  REPORTS, AND ALL PHYSICIAN
01/01/1977   12/31/3999   00536   PROGRESS REPORTS.                         F2      Finalized/Denial - The claim/line has been denied.               297


                                  HHSC/OIE HAS REQUESTED THIS ITEM
                                  BE RECOUPED. APPEALS MUST BE                      Finalized/Adjudication Complete - No payment forthcoming - The
                                  FORWARDED TO THE OIE/MPI DIVISION                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00537   OF HHSC.                                  F4      forthcoming.                                                     101


                                  DOCUMENTATION INSUFFICIENT TO
                                  VERIFY MEDICAL NECESSITY. PLEASE
                                  RESUBMIT WITH SIGNED CLAIM COPY,
                                  R&S COPY, AND COMPLETE
                                  DOCUMENTATION OF MEDICAL
01/01/1977   12/31/3999   00543   NECESSITY.                                F2      Finalized/Denial - The claim/line has been denied.               287



                                  ADDITIONAL INFO NEEDED TO PROCESS
                                  CLAIM. PLEASE RESUBMIT WITH SIGNED
                                  CLAIM COPY, R&S COPY, AND DATE OF
01/01/1977   12/31/3999   00544   ONSET OF DIALYSIS TREATMENTS.             F2      Finalized/Denial - The claim/line has been denied.               213


                                  ADD'L INFO NEEDED TO PROCESS CLAIM.
                                  RESUBMIT SIGNED CLAIM COPY, R&S
                                  COPY, ITEMIZED CHARGES ALL THERAPY
                                  PROGRESS NOTES AND DATE OF ONSET
01/01/1977   12/31/3999   00545   OF INJURY/ILLNESS.                        F2      Finalized/Denial - The claim/line has been denied.               310


                                  PROCEDURE/SERVICE EXCEEDS THE
                                  BENEFIT LIMITATION OF 12
                                  CHIROPRACTIC VISITS FOR A 12 MONTH
01/01/1977   12/31/3999   00546   PERIOD.                                   F2      Finalized/Denial - The claim/line has been denied.               348




                                                                        Page 216 of 378
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                                  SUBMISSION OF FRONT AND BACK OF
                                  CONSENT FORM IS REQUIRED. PLEASE
                                  RESUBMIT WITH SIGNED CLAIM COPY,
                                  R&S COPY, AND COPY OF CORRECTED
01/01/1977   12/31/3999   00547   CONSENT FORM.                              F2      Finalized/Denial - The claim/line has been denied.                     122



                                  YOUR MOST RECENT APPEAL HAS BEEN
                                  REVIEWED AND FURTHER
                                  CLARIFICATION IS NEEDED. IT HAS BEEN
                                  REFERRED TO PROVIDER RELATIONS                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00548   AND SOMEONE WILL CONTACT YOU.              F0      and no more action will be taken.                                      0



                                  THIS ADJUSTMENT IS THE RESULT OF                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  REQUIRED INTERNAL PROCESSING. NO                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00549   ACTION ON YOUR PART IS REQUIRED.           F4      forthcoming.                                                           101


                                  THIS EQUIPMENT/SUPPLY/SERVICE IS
                                  CONSIDERED PART OF, DUPLICATE OF,
                                  OR AN UNNEEDED EXTENSION OF
                                  ANOTHER PIECE OF
01/01/1977   12/31/3999   00550   EQUIPMENT/SUPPLY/SERVICE.                  F2      Finalized/Denial - The claim/line has been denied.                     483


                                  TECHNICAL CLAIM DENIAL DUE TO LACK
                                  OF COMPLETE MED RECORD.                            Finalized/Adjudication Complete - No payment forthcoming - The
                                  RESUBMISSION MUST BE WITHIN 30                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00552   DAYS TO BE RECONSIDERED.                   F4      forthcoming.                                                           101



                                  ADDITIONAL INFO NEEDED TO PROCESS
                                  CLAIM. PLEASE RESUBMIT WITH SIGNED
                                  CLAIM COPY, R&S COPY, SEPARATE
01/01/1977   12/31/3999   00553   DATES AND CHARGES FOR SERVICES.            F2      Finalized/Denial - The claim/line has been denied.                     84


                                  YOUR REQUEST FOR DX/PROC.
                                  CODE/DRG CHANGE CANNOT BE
                                  ACCOMPLISHED UNTIL AFTER YOUR
                                  RETROSPECTIVE REVIEW IS                            Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00556   COMPLETED.                                 F0      and no more action will be taken.                                      46




                                                                         Page 217 of 378
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                                  YOUR CLAIMS HAVE BEEN DENIED IN
                                  ORDER TO BE COMBINED FOR CORRECT
                                  DRG PAYMENT. NO ACTION ON YOUR
01/01/1977   12/31/3999   00557   PART IS NECESSARY.                        F2      Finalized/Denial - The claim/line has been denied.   103


                                  THESE COMPONENTS SHOULD BE
                                  COMBINED & BILLED AS A URINALYSIS.
                                  PLEASE RESUBMIT SIGNED CLAIM COPY,
                                  R&S COPY, AND APPROPRIATE
01/01/1977   12/31/3999   00558   URINALYSIS CODE.                          F2      Finalized/Denial - The claim/line has been denied.   454


                                  THESE TESTS SHOULD BE COMBINED &
                                  BILLED AS A CBC/PANEL. PLEASE
                                  RESUBMIT WITH SIGNED CLAIM COPY,
                                  R&S COPY, & APPROPRIATE CODE
01/01/1977   12/31/3999   00559   (X7619, 85021-85027, 85031).              F2      Finalized/Denial - The claim/line has been denied.   454


                                  THIS SERVICE DETERMINED NOT
                                  MEDICALLY NECESSARY BY THE
                                  MEDICAL DIRECTOR. IF YOU FIND YOU
                                  DID NOT RECEIVE ADEQUATE REVIEW,
08/01/2002   12/31/3999   00560   YOU MAY FILE A COMPLAINT W/TDH.           F2      Finalized/Denial - The claim/line has been denied.   9


                                  ADDITIONAL INFORMATION NEEDED TO
                                  PROCESS CLAIM. PLEASE RESUBMIT
                                  WITH SIGNED CLAIM COPY, R&S COPY,
01/01/1977   12/31/3999   00561   NEW, AND OLD PRESCRIPTION.                F2      Finalized/Denial - The claim/line has been denied.   403


                                  CLAIM HAS BEEN DENIED AS THE
                                  PATIENT LIABILITY IS GREATER THAN
                                  THE DRG PAYABLE AMOUNT. FOR MORE
                                  INFORMATION, CONTACT NHIC
01/01/1977   12/31/3999   00562   CUSTOMER SERVICE.                         F2      Finalized/Denial - The claim/line has been denied.   9


                                  ADDITIONAL INFORMATION NEEDED TO
                                  PROCESS CLAIM. PLEASE RESUBMIT
                                  WITH SIGNED CLAIM COPY, R&S COPY
                                  AND COMPLETE DOCUMENTATION OF ER
01/01/1977   12/31/3999   00563   VISIT.                                    F2      Finalized/Denial - The claim/line has been denied.   299




                                                                        Page 218 of 378
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                                  RECEIVED PAST 95 DAY FILING
                                  DEADLINE. REFER TO CLAIMS FILING
                                  DEADLINE SECTION OF PROVIDER
                                  PROCEDURES MANUAL FOR
01/01/1977   12/31/3999   00565   INSTRUCTIONS.                              F2      Finalized/Denial - The claim/line has been denied.   9


                                  CLAIM INDICATES REPLACING EYEWEAR
                                  BUT PROC CODE INDICATES NEW
                                  EYEWEAR. PLEASE RESUBMIT WITH
                                  SIGNED CLAIM COPY, R&S COPY, &
01/01/1977   12/31/3999   00566   APPROPRIATE EYEWEAR CODES(S).              F2      Finalized/Denial - The claim/line has been denied.   454


                                  THESE LAB TESTS SHOULD BE BILLED AS
                                  A PANEL. PLEASE COMBINE THE
                                  CHARGES AND RESUBMIT WITH THE
01/01/1977   12/31/3999   00567   APPROPRIATE PANEL CODE.                    F2      Finalized/Denial - The claim/line has been denied.   454


                                  THIS SERVICE IS CONSIDERED PART OF
                                  AN INCLUSIVE PAYMENT MADE ON
                                  ANOTHER SERVICE OR ITEM THAT HAS
01/01/1977   12/31/3999   00568   ALREADY BEEN PROVIDED.                     F2      Finalized/Denial - The claim/line has been denied.   483


                                  THIS CLAIM REPROCESSED FOR NHIC
                                  INTERNAL REPORTING PURPOSES ONLY.
                                  NO ACTION ON YOUR PART IS
01/01/1977   12/31/3999   00569   NECESSARY.                                 F2      Finalized/Denial - The claim/line has been denied.   101


                                  THE STERILIZATION CONSENT FORM
                                  MUST BE SIGNED AT LEAST 30 DAYS
                                  PRIOR TO THE DAY OF SURGERY OR THE
01/01/1977   12/31/3999   00570   EXPECTED DATE OF DELIVERY.                 F2      Finalized/Denial - The claim/line has been denied.   468


                                  DATE OF SURGERY ON CLAIM &
                                  CONSENT FORM DO NOT MATCH.
                                  RESUBMIT W/ SIGNED CLAIM COPY,
                                  VALID CONSENT FORM, R&S COPY & OP
                                  REPORT TO DOCUMENT DATE OF
01/01/1977   12/31/3999   00571   SURGERY.                                   F2      Finalized/Denial - The claim/line has been denied.   187


                                  IT IS MANDATORY THAT AUTHORIZATION
                                  BE OBTAINED. DUE TO THE LACK OF
                                  APPROVAL, THE SERVICE IS NON-
01/01/1977   12/31/3999   00572   PAYABLE.                                   F2      Finalized/Denial - The claim/line has been denied.   84


                                                                         Page 219 of 378
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                                  THE PLACE OF SERVICE IS UNCLEAR.
                                  PLEASE SPECIFY INPATIENT OR
01/01/1977   12/31/3999   00573   OUTPATIENT FOR HOSPITAL SERVICES.           F2      Finalized/Denial - The claim/line has been denied.   249


                                  SERVICES ARE COVERED BY HOSPICE
                                  PROGRAM ADMINISTERED BY THE
                                  DEPARTMENT OF HUMAN SERVICES.
                                  PLEASE REFER TO YOUR PROVIDER
01/01/1977   12/31/3999   00574   PROCEDURE MANUAL.                           F2      Finalized/Denial - The claim/line has been denied.   116


                                  AN ELIGIBILITY UPDATE ON THIS CLIENT
                                  HAS BEEN SENT TO DHS. PLEASE
01/01/1977   12/31/3999   00576   REAPPEAL WITHIN 180 DAYS.                   F2      Finalized/Denial - The claim/line has been denied.   7


                                  TO REIMBURSE ORAL/TOPICAL
                                  MEDICATION CHARGES "OH DRUG" OR
                                  APPROPRIATE REVENUE CODE MUST BE
01/01/1977   12/31/3999   00578   INDICATED ON THE UB92.                      F2      Finalized/Denial - The claim/line has been denied.   453


                                  THIS IS AN INFORMATIONAL APPEAL TO
                                  DOCUMENT YOUR TELEPHONE APPEAL
                                  ATTEMPT. RESUBMIT YOUR APPEAL TO
                                  NHIC WITH THE REQUIRED
01/01/1977   12/31/3999   00579   DOCUMENTATION.                              F2      Finalized/Denial - The claim/line has been denied.   294


                                  IN ACCORDANCE WITH OBRA (OMNIBUS
                                  BUDGET RECONCILIATION ACT) OF 1987,
                                  THE COST OF THE IOL IS INCLUDED IN
01/01/1977   12/31/3999   00580   THE FACILITY PAYMENT.                       F1      Finalized/Payment - The claim/line has been paid.    9


                                  ADDITIONAL INFO NEEDED TO PROCESS
                                  CLAIM. PLEASE RESUBMIT WITH SIGNED
                                  CLAIM COPY. R&S COPY, AND INVOICE
                                  SHOWING ACQUISITION COST OF
01/01/1977   12/31/3999   00581   INTRAOCULAR LENS.                           F2      Finalized/Denial - The claim/line has been denied.   110


                                  CLIENT STATEMENT OF NO OTHER
                                  INSURANCE IS NOT SUFFICIENT
                                  DOCUMENTATION. PLEASE RESUBMIT
                                  WITH DISPOSITION FROM THE
01/01/1977   12/31/3999   00582   INSURANCE COMPANY.                          F2      Finalized/Denial - The claim/line has been denied.   286


                                                                          Page 220 of 378
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                                  MEDICARE-ONLY PROC CODE. PLEASE
                                  RESUBMIT WITH R&S COPY, SIGNED
                                  CLAIM COPY AND APPROPRIATE CPT,
                                  HCFA, MEDICAID LOCAL CODE OR
01/01/1977   12/31/3999   00583   COMPLETE DESCRIPTION OF SVC.               F2      Finalized/Denial - The claim/line has been denied.   454


                                  CLAIM DENIED DUE TO INCOMPLETE
                                  SCREEN. PLEASE REFER TO PROVIDER
                                  PROCEDURES MANUAL FOR SCREEN
01/01/1977   12/31/3999   00584   REQUIREMENTS.                              F2      Finalized/Denial - The claim/line has been denied.   476



                                  INITIAL HOSPITAL VISIT OR PSYCH EXAM
                                  WITHIN 30 DAYS OF CONSULT CUTBACK
01/01/1977   12/31/3999   00586   TO SUBSEQUENT CARE VISIT.                  F2      Finalized/Denial - The claim/line has been denied.   104



                                  YOUR INPATIENT CLAIM HAS BEEN
                                  DENIED. IT WILL BE REPROCESSED AS
                                  AN OUTPATIENT CLAIM. NO FURTHER
01/01/1977   12/31/3999   00588   ACTION ON YOUR PART IS NECESSARY.          F2      Finalized/Denial - The claim/line has been denied.   7


                                  THIS CPT-4 ANESTHESIA CODE IS NOT
                                  PAYABLE FOR DOS BEFORE 1-1-91.
                                  PLEASE RESUBMIT SIGNED CLAIM COPY,
                                  R&S COPY, AND APPROPRIATE CPT-4
01/01/1977   12/31/3999   00589   SURGICAL CODE.                             F2      Finalized/Denial - The claim/line has been denied.   454



                                  RESUBMIT W/SIGNED CLAIM COPY, R&S
                                  COPY, MEDICARE REMITTANCE ADVICE
                                  OR NOTICE, & INDICATE WHETHER
01/01/1977   12/31/3999   00590   MEDICAID ASSIGNMENT IS ACCEPTED.           F2      Finalized/Denial - The claim/line has been denied.   358


                                  PROCEDURE REQUIRES A VALID
                                  HYSTERECTOMY/STERILIZATION/ABORTI
                                  ON MODIFIER. PLEASE RESUBMIT WITH
                                  AN APPROPRIATE MODIFIER AND A
01/01/1977   12/31/3999   00591   SIGNED CLAIM COPY.                         F2      Finalized/Denial - The claim/line has been denied.   453




                                                                         Page 221 of 378
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                                  IT IS NOT ANATOMICALLY POSSIBLE TO
                                  PERFORM THIS PROCEDURE ON THIS
                                  CLIENT. PLEASE CORRECT CLIENT
                                  AND/OR PROCEDURE INFORMATION AND
01/01/1977   12/31/3999   00593   RESUBMIT.                                  F2      Finalized/Denial - The claim/line has been denied.               474


                                  CLIENT IS COVERED BY LIABILITY
                                  INSURANCE, WHICH MUST BE BILLED
                                  PRIOR TO THIS PROGRAM. PLEASE
                                  REFER TO RESPONSIBLE PARTY
01/01/1977   12/31/3999   00594   INFORMATION.                               F2      Finalized/Denial - The claim/line has been denied.               171


                                  THIS CLIENT HAS RECENTLY RECEIVED
                                  MEDICAID ELIGIBILITY FOR THESE DATES
                                  OF SERVICE. PLEASE BILL MEDICAID
01/01/1977   12/31/3999   00598   FIRST.                                     F2      Finalized/Denial - The claim/line has been denied.               116


                                  THE QUANTITY BILLED SHOULD REFLECT
                                  THE TOTAL VOLUME (IN CC'S)
                                  CONTAINED IN THE VIAL OF ALLERGY
01/01/1977   12/31/3999   00600   VACCINE                                    F2      Finalized/Denial - The claim/line has been denied.               222



                                  A RECEIVABLE HAS BEEN ESTABLISHED
                                  IN THE AMOUNT OF THE ORIGINAL
                                  PAYMENT: %1. FUTURE PAYMENTS WILL                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  BE REDUCED OR WITHHELD UNTIL SUCH                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00601   AMOUNT IS PAID IN FULL.                    F4      forthcoming.                                                     101


                                  ORIGINAL PROCESSING REVIEWED AND
                                  DETERMINED TO BE CORRECT. SUBMIT
                                  APPEAL TO TX DEPT OF HEALTH - CIDC                 Finalized/Adjudication Complete - No payment forthcoming - The
                                  APPEALS 1100 WEST 49TH ST. AUSTIN                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00602   TX. 78756-3179.                            F4      forthcoming.                                                     101


                                  PLEASE RESUBMIT WITH
                                  HYSTERECTOMY ACKNOWLEDGEMENT
                                  OR PHYSICIAN SIGNED/DATED
                                  STATEMENT IF CLIENT IS POST
                                  MENOPAUSAL OR HAS BEEN
01/01/1977   12/31/3999   00604   SURGICALLY STERILIZED.                     F2      Finalized/Denial - The claim/line has been denied.               466




                                                                         Page 222 of 378
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                                  REQUEST FOR DRG CHANGE CANNOT BE
                                  ACCOMPLISHED WITHOUT THE ORIGINAL
                                  AND REVISED UB92S AND COMPLETE
01/01/1977   12/31/3999   00605   MEDICAL RECORDS. PLEASE RESUBMIT.          F2      Finalized/Denial - The claim/line has been denied.               275


                                  WELL CHILD SERVICES ARE NOT
                                  PAYABLE ON THIS CLAIM. WELL CHILD
                                  SERVICES ARE COVERED UNDER THE
                                  THSTEPS PROGRAM TO THSTEPS
01/01/1977   12/31/3999   00606   PROVIDERS.                                 F2      Finalized/Denial - The claim/line has been denied.               454



                                  DOCUMENTATION DOES NOT INDICATE A
                                  SUFFICIENT CHANGE IN PRESCRIPTION
01/01/1977   12/31/3999   00609   ACCORDING TO MEDICAID GUIDELINES.          F2      Finalized/Denial - The claim/line has been denied.               294


                                  IF EYEWEAR IS LOST OR DESTROYED,
                                  CIRCLE ITEM B IN BLOCK 7 AND HAVE
                                  THE CLIENT SIGN IN BLOCK 11 OF THE
01/01/1977   12/31/3999   00610   CLAIM FORM.                                F2      Finalized/Denial - The claim/line has been denied.               466


                                  PLEASE RESUBMIT ROUTINE NEWBORN
                                  CARE WITH SIGNED CLAIM COPY, R&S
                                  COPY, INDIVIDUAL DATES & CHARGES
                                  FOR EACH DAY OF ROUTINE CARE USING
01/01/1977   12/31/3999   00611   CODES 90225 & 90282.                       F2      Finalized/Denial - The claim/line has been denied.               454


                                  THIS CLAIM HAS BEEN REPROCESSED
                                  AFTER RETROSPECTIVE REVIEW.                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  PLEASE REFER TO FOLLOW-UP LETTER                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00612   FOR DETAILED EXPLANATION.                  F4      forthcoming.                                                      2


                                  DENIED. INCOMPLETE CLAIM RECEIVED
                                  PAST 95 DAY FILING DEADLINE.
                                  RESUBMIT CORRECTED CLAIM FORM,
                                  ALL PREVIOUS R&S REPORTS, IF CLAIM
01/01/1977   12/31/3999   00613   WAS FILED W/IN DEADLINE.                   F2      Finalized/Denial - The claim/line has been denied.                7




                                                                         Page 223 of 378
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                                  MEDICARE PD AMT IS LESS THAN
                                  MEDICAID PD AMT. CO-INS AND/OR DED
                                  GREATER THAN THE DIFFERENCE
                                  BETWEEN MEDICARE PD & MEDICAID PD.
01/01/1977   12/31/3999   00614   MEDICAID PAYS THE DIFF.                    F1      Finalized/Payment - The claim/line has been paid.                      65


                                  SHARS SERVICES MUST BE BILLED TO
                                  OTHER INSURANCE PRIOR TO BILLING
                                  MEDICAID. PLEASE REFER TO SHARS
                                  SECTION OF THE PROVIDER
01/01/1977   12/31/3999   00615   PROCEDURES MANUAL.                         F2      Finalized/Denial - The claim/line has been denied.                     116


                                  MEDICARE PD AMT IS LESS THAN
                                  MEDICAID PD AMT. THE DIFF. IS EQUAL
                                  TO OR GREATER THAN THE CO-INS
                                  AND/OR DED. MEDICAID PAYS THE CO-
01/01/1977   12/31/3999   00617   INS AND/OR DED.                            F1      Finalized/Payment - The claim/line has been paid.                      65


                                  YOUR CLAIM IS BEING ROUTED WITHIN
                                  NHIC FOR CORRECT PROCESSING. NO                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00618   ACTION REQUIRED ON YOUR PART.              F0      and no more action will be taken.                                      1


                                  SURGICAL PROCEDURE AND/OR
                                  DIAGNOSIS WAS DISALLOWED FROM
                                  DRG ASSIGNMENT DUE TO INELIGIBLE
01/01/1977   12/31/3999   00620   DATES.                                     F1      Finalized/Payment - The claim/line has been paid.                      104


                                  DIAGNOSIS SEQUENCE HAS BEEN
                                  CHANGED AND SURGICAL PROCEDURE
                                  HAS BEEN CHANGED OR EXCLUDED FOR
01/01/1977   12/31/3999   00622   DRG ASSIGNMENT.                            F1      Finalized/Payment - The claim/line has been paid.                      15



                                  THIS PAYMENT IS DUE TO ADDITIONAL
                                  REIMBURSEMENT TO
01/01/1977   12/31/3999   00623   DISPROPORTIONATE SHARE HOSPITALS.          F1      Finalized/Payment - The claim/line has been paid.                      104



                                  THE COINSURANCE PAYMENT FOR THIS
                                  SERVICE IS LIMITED TO MQMB AND QMB
                                  CLIENTS. CHECK THE MEDICAID ID TO
01/01/1977   12/31/3999   00625   VERIFY THE CLIENT'S PROGRAM TYPE.          F1      Finalized/Payment - The claim/line has been paid.                      65



                                                                         Page 224 of 378
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                                  APPEALS FOR CHANGING
                                  DRG/DIAGNOSES/PROCEDURE CODES
                                  FOR YOUR HOSPITAL CAN ONLY BE
08/01/2002   12/31/3999   00626   ACCOMPLISHED THROUGH TDH.                    F2       Finalized/Denial - The claim/line has been denied.               7


                                  YOUR CLAIM HAS BEEN SPLIT TO
                                  FACILITATE PROCESSING OF OTHER
                                  INSURANCE. NO ACTION ON YOUR PART
01/01/1977   12/31/3999   00628   IS NECESSARY.                                F1       Finalized/Payment - The claim/line has been paid.                72


                                  THIS SERVICE MUST BE BILLED USING A
                                  CCP PROCEDURE CODE. PLEASE
01/01/1977   12/31/3999   00629   RESUBMIT USING THE CORRECT CODE.             F2       Finalized/Denial - The claim/line has been denied.               454


                                  ADJUSTMENT HAS BEEN INITIATED FOR
                                  RECOUPMENT OF PHYSICIAN SERVICES
                                  EXCEEDING 30 DAY INPATIENT                            Finalized/Adjudication Complete - No payment forthcoming - The
                                  LIMITATION. (EFFECTIVE SEPTEMBER 1,                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00630   1986)                                        F4       forthcoming.                                                     101


                                  NHIC WILL NOT KEY CLAIM DATA FROM
                                  AN ATTACHMENT/SUPERBILL, OR
01/01/1977   12/31/3999   00631   CHARGE TICKETS.                              F2       Finalized/Denial - The claim/line has been denied.               454



                                  MEDICARE DENIAL INSUFFICIENT TO
                                  CONSIDER PAYMENT OF CLAIM. APPEAL
01/01/1977   12/31/3999   00632   TO THE MEDICARE RELATED HMO                  F2       Finalized/Denial - The claim/line has been denied.               115


                                  MODIFIER 7A, 7C, 7D, AJ, AL, OR AN MUST
                                  BE USED TO IDENTIFY THE
                                  PROFESSIONAL PERFORMING THIS
01/01/1977   12/31/3999   00633   SERVICE.                                     F2       Finalized/Denial - The claim/line has been denied.               453



                                  MISSING/INVALID/FUTURE DATE OF
                                  SERVICE HAS BEEN REPLACED WITH
                                  DATE OF RECEIPT TO ALLOW FOR
                                  PROCESSING. PLEASE RESUBMIT CLAIM
01/01/1977   12/31/3999   00634   WITH CORRECT DATE OF SERVICE.                F2       Finalized/Denial - The claim/line has been denied.               187




                                                                            Page 225 of 378
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                                  TWO MODIFIERS ARE REQUIRED ON THIS
                                  DETAIL. ONE IDENTIFYING THE CASE
                                  MANAGER AND ONE IDENTIFYING THE
01/01/1977   12/31/3999   00636   SERVICE PERFORMED.                        F2      Finalized/Denial - The claim/line has been denied.               453


                                  EFFECTIVE DATE OF SERVICE 10-01-92
                                  CLIENTS UNDER 1 YEAR OLD REQUIRE
                                  EMERGENCY OR EXCEPTION TO
                                  PERIODICITY INDICATOR FOR THSTEPS
01/01/1977   12/31/3999   00639   DENTAL SERVICES.                          F2      Finalized/Denial - The claim/line has been denied.               471


                                  DIAGNOSIS CODE DOES NOT MEET
                                  THERAPY GUIDELINES OF A
                                  MUSCULOSKELETAL CONDITION. IF
                                  APPLICABLE, PLEASE RESUBMIT WITH
01/01/1977   12/31/3999   00641   ADDITIONAL DIAGNOSIS CODE.                F2      Finalized/Denial - The claim/line has been denied.               255



                                  DECISION DETERMINED TO BE
                                  CORRECT. IF YOU FIND NHIC DID NOT
                                  PROVIDE FULL APPEAL CONSIDERATION,                Finalized/Adjudication Complete - No payment forthcoming - The
                                  YOU MAY FILE A COMPLAINT WITH TDH                 claim/encounter has been adjudicated and no further payment is
08/01/2002   12/31/3999   00642   WITHIN 60 CALENDAR DAYS.                  F4      forthcoming.                                                     101


                                  CLAIM INDICATES OUTPATIENT
                                  CHARGES IN EXCESS OF 23 HOURS.
                                  RESUBMIT CLAIM WITH CHARGES FOR
01/01/1977   12/31/3999   00643   THE INITIAL 23 HOURS ONLY.                F2      Finalized/Denial - The claim/line has been denied.               7


                                  PROCEDURE REQUIRES ADDITIONAL
                                  CIDC SPECIALTY TEAM/CENTER
                                  PROVIDER ENROLLMENT. CONTACT
                                  TDH/CIDC FOR MORE INFORMATION, 1-
01/01/1977   12/31/3999   00645   800-252-8023.                             F2      Finalized/Denial - The claim/line has been denied.               145


                                  ON OR AFTER 10-01-92 PROVIDERS MUST
                                  STATE ON THEIR CLAIMS, OR BY
                                  ATTACHED INVOICE, THE RETAIL PRICE
01/01/1977   12/31/3999   00646   OF THE EQUIPMENT BEING BILLED.            F2      Finalized/Denial - The claim/line has been denied.               110




                                                                        Page 226 of 378
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                                  AN INTERNAL REVIEW FOUND THIS
                                  FAMILY PLANNING CLAIM WAS SPLIT IN
                                  ERROR. CLAIM WILL BE REPROCESSED;                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  NO ACTION ON YOUR PART IS                          claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00647   NECESSARY.                                 F4      forthcoming.                                                     101


                                  XRAY DENIED - THE NECESSITY OF
                                  THIS XRAY IN AN EMERGENCY
                                  SITUATION NOT DOCUMENTED BY
01/01/1977   12/31/3999   00648   PROVIDER.                                  F2      Finalized/Denial - The claim/line has been denied.               294



                                  THE MEDICAL PORTION OF THIS SERVICE
                                  HAS BEEN PROCESSED ON THIS CLAIM.
                                  THE FAMILY PLANNING PORTION WILL BE
01/01/1977   12/31/3999   00649   PROCESSED ON A SEPARATE CLAIM.             F1      Finalized/Payment - The claim/line has been paid.                72


                                  THIS PROCEDURE NOT COMPATIBLE
                                  WITH TOOTH ID SUBMITTED. PROPER
                                  TOOTH ID IS REQUIRED FOR THIS
01/01/1977   12/31/3999   00650   PROCEDURE.                                 F2      Finalized/Denial - The claim/line has been denied.               240



                                  THIS PROCEDURE IS LIMITED IN THE
                                  THSTEPS DENTAL PROGAM. IT IS
01/01/1977   12/31/3999   00651   PAYABLE ONLY ON EMERGENCY CLAIMS.          F2      Finalized/Denial - The claim/line has been denied.               471



                                  PROVIDER NOT CERTIFIED TO PERFORM
01/01/1977   12/31/3999   00652   THIS TYPE OF LABORATORY SERVICE.           F2      Finalized/Denial - The claim/line has been denied.               142



                                  PAYMENT FOR THIS SERVICE IS DENIED -
                                  DOCUMENTATION DOES NOT SUPPORT
                                  THE NECESSITY FOR THIS PROCEDURE
01/01/1977   12/31/3999   00653   ON AN EMERGENCY CLAIM.                     F2      Finalized/Denial - The claim/line has been denied.               287


                                  THE CLIENT'S AGE DOES NOT FALL
                                  WITHIN THE AGE SPAN FOR THIS
01/01/1977   12/31/3999   00654   PROCEDURE.                                 F2      Finalized/Denial - The claim/line has been denied.               475




                                                                         Page 227 of 378
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                                  PARTIAL DENTURES ARE LIMITED TO
                                  MISSING ANTERIOR TEETH OR EIGHT                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00655   OCCLUDING POSTERIOR TEETH.                 F0      and no more action will be taken.                                      104



                                  THE COMBINATION OF THE PROCEDURE
                                  CODE, THE TOOTH ID AND THE SURFACE
01/01/1977   12/31/3999   00656   ID SUBMITTED ARE INCOMPATIBLE.             F2      Finalized/Denial - The claim/line has been denied.                     240


                                  SURFACE ID IS BLANK OR INVALID.
01/01/1977   12/31/3999   00657   PLEASE CORRECT AND RESUBMIT.               F2      Finalized/Denial - The claim/line has been denied.                     240


                                  TEMPORARY FILLING/SEALANTS NOT
                                  PAYABLE WITH CROWN OR
                                  RESTORATION. INCISION AND DRAINAGE
                                  OF ABSCESS NOT PAYABLE SAME DATE
01/01/1977   12/31/3999   00658   AS EXTRACITON.                             F2      Finalized/Denial - The claim/line has been denied.                     104


                                  LIMITATIONS PREVENT PAYMENT OF A
                                  PULPOTOMY AND A ROOT CANAL ON THE
01/01/1977   12/31/3999   00659   SAME TOOTH ID.                             F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PAYMENT FOR THIS PROCEDURE NOT
                                  ALLOWED WHEN ANOTHER EXAM/X-RAY
01/01/1977   12/31/3999   00660   ALLOWED ON THE SAME CLAIM.                 F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS TID HAS BEEN EXTRACTED.
01/01/1977   12/31/3999   00661   APPEAL WITH X-RAY                          F2      Finalized/Denial - The claim/line has been denied.                     318


                                  IV OR IM MEDICATION FOR SEDATION IS
                                  NOT PAYABLE ON THE SAME DAY AS
01/01/1977   12/31/3999   00662   GENERAL ANESTHESIA.                        F2      Finalized/Denial - The claim/line has been denied.                     104


                                  OUR RECORDS INDICATE THIS TOOTH ID
                                  WAS PREVIOUSLY CROWNED. THIS
01/01/1977   12/31/3999   00663   PROCEDURE IS DENIED.                       F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS PROCEDURE NOT PAYABLE -
                                  PAYMENT INCLUDED IN THE FEE
                                  PREVIOUSLY BILLED FOR THE CROWN
01/01/1977   12/31/3999   00664   ON SAME TOOTH.                             F2      Finalized/Denial - The claim/line has been denied.                     104


                                                                         Page 228 of 378
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                                  PROCEDURES/SERVICE LIMITED TO
                                  ONCE PER 6 MONTH PERIOD
                                  CALCULATED FROM LAST DATE OF
01/01/1977   12/31/3999   00665   SERVICE.                                     F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS PROCEDURE IS LIMITED. IT IS
                                  PAYABLE ONLY ONCE EVERY THIRTY-SIX
01/01/1977   12/31/3999   00666   MONTHS.                                      F2      Finalized/Denial - The claim/line has been denied.                     104



                                  THIS PROCEDURE DENIED OR CUTBACK -
                                  CLAIM EXCEEDS TOTAL AMOUNT                           Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00668   PAYABLE FOR X-RAYS PER CASE.                 F0      and no more action will be taken.                                      104



                                  THIS PROCEDURE DENIED OR CUTBACK.
                                  SERVICES EXCEED TOTAL PAYABLE
                                  AMOUNT FOR RESTORATIVE/CROWN                         Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00669   PROCEDURES ON EACH TOOTH.                    F0      and no more action will be taken.                                      104


                                  PROVIDERS MANUFACTURING DME
                                  EQUIPMENT ON SITE MUST BE
                                  REGISTERED WITH APPROPRIATE
01/01/1977   12/31/3999   00671   STATE/FEDERAL AGENCIES.                      F2      Finalized/Denial - The claim/line has been denied.                     335



                                  ALLOWED AMT FOR THIS OUTPATIENT
                                  SERVICE IS REDUCED BY 22.4% FOR SFY
01/01/1977   12/31/3999   00672   '98, &'99, 19.7 % FOR 2000 AND BEYOND.       F1      Finalized/Payment - The claim/line has been paid.                      104


                                  DOCUMENTATION OF NECESSITY OF
                                  SERVICE AND/OR XRAYS MUST BE
                                  SUBMITTED FOR CONSIDERATION OF
01/01/1977   12/31/3999   00673   PAYMENT.                                     F2      Finalized/Denial - The claim/line has been denied.                     287



                                  PALLIATIVE AND SEDATIVE/TEMPORARY
                                  FILLINGS ARE NOT BOTH PAYABLE ON                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00674   THE SAME DATE OF SERVICE.                    F0      and no more action will be taken.                                      104




                                                                           Page 229 of 378
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                                  PROVIDERS MAY NOT BE REIMBURSED
                                  FOR IMMUNIZATIONS THAT MAY BE
                                  OBTAINED AT NO CHARGE FROM THE                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00677   TEXAS DEPT. OF HEALTH.                     F0      and no more action will be taken.                                      104


                                  PAYMENT RECOUPED FROM
                                  OUTPATIENT PROVIDER NUMBER.
                                  RESUBMIT FOR ELECTIVE/NON-
                                  EMERGENCY DAY SURGERY USING                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  CORRECT PROVIDER NUMBER. HASC-                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00678   MEDICAID, IPS-CIDC.                        F4      forthcoming.                                                           7


                                  DRUGS/SUPPLIES COVERED THROUGH
                                  THE VENDOR DRUG PROGRAM CANNOT
                                  BE PAID BY THSTEPS/CCP/HOME
                                  HEALTH. PLEASE BILL THE VENDOR
01/01/1977   12/31/3999   00679   DRUG PROGRAM.                              F2      Finalized/Denial - The claim/line has been denied.                     116


                                  OUR RECORDS INDICATE THIS PATIENT
                                  IS ENROLLED WITH MEDICAID. PLEASE
                                  BILL MEDICAID FIRST. CIDC DOES NOT
                                  SUPPLEMENT MEDICAID
01/01/1977   12/31/3999   00680   REIMBURSEMENT.                             F2      Finalized/Denial - The claim/line has been denied.                     116



                                  RESUBMIT ANTEPARTUM SERVICE
                                  W/SIGNED CLAIM COPY, R&S COPY,
                                  INDIVIDUAL DATES AND CHARGES USING
01/01/1977   12/31/3999   00682   THE APPROPRIATE PROCEDURE CODES.           F2      Finalized/Denial - The claim/line has been denied.                     454


                                  MEDICAID RECOUPMENT DUE TO RETRO
                                  MEDICARE ELIGIBILITY. TO BILL
                                  MEDICARE INCLUDE THIS MESSAGE IN                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  COMMENT/REMARK FIELD FOR EMC OR                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00688   ATTACH FOR PAPER CLAIM.                    F4      forthcoming.                                                           116


                                  PAYMENT REDUCED DUE TO NON-
                                  RECEIPT OF THE IRS W-9/IRS LETTER
                                  147C PREVIOUSLY SENT TO YOUR
01/01/1977   12/31/3999   00689   FACILITY/OFFICE.                           F1      Finalized/Payment - The claim/line has been paid.                      68




                                                                         Page 230 of 378
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                                  CHARGES FOR TAKE HOME DRUGS
                                  MUST BE SUBMITTED TO THE VENDOR
07/19/2002   12/31/3999   00690   DRUG PROGRAM                              F2      Finalized/Denial - The claim/line has been denied.   116


                                  ELECTIVE ABORTIONS ARE NOT A
                                  BENEFIT OF MEDICAID UNLESS THE
                                  PREGNANCY ENDANGERS THE LIFE OF
                                  THE MOTHER OR IS THE RESULT OF
01/01/1977   12/31/3999   00691   RAPE OR INCEST.                           F2      Finalized/Denial - The claim/line has been denied.   287


                                  TEXAS MEDICAID PLAN OF CARE
                                  REQUIRES PHYSICIAN SIGNATURE
                                  AND/OR DATE. RESUBMIT WITH A
                                  CORRECTED PLAN OF CARE, R & S, AND
01/01/1977   12/31/3999   00694   A SIGNED CLAIM COPY.                      F2      Finalized/Denial - The claim/line has been denied.   295


                                  PLEASE RESUBMIT WITH R&S, SIGNED
                                  CLAIM COPY, AND ANESTHESIA RECORD
                                  DOCUMENTING PROCEDURE
                                  LENGTH/TIME, SIGNED BY THE
01/01/1977   12/31/3999   00697   PHYSICIAN/CRNA.                           F2      Finalized/Denial - The claim/line has been denied.   251


                                  ATTENDING PHYSICIAN AND SURGEON
                                  MUST BE ENROLLED IN THIS PROGRAM
01/01/1977   12/31/3999   00698   FOR CONSIDERATION OF PAYMENT.             F2      Finalized/Denial - The claim/line has been denied.   109


                                  THE SUBSTITUTE PROVIDER MODIFIER
                                  "Q" INDICATED ON YOUR CLAIM IS
                                  INVALID. PLEASE REFER TO PROVIDER
01/01/1977   12/31/3999   00699   PROCEDURES MANUAL.                        F2      Finalized/Denial - The claim/line has been denied.   453


                                  SERVICE(S) REQUIRE REFERRING
                                  PROVIDER NUMBER FOR PROCESSING.
                                  REFERRING PROVIDER CANNOT BE THE
                                  SAME PROVIDER WHO RENDERED
01/01/1977   12/31/3999   00701   THESE SERVICE(S).                         F2      Finalized/Denial - The claim/line has been denied.   132


                                  IN HOUSE TRANSFERS ARE NOT
                                  ELIGIBLE FOR BOTH DRG AND A PER
                                  DIEM PAYMENT. RESUBMIT ENTIRE
01/01/1977   12/31/3999   00702   LENGTH OF STAY ON ONE CLAIM FORM          F2      Finalized/Denial - The claim/line has been denied.   7




                                                                        Page 231 of 378
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                                  THE CLIENT'S CONDITION DOES NOT
                                  MEET THE "SEVERELY DISABLED"
                                  CRITERIA, THEREFORE, IT IS NOT A
01/01/1977   12/31/3999   00703   BENEFIT.                                   F2      Finalized/Denial - The claim/line has been denied.   9



                                  PLEASE RESUBMIT WITH APPROPRIATE
                                  MODIFIER TO INDICATE NUMBER OF
                                  CONCURRENT ANESTHESIA
01/01/1977   12/31/3999   00704   PROCEDURES SUPERVISED.                     F2      Finalized/Denial - The claim/line has been denied.   453


                                  ADMINISTRATION OF IMMUNIZATIONS IS
                                  NOT A PAYABLE SERVICE PRIOR TO 7-1-
                                  93 OR FOR CLIENTS 21 YEARS OF AGE
01/01/1977   12/31/3999   00705   OR OLDER.                                  F2      Finalized/Denial - The claim/line has been denied.   475



                                  THE CHARGES AND/OR DATES OF
                                  SERVICE ON THE CLAIM DO NOT MATCH
                                  THOSE ON YOUR R&S STATEMENT.
                                  PLEASE RESUBMIT WITH MATCHING
01/01/1977   12/31/3999   00706   CHARGES AND DATES OF SERVICE.              F2      Finalized/Denial - The claim/line has been denied.   187


                                  BLOCK 24K PERFORMING PROVIDER
                                  NUMBER IS MISSING OR INVALID OR
                                  DOESN'T CORRESPOND TO A GROUP
01/01/1977   12/31/3999   00707   BILLING NUMBER.                            F2      Finalized/Denial - The claim/line has been denied.   132


                                  THE CLIENT'S NAME IN THE CONSENT TO
                                  STERILIZATION DOES NOT MATCH THE
                                  CLIENT'S NAME IN THE PHYSICIAN'S
                                  STATEMENT PART OF THE
01/01/1977   12/31/3999   00708   STERILIZATION CONSENT FORM.                F2      Finalized/Denial - The claim/line has been denied.   125


                                  TYPED/STAMPED SIGNATURES ARE NOT
                                  ACCEPTABLE FOR THE PERSON
                                  OBTAINING CONSENT OR PHYSICIAN
                                  STATEMENT. RESUBMIT WITH
                                  APPLICABLE HANDWRITTEN
01/01/1977   12/31/3999   00709   SIGNATURE(S).                              F2      Finalized/Denial - The claim/line has been denied.   466




                                                                         Page 232 of 378
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                                  PLEASE RESUBMIT A COPY OF THE
                                  CONSENT FORM WITH TIME OF DAY THE
                                  CLIENT SIGNED THE CONSENT TO
                                  STERILIZATION AND TIME OF DAY THE
01/01/1977   12/31/3999   00710   SURGERY WAS PERFORMED.                    F2      Finalized/Denial - The claim/line has been denied.   21


                                  CLAIM DENIED. INPATIENT HOSPITAL
                                  STAYS FOR NON-EMERGENCY
                                  DIAGNOSES ARE NOT COVERED IN NON-
01/01/1977   12/31/3999   00713   CONTRACTED HOSPITALS.                     F2      Finalized/Denial - The claim/line has been denied.   107


                                  THIS SERVICE/SITUATION/SURGERY
                                  DOES NOT MEET AUTHORIZATION
                                  CRITERIA. PLEASE APPEAL WITH
                                  COMPLETE MEDICAL RECORD FOR
01/01/1977   12/31/3999   00714   EXTENDED LENGTH OF STAY.                  F2      Finalized/Denial - The claim/line has been denied.   317


                                  CLAIM DENIED. INPATIENT STAYS
                                  LONGER THAN 3 DAYS REQUIRE
                                  AUTHORIZATION. PLEASE APPEAL WITH
                                  COMPLETE MEDICAL RECORDS TO
01/01/1977   12/31/3999   00715   DETERMINE STABILIZATION DATE.             F2      Finalized/Denial - The claim/line has been denied.   317


                                  ADOLESCENT PREVENTIVE VISIT MUST
                                  BE BILLED IN ACCORDANCE W/THE
                                  PERIODICITY SCHEDULE. REFER TO
01/01/1977   12/31/3999   00716   PROVIDER PROCEDURE MANUAL.                F2      Finalized/Denial - The claim/line has been denied.   104


                                  HEARING AID PURCHASES ARE LIMITED
                                  TO ONCE EVERY 6 YEARS EXCEPT FOR
01/01/1977   12/31/3999   00717   PERSONS UNDER 21 YEARS OF AGE.            F2      Finalized/Denial - The claim/line has been denied.   104


                                  OBSERVATION/OUTPATIENT CHARGES
                                  RELATED TO OR WITHIN ONE DAY OF
                                  INPATIENT STAY MUST BE BILLED ON
01/01/1977   12/31/3999   00718   THE INPATIENT CLAIM FORM.                 F2      Finalized/Denial - The claim/line has been denied.    9



                                  FAMILY PLANNING SERVICES PROVIDED
                                  BY THE FQHC MUST BE FILED WITH THE
                                  APPROPRIATE FAMILY PLANNING
01/01/1977   12/31/3999   00720   PROCEDURE CODE ON THE CLAIM FORM.         F2      Finalized/Denial - The claim/line has been denied.   454



                                                                        Page 233 of 378
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                                  THIS RECOUPMENT IS THE RESULT OF
                                  THE UTILIZATION REVIEW PROCESS.
                                  PLEASE REFER TO WRITTEN                           Finalized/Adjudication Complete - No payment forthcoming - The
                                  CORRESPONDENCE FOR MORE                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00721   INFORMATION.                              F4      forthcoming.                                                     2


                                  ITEM(S) DENIED AS PART OF RENTAL
                                  FEE. APPEAL MUST INCLUDE
                                  STATEMENT INDICATING CLIENT OWNS
                                  EQUIPMENT AND REASON(S) WHY
01/01/1977   12/31/3999   00723   REPLACEMENT IS NEEDED.                    F2      Finalized/Denial - The claim/line has been denied.               186


                                  TB SKIN TEST CODE MUST BE ON THE
                                  CLAIM. SUBMIT APPROPRIATE
                                  PROCEDURE CODE. REFER TO THE
01/01/1977   12/31/3999   00724   PROVIDER PROCEDURES MANUAL.               F2      Finalized/Denial - The claim/line has been denied.               454


                                  IMMUNIZATION/NON-IMMUNIZATION
                                  CODE MUST BE ON CLAIM. REFER TO
01/01/1977   12/31/3999   00725   THE PROVIDER PROCEDURE MANUAL.            F2      Finalized/Denial - The claim/line has been denied.               454


                                  SUPPLIES AND/OR DURABLE MEDICAL
                                  EQUIPMENT ARE NOW PAYABLE TO
                                  DME/DMEH AND VP PROVIDER NUMBERS
01/01/1977   12/31/3999   00727   ONLY.                                     F2      Finalized/Denial - The claim/line has been denied.               25



                                  ATTENDING PROVIDER IDENTIFIER
01/01/1977   12/31/3999   00728   REQUIRED.                                 F2      Finalized/Denial - The claim/line has been denied.               143


                                  ONLY CLAIMS WITH AN APPROVED
                                  EMERGENCY DIAGNOSIS ARE PAYABLE.
                                  REFER TO YOUR FACILITY'S
01/01/1977   12/31/3999   00731   PREPAYMENT REVIEW GUIDELINES.             F2      Finalized/Denial - The claim/line has been denied.               471


                                  THESE SERVICES BILLED WITHOUT A
                                  FAMILY PLANNING DIAGNOSIS MUST BE
                                  BILLED AS AN ENCOUNTER BY THE
01/01/1977   12/31/3999   00733   FQHC.                                     F2      Finalized/Denial - The claim/line has been denied.               454




                                                                        Page 234 of 378
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                                  CLAIM/PROCEDURE NOT PAYABLE BY
                                  NHIC. RESUBMIT CLAIM TO CIDC
                                  CENTRAL OFFICE, 1100 WEST 49TH ST,
01/01/1977   12/31/3999   00736   AUSTIN TEXAS, 78756-3179                   F2      Finalized/Denial - The claim/line has been denied.                     116


                                  INPATIENT ADMISSION DENIED AS A                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  RESULT OF RETROSPECTIVE                            claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00738   UTILIZATION REVIEW.                        F4      forthcoming.                                                           101


                                  DX/PROCEDURE CODE SEQUENCING
                                  CHANGE FOR APPROPRIATE DRG
                                  ASSIGNMENT AS A RESULT OF                          Finalized/Adjudication Complete - No payment forthcoming - The
                                  RETROSPECTIVE UTILIZATION REVIEW                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00739   OR TO CORRECT CODING ERROR.                F4      forthcoming.                                                           101


                                  THIS CASE INVOLVED A PATIENT
                                  TRANSFER. PAYMENT CALCULATED ON
01/01/1977   12/31/3999   00740   A PER DIEM BASIS.                          F1      Finalized/Payment - The claim/line has been paid.                      104


                                  THIS IS THE MAXIMUM PAYMENT FOR AN
                                  INPATIENT STAY ACCORDING TO YOUR
                                  FACILITY'S REIMBURSEMENT
01/01/1977   12/31/3999   00741   METHODOLOGY.                               F1      Finalized/Payment - The claim/line has been paid.                      104


                                  FOR INFORMATIONAL PURPOSES ONLY --
                                  THIS CASE CONSIDERED FOR PAYMENT                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00742   ON ANOTHER CLAIM.                          F0      and no more action will be taken.                                      103


                                  CLAIM HAS BEEN REDUCED DUE TO
                                  MEDICALLY NEEDY SPENDDOWN. FOR
                                  PATIENT LIABILITY INFORMATION,
01/01/1977   12/31/3999   00743   PLEASE CALL CUSTOMER SERVICE.              F1      Finalized/Payment - The claim/line has been paid.                      104


                                  MAXIMUM PAYMENT FOR TRANSPLANT
                                  HOSPITAL STAY ACCORDING TO DRG
01/01/1977   12/31/3999   00745   REIMBURSEMENT METHOD.                      F1      Finalized/Payment - The claim/line has been paid.                      104


                                  DRG ASSIGNMENT BASED ONLY ON
                                  COMPLICATION REQUIRING INPATIENT
                                  ADMISSION OR READMISSION; RESUBMIT
                                  SURGICAL PROCEDURES ON HASC
01/01/1977   12/31/3999   00747   CLAIM.                                     F2      Finalized/Denial - The claim/line has been denied.                     189


                                                                         Page 235 of 378
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                                  SECOND NEWBORN HERE/METABOLIC
                                  TEST CODE MUST BE ON THE CLAIM.
                                  REFER TO PROVIDER PROCEDURE
                                  MANUAL OR CONTACT CUSTOMER
01/01/1977   12/31/3999   00748   SERVICE.                                  F2      Finalized/Denial - The claim/line has been denied.                     454


                                  ACCORDING TO STATE DIRECTION A
                                  SHARS OR ECI PROVIDER MUST OBTAIN
                                  PARENTAL CONSENT BEFORE FILING                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00749   WITH PRIVATE INSURANCE.                   F0      and no more action will be taken.                                      104


                                  INFORMATION NOT RECEIVED WITHIN 60
01/01/1977   12/31/3999   00750   DAYS: TECHNICAL DENIAL IS FINAL.          F2      Finalized/Denial - The claim/line has been denied.                     104


                                  EXTRA CHARGE FOR NIGHT CALL BILLED
                                  WITH NON-EMERGENCY TRANSPORT
01/01/1977   12/31/3999   00752   ARE NOT PAYABLE.                          F2      Finalized/Denial - The claim/line has been denied.                     9


                                  PRECISE LEVEL OF SUBLUXATION MUST
                                  BE INDICATED ON CLAIM FOR
01/01/1977   12/31/3999   00753   CONSIDERATION OF PAYMENT.                 F2      Finalized/Denial - The claim/line has been denied.                     270


                                  ATTACHMENTS TO YOUR CLAIM DID NOT
                                  SUPPORT OR AGREE WITH SERVICES
01/01/1977   12/31/3999   00754   BILLED.                                   F2      Finalized/Denial - The claim/line has been denied.                     421


                                  PROCEDURE PAYMENT DETERMINED BY
                                  PROGRAM/BENEFIT PLAN,
                                  REIMBURSEMENT METHODOLOGY, DATE
                                  OF SERVICE AND/OR TEFRA GUIDELINES
                                  AS DESCRIBED IN PROVIDER
01/01/1977   12/31/3999   00755   PROCEDURES MANUAL.                        F1      Finalized/Payment - The claim/line has been paid.                      104


                                  SERVICE PROCESSED ACCORDING TO
                                  TEFRA GUIDELINES DESCRIBED IN
01/01/1977   12/31/3999   00756   PROVIDER PROCEDURES MANUAL.               F1      Finalized/Payment - The claim/line has been paid.                      104




                                                                        Page 236 of 378
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                                  PROCEDURE PAYMENT BASED ON
                                  PROGRAM/BENEFIT PLAN, DATE OF
                                  SERVICE AND IS CALCULATED AT THE
01/01/1977   12/31/3999   00757   DETAIL BILLED AMOUNT.                      F1      Finalized/Payment - The claim/line has been paid.                104



                                  THESE SERVICES ARE NOT PAYABLE
01/01/1977   12/31/3999   00759   FOR CHRONIC/LONG-TERM CONDITIONS.         F2       Finalized/Denial - The claim/line has been denied.
                                                                            104      Processed according to plan provisions.

                                  TOTAL BILLED HAS BEEN CHANGED TO
01/01/1977   12/31/3999   00760   REFLECT INVOICE COST.                      F1      Finalized/Payment - The claim/line has been paid.                178


                                  CLINICAL LABORATORY PROCEDURE
                                  PAYMENT BASED ON NATIONAL FEE
                                  SCHEDULE, PROGRAM/BENEFIT PLAN
01/01/1977   12/31/3999   00761   AND DATE OF SERVICE.                       F1      Finalized/Payment - The claim/line has been paid.                104


                                  THIS CHARGE IS CONSIDERED PART OF
                                  DAILY ROOM/RATE AND/OR NURSING
01/01/1977   12/31/3999   00762   CARE.                                      F2      Finalized/Denial - The claim/line has been denied.               104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT RECOUPED/DENIED PER                        claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00763   PROVIDER REQUEST.                          F4      forthcoming.                                                     101


                                  PAYMENT FOR REPEAT LASER
                                  TREATMENT WITHIN 6 MONTHS IS
01/01/1977   12/31/3999   00764   INCLUDED IN INITIAL LASER PAYMENT.         F2      Finalized/Denial - The claim/line has been denied.               104


                                  SERVICE FILED ON AN INCORRECT
                                  CLAIM FORM. PLEASE REFILE ON HCFA
01/01/1977   12/31/3999   00765   1500.                                      F2      Finalized/Denial - The claim/line has been denied.               275


                                  ITEMIZED CHARGES FOR THESE
                                  SERVICES ARE NEEDED BEFORE
01/01/1977   12/31/3999   00766   PAYMENT CAN BE CONSIDERED.                 F2      Finalized/Denial - The claim/line has been denied.               279


                                  DAILY RENTAL CHARGES FOR
                                  EQUIPMENT ARE NOT PAYABLE IN
01/01/1977   12/31/3999   00767   ADDITION TO INITIAL EQUIPMENT FEE.         F2      Finalized/Denial - The claim/line has been denied.               104



                                                                         Page 237 of 378
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                                  A NARRATIVE DESCRIPTION OF THE
                                  CLIENT'S CONDITION AND/OR SYMPTOMS
01/01/1977   12/31/3999   00770   IS REQUIRED.                               F2      Finalized/Denial - The claim/line has been denied.                     431


                                  INITIAL CONSULT WITHIN 12 MONTHS OF
                                  ANY OTHER CONSULT CUTBACK TO
01/01/1977   12/31/3999   00772   FOLLOW-UP CONSULT.                         F1      Finalized/Payment - The claim/line has been paid.                      15


                                  PHYSICIAN'S NAME MUST BE AT THE TOP
                                  OF THE CONSENT FORM AND AFTER "TO
01/01/1977   12/31/3999   00774   BE STERILIZED BY".                         F2      Finalized/Denial - The claim/line has been denied.                     125


                                  REPEAT INITIAL HOSPITAL CARE WITHIN
                                  30 DAYS PAYABLE AS SUBSEQUENT
01/01/1977   12/31/3999   00775   CARE VISIT.                                F1      Finalized/Payment - The claim/line has been paid.                      15


                                  SUBSEQUENT HOSPITAL CARE NOT
01/01/1977   12/31/3999   00776   PAYABLE TO CONSULTING PHYSICIAN.                                                                                          F2
                                                                            104      Processed according to plan provisions.

                                  FOLLOW-UP CONSULTATIONS ARE                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00778   LIMITED TO ONE PER WEEK.                   F0      and no more action will be taken.                                      104


                                  INITIAL CONSULT ON ESTABLISHED
                                  PATIENT CUTBACK TO FOLLOW-UP
01/01/1977   12/31/3999   00779   CONSULT.                                   F1      Finalized/Payment - The claim/line has been paid.                      15


                                  PLEASE SUBMIT ONE R&S COPY WITH
                                  EACH CORRECTED CLAIM/APPEAL,                       Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00780   REFER TO PROVIDER MANUAL.                  F0      and no more action will be taken.                                      285


                                  THIS CLAIM HAS BEEN ADJUSTED TO
                                  PAY AT YOUR SELECTIVELY
01/01/1977   12/31/3999   00783   CONTRACTED RATE.                           F1      Finalized/Payment - The claim/line has been paid.                      107


                                  PLEASE RESUBMIT FACILITY SERVICES
                                  WITH THE APPROPRIATE PROVIDER
01/01/1977   12/31/3999   00784   NUMBER.                                    F2      Finalized/Denial - The claim/line has been denied.                     132




                                                                         Page 238 of 378
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                                  REQUIRED INVOICE INSUFFICIENT OR
                                  MISSING. RESUBMIT WITH CORRECTED
01/01/1977   12/31/3999   00785   INVOICE.                                   F2      Finalized/Denial - The claim/line has been denied.   21


                                  THIS DETAIL HAS BEEN DIVIDED TO
                                  REFLECT A ROOM ACCOMODATION FOR
01/01/1977   12/31/3999   00787   THE DATE OF SERVICE.                       F1      Finalized/Payment - The claim/line has been paid.    15


                                  RADIATION THERAPY FACILITY
                                  TECHNICAL SERVICES ARE NOT
01/01/1977   12/31/3999   00788   PAYABLE TO PHYSICIANS.                     F2      Finalized/Denial - The claim/line has been denied.   107


                                  THIS VISIT DENIED AS INCLUDED IN
01/01/1977   12/31/3999   00791   PAYMENT FOR ANTEPARTUM CARE.               F2      Finalized/Denial - The claim/line has been denied.   107


                                  INCORRECT DIAGNOSIS/MISSING INFO
                                  PREVENTS DRG ASSIGNMENT. PLEASE
01/01/1977   12/31/3999   00792   CORRECT AND RESUBMIT.                      F2      Finalized/Denial - The claim/line has been denied.   255


01/01/1977   12/31/3999   00793   DRG CODE INVALID/NOT ON FILE.              F2      Finalized/Denial - The claim/line has been denied.   21


                                  ASSIGNMENT ACCEPTANCE IS
01/01/1977   12/31/3999   00794   REQUIRED FOR CLAIM PAYMENT.                F2      Finalized/Denial - The claim/line has been denied.   358


                                  THESE SERVICES DENIED DUE TO
                                  FAILURE TO SUBMIT REQUESTED
01/01/1977   12/31/3999   00795   INFORMATION.                               F2      Finalized/Denial - The claim/line has been denied.   95


                                  EXCESSIVE SUPPLIES BILLED AS HOME
                                  HEALTH SERVICES HAVE BEEN
01/01/1977   12/31/3999   00797   CUTBACK/REDUCED.                           F1      Finalized/Payment - The claim/line has been paid.    104


                                  CATARACT GLASSES OR LENS SERVICES
                                  REQUIRE THE DATE OF THE RELATED
01/01/1977   12/31/3999   00799   CATARACT SURGERY.                          F2      Finalized/Denial - The claim/line has been denied.   374


                                  SECOND OPINIONS ARE PAYABLE AS
                                  THE APPROPRIATE EVALUATION AND
01/01/1977   12/31/3999   00802   MANAGEMENT CODE.                           F1      Finalized/Payment - The claim/line has been paid.    15



                                                                         Page 239 of 378
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                                  MRI NOT PAYABLE WHEN PERFORMED
                                  ON SAME DAY OR WITHIN 7 DAYS AFTER
01/01/1977   12/31/3999   00803   CT SCAN OF SAME AREA.                      F2      Finalized/Denial - The claim/line has been denied.   104


                                  CT SCAN NOT PAYABLE WHEN
                                  PERFORMED WITHIN 7 DAYS AFTER MRI
01/01/1977   12/31/3999   00804   OF SAME AREA.                              F2      Finalized/Denial - The claim/line has been denied.   104


                                  THIS PROCEDURE IS DENIED, NOT
01/01/1977   12/31/3999   00805   MEDICALLY NECESSARY.                       F2      Finalized/Denial - The claim/line has been denied.   9


                                  MORE THAN ONE RESTORATION ON A
                                  SINGLE SURFACE IS CONSIDERED A
01/01/1977   12/31/3999   00806   SINGLE RESTORATION.                        F2      Finalized/Denial - The claim/line has been denied.   104


                                  THE PROVIDER WHO PERFORMED THIS
                                  SERVICE MUST BILL UNDER HIS/HER
01/01/1977   12/31/3999   00807   OWN PROVIDER NUMBER.                       F2      Finalized/Denial - The claim/line has been denied.   132


                                  THIS SERVICE IS NOT A BENEFIT MORE
01/01/1977   12/31/3999   00808   THAN ONCE IN A 6-YEAR PERIOD.              F2      Finalized/Denial - The claim/line has been denied.   104


                                  DOCUMENTATION INDICATES SERVICES
                                  WERE AVAILABLE AT THE FACILITY OF
01/01/1977   12/31/3999   00809   ORIGIN.                                    F2      Finalized/Denial - The claim/line has been denied.   430


                                  PLEASE PROVIDE/EXPLAIN
01/01/1977   12/31/3999   00810   DIAGNOSIS/REASON FOR SERVICES.             F2      Finalized/Denial - The claim/line has been denied.   287


                                  AUTHORIZATION MUST BE OBTAINED
                                  BEFORE DISPENSING CONTACT LENS,
01/01/1977   12/31/3999   00811   W/EXCEPTION OF DX-APHAKIA.                 F2      Finalized/Denial - The claim/line has been denied.   84


                                  OBSERVATION ROOM AND RELATED
                                  SERVICES PROVIDED IN EXCESS OF 23
01/01/1977   12/31/3999   00812   HOURS ARE NOT PAYABLE.                     F2      Finalized/Denial - The claim/line has been denied.   104


                                  THIS PROCEDURE/SERVICE IS
                                  CONSIDERED BILATERAL AND INCLUDES
01/01/1977   12/31/3999   00813   THE UNILATERAL SERVICE.                    F2      Finalized/Denial - The claim/line has been denied.   104


                                                                         Page 240 of 378
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                                  ANESTHESIOLOGIST ASSISTANT                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00814   INFORMATIONAL DETAIL ONLY.                F0      and no more action will be taken.                                      104


                                  ACCOMMODATION IS PAID TO THE
                                  FACILITY WHO HAD THE CLIENT AT
01/01/1977   12/31/3999   00816   MIDNIGHT THE DAY OF TRANSFER.             F2      Finalized/Denial - The claim/line has been denied.                     104


                                  EMERGENCY ROOM CHARGE NOT
                                  PAYABLE ON THE SAME DAY AS AN
01/01/1977   12/31/3999   00818   OBSERVATION ROOM CHARGE.                  F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PLEASE VERIFY THE YEAR OF SERVICE
                                  INDICATED ON YOUR CLAIM AND
01/01/1977   12/31/3999   00820   RESUBMIT.                                 F2      Finalized/Denial - The claim/line has been denied.                     482



                                  GROUP BILLING PROVIDER NUMBER
01/01/1977   12/31/3999   00821   NEEDED FOR CLAIM TO BE PROCESSED.         F2      Finalized/Denial - The claim/line has been denied.                     132


                                  THIS SERVICE IS DENIED. ONSET DATE
                                  MUST BE PRIOR TO THE DATE OF
01/01/1977   12/31/3999   00822   SERVICE.                                  F2      Finalized/Denial - The claim/line has been denied.                     397


                                  COMPLETE MEDICAL RECORD WAS NOT                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  RECEIVED WITHIN 30 DAYS; TECHNICAL                claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00824   DENIAL IS FINAL.                          F4      forthcoming.                                                           9


                                  OUR REVIEW INDICATES THE
                                  DESIGNATED LOCK-IN PROVIDER
                                  NAME/NUMBER FURNISHED IS
01/01/1977   12/31/3999   00825   INCORRECT.                                F2      Finalized/Denial - The claim/line has been denied.                     132


                                  CLAIM DENIED. PATIENT TRANSFERS
                                  WITHIN THE SAME FACILITY RECEIVE
01/01/1977   12/31/3999   00826   ONLY ONE DRG PAYMENT.                     F2      Finalized/Denial - The claim/line has been denied.                     104


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS ADJUSTMENT IS NOT THE RESULT                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00827   OF THE UTILIZATION REVIEW PROCESS.        F4      forthcoming.                                                           101


                                                                        Page 241 of 378
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                                  YOUR APPEAL HAS BEEN REVIEWED.                        Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAID AMOUNT REFLECTS AN                               claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00828   ADJUSTMENT.                                   F4      forthcoming.                                                           101


                                  YOUR CLAIM HAS BEEN REVIEWED BY
                                  THE PHYSICIANS & HAS BEEN ADJUSTED                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00829   ACCORDINGLY.                                  F0      and no more action will be taken.                                      46


                                  PLEASE RESUBMIT YOUR CLAIM WITH
                                  RADIOLOGY NOTES DESCRIBING AREA
01/01/1977   12/31/3999   00830   OF BODY SCANNED.                              F2      Finalized/Denial - The claim/line has been denied.                     297


                                  YOUR PAYMENT REFLECTS MARCH 1,
01/01/1977   12/31/3999   00831   1988, SDA/PDI UPDATE.                         F1      Finalized/Payment - The claim/line has been paid.                      104


                                  THE D&C IS CONSIDERED PART OF THIS
01/01/1977   12/31/3999   00832   TUBAL LIGATION PROCEDURE.                     F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PROVIDER NOT CERTIFIED FOR THIS
01/01/1977   12/31/3999   00834   DATE OF SERVICE.                              F2      Finalized/Denial - The claim/line has been denied.                     142


                                  MEDICARE REMITTANCE ADVICE OR
                                  NOTICE MUST BE SUBMITTED WITH A
01/01/1977   12/31/3999   00836   COMPLETED CLAIM FORM.                         F2      Finalized/Denial - The claim/line has been denied.                     286


                                  THIS CLIENT IS ELIGIBLE FOR
01/01/1977   12/31/3999   00837   EMERGENCY SERVICES ONLY.                      F2      Finalized/Denial - The claim/line has been denied.                     90


                                  CLIENT IS NOT ELIGIBLE FOR FAMILY
01/01/1977   12/31/3999   00838   PLANNING SERVICES UNDER TITLE XIX.            F2      Finalized/Denial - The claim/line has been denied.                     88


                                  THE MAXIMUM NUMBER OF ALLOWABLE
                                  ORTHODONTIC ADJUSTMENTS HAS BEEN
01/01/1977   12/31/3999   00840   EXCEEDED.                                     F2      Finalized/Denial - The claim/line has been denied.                     483


                                  ORTHODONTIC ADJUSTMENTS ARE NOT
                                  A BENEFIT ONCE BOTH RETAINERS HAVE
01/01/1977   12/31/3999   00841   BEEN APPLIED.                                 F2      Finalized/Denial - The claim/line has been denied.                     483


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                                  INITIAL VISIT NOT PAYABLE WITH OTHER
01/01/1977   12/31/3999   00842   ORTHODONTIC PROCEDURES.                      F2      Finalized/Denial - The claim/line has been denied.                     104


                                  PROCEDURE CODE HAS BEEN CHANGED
                                  IN ACCORDANCE WITH THSTEPS DENTAL                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00843   GUIDELINES.                                  F0      and no more action will be taken.                                      15


                                  CLAIMS SUBMITTED FOR NON-
                                  RENDERED SERVICES ARE NOT                            Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00844   REQUIRED.                                    F0      and no more action will be taken.                                      9


                                  INFORMATION ON CLAIM DOES NOT
01/01/1977   12/31/3999   00846   MATCH WHAT WAS AUTHORIZED.                   F2      Finalized/Denial - The claim/line has been denied.                     84


                                  PART A CHARGES MUST BE PROCESSED
                                  BY MEDICARE PRIOR TO SUBMITTING TO
01/01/1977   12/31/3999   00847   MEDICAID.                                    F2      Finalized/Denial - The claim/line has been denied.                     85



                                  PLEASE CLARIFY TYPE OF TRANSPORT.
                                  EMERGENCY/NON-EMERGENCY/AIR.
01/01/1977   12/31/3999   00848   CHANGE CODES ACCORDINGLY.                    F2      Finalized/Denial - The claim/line has been denied.                     428


                                  THIS SERVICE WAS CHANGED AND/OR
                                  NOT APPROVED BY THE ASSOCIATE                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00849   DENTAL DIRECTOR.                             F0      and no more action will be taken.                                      46


                                  MAXIMUM PAYMENT FOR INPATIENT
                                  STAY BASED ON LONESTAR SELECTII
01/01/1977   12/31/3999   00852   PERDIEM REIMBURSEMENT METHOD.                F1      Finalized/Payment - The claim/line has been paid.                      104


                                  PRIMARY DX/SEQUENCING CHANGED BY
                                  NHIC PHYSICIAN FOR APPROPRIATE DRG
01/01/1977   12/31/3999   00854   ASSIGNMENT.                                  F1      Finalized/Payment - The claim/line has been paid.                      104


                                  PAYMENT FOR THESE ITEMS IS
01/01/1977   12/31/3999   00855   INCLUDED IN THE BASE RATE.                   F1      Finalized/Payment - The claim/line has been paid.                      104




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                                  ACCOMMODATIONS/ANCILLARY                            Finalized/Adjudication Complete - No payment forthcoming - The
                                  SERVICES DENIED AS A RESULT OF                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00856   RETROSPECTIVE REVIEW.                       F4      forthcoming.                                                           101


                                  DRG ASSIGNMENT EXCLUDED SURGICAL
                                  PROCEDURE UNRELATED TO PRINCIPAL
01/01/1977   12/31/3999   00857   DIAGNOSIS.                                  F1      Finalized/Payment - The claim/line has been paid.                      104


                                  SERVICES PROVIDED OUTSIDE THE
                                  STATE OF TEXAS ARE PAYABLE ONLY
01/01/1977   12/31/3999   00858   FOR EMERGENCY SITUATIONS.                   F2      Finalized/Denial - The claim/line has been denied.                     471



                                  ONE OR MORE OF THE DIAGNOSES                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00859   REQUIRE 4TH OR 5TH DIGIT SPECIFICITY.       F0      and no more action will be taken.                                      426



                                  MEDICAID CANNOT PAY FOR SERVICES
                                  DENIED BY MEDICARE DUE TO
01/01/1977   12/31/3999   00860   ENROLLMENT IN A HOSPICE PROGRAM.            F2      Finalized/Denial - The claim/line has been denied.                     85


                                  OTHER INSURANCE PAYMENT IS                          Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00861   GREATER THAN DRG PAYABLE.                   F0      and no more action will be taken.                                      9


                                  APPEAL REVIEWED BY MED                              Finalized/Adjudication Complete - No payment forthcoming - The
                                  DIRECTOR/ASSOCIATE MED. DIRECTOR &                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00862   ADJUSTED PER INSTRUCTIONS.                  F4      forthcoming.                                                           101


                                  PLEASE REFILE A CORRECTED CLAIM
                                  FORM, INCLUDING THE AMBULANCE                       Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00866   BASE RATE PROCEDURE CODE.                   F0      and no more action will be taken.                                      7


                                  YOUR APPEAL HAS BEEN REVIEWED                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  AND THIS SERVICE REMAINS DENIED AS                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00868   NOT A BENEFIT.                              F4      forthcoming.                                                           9


                                  PROCEDURE/SERVICE LIMITED TO ONCE
                                  PER 12 MONTHS FROM LAST DATE OF
01/01/1977   12/31/3999   00870   SERVICE.                                    F2      Finalized/Denial - The claim/line has been denied.                     483




                                                                          Page 244 of 378
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                                  INDICATE THE AMOUNT OF TIME/HOURS
01/01/1977   12/31/3999   00871   INVOLVED IN PSYCHOLOGICAL TESTING.         F2      Finalized/Denial - The claim/line has been denied.                     263


                                  DIAGNOSIS CODE FOR DELIVERY IS
01/01/1977   12/31/3999   00872   MISSING.                                   F2      Finalized/Denial - The claim/line has been denied.                     254


                                  THE DIAGNOSIS AND/OR PROCEDURE
                                  CODE SUBMITTED DOES NOT
01/01/1977   12/31/3999   00873   CORRESPOND TO CLIENT'S AGE/SEX.            F2      Finalized/Denial - The claim/line has been denied.                     157


01/01/1977   12/31/3999   00874   PLACE OF SERVICE MISSING/INVALID.          F2      Finalized/Denial - The claim/line has been denied.                     249


                                  THE REMITTANCE ADVICE OR
                                  NOTICE/R&S MUST INDICATE CORRECT
01/01/1977   12/31/3999   00877   NAME/PCN OF CLIENT BEING BILLED.           F2      Finalized/Denial - The claim/line has been denied.                     125


                                  DATE AND TIME OF DEATH MUST BE
                                  PROVIDED TO PROCESS. REFILE CLAIM
01/01/1977   12/31/3999   00878   WITH REQUIRED INFORMATION.                 F2      Finalized/Denial - The claim/line has been denied.                     159


                                  PHYSICIAN SIGNATURE AND DATE OF
01/01/1977   12/31/3999   00879   SERVICE REQUIRED ON EXAM REPORT.           F2      Finalized/Denial - The claim/line has been denied.                     466


                                  THIS DETAIL IS FOR INFORMATIONAL                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00880   PURPOSES ONLY.                             F0      and no more action will be taken.                                      247


                                  IDENTITY OF THE WITNESS MISSING ON
01/01/1977   12/31/3999   00882   PATIENT CERTIFICATION STATEMENT.           F2      Finalized/Denial - The claim/line has been denied.                     21


                                  PATIENT CERTIFICATION MISSING OR
01/01/1977   12/31/3999   00883   NOT SIGNED.                                F2      Finalized/Denial - The claim/line has been denied.                     21


                                  THSTEPS MEDICAL INFORMATIONAL                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00884   DETAIL ONLY.                               F0      and no more action will be taken.                                      247


                                  CLAIM DENIED BECAUSE ITEM 3 ON
                                  PHYSICIAN EXAM REPORT CHECKED
01/01/1977   12/31/3999   00885   YES.                                       F2      Finalized/Denial - The claim/line has been denied.                     104


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                                  CLAIM DENIED BECAUSE OF NO
                                  RECOMMENDED HEARING AID OR COST
01/01/1977   12/31/3999   00886   OF HEARING AID ON EVAL REPORT.             F2      Finalized/Denial - The claim/line has been denied.   104


                                  DATE OF CALIBRATION REQUIRED ON
01/01/1977   12/31/3999   00887   HEARING AID EVAL FORM.                     F2      Finalized/Denial - The claim/line has been denied.   187


                                  CLAIM DENIED DUE TO INCONSISTENT
                                  TEST SCORES IN SOUND FIELD TEST
01/01/1977   12/31/3999   00888   RESULTS.                                   F2      Finalized/Denial - The claim/line has been denied.   104


                                  SIGNATURE OF DESIGNATED
                                  FITTER/DISPENSER REQUIRED ON
01/01/1977   12/31/3999   00889   EVALUATION REPORT (FORM 3503).             F2      Finalized/Denial - The claim/line has been denied.   466


                                  CLAIM DENIED FOR LACK OF A SERIAL
01/01/1977   12/31/3999   00890   NUMBER ON THE INVOICE.                     F2      Finalized/Denial - The claim/line has been denied.   21


                                  PHYSICIAN'S ADDRESS IS REQUIRED ON
01/01/1977   12/31/3999   00891   PHYSICIAN EXAM REPORT.                     F2      Finalized/Denial - The claim/line has been denied.   126



                                  PHYSICIAN'S NAME MUST BE PRINTED
01/01/1977   12/31/3999   00892   OR TYPED ON PHYSICIAN EXAM REPORT.         F2      Finalized/Denial - The claim/line has been denied.   125


                                  PROVIDER SIGNATURE MISSING ON
01/01/1977   12/31/3999   00893   HEARING AID EVAL FORM.                     F2      Finalized/Denial - The claim/line has been denied.   466


                                  CLAIM DENIED DUE TO INCOMPLETE
01/01/1977   12/31/3999   00894   TESTING.                                   F2      Finalized/Denial - The claim/line has been denied.   417


                                  CLAIM DENIED FOR LACK OF PATIENT
                                  CERTIFICATION STATEMENT FOR COST
01/01/1977   12/31/3999   00895   OVER ALLOWABLE.                            F2      Finalized/Denial - The claim/line has been denied.   408




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                                  ROUTINE DENTAL EMERGENT AND
                                  ORTHODONTIC SERVICES MUST BE
01/01/1977   12/31/3999   00896   BILLED ON SEPERATE CLAIMS.                  F1      Finalized/Payment - The claim/line has been paid.    275


                                  CLIENT NOT ELIGIBLE FOR THSTEPS
                                  DENTAL SERVICE. ONLY CLIENTS UNDER
01/01/1977   12/31/3999   00897   21 OR ICF-MR.                               F2      Finalized/Denial - The claim/line has been denied.   475


                                  SURGICAL DATE AND/OR PROCEDURE
                                  REQUIRED FOR PROCESSING. REFILE
01/01/1977   12/31/3999   00898   CORRECTED CLAIM.                            F2      Finalized/Denial - The claim/line has been denied.   454


                                  EYEGLASS LENSES REQUIRE A
01/01/1977   12/31/3999   00899   PRESCRIPTION IN BLOCK 13.                   F2      Finalized/Denial - The claim/line has been denied.   21



                                  TYPED OR HANDWRITTEN INFORMATION
                                  MUST HAVE MEDICAL CARRIER
01/01/1977   12/31/3999   00900   VERIFICATION TO BE PROCESSED.               F2      Finalized/Denial - The claim/line has been denied.   286



                                  THIS LAB SVC IS PART OF A PANEL CODE
01/01/1977   12/31/3999   00902   AND WILL NOT BE PAID SEPERATELY.            F2      Finalized/Denial - The claim/line has been denied.   454


                                  TYPE OF BILL INVALID, MISSING OR
                                  INCOMPATIBLE WITH PROVIDER TYPE
01/01/1977   12/31/3999   00903   OR SERVICES BILLED.                         F2      Finalized/Denial - The claim/line has been denied.   228


                                  DATE OF ADMISSION REQUIRED IN
01/01/1977   12/31/3999   00904   BLOCK 17 FOR PROCESSING.                    F2      Finalized/Denial - The claim/line has been denied.   189


                                  DISCHARGE PATIENT STATUS MISSING
01/01/1977   12/31/3999   00905   OR INVALID.                                 F2      Finalized/Denial - The claim/line has been denied.   21


                                  REFILE CLAIM WITH MEDICAL RECORD
01/01/1977   12/31/3999   00906   NUMBER.                                     F2      Finalized/Denial - The claim/line has been denied.   478


                                  FORM 3503 IS MISSING. RESUBMIT
                                  CLAIM WITH FORM 3503 SIGNED BY THE
01/01/1977   12/31/3999   00908   DESIGNATED PROVIDER.                        F2      Finalized/Denial - The claim/line has been denied.   466


                                                                          Page 247 of 378
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                                  TOTAL NUMBER OF CC'S PER ANTIGEN
                                  VIAL IS NEEDED FOR FURTHER
01/01/1977   12/31/3999   00909   PROCESSING OF THIS CLAIM.                   F2      Finalized/Denial - The claim/line has been denied.               258



                                  RESUBMIT YOUR CLAIM WITH THE NAME
01/01/1977   12/31/3999   00911   OF THE MOTHER OF THIS NEWBORN.              F2      Finalized/Denial - The claim/line has been denied.               125


                                  PLEASE PROVIDE THE NUMBER OF
01/01/1977   12/31/3999   00913   COVERED DAYS.                               F2      Finalized/Denial - The claim/line has been denied.               456


                                  TYPE AND SOURCE OF ADMIT
01/01/1977   12/31/3999   00914   MISSING/INVALID. PLEASE RESUBMIT.           F2      Finalized/Denial - The claim/line has been denied.               21


                                  INFORMATION IN FORM LOCATOR 63, 79,
01/01/1977   12/31/3999   00915   OR 86 IS MISSING OR INVALID.                F2      Finalized/Denial - The claim/line has been denied.               187


                                  DIAGNOSIS REFERENCE NUMBER
01/01/1977   12/31/3999   00916   REQUIRED IN FORM LOCATOR 43.                F2      Finalized/Denial - The claim/line has been denied.               477


                                  BILL ONLY DATES OF SERVICE
                                  APPLICABLE TO PAN NUMBER IN FORM
01/01/1977   12/31/3999   00917   LOCATOR 63.                                 F2      Finalized/Denial - The claim/line has been denied.               48


                                  START OF CARE DATE IS MISSING OR
01/01/1977   12/31/3999   00918   INVALID.                                    F2      Finalized/Denial - The claim/line has been denied.               192


                                  CLIENT HAS TWO PCN'S. DHS HAS BEEN
                                  NOTIFIED TO MERGE PCN'S. PLEASE
01/01/1977   12/31/3999   00920   REAPPEAL IN 180 DAYS.                       F2      Finalized/Denial - The claim/line has been denied.               7


                                  DRG CHANGE DUE TO HOSPITALS
                                  REQUEST TO CORRECT A                                Finalized/Adjudication Complete - No payment forthcoming - The
                                  DIAGNOSIS/PROCEDURE CODING                          claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00922   ERROR.                                      F4      forthcoming.                                                     101


                                  CLAIM DENIAL: BLOCK 12A OR 12B IS
01/01/1977   12/31/3999   00923   MISSING.                                    F2      Finalized/Denial - The claim/line has been denied.               480


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                                  THE DATE OF X-RAY MUST BE PRIOR TO
01/01/1977   12/31/3999   00924   THE SUBLUXATION MANIPULATION.              F2      Finalized/Denial - The claim/line has been denied.               210


                                  CLIENT'S FULL NAME, CLIENT NUMBER,
                                  SEX & CORRECT DOB MUST BE ON CLAIM
01/01/1977   12/31/3999   00925   FOR PROCESSING.                            F2      Finalized/Denial - The claim/line has been denied.               21


                                  CLAIMS THAT HAVE CREDIT/NEGATIVE
                                  AMOUNTS CANNOT BE PROCESSED.
01/01/1977   12/31/3999   00926   PLEASE CORRECT AND RESUBMIT.               F2      Finalized/Denial - The claim/line has been denied.               402


                                  DATE OF SURGERY (FL 80) IS PRIOR TO
                                  ADMISSION DATE (FL 17). PLEASE
01/01/1977   12/31/3999   00927   RECONCILE AND RESUBMIT.                    F2      Finalized/Denial - The claim/line has been denied.               486


                                  TOTAL CLAIM CHARGE DOES NOT MATCH
01/01/1977   12/31/3999   00928   ATTACHMENT CHARGES.                        F2      Finalized/Denial - The claim/line has been denied.               178


                                  ACCOMMODATION CHARGES MUST
01/01/1977   12/31/3999   00929   INCLUDE THE RATE PER DAY.                  F2      Finalized/Denial - The claim/line has been denied.               181


                                  SURGERY DATE MUST FALL WITHIN
                                  SPAN DATES (BLOCK 6). PLEASE REFILE
01/01/1977   12/31/3999   00930   CORRECTED CLAIM.                           F2      Finalized/Denial - The claim/line has been denied.               486



                                  PLEASE PROVIDE THE ORIGIN AND/OR
01/01/1977   12/31/3999   00931   DESTINATION OF AMBULANCE SERVICE.          F2      Finalized/Denial - The claim/line has been denied.               266


                                  NUMBER OF MILES AND CHARGE PER
                                  MILE MUST EQUAL THE TOTAL MILEAGE
01/01/1977   12/31/3999   00932   CHARGE.                                    F2      Finalized/Denial - The claim/line has been denied.               267


                                  THIS ADJUSTMENT IS DUE TO A PATIENT                Finalized/Adjudication Complete - No payment forthcoming - The
                                  TRANSFER. PAYMENT IS CALCULATED                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00933   ON A PER DIEM BASIS.                       F4      forthcoming.                                                     101




                                                                         Page 249 of 378
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                                  THIS IS A DUPLICATE ADJUSTMENT
                                  REQUEST. PLEASE DO NOT FILE
01/01/1977   12/31/3999   00934   DUPLICATES.                               F2      Finalized/Denial - The claim/line has been denied.               78


                                  MEDICARE ATTACHMENT IS NOT A
                                  MEDICARE REMITTANCE ADVICE OR
01/01/1977   12/31/3999   00935   NOTICE.                                   F2      Finalized/Denial - The claim/line has been denied.               286


                                  THESE SERVICES PAID IN ACCORDANCE
                                  WITH THE FEDERAL MATCHING FUND
01/01/1977   12/31/3999   00936   RATE.                                     F1      Finalized/Payment - The claim/line has been paid.                104


                                  SNF MEDICARE PART A COINSURANCE
                                  AND DEDUCTIBLES ARE PROCESSED BY
01/01/1977   12/31/3999   00937   DHS.                                      F2      Finalized/Denial - The claim/line has been denied.               116


                                  HOSPICE INFORMATION MUST BE SENT
01/01/1977   12/31/3999   00938   TO DHS. REAPPEAL WITHIN 180 DAYS.         F2      Finalized/Denial - The claim/line has been denied.               85


                                  THIS PROCEDURE NOT COVERED FOR
01/01/1977   12/31/3999   00940   THIS PROVIDER SPECIALTY.                  F2      Finalized/Denial - The claim/line has been denied.               145


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS CLAIM HAS BEEN READJUSTED AT                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   00941   THE REQUEST OF HHSC.                      F4      forthcoming.                                                     101


                                  PAID UNDER THSTEPS COMPREHENSIVE
01/01/1977   12/31/3999   00942   CARE PROGRAM.                             F1      Finalized/Payment - The claim/line has been paid.                104



                                  ADMITTING DIAGNOSIS CODE IS
                                  REQUIRED IN FORM LOCATOR 76.
01/01/1977   12/31/3999   00944   PLEASE RESUBMIT WITH A VALID CODE.        F2      Finalized/Denial - The claim/line has been denied.               232


                                  RESUBMIT CORRECTED CLAIM WITH
                                  DATE AND PROCEDURE CODE FOR
01/01/1977   12/31/3999   00946   STERILIZATION.                            F2      Finalized/Denial - The claim/line has been denied.               454




                                                                        Page 250 of 378
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                                  RESUBMIT CORRECTED CLAIM WITH
                                  DATE AND PROCEDURE CODE FOR
01/01/1977   12/31/3999   00947   DELIVERY.                                  F2      Finalized/Denial - The claim/line has been denied.   454


                                  CLAIM DOCUMENTATION DOES NOT
                                  SUPPORT REQUESTED DIAGNOSIS/DRG
01/01/1977   12/31/3999   00948   CHANGE.                                    F2      Finalized/Denial - The claim/line has been denied.   294


                                  MEDICAID CONSIDERS CASTING,
                                  STRAPPING, & SPLINTING TO BE PART
01/01/1977   12/31/3999   00949   OF THE GLOBAL SURGICAL FEE.                F2      Finalized/Denial - The claim/line has been denied.   104


                                  THIS CLIENT DOESN'T HAVE THSTEPS
                                  ELIGIBILITY AND DOESN'T QUALIFY FOR
01/01/1977   12/31/3999   00951   THSTEPS-CCP SERVICES.                      F2      Finalized/Denial - The claim/line has been denied.   88


                                  THE AUTHORIZATION NUMBER USED ON
01/01/1977   12/31/3999   00953   THIS CLAIM IS INVALID.                     F2      Finalized/Denial - The claim/line has been denied.   21


                                  THE AUTHORIZATION NUMBER USED ON
                                  THIS CLAIM IS NOT VALID FOR THE DATE
01/01/1977   12/31/3999   00954   OF SERVICE.                                F2      Finalized/Denial - The claim/line has been denied.   252


                                  THIS IS NOT A VALID PROC CODE FOR
                                  THIS DATE OF SERVICE. RESUBMIT WITH
01/01/1977   12/31/3999   00958   A VALID PROC CODE.                         F2      Finalized/Denial - The claim/line has been denied.   454



                                  PAID ACCORDING TO CO-
01/01/1977   12/31/3999   00959   SURGEON/TEAM SURGEON GUIDELINES.           F1      Finalized/Payment - The claim/line has been paid.    104


                                  EKG INTERPRETATIONS ARE NOT
                                  SEPARATELY PAYABLE UNDER TEXAS
01/01/1977   12/31/3999   00960   MEDICAID.                                  F1      Finalized/Payment - The claim/line has been paid.    104


                                  SERVICE DENIED SINCE IT IS INCLUDED
                                  IN THE PAYMENT FOR EVALUATION OF
01/01/1977   12/31/3999   00962   THE CLIENT.                                F1      Finalized/Payment - The claim/line has been paid.    104




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                                  PAID ACCORDING TO THE
                                  ACCOMMODATION CODE PER DIEM
01/01/1977   12/31/3999   00965   PRICING METHODOLOGY.                      F1      Finalized/Payment - The claim/line has been paid.                      104


                                  THE DETAIL(S) QUANTITY WAS CHANGED
                                  TO MATCH WHAT THE PROVIDER
01/01/1977   12/31/3999   00966   DESCRIBED.                                F3      Finalized/Revised - Adjudication information has been changed          258


                                  THE DETAIL(S) PLACE OF SERVICE WAS
                                  CHANGED TO MATCH WHAT THE
01/01/1977   12/31/3999   00967   PROVIDER DESCRIBED.                       F3      Finalized/Revised - Adjudication information has been changed          249


                                  THE TOTAL MEDICARE PAID IS EQUAL TO
                                  OR GREATER THAN YOUR ENCOUNTER                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00968   RATE.                                     F0      and no more action will be taken.                                      104


                                  COMBINED TOTAL OF MEDICARE AND
                                  MEDICAID PAYMENT EQUALS YOUR                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00969   ENCOUNTER RATE.                           F0      and no more action will be taken.                                      104


                                  THIS IS A DUPLICATE SERVICE THAT
                                  WAS PAID TO THIS PROVIDER UNDER A
01/01/1977   12/31/3999   00970   DIFFERENT NUMBER.                         F2      Finalized/Denial - The claim/line has been denied.                     54


                                  THE COST OF FREIGHT FROM
                                  MANUFACTURER TO VENDOR IS NOT
01/01/1977   12/31/3999   00971   PAYABLE AFTER OCTOBER 1, 1992.            F2      Finalized/Denial - The claim/line has been denied.                     104


                                  LABOR FEE (TECHNICIAN FITTING AND
                                  MEASURING FEE) NOT PAYABLE AFTER
01/01/1977   12/31/3999   00972   OCTOBER 1, 1992.                          F2      Finalized/Denial - The claim/line has been denied.                     104


                                  SERVICE BILLED IS CONSIDERED PART
                                  OF APPROPRIATE STANDARD OF CARE &
01/01/1977   12/31/3999   00973   NOT PAYABLE SEPARATELY.                   F2      Finalized/Denial - The claim/line has been denied.                     104


                                  HOUR OF ADMISSION REQUIRED FOR
01/01/1977   12/31/3999   00974   PROCESSING.                               F2      Finalized/Denial - The claim/line has been denied.                     21




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                                  PLEASE RESUBMIT USING APPROPRIATE
01/01/1977   12/31/3999   00976   HCPCS/CPT PROCEDURE CODE.                 F2      Finalized/Denial - The claim/line has been denied.                     21


                                  IN ORDER TO FACILITATE PROCESSING
                                  LIKE REVENUE CODES HAVE BEEN                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   00980   COMBINED.                                 F0      and no more action will be taken.                                      15


                                  MEDICATIONS PAID UNDER THSTEPS-
                                  CCP MUST BE BILLED BY ENROLLED VP
01/01/1977   12/31/3999   00982   PROVIDER.                                 F2      Finalized/Denial - The claim/line has been denied.                     132


                                  USED DME IS NOT A BENEFIT OF CCP.
                                  PLEASE APPEAL WITH CORRECT TYPE
01/01/1977   12/31/3999   00983   OF SERVICE.                               F2      Finalized/Denial - The claim/line has been denied.                     250


                                  PLEASE FURNISH THE SURGEON'S
                                  LICENSE NUMBER IN A VALID FORMAT
01/01/1977   12/31/3999   00984   (EXAMPLE: TXBL1234).                      F2      Finalized/Denial - The claim/line has been denied.                     143


                                  CLAIM DENIED DUE TO RETROSPECTIVE                 Finalized/Adjudication Complete - No payment forthcoming - The
                                  UTILIZATION REVIEW PROCESS. PLEASE                claim/encounter has been adjudicated and no further payment is
08/01/2002   12/31/3999   00985   APPEAL TO TDH.                            F4      forthcoming.                                                           101


                                  THE ADMIT AND/OR DISCHARGE DATE
                                  DOES NOT MATCH THE SERVICE DATE
01/01/1977   12/31/3999   00986   ON ONE OR MORE DETAILS.                   F2      Finalized/Denial - The claim/line has been denied.                     189


                                  ALLERGY VIAL DENIED. PAYMENT OF
                                  ALLERGY INJECTION INCLUDES THE
01/01/1977   12/31/3999   00987   COST OF THE EXTRACT.                      F2      Finalized/Denial - The claim/line has been denied.                     104


                                  THIS SERVICE(S) INCLUDED IN THE
                                  REIMBURSEMENT FOR CUSTOMIZED
01/01/1977   12/31/3999   00988   EQUIPMENT.                                F2      Finalized/Denial - The claim/line has been denied.                     104


                                  DOCUMENTATION FOR AUTHORIZATION
                                  REQUEST OR EXTENSION NOT RECEIVED
01/01/1977   12/31/3999   00989   WITHIN TIME LIMITS.                       F2      Finalized/Denial - The claim/line has been denied.                     294




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                                  NHIC RECEIVED AN ELECTRONICALLY
                                  SUBMITTED MCARE CLAIM CORRECTION
                                  FROM YOUR INTERMEDIARY. NHIC DOES
                                  NOT PROCESS MCARE CORRECTIONS
                                  ELECTRONICALLY. PLEASE RESUBMIT
                                  THE ORIGINAL CLAIM AND THE
                                  CORRECTED CLAIM WITH APPLICABLE
11/14/2001   12/31/3999   00990   MRANS.                                    F2      Finalized/Denial - The claim/line has been denied.   286


                                  DENIED DUE TO HMO REQUIREMENTS
01/01/1977   12/31/3999   00991   NOT BEING MET.                            F2      Finalized/Denial - The claim/line has been denied.   115


                                  MEDICAID R&S AND CIDC CLAIM DO NOT
                                  MATCH. RESUBMIT WITH EXACT
01/01/1977   12/31/3999   00992   MATCHING R&S AND CLAIM.                   F2      Finalized/Denial - The claim/line has been denied.   7


                                  OUR RECORDS INDICATE THIS CLIENT IS
01/01/1977   12/31/3999   00994   NOT ELIGIBLE FOR THIS DIAGNOSIS.          F2      Finalized/Denial - The claim/line has been denied.   255


                                  THIS SERVICE SHOULD BE APPEALED TO
01/01/1977   12/31/3999   00995   MEDICAID BEFORE BILLING CIDC.             F2      Finalized/Denial - The claim/line has been denied.   116


                                  THIS SERVICE HAS BEEN PAID/DENIED
                                  BY MEDICAID. NO FURTHER PAYMENT BY
01/01/1977   12/31/3999   00996   CIDC.                                     F2      Finalized/Denial - The claim/line has been denied.   104


                                  OUR RECORDS INDICATE THIS CLIENT IS
                                  ENROLLED WITH MEDICAID. PLEASE BILL
01/01/1977   12/31/3999   00997   MEDICAID FIRST.                           F2      Finalized/Denial - The claim/line has been denied.   88


                                  WE ARE UNABLE TO PROCESS YOUR
                                  ELECTRONIC APPEAL. PLEASE
                                  RESUBMIT YOUR APPEAL AND APPLY
                                  CHANGES TO THE CORRESPONDING
                                  DETAIL # YOU ARE APPEALING FROM
                                  THE PREVIOUS CLAIM. CONTACT THE EDI
                                  HELP DESK FOR MORE INFORMATION
10/30/2001   12/31/3999   01000   888-863-3638.                             F2      Finalized/Denial - The claim/line has been denied.   7




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                                  THIS PAYMENT WAS INCREASED BY 1.9%
                                  PER THE 77TH LEGISLATURE FUNDING
                                  FOR MEDICAID PROFESSIONAL
01/18/2002   12/31/3999   01001   SERVICES SFY02                              F1      Finalized/Payment - The claim/line has been paid.    104


                                  THIS PAYMENT WAS INCREASED BY 6.1%
                                  PER THE 77TH LEGISLATURE FUNDING
                                  FOR MEDICAID PROFESSIONAL
01/18/2002   12/31/3999   01002   SERVICES SFY02                              F1      Finalized/Payment - The claim/line has been paid.    104



                                  THIS PAYMENT WAS INCREASED BY 3.7%
                                  PER THE 77TH LEGISLATURE FUNDING
01/18/2002   12/31/3999   01003   FOR MEDICAID DENTAL SERVICES SFY02          F1      Finalized/Payment - The claim/line has been paid.    104


                                  THIS PAYMENT WAS REDUCED 2.5% IN
                                  ACCORDANCE WITH THE 78TH TEXAS
                                  LEGISLATURE, ARTICLE II OF HOUSE BILL
                                  1, AND SECTION 2.03 OF HOUSE BILL
01/01/1977   12/31/3999   01004   2292.                                       F1      Finalized/Payment - The claim/line has been paid.    104


                                  PAYMENT REDUCED ACCORDING TO
01/01/1977   12/31/3999   01005   GUIDELINES.                                 F1      Finalized/Payment - The claim/line has been paid.    104



                                  FAMILY PLANNING SERVICES MUST BE
                                  BILLED ON THE FAMILY PLANNING 2017
                                  CLAIM FORM. PLEASE RESUBMIT YOUR
01/01/1977   12/31/3999   01007   CLAIM ON THE APPROPRIATE FORM.              F2      Finalized/Denial - The claim/line has been denied.   275


                                  CLAIM DIAGNOSIS IS INVALID TO
01/01/1977   12/31/3999   01008   CLIENT'S SEX.                               F2      Finalized/Denial - The claim/line has been denied.   86


                                  PROCEDURE CODE AND/OR DIAGNOSIS
01/01/1977   12/31/3999   01009   ARE NOT PART OF THIS BENEFIT PLAN.          F2      Finalized/Denial - The claim/line has been denied.   104


                                  BILLING PROVIDER NUMBER FORMAT IS
01/01/1977   12/31/3999   01010   INVALID.                                    F2      Finalized/Denial - The claim/line has been denied.   132


                                  REFERRING PROVIDER NUMBER FORMAT
01/01/1977   12/31/3999   01013   IS INVALID.                                 F2      Finalized/Denial - The claim/line has been denied.   132


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                                  PROCEDURE IS NOT ALLOWED TO SPAN
                                  DATES OF SERVICE, OR QUANTITY
                                  BILLED IS NOT EVENLY DIVISIBLE BY
01/01/1977   12/31/3999   01015   NUMBER OF DAYS.                            F2      Finalized/Denial - The claim/line has been denied.   21


                                  PROCEDURE CODE IS BLANK. PLEASE
01/01/1977   12/31/3999   01016   RESUBMIT CORRECTED CLAIM.                  F2      Finalized/Denial - The claim/line has been denied.   122


                                  OTHER PROVIDER NUMBER FORMAT
01/01/1977   12/31/3999   01017   INVALID.                                   F2      Finalized/Denial - The claim/line has been denied.   132


                                  OPERATING PROVIDER NUMBER
01/01/1977   12/31/3999   01018   FORMAT INVALID.                            F2      Finalized/Denial - The claim/line has been denied.   132



                                  LAB NAME AND ADDRESS ARE REQUIRED
01/01/1977   12/31/3999   01019   WHEN BILLING LAB HANDLING FEE.             F2      Finalized/Denial - The claim/line has been denied.   126


                                  FACILITY PROVIDER STATE
01/01/1977   12/31/3999   01021   ABBREVIATION IS INVALID.                   F2      Finalized/Denial - The claim/line has been denied.   21


                                  FACILITY PROVIDER ZIP MUST BE A 5 OR
01/01/1977   12/31/3999   01022   9 DIGIT NUMBER.                            F2      Finalized/Denial - The claim/line has been denied.   126


                                  BILLING PROVIDER TAX ID MUST BE
01/01/1977   12/31/3999   01024   NUMERIC.                                   F2      Finalized/Denial - The claim/line has been denied.   128


                                  PROVIDER TPI-PRACTICE LOCATION IS IN
01/01/1977   12/31/3999   01025   PENDING STATUS.                            F2      Finalized/Denial - The claim/line has been denied.   44


                                  A VALID CLIENT DATE OF BIRTH IS
                                  REQUIRED AND CANNOT BE IN THE
01/01/1977   12/31/3999   01026   FUTURE.                                    F2      Finalized/Denial - The claim/line has been denied.   158


                                  A VALID DATE OF DEATH IS REQUIRED
01/01/1977   12/31/3999   01027   AND CANNOT BE IN THE FUTURE.               F2      Finalized/Denial - The claim/line has been denied.   159




                                                                         Page 256 of 378
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                                  CLAIM INDICATES CLIENT HAS OTHER
                                  INSURANCE. ALL OR PART OF THE
                                  REQUIRED INFORMATION IS MISSING.
                                  SEE PROVIDER MANUAL FOR REQUIRED
01/01/1977   12/31/3999   01028   OTHER INSURANCE INFORMATION.                F2      Finalized/Denial - The claim/line has been denied.   171


                                  TOTAL CLAIM CHARGES IS A REQUIRED
01/01/1977   12/31/3999   01035   NUMERIC FIELD.                              F2      Finalized/Denial - The claim/line has been denied.   178


                                  INCOMPLETE PROVIDER ELIGIBILITY,
01/01/1977   12/31/3999   01046   CONTACT PROVIDER ENROLLMENT.                F2      Finalized/Denial - The claim/line has been denied.   109


                                  SOURCE OF PAYMENT MUST BE A VALID
01/01/1977   12/31/3999   01054   VALUE.                                      F2      Finalized/Denial - The claim/line has been denied.   401


                                  CURR-SOURCE OF PAYMENT IS
01/01/1977   12/31/3999   01058   REQUIRED.                                   F2      Finalized/Denial - The claim/line has been denied.   401


01/01/1977   12/31/3999   01062   AUTO ACCIDENT INDICATOR IS INVALID.         F2      Finalized/Denial - The claim/line has been denied.   366


                                  EMPLOYMENT RELATED INDICATOR IS
01/01/1977   12/31/3999   01063   INVALID.                                    F2      Finalized/Denial - The claim/line has been denied.   364


01/01/1977   12/31/3999   01071   COVERED DAYS IS REQUIRED.                   F2      Finalized/Denial - The claim/line has been denied.   456


                                  OCCURRENCE SPAN FROM DATE IS
                                  REQUIRED AND CANNOT BE A FUTURE
01/01/1977   12/31/3999   01074   DATE.                                       F2      Finalized/Denial - The claim/line has been denied.   462


                                  OCCURRENCE SPAN TO DATE IS
                                  REQUIRED AND CANNOT BE A FUTURE
01/01/1977   12/31/3999   01075   DATE.                                       F2      Finalized/Denial - The claim/line has been denied.   462



01/01/1977   12/31/3999   01076   OCCURRENCE CODE MUST BE NUMERIC.            F2      Finalized/Denial - The claim/line has been denied.   461


01/01/1977   12/31/3999   01077   OCCURRENCE DATE IS REQUIRED.                F2      Finalized/Denial - The claim/line has been denied.   461



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                                  EYEGLASS PRESCRIPTION
01/01/1977   12/31/3999   01078   REPLACEMENT CODE IS INVALID.                  F2      Finalized/Denial - The claim/line has been denied.                    219


01/01/1977   12/31/3999   01079   CONDITION CODE MUST BE NUMERIC.               F2      Finalized/Denial - The claim/line has been denied.                    460


                                  THE TID IS INCONSISTENT FOR THIS
                                  PROCEDURE CODE AND THE CLIENT'S
01/01/1977   12/31/3999   01080   AGE.                                          F2      Finalized/Denial - The claim/line has been denied.                    244


                                  THSTEPS REFERRAL INDICATOR IS
01/01/1977   12/31/3999   01081   INVALID.                                      F2      Finalized/Denial - The claim/line has been denied.                    48


                                  DENTAL EXCEPTION TO PERIODICITY
01/01/1977   12/31/3999   01082   INVALID.                                      F2      Finalized/Denial - The claim/line has been denied.                    239


                                  DENTAL EMERGENCY INDICATOR IS
01/01/1977   12/31/3999   01083   INVALID.                                      F2      Finalized/Denial - The claim/line has been denied.                    471


01/01/1977   12/31/3999   01084   ORTHO INDICATOR IS INVALID.                   F2      Finalized/Denial - The claim/line has been denied.                    239


                                  CONDITION INDICATOR IS REQUIRED
                                  WITH THIS PROCEDURE AND PROVIDER                      Acknowledgement/Returend as unprocessable claim-The
                                  TYPE. PLEASE RESUBMIT WITH A                          claim/encounter has been rejected and has not been entered into the
01/01/1977   12/31/3999   01085   CORRECTED CLAIM.                              A3      adjudication system.                                                  104


                                  A VALID VACCINE PROCEDURE CODE IS                     Acknowledgement/Returend as unprocessable claim-The
                                  REQUIRED ON THE SAME CLAIM WITH AN                    claim/encounter has been rejected and has not been entered into the
01/01/1977   12/31/3999   01086   ADMINISTRATION.                               A3      adjudication system.                                                  104


                                  QUANTITY BILLED IS MISSING+D2757.
01/01/1977   12/31/3999   01088   PLEASE RESUBMIT.                              F2      Finalized/Denial - The claim/line has been denied.                     7


01/01/1977   12/31/3999   01093   BILLED AMOUNT IS REQUIRED.                    F2      Finalized/Denial - The claim/line has been denied.                    178


01/01/1977   12/31/3999   01100   CSHCN (CIDC) EOB MUST BE NUMERIC.             F2      Finalized/Denial - The claim/line has been denied.                    21


                                  CSHCN DURABLE MEDICAL EQUIPMENT
                                  AND PARTS MUST BE NEW, NOT USED,
01/01/1977   12/31/3999   01101   RECONDITIONED OR DAMAGED                      F2      Finalized/Denial - The claim/line has been denied.                    377

                                                                            Page 258 of 378
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01/01/1977   12/31/3999   01105   FUNDING SOURCE MUST BE INDICATED.             F2      Finalized/Denial - The claim/line has been denied.   401


01/01/1977   12/31/3999   01106   PAYMENT CODE INDICATED IS INVALID.            F2      Finalized/Denial - The claim/line has been denied.   401


01/01/1977   12/31/3999   01107   CLIENT LAST NAME IS BLANK.                    F2      Finalized/Denial - The claim/line has been denied.   125


01/01/1977   12/31/3999   01108   CLIENT FIRST NAME IS BLANK.                   F2      Finalized/Denial - The claim/line has been denied.   125


                                  NO ATTACHMENTS ON AN AMBULANCE
01/01/1977   12/31/3999   01111   CLAIM.                                        F2      Finalized/Denial - The claim/line has been denied.   472


01/01/1977   12/31/3999   01112   DATE OF DEATH IS INVALID.                     F2      Finalized/Denial - The claim/line has been denied.   159


01/01/1977   12/31/3999   01114   CLIENT SIGNATURE IS MISSING.                  F2      Finalized/Denial - The claim/line has been denied.   466


                                  PLEASE ENTER THE CORRECT FP TITLE
01/01/1977   12/31/3999   01116   BEING BILLED.                                 F2      Finalized/Denial - The claim/line has been denied.   104


                                  PLEASE INDICATE WHETHER THIS IS A
01/01/1977   12/31/3999   01117   NEW OR EXISTING PATIENT.                      F2      Finalized/Denial - The claim/line has been denied.   387



01/01/1977   12/31/3999   01118   PLEASE INDICATE THE PATIENT'S RACE.           F2      Finalized/Denial - The claim/line has been denied.   122


                                  PLEASE INDICATE THE PATIENT'S
01/01/1977   12/31/3999   01119   ETHNICITY.                                    F2      Finalized/Denial - The claim/line has been denied.   122


01/01/1977   12/31/3999   01120   PLEASE ENTER FAMILY INCOME.                   F2      Finalized/Denial - The claim/line has been denied.   122


                                  PLEASE ENTER THE TOTAL NUMBER OF
                                  PEOPLE SUPPORTED BY THE FAMILY
01/01/1977   12/31/3999   01121   INCOME.                                       F2      Finalized/Denial - The claim/line has been denied.   122




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                                  PLEASE ENTER THE NUMBER OF TIMES
01/01/1977   12/31/3999   01122   THE PATIENT HAS BEEN PREGNANT.                F2      Finalized/Denial - The claim/line has been denied.   122


                                  PLEASE ENTER THE NUMBER OF LIVE
01/01/1977   12/31/3999   01123   BIRTHS FOR THE PATIENT.                       F2      Finalized/Denial - The claim/line has been denied.   122


                                  PLEASE ENTER THE NUMBER OF LIVING
01/01/1977   12/31/3999   01124   CHILDREN THE PATIENT HAS.                     F2      Finalized/Denial - The claim/line has been denied.   122


01/01/1977   12/31/3999   01128   ENTER THE LEVEL OF PRACTIONER.                F2      Finalized/Denial - The claim/line has been denied.   147


                                  ENTER THE DATE OF OCCURRENCE IF
                                  BILLING FOR COMPLICATIONS RELATED
                                  TO STERILIZATIONS, CONTRACEPTIVE
01/01/1977   12/31/3999   01130   IMPLANTS OR IUDS.                             F2      Finalized/Denial - The claim/line has been denied.   122


01/01/1977   12/31/3999   01132   TYPE OF SERVICE IS INVALID.                   F2      Finalized/Denial - The claim/line has been denied.   250


01/01/1977   12/31/3999   01133   DIAGNOSIS REFERENCE IS INVALID.               F2      Finalized/Denial - The claim/line has been denied.   477


                                  ATTACHMENT/OI DISPOSITION CODE IS
01/01/1977   12/31/3999   01138   INVALID.                                      F2      Finalized/Denial - The claim/line has been denied.   480


01/01/1977   12/31/3999   01139   ATTACHMENT INDICATOR IS INVALID.              F2      Finalized/Denial - The claim/line has been denied.   122


                                  UNABLE TO ASSIGN PROGRAM/BENEFIT
                                  PLAN. PLEASE REFILE CLAIM WITH
                                  CORRECTED CLIENT/PROVIDER
                                  INFORMATION. NOTE: FP TITLE V, X,
                                  AND XX CLAIMS AND ENCOUNTERS WITH
                                  DATES OF SERVICE PRIOR TO 09/01/2001
                                  SHOULD BE SUBMITTED TO STATE
01/01/1977   12/31/3999   01140   AGENCY.                                       F2      Finalized/Denial - The claim/line has been denied.   116


                                  THIS DETAIL CANNOT BE PROCESSED
                                  UNDER THE CURRENT PROGRAM.
                                  PLEASE APPEAL UNDER THE PREVIOUS
01/01/1977   12/31/3999   01141   PROGRAM.                                      F2      Finalized/Denial - The claim/line has been denied.   104



                                                                            Page 260 of 378
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                                  PRIMARY BIRTH CONTROL METHOD AT
                                  END OF VISIT IS 'NO METHOD'. PLEASE
                                  SUPPLY REASON NO METHOD USED
01/01/1977   12/31/3999   01142   FIELD.                                     F2      Finalized/Denial - The claim/line has been denied.                     294


01/01/1977   12/31/3999   01143   SURGERY DATE IS MISSING OR INVALID         F2      Finalized/Denial - The claim/line has been denied.                     390


                                  SERVICE FILED ON AN INCORRECT
                                  FORM. PROVIDER ELIGIBLE FOR
                                  COINSURANCE OR DEDUCTIBLE
                                  PAYMENT ONLY. CONTACT NHIC
01/01/1977   12/31/3999   01144   CUSTOMER SERVICE.                          F2      Finalized/Denial - The claim/line has been denied.                     91


                                  CLAIM FORM NOT ALLOWED FOR THIS
01/01/1977   12/31/3999   01145   PROGRAM.                                   F2      Finalized/Denial - The claim/line has been denied.                     275


                                  CLAIM/PROCEDURE NOT PAYABLE BY
                                  NHIC PRIOR TO 08/06/2001. RESUBMIT
                                  CLAIM TO CIDC CENTRAL OFFICE, 1100
                                  WEST 49TH ST, AUSTIN TEXAS, 78756-
01/01/1977   12/31/3999   01146   3179                                       F2      Finalized/Denial - The claim/line has been denied.                     116


                                  PLEASE REFER TO OTHER EOB
                                  MESSAGES ASSIGNED TO THIS CLAIM                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01147   FOR PAYMENT/DENIAL INFORMATION.            F0      and no more action will be taken.                                      1


                                  HMO COPAY DETERMINED BY TDH, DATE
                                  OF SERVICE AND PROGRAM/BENEFIT                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01500   PLAN.                                      F0      and no more action will be taken.                                      104


                                  IMMUNIZATION PROCEDURE PAYMENT
                                  DETERMINED BY PROGRAM/BENEFIT
                                  PLAN, DATE OF SERVICE, BILLED
                                  AMOUNT AND IS SET AT A MAXIMUM                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01501   ALLOWABLE RATE.                            F0      and no more action will be taken.                                      104


                                  FAMILY PLANNING TITLE V, X
                                  PROCEDURE PAYMENT DETERMINED BY
                                  TDH, DATE OF SERVICE AND BILLED                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01502   AMOUNT.                                    F0      and no more action will be taken.                                      104



                                                                         Page 261 of 378
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                                  PROCEDURE PAYMENT BASED ON TDH
                                  MANDATED ASC/HASC GROUP RATES,
                                  PROGRAM/BENEFIT PLAN,
                                  LOCALITY/SPECIALTY, BILLED AMOUNT                 Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01503   AND DATE OF SERVICE.                      F0      and no more action will be taken.                                      104


                                  DRG CLAIM DENIED; SEE SEPARATE EOB                Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01504   FOR FUTHER EXPLANATION.                   F0      and no more action will be taken.                                      1


                                  MEDICAID PAYS THE DEDUCTIBLE AND
                                  CO-INSURANCE ONLY FOR SERVICES                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   01505   PAID BY MEDICARE.                         F0      and no more action will be taken.                                      104


                                  BILLING PROVIDER NUMBER NOT ON
                                  PROVIDER FILE. PLEASE SUBMIT A
01/01/1977   12/31/3999   01600   VALID NPI/API.                            F2      Finalized/Denial - The claim/line has been denied.                     562
                                  BILLING PROVIDER NPI/API TO TPI
                                  COMBINATION OR NPI/API INFORMATION
01/01/1977   12/31/3999   01601   IS INVALID                                F2      Finalized/Denial - The claim/line has been denied.                     153
                                  PERFORMING PROVIDER NUMBER NOT
                                  ON PROVIDER FILE. PLEAS SUBMIT A
01/01/1977   12/31/3999   01602   VALID NPI/API.                            F2      Finalized/Denial - The claim/line has been denied.                     562
                                  PERFORMING PROVIDER NPI/API TO TPI
                                  COMBINATION OR NPI/API INFORMATION
01/01/1977   12/31/3999   01603   IS INVALID.                               F2      Finalized/Denial - The claim/line has been denied.                     153
                                  BILLING PROVIDER TAXONOMY IS
01/01/1977   12/31/3999   01604   MISSING                                   F2      Finalized/Denial - The claim/line has been denied.                     21
                                  BILLING NPI/API PROVIDER TAXONOMY
01/01/1977   12/31/3999   01605   NOT MATCHED TO SUBMITTED NPI/API.         F2      Finalized/Denial - The claim/line has been denied.                     21
                                  PERFORMING PROVIDER TAXONOMY IS
01/01/1977   12/31/3999   01606   MISSING                                   F2      Finalized/Denial - The claim/line has been denied.                     21
                                  PERFORMING NPI/API PROVIDER
                                  TAXONOMY NOT MATCHED TO
01/01/1977   12/31/3999   01607   SUBMITTED NPI/API.                        F2      Finalized/Denial - The claim/line has been denied.                     21


                                  YOUR ADJUSTMENT IS BEING                          Finalized/Adjudication Complete - No payment forthcoming - The
                                  RESEARCHED. NO ACTION ON YOUR                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   05001   PART IS NECESSARY.                        F4      forthcoming.                                                           101


                                  THANK YOU FOR YOUR REFUND OF THE
                                  GRADUATE MEDICAL EDUCATION COST                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  AUDIT SETTLEMENT. YOUR 1099 WILL BE               claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06000   CREDITED.                                 F4      forthcoming.                                                           101



                                                                        Page 262 of 378
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                                  THANK YOU FOR YOUR REFUND OF THE                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIRD PARTY REIMBURSEMENT AUDIT.                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06001   YOUR 1099 WILL BE CREDITED.                F4      forthcoming.                                                           101


                                  THANK YOU FOR YOUR REFUND OF THE
                                  FQHC OR PSYCH COST AUDIT                           Finalized/Adjudication Complete - No payment forthcoming - The
                                  SETTLEMENT. YOUR 1099 WILL BE                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06002   CREDITED.                                  F4      forthcoming.                                                           101


                                  THANK YOU FOR YOUR REFUND OF THE                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  FQHC INTERIM SETTLEMENT. YOUR 1099                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06003   WILL BE CREDITED.                          F4      forthcoming.                                                           101


                                  THANK YOU FOR YOUR REFUND OF THE                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  RHC INTERIM SETTLEMENT. YOUR 1099                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06004   LIABILITY WILL BE CREDITED.                F4      forthcoming.                                                           101


                                  PAYMENT IS THE RESULT OF A COST
01/01/1977   12/31/3999   06005   AUDIT SETTLEMENT.                          F1      Finalized/Payment - The claim/line has been paid.                      104



                                  ADDITIONAL INFORMATION IS REQUIRED
01/01/1977   12/31/3999   06006   TO IDENTIFY THE CLIENT AND /OR DOS.        F2      Finalized/Denial - The claim/line has been denied.                     187


                                  THIS PAYMENT IS THE RESULT OF A
                                  GRADUATE MEDICAL EDUCATION COST
01/01/1977   12/31/3999   06007   AUDIT SETTLEMENT.                          F1      Finalized/Payment - The claim/line has been paid.                      104


                                  RELEASE OF FUNDS HELD AT THE                       Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06008   REQUEST OF THE STATE.                      F0      and no more action will be taken.                                       9


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS IS A REFUND OF A BACK-UP                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06009   WITHHOLDING PENALTY.                       F4      forthcoming.                                                           101


                                  PAYMENT IS A RESULT OF FQHC INTERIM
01/01/1977   12/31/3999   06010   SETTLEMENT.                                F1      Finalized/Payment - The claim/line has been paid.                      104




                                                                         Page 263 of 378
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                                  PAYMENT IS A RESULT OF RHC INTERIM
01/01/1977   12/31/3999   06011   SETTLEMENT.                                  F1      Finalized/Payment - The claim/line has been paid.                      104


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS PAYMENT IS A REPAYMENT OF                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06012   MONIES WITHHELD.                             F4      forthcoming.                                                           101


                                  REFUND IS DUE TO THE RELEASE OF AN
01/01/1977   12/31/3999   06013   IRS LEVY.                                    F1      Finalized/Payment - The claim/line has been paid.                      104


                                  PAYMENT FOR FQHC OR PSYCH COST
01/01/1977   12/31/3999   06014   AUDIT SETTLEMENT.                            F1      Finalized/Payment - The claim/line has been paid.                      104



                                  A CHECK HAS BEEN SENT SEPARATELY
                                  AS PAYMENT FOR THIS ITEM. YOUR 1099                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06015   LIABILITY HAS BEEN INCREASED.                F0      and no more action will be taken.                                      1


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS IS A RECOUPMENT OF AN                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06017   ADVANCE.                                     F4      forthcoming.                                                           101


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS RECOUPMENT IS THE RESULT OF                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06018   NON-RECEIPT OF THE COST REPORT.              F4      forthcoming.                                                           101


                                  THIS RECOUPMENT IS THE RESULT OF                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  DELINQUENT PAYMENT REQUIRED FOR A                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06019   COST AUDIT SETTLEMENT.                       F4      forthcoming.                                                           101


                                  THIS RECOUPMENT IS THE RESULT OF
                                  DELINQUENT PAYMENT REQUIRED FOR A                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  GRADUATE MEDICAL EDUCATION COST                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06020   AUDIT SETTLEMENT.                            F4      forthcoming.                                                           101


                                                                                       Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT WITHHELD AT THE DIRECTION                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06022   OF HHSC MPI.                                 F4      forthcoming.                                                           101




                                                                           Page 264 of 378
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                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT WITHHELD AT THE DIRECTION                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06023   OF SYSTEM RESOURCES MFADS.                F4      forthcoming.                                                     101


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT WITHHELD DUE TO A CIVIL                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06024   MONETARY PENALTY.                         F4      forthcoming.                                                     101


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT WITHHELD DUE TO                           claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06027   INVESTIGATIVE COSTS .                     F4      forthcoming.                                                     101


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  PAYMENT WITHTHELD DUE TO OTHER                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06028   RECOUPMENTS.                              F4      forthcoming.                                                     101


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                                                                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06029   PAYMENT WITHHELD DUE TO MEDICARE.         F4      forthcoming.                                                     101


                                                                                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  FINANCIAL ACTION DUE TO TDH                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06031   DIRECTIVE.                                F4      forthcoming.                                                     101


                                  THIS RECOUPMENT IS THE RESULT OF A                Finalized/Adjudication Complete - No payment forthcoming - The
                                  COST AUDIT SETTLEMENT TO AN OLD                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06032   OWNER.                                    F4      forthcoming.                                                     101


                                  THIS RECOUPMENT IS THE RESULT OF                  Finalized/Adjudication Complete - No payment forthcoming - The
                                  DELINQUENT PAYMENT REQUIRED FOR                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06033   AN FQHC INTERIM SETTLEMENT.               F4      forthcoming.                                                     101


                                  RECOUPMENT IS RESULT OF
                                  DELINQUENT PAYMENT REQUIRED FOR                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  AN FQHC OR PSYCH COST AUDIT                       claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06034   SETTLEMENT.                               F4      forthcoming.                                                     101


                                  RECOUPMENT IS RESULT OF                           Finalized/Adjudication Complete - No payment forthcoming - The
                                  DELINQUENT PAYMENT REQUIRED FOR                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06035   AN RHC INTERIM SETTLEMENT.                F4      forthcoming.                                                     101



                                                                        Page 265 of 378
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                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING                        Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06036   REASON: DIRECTION FROM HHSC-MPI.          F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM HHSC-MPI                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06038   DUE TO CIVIL MONETARY PENALTY.            F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM HHSC-MPI                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06041   DUE TO INVESTIGATIVE COSTS.               F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM HHSC-MPI                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06042   DUE TO OTHER RECOUPMENTS.                 F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM HHSC-MPI                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06043   DUE TO MEDICARE.                          F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM TEXAS                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06045   DEPARTMENT OF HEALTH .                    F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM DIRECTION                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06046   FROM TDH DUE TO CHILD SUPPORT.            F0      and no more action will be taken.                                      104


                                  YOUR PAYMENT FOR THE AMOUNT %1
                                  WAS HELD FOR THE FOLLOWING
                                  REASON: DIRECTION FROM OFFICE OF                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06047   ATTORNEY GENERAL.                         F0      and no more action will be taken.                                      104


                                  THIS IS AN ADVANCE OF FUTURE                      Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06048   NURSING FACILITY PAYMENTS.                F0      and no more action will be taken.                                      104


                                                                        Page 266 of 378
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                                  THIS IS AN ADVANCE OF FUTURE                       Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06049   PAYMENTS.                                  F0      and no more action will be taken.                                      104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THIS IS A RECOUPMENT OF A NURSING                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06050   FACILITIES ADVANCE.                        F4      forthcoming.                                                           101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  RECOUPMENT IS DUE TO TITLE XIX                     claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06051   RETRO-ELIGIBILITY.                         F4      forthcoming.                                                           101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  RECOUPMENT IS DUE TO AN ADVANCE                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06052   PREVIOUSLY RECEIVED.                       F4      forthcoming.                                                           101


                                  NO EOB PRINTS ON THE R&S. THE EOB                  Finalized-The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06053   CODE IS FOR THE ER&S.                      F0      and no more action will be taken.                                      285


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  RECOUPMENT IS DUE TO RHC HOSPITAL                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06056   BASED INTERIM SETTLEMENT.                  F4      forthcoming.                                                           101


                                  YOUR PAYMENT IN THE AMOUNT %1
                                  WAS HELD AT THE DIRECTION OF THE                   Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06057   STATE MEDICAID AGENCY.                     F0      and no more action will be taken.                                      104


                                  THANK YOU FOR YOUR REFUND OF THE
                                  RHC HOSPITAL BASED INTERIM                         Finalized/Adjudication Complete - No payment forthcoming - The
                                  SETTLEMENT. YOUR 1099 LIABILITY WILL               claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06058   BE CREDITED.                               F4      forthcoming.                                                           101


                                  THANK YOU FOR YOUR REFUND OF THE                   Finalized/Adjudication Complete - No payment forthcoming - The
                                  COST AUDIT SETTLEMENT. YOUR 1099                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06059   LIABILITY HAS BEEN CREDITED.               F4      forthcoming.                                                           101


                                  PAYMENT IS FOR RHC HOSPITAL BASED                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06060   INTERIM SETTLEMENT.                        F0      and no more action will be taken.                                      104




                                                                         Page 267 of 378
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                                  OVERPAYMENT MADE TO NHIC BY THE                    Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06061   THIRD PARTY CARRIER.                       F0      and no more action will be taken.                                      104


                                  PAYMENT IS FOR CASE MANAGEMENT                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06062   FEES.                                      F0      and no more action will be taken.                                      104



                                  RECOUPMENT IS DUE TO OVERPAYMENT                   FNL/Adj Complt: Claim was processed as adjustment to previous
01/01/1977   12/31/3999   06063   OF CASE MANAGEMENT FEES.                   F4      claim.                                                                 101



                                  CONTACT CUSTOMER SERVICE AT 1-800-                 Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06064   925-9126 FOR ADDITIONAL INFORMATION.       F0      and no more action will be taken.                                      0


                                  ACCOUNT RECEIVABLE IS DUE TO THE
                                  ADJUSTED CLAIM LISTED. FOR DETAILS,
                                  REFER TO YOUR R&S FOR THE DATE                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  LISTED WITHIN THE ORIGINAL DATE                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06065   FIELD.                                     F4      forthcoming.                                                           101


                                  CASH RECEIPT APPLIED TO AN ACCOUNT                 Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06066   RECEIVABLE.                                F0      and no more action will be taken.                                      104


                                                                                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   06067   CASH RECEIPT APPLIED TO A PAYOUT.          F0      and no more action will be taken.                                      104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  MONEY WAS WITHHELD BY NHIC AT THE                  claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06068   PROVIDER'S REQUEST.                        F4      forthcoming.                                                           101


                                  MONEY REFUNDED BY YOUR OFFICE                      Finalized/Adjudication Complete - No payment forthcoming - The
                                  WAS INSUFFICIENT FOR THE AMOUNT                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06069   DUE NHIC.                                  F4      forthcoming.                                                           101


                                  MONEY WAS WITHHELD DUE TO AN NHIC
                                  PAYMENT ERROR. CONTACT CUSTOMER                    Finalized/Adjudication Complete - No payment forthcoming - The
                                  SERVICE AT 1-800-925-9126 FOR                      claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06070   ADDITIONAL INFORMATION.                    F4      forthcoming.                                                           101




                                                                         Page 268 of 378
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                                  MONEY WAS WITHHELD DUE TO AN NHIC
                                  NON-PAYMENT ERROR. CONTACT                         Finalized/Adjudication Complete - No payment forthcoming - The
                                  CUSTOMER SERVICE AT 1-800-925-9126                 claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06071   FOR ADDITIONAL INFORMATION.                F4      forthcoming.                                                           101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THANK YOU FOR YOUR REFUND OF THE                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06072   OLD OWNER COST SETTLEMENT.                 F4      forthcoming.                                                           101


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  THANK YOU FOR YOUR REFUND OF THE                   claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06073   CASE MANAGEMENT FEE.                       F4      forthcoming.                                                           101


                                  PAYMENT DUE TO DUPLICATE                           Finalized/Adjudication Complete - No payment forthcoming - The
                                  RECOVERY BY REFUND AND                             claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   06135   RECOUPMENT.                                F4      forthcoming.                                                           101



                                  APPROVED TO PAY - 'FUNDS GONE'. THE
                                  BILLING PROVIDER'S FISCAL YEAR
                                  BUDGET CEILING HAS BEEN EXCEEDED.
                                  IF FUNDS BECOME AVAILABLE IN THE
                                  FUTURE, THIS CLAIM WILL BE                         Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   30000   REPROCESSED FOR PAYMENT.                   F0      and no more action will be taken.                                      104



                                  PROCEDURE PAYMENT FOR FAMILY
                                  PLANNING TEEN GROUP COUNSELING IS
                                  BASED ON A MINIMUM OR MAXIMUM FEE                  Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   30001   DETERMINED BY QUANTITY BILLED.             F0      and no more action will be taken.                                      104


                                                                                     Finalized/Adjudication Complete - No payment forthcoming - The
                                  ADJUSTMENT TO THIS CLAIM/DETAIL                    claim/encounter has been adjudicated and no further payment is
01/01/1977   12/31/3999   30002   INITIATED BY NHIC                          F4      forthcoming.                                                           101


                                                                                     Finalized - The claim/encounter has completed the adjudication cycle
01/01/1977   12/31/3999   90000   THIS CLAIM WAS MANUALLY REVIEWED.          F0      and no more action will be taken.                                      46


                                  AMOUNT SUBMITTED EXCEEDS FIELD
01/01/1977   12/31/3999   90013   LENGTH. PLEASE RESUBMIT.                   F2      Finalized/Denial - The claim/line has been denied.                     178




                                                                         Page 269 of 378
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                                  NET BILLED OUT OF BALANCE TO TOTAL
01/01/1977   12/31/3999   90016   BILLED AMOUNT                              F2      Finalized/Denial - The claim/line has been denied.   178


                                  ADMISSION DATE NOT ENTERED ON
01/01/1977   12/31/3999   90052   INPATIENT CLAIMS                           F2      Finalized/Denial - The claim/line has been denied.   189


                                  DISCHARGE DATE INVALID TO PATIENT
01/01/1977   12/31/3999   90054   STATUS OR DOS                              F2      Finalized/Denial - The claim/line has been denied.   190


01/01/1977   12/31/3999   90056   HEADER FROM DATE OF SERVICE                F2      Finalized/Denial - The claim/line has been denied.   194


01/01/1977   12/31/3999   90057   HEADER TO DATES OF SERVICE                 F2      Finalized/Denial - The claim/line has been denied.   194



01/01/1977   12/31/3999   90060   DISCHARGE DIAGNOSIS INVALID FORMAT         F2      Finalized/Denial - The claim/line has been denied.   254


                                  ADMITTING DIAGNOSIS IS AN INVALID
01/01/1977   12/31/3999   90080   FORMAT                                     F2      Finalized/Denial - The claim/line has been denied.   232


01/01/1977   12/31/3999   90089   OCCURRENCE SPAN CODE INVALID               F2      Finalized/Denial - The claim/line has been denied.   462


                                  TYPE OF ADMISSION CODE IS INVALID TO
01/01/1977   12/31/3999   90091   CLIENT'S AGE                               F2      Finalized/Denial - The claim/line has been denied.   231


                                  DETAIL SURGERY DATE OUTSIDE
                                  HEADER DATES OF SERVICE ON
01/01/1977   12/31/3999   90165   INPATIENT CLAIMS                           F2      Finalized/Denial - The claim/line has been denied.   187


                                  CLAIM DIAGNOSIS REFERENCE INVALID
01/01/1977   12/31/3999   90174   FORMAT                                     F2      Finalized/Denial - The claim/line has been denied.   477


                                  THE NUMBER OF DETAILS IN THE
                                  HEADER DOES NOT MATCH THE ACTUAL
                                  NUMBER OF DETAILS SUBMITTED ON
01/01/1977   12/31/3999   91816   THE CLAIM                                  F2      Finalized/Denial - The claim/line has been denied.   481




                                                                         Page 270 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




CSC NARRATIVE

Nearest appropriate facility




Claim was processed as adjustment to previous claim.




Processed according to plan provisions.



Processed according to plan provisions.




No payment will be made for this claim.




Claim was processed as adjustment to previous claim.



Missing or invalid information.




Entity's qualification degree/designation (e.g. RN,PhD,MD)




Patient discharge status.


                                                                         Page 271 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Referral/authorization.




Dental information.




Frequency of service.



Diagnosis code.




Claim was processed as adjustment to previous claim.




Processed according to plan provisions




No payment will be made for this claim.




Entity not eligible for benefits for submitted dates of service.




Allowable/paid from primary coverage.



No payment will be made for this claim.




                                                                               Page 272 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Processed according to plan provisions




No payment will be made for this claim.




Date(s) of service




Processed according to plan provisions.



Length of medical necessity, including begin date.




No payment will be made for this claim.



Other insurance coverage information (health, liability, auto, etc.).




Allowable/paid from primary coverage.



Referral/authorization.



Processed according to plan provisions



Entity's name.




                                                                                    Page 273 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Missing/invalid data prevents payer from processing claim.



Entity's ID Number.




Entity not approved as an electronic submitter.



Maximum coverage amount met or exceeded for benefit period.



Maximum coverage amount met or exceeded for benefit period.




Missing/invalid data prevents payer from processing claim.




Source of payment is not valid




Cannot process HMO claims




Maximum coverage amount met or exceeded for benefit period.




Duplicate of a previously processed claim/line.




Processed according to plan provisions.


                                                                          Page 274 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Duplicate of a previously processed claim/line.



Duplicate of a previously processed claim/line.




Other insurance coverage information (health, liability, auto, etc.).


Duplicate of a previously processed claim/line.



Entity's date of birth




No payment will be made for this claim.




Entity not eligible for benefits for submitted dates of service.




Diagnosis code.



Entity's social security number.




Internal review/audit.


Entity's Gender




                                                                                    Page 275 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Entity's license/certification number.




Claim was processed as adjustment to previous claim.


Entity not eligible.



No payment will be made for this claim.




Partial payment made for this claim.




Processed according to plan provisions.



Maximum coverage amount met or exceeded for benefit period.




Purchase price for the rented durable medical equipment.



Prescription number.




Authorization/certification (include period covered).




Ambulance Run Sheet



                                                                          Page 276 of 378
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Maximum coverage amount met or exceeded for benefit period.



Missing/invalid data prevents payer from processing claim.




Entity is not selected primary care provider.



Maximum coverage amount met or exceeded for benefit period.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.



Processed according to plan provisions



No payment will be made for this claim.




No payment will be made for this claim.



Charges applied to deductible.




No payment will be made for this claim.




                                                                          Page 277 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Date(s) of service.



Type of service.



Place of service.



Procedure code for services rendered.



Entity is not selected primary care provider.


Missing/invalid data prevents payer from processing claim.




Cannot process HMO claims




No payment will be made for this claim.



Cannot process HMO claims




X-rays.




Entity's Medicaid provider id.




Referral/authorization.


                                                                         Page 278 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Entity's marital status



Entity not approved.




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.



Entity not primary.




Procedure code for services rendered.



Maximum coverage amount met or exceeded for benefit period.




Payment made in full.




Payment made in full.




Processed according to plan provisions.



                                                                          Page 279 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Awaiting eligibility determination.


Payment made in full.



Claim requires pricing information.




Claim was processed as adjustment to previous claim.



No payment will be made for this claim.



Maximum coverage amount met or exceeded for benefit period.




Claim was processed as adjustment to previous claim.



Service not authorized.




Entity's license/certification number.



Entity's Medicaid provider id.


Entity's license/certification number.


                                                                          Page 280 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Date of the last x-ray.




Entity's Medicaid provider id.




Processed according to plan provisions.




Processed according to plan provisions.




Other payer's Explanation of Benefits/payment information.




Procedure code for services rendered.




Duplicate of a previously processed claim/line.



Cannot process HMO claims




This amount is not entity's responsibility.




Entity's Medicaid provider id.




                                                                         Page 281 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Missing or invalid units of service




Processed according to plan provisions.




Missing or invalid information.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




X-rays.




Processed according to plan provisions.


Duplicate of a previously processed claim/line.




Service not authorized.



Internal review/audit - partial payment made.


                                                                   Page 282 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Other insurance coverage information (health, liability, auto, etc.).




Authorization/certification number.




Maximum coverage amount met or exceeded for benefit period.



Internal review/audit.




Claim was processed as adjustment to previous claim.




Referral/authorization.



Maximum coverage amount met or exceeded for benefit period.




Claim combined with other claim(s).



Processed according to plan provisions.



Other payer's Explanation of Benefits/payment information.




                                                                                    Page 283 of 378
                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Processed according to plan provisions.




Service not authorized.




Claim may be reconsidered at a future date.




Entity not primary.



No payment will be made for this claim.



No payment will be made for this claim.




Processed according to plan provisions.




Processed according to plan provisions.




Procedure code for services rendered.




Processed according to plan provisions.




                                                          Page 284 of 378
                                                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Processed according to plan provisions.




Claim was processed as adjustment to previous claim.



Maximum coverage amount met or exceeded for benefit period.



Claim/line is capitated.



Claim submitted to incorrect payer.


Claim submitted to incorrect payer.




Claim was processed as adjustment to previous claim.



No payment will be made for this claim.



Entity not eligible for dental benefits for submitted dates of service.




Entity's Medicaid provider id.


Entity not eligible for benefits for submitted dates of service.




                                                                                      Page 285 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.



Claim/line has been paid.



No payment will be made for this claim.


One or more originally submitted procedure code have been
modified.



One or more originally submitted procedure code have been
modified.




No payment will be made for this claim.


Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




No payment will be made for this claim.



Processed according to plan provisions.




                                                                        Page 286 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Processed according to plan provisions.




Entity not approved.




Maximum coverage amount met or exceeded for benefit period.




Type of bill for UB-92 claim.




No payment will be made for this claim.




Entity's Medicaid provider id.




Entity's id number.




Entity's name.




Entity not eligible for benefits for submitted dates of service.




                                                                               Page 287 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Service not authorized.




Processed according to plan provisions.




Partial payment made for this claim.




Claim requires pricing information.




Processed according to plan provisions.




Procedure code for services rendered.




Cannot process HMO claims.




Entity not eligible for benefits for submitted dates of service.




Procedure code not valid for patient age




Processed according to plan provisions.




                                                                               Page 288 of 378
                                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Processed according to plan provisions.




Missing/invalid data prevents payer from porcessing corrected claim.




Procedure code for services rendered.




Procedure code not valid for patient age




Homebound status




Maximum coverage amount met or exceeded for benefit period.



Hospital discharge hour.




Reason for transport by ambulance




Missing/invalid data prevents payer from processing claim.




                                                                                   Page 289 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Need for more than one physician to treat patient


No payment will be made for this claim.




Duplicate of a previously processed claim/line.



Procedure code for services rendered.




Other payer's Explanation of Benefits/payment information.




Procedure Code Modifier(s) for Service(s) Rendered




Ambulance certification/documentation.



Authorization/certification number.




Claim contains split payment.



Maximum coverage amount met or exceeded for benefit period.



                                                                          Page 290 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Outside lab charges.



Itemize non-covered services



One or more originally submitted procedure code have been
modified.




Processed according to plan provisions.




Operative report.




Processed according to plan provisions.




Entities Original Signature



No payment will be made for this claim.




Date of dental prior replacement/reason for replacement.



Referral/authorization.




                                                                        Page 291 of 378
                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Referral/authorization.



Referral/authorization.




Awaiting next periodic adjudication cycle.




Processed according to plan provisions.




Processed according to plan provisions.



Referral/authorization.




Partial payment made for this claim.




No payment will be made for this claim.




Claim.




Claim submitted to incorrect payer.




                                                         Page 292 of 378
                                                  39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Allowable/paid from primary coverage.




Procedure code for services rendered




Missing or invalid information.




This amount is not entity's responsibility.




Processed according to plan provisions.




Duplicate of a previously processed claim/line.




Referral/authorization.



Claim may be reconsidered at a future date.




Processed according to plan provisions.




Reason for termination of pregnancy.




                                                              Page 293 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



No payment will be made for this claim.




No payment will be made for this claim.




Processed according to plan provisions.




Medical notes/report.




Date of conception and expected date of delivery.




Other payer's Explanation of Benefits/payment information.




Procedure code not valid for patient age




Claim is out of balance




Awaiting eligibility determination.




                                                                         Page 294 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Maximum coverage amount met or exceeded for benefit period.




Other payer's Explanation of Benefits/payment information




Procedure code for services rendered.




Entities Original Signature



One or more originally submitted procedure code have been
modified.




One or more originally submitted procedure code have been
modified.




Maximum coverage amount met or exceeded for benefit period.




Supporting documentation.




                                                                          Page 295 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


One or more originally submitted procedure code have been
modified.




Procedure code for services rendered




Entities Original Signature




Medicare effective date.




Supporting documentation.




Supporting documentation.




Vouchers/explanation of benefits (EOB).




                                                                        Page 296 of 378
                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Entity's date of birth




Entity's name.




Copy of Medicare ID card.




Authorization/certification (include period covered).




Processed according to contract/plan provisions.




Claim was processed as adjustment to previous claim.




                                                                    Page 297 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Maximum coverage amount met or exceeded for benefit period.




Entities Original Signature




                                                                          Page 298 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Missing/invalid data prevents payer from processing claim.




Missing or invalid units of service




Claim may be reconsidered at a future date.




Payment reflects usual and customary charges.




No payment will be made for this claim.



Entity's Medicaid provider id.




Processed according to plan provisions.




No payment will be made for this claim.



                                                                         Page 299 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Entities Original Signature




Processed according to plan provisions.




Entities Original Signature




Claim submitted to incorrect payer.




Processed according to plan provisions.




Maximum coverage amount met or exceeded for benefit period.




Claim may be reconsidered at a future date.




                                                                          Page 300 of 378
                                                                39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim




Date(s) of service.




Claim.




Entity not referred by selected primary care provider.




Entity's id number




Service line number greater than maximum allowable for payer.



Entities Original Signature




Date entity signed certification/recertification




No payment will be made for this claim.


                                                                            Page 301 of 378
                                                                39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Maximum coverage amount met or exceeded for benefit period.




Service line number greater than maximum allowable for payer.




Processed according to plan provisions.




Claim




Supporting documentation.




Procedure code for services rendered.




Processed according to plan provisions.




No payment will be made for this claim.


                                                                            Page 302 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




This amount is not entity's responsibility.




Claim was processed as adjustment to previous claim.




One or more originally submitted procedure code have been
modified.




Individual test(s) comprising the panel and the charges for each test




No payment will be made for this claim.




Reason for transport by ambulance




No payment will be made for this claim.




No payment will be made for this claim.




                                                                                    Page 303 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




No payment will be made for this claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




No payment will be made for this claim.




Entity not eligible/not approved for dates of service.




Procedure code for services rendered.




One or more originally submitted procedure code have been
modified.



Maximum coverage amount met or exceeded for benefit period.




                                                                          Page 304 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




No payment will be made for this claim.




Missing or invalid information.



One or more originally submitted procedure code have been
modified.




Service not authorized.




Processed according to plan provisions.




Reason for transport by ambulance




Entity's Medicaid provider id.




No payment will be made for this claim.


                                                                        Page 305 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Emergency room notes/report.




Specific findings, complaints, or symptoms necessitating service




Provide condition/functional status at time of service




Entity's address.




No payment will be made for this claim.




Claim was processed as adjustment to previous claim.




Progress notes for the six months prior to statement date.




                                                                               Page 306 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Modalities of service




Supporting documentation.




Service not authorized.




Other insurance coverage information (health, liability, auto, etc.).




Diagnosis code.




Claim is out of balance




Claim may be reconsidered at a future date.




Claim was processed as adjustment to previous claim.




                                                                                    Page 307 of 378
                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Entity's Medicaid provider id.




Drug name, strength and dosage form.




Procedure code for services rendered.




Facility point of origin and destination - ambulance.




Claim was processed as adjustment to previous claim.




More detailed information in letter.




No payment will be made for this claim.


                                                                    Page 308 of 378
                                                                39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim contains split payment.



Entity is not selected primary care provider.



Claim was processed as adjustment to previous claim.




Entity's license/certification number.




No payment will be made for this claim.




Lab/test report/notes/results.




Service line number greater than maximum allowable for payer.




                                                                            Page 309 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




DRG code(s).




Processed according to plan provisions.




Entity's Medicaid provider id.




Entity's Medicaid provider id.




Total anesthesia minutes.




Other payer's Explanation of Benefits/payment information.




Copy of Medicare ID card.



                                                                         Page 310 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Maximum coverage amount met or exceeded for benefit period.




Processed according to plan provisions.



One or more originally submitted procedure code have been
modified.




Entity not eligible/not approved for dates of service.




Missing/invalid data prevents payer from processing claim.




Itemize non-covered services




Statement from-through dates.




                                                                          Page 311 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Medicare effective date.




Processed according to plan provisions.




Missing or invalid information.




Claim/submission format is invalid.




Entity's Medicaid provider id.




Entity's Medicaid provider id.




                                                      Page 312 of 378
                                                         39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




No payment will be made for this claim




Complications/mitigating circumstances




Procedure Code Modifier(s) for Service(s) Rendered




Claim was processed as adjustment to previous claim.




Claim.




Hospital admission hour.




Entity not eligible/not approved for dates of service.




Service not authorized.



                                                                     Page 313 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Maximum coverage amount met or exceeded for benefit period.




Claim




Drug name, strength and dosage form.




Duplicate of a previously processed claim/line.




Claim.




Procedure code for services rendered.




Entity not eligible.




                                                                          Page 314 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Supporting documentation.




Other payer's Explanation of Benefits/payment information.




Outside lab charges.




Claim submitted to incorrect payer.




Ambulance certification/documentation.




X-rays.




                                                                         Page 315 of 378
                                                  39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Entity not approved as an electronic submitter.




Entity's id number.




Processed according to plan provisions.




Diagnosis and patient gender mismatch.




Medical necessity for service.




Ambulance Run Sheet




Ambulance Run Sheet



                                                              Page 316 of 378
                                           39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Ambulance Run Sheet




Entity's id number.




Procedure code not valid for patient age




Procedure code not valid for patient age




Entity's Medicaid provider id.




Reason for transport by ambulance




Medical notes/report.




                                                       Page 317 of 378
                                                                39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Diagnosis code.




One or more originally submitted procedure code have been
modified.




Service line number greater than maximum allowable for payer.




Service not authorized.




Procedure code for services rendered.




Payment made in full.




No payment will be made for this claim.




Nearest appropriate facility



                                                                            Page 318 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Procedure code for services rendered.




Medical notes/report.




Primary diagnosis code.




Entity's license/certification number.




Processed according to plan provisions.




Missing/invalid data prevents payer from processing claim.




                                                                         Page 319 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Lab/test report/notes/results.




Total anesthesia minutes.




Claim submitted to incorrect payer.




Ambulance Run Sheet




Processed according to plan provisions.




Separate claim for mother/baby charges.



                                                                   Page 320 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Revenue code for services rendered.




Partial payment made for this claim.




One or more originally submitted procedure code have been
modified.




Claim may be reconsidered at a future date.




Service not authorized.




Complications/mitigating circumstances




Medical necessity for service.




                                                                        Page 321 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Ambulance Run Sheet




Processed according to plan provisions.




One or more originally submitted procedure code have been
modified.




Entities Original Signature



One or more originally submitted procedure code have been
modified.




Reason for physical therapy.




Procedure Code Modifier(s) for Service(s) Rendered




Progress notes for the six months prior to statement date.




                                                                         Page 322 of 378
                                                                 39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Type of surgery/service for which anesthesia was administered.




No payment will be made for this claim.




Lab/test report/notes/results.




Processed according to contract/plan provisions.




Outside lab charges.




Claim may be reconsidered at a future date.




Missing/invalid data prevents payer from processing claim.




                                                                             Page 323 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Entity's Medicaid provider id.




Medical notes/report.




Claim was processed as adjustment to previous claim.




Medical necessity for service.




Date of first routine dialysis.




Progress notes for the six months prior to statement date.




Chiropractic treatment plan.




                                                                         Page 324 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Missing/invalid data prevents payer from processing claim.




Cannot provide further status electronically.




Claim was processed as adjustment to previous claim.




Maximum coverage amount met or exceeded for benefit period.




Claim was processed as adjustment to previous claim.




Service not authorized.




Internal review/audit.




                                                                          Page 325 of 378
                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim combined with other claim(s).




Procedure code for services rendered.




Procedure code for services rendered.




No payment will be made for this claim




Entity referral notes/orders/prescription




No payment will be made for this claim.




Emergency room notes/report.




                                                        Page 326 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




No payment will be made for this claim.




Procedure code for services rendered.




Procedure code for services rendered.




Maximum coverage amount met or exceeded for benefit period.




Claim was processed as adjustment to previous claim.




Patient Signature Source




Date(s) of service




Service not authorized.


                                                                          Page 327 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Place of service.




Claim submitted to incorrect payer.




Claim may be reconsidered at a future date.




Procedure Code Modifier(s) for Service(s) Rendered




Supporting documentation.




No payment will be made for this claim.




Claim requires pricing information.




Other payer's Explanation of Benefits/payment information.


                                                                         Page 328 of 378
                                                     39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Procedure code for services rendered.




Missing or invalid units of service




Processed according to plan provisions




Claim may be reconsidered at a future date.




Procedure code for services rendered.




Does provider accept assignment of benefits?




Procedure Code Modifier(s) for Service(s) Rendered




                                                                 Page 329 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Procedure code and patient gender mismatch




Other insurance coverage information (health, liability, auto, etc.).




Claim submitted to incorrect payer.




Drug dispensing units and average wholesale price (AWP).




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Entity's original signature.




                                                                                    Page 330 of 378
                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim




Procedure code for services rendered.




Supporting documentation.




Entities Original Signature




Procedure code for services rendered.




More detailed information in letter.




Claim may be reconsidered at a future date.




                                                          Page 331 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim/line has been paid.




Claim submitted to incorrect payer.




Claim/line has been paid.




For more detailed information, see remittance advice.




Processed according to plan provisions.




One or more originally submitted procedure code have been
modified.




Processed according to plan provisions.




Claim/line has been paid.



                                                                        Page 332 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim may be reconsidered at a future date.




Claim contains split payment.




Procedure code for services rendered.




Claim was processed as adjustment to previous claim.




Procedure code for services rendered.




Cannot process HMO claims




Procedure Code Modifier(s) for Service(s) Rendered




Date(s) of service.




                                                                   Page 333 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Procedure Code Modifier(s) for Service(s) Rendered




Were services related to an emergency?




Diagnosis code.




Claim was processed as adjustment to previous claim.




Claim may be reconsidered at a future date.




Entity's specialty code.




Claim requires pricing information.




                                                                   Page 334 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Supporting documentation.




Claim contains split payment.




Tooth surface(s) involved.




Were services related to an emergency?




Entity's license/certification number.




Medical necessity for service.




Procedure code not valid for patient age




                                                                   Page 335 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Processed according to plan provisions.




Tooth surface(s) involved.



Tooth surface(s) involved.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.



X-rays.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.


                                                      Page 336 of 378
                                           39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Durable medical equipment certification.




Processed according to plan provisions.




Medical necessity for service.




Processed according to plan provisions.




                                                       Page 337 of 378
                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Claim may be reconsidered at a future date.




Claim submitted to incorrect payer.




Claim submitted to incorrect payer.




Procedure code for services rendered.




Claim submitted to incorrect payer.




Partial payment made for this claim.




                                                          Page 338 of 378
                                                     39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Claim submitted to incorrect payer.




Medical necessity for service.




Attending physician report.




Total anesthesia minutes.




Entity not eligible.




Procedure Code Modifier(s) for Service(s) Rendered




Entity's Medicaid provider id.




Claim may be reconsidered at a future date.




                                                                 Page 339 of 378
                                                     39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




No payment will be made for this claim.




Procedure Code Modifier(s) for Service(s) Rendered




Procedure code not valid for patient age




Date(s) of service.




Entity's Medicaid provider id.




Entity's name.




Entities Original Signature




                                                                 Page 340 of 378
                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Missing or invalid information.




Processed according to contract/plan provisions.




Patient's medical records.




Patient's medical records.




Processed according to plan provisions.




Processed according to plan provisions.




No payment will be made for this claim




Procedure code for services rendered.



                                                               Page 341 of 378
                                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




More detailed information in letter.




Purchase and rental price of durable medical equipment.




Procedure code for services rendered.




Procedure code for services rendered.




Entity not approved.




Entity's state license number.




Were services related to an emergency?




Procedure code for services rendered.




                                                                      Page 342 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim submitted to incorrect payer.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Processed according to plan provisions.




Processed according to plan provisions.




Claim combined with other claim(s).




Processed according to plan provisions.




Processed according to plan provisions.




Hospital admission date.


                                                                   Page 343 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Procedure code for services rendered.




Processed according to plan provisions.



Processed according to plan provisions.




No payment will be made for this claim.




Subluxation location.




Medical review attachment/information for service(s)




Processed according to plan provisions.




Processed according to plan provisions.




                                                                   Page 344 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Submitted charges.




Processed according to plan provisions.




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




Processed according to plan provisions.




Claim.




Itemized claim.




Processed according to plan provisions.



                                                                   Page 345 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Provide condition/functional status at time of service



One or more originally submitted procedure code have been
modified.




Entity's name



One or more originally submitted procedure code have been
modified.



Finalized/Denial - The claim/line has been denied.



Processed according to plan provisions.



One or more originally submitted procedure code have been
modified.




Vouchers/explanation of benefits (EOB)




Processed according to contract/plan provisions.




Entity's Medicaid provider id.




                                                                        Page 346 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Missing or invalid information.



One or more originally submitted procedure code have been
modified.




Processed according to contract/plan provisions.



Processed according to contract/plan provisions.




Diagnosis code.


Missing or invalid information



Does provider accept assignment of benefits?




Requested additional information not received.




Processed according to plan provisions.




Is prescribed lenses a result of cataract surgery?



One or more originally submitted procedure code have been
modified.



                                                                        Page 347 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Processed according to plan provisions.




Processed according to plan provisions.



No payment will be made for this claim




Processed according to plan provisions.




Entity's Medicaid provider id.



Processed according to plan provisions.




Nearest appropriate facility



Medical necessity for service.




Service not authorized.




Processed according to plan provisions.




Processed according to plan provisions.


                                                      Page 348 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Date Error, Century Missing




Entity's Medicaid provider id.




Date of onset/exacerbation of illness/condition




No payment will be made for this claim.




Entity's Medicaid provider id.




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.


                                                                   Page 349 of 378
                                                                           39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Internal review/audit.




Medical notes/report.



Processed according to plan provisions.



Processed according to plan provisions.



Entity's license/certification number.




Other payer's Explanation of Benefits/payment information.



Entity not eligible for medical benefits for submitted dates of service.



Entity not eligible for benefits for submitted dates of service.




Maximum coverage amount met or exceeded for benefit period.




Maximum coverage amount met or exceeded for benefit period.


                                                                                       Page 350 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.



One or more originally submitted procedure code have been
modified.




No payment will be made for this claim.



Service not authorized.




Entity not primary.




Reason for transport by ambulance




Internal review/audit.




Processed according to plan provisions.




Processed according to plan provisions.



Processed according to plan provisions.




                                                                        Page 351 of 378
                                                              39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Claim was processed as adjustment to previous claim.




Processed according to plan provisions.




Were services related to an emergency?




All current diagnoses




Entity not primary.



No payment will be made for this claim.




Claim was processed as adjustment to previous claim.




Claim may be reconsidered at a future date.




No payment will be made for this claim.




Maximum coverage amount met or exceeded for benefit period.




                                                                          Page 352 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Length of time for services rendered.



Primary diagnosis code.




Entity's Gender


Place of service.




Entity's name.




Entity's date of death



Entities Original Signature



Line information.



Missing or invalid information.



Missing or invalid information



Line information.




Processed according to plan provisions.


                                                      Page 353 of 378
                                                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.



Date(s) of service.




Processed according to plan provisions.




Entities Original Signature



Missing or invalid information



Entity's address.




Entity's name.



Entities Original Signature



Prior testing, including result(s) and date(s) as related to service(s)




Initial certification




                                                                                      Page 354 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Claim




Procedure code not valid for patient age




Procedure code for services rendered.



Missing or invalid information.




Other payer's Explanation of Benefits/payment information.




Procedure code for services rendered.




Type of bill for UB-92 claim.



Hospital admission date.



Missing or invalid information.



Claim submitter's identifier (patient account number) is missing




Entities Original Signature


                                                                               Page 355 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Days/units for procedure/revenue code.




Entity's name.



Covered Day(s)



Missing or invalid information



Date(s) of service.



Diagnosis code pointer is missing or invalid




Referral/authorization.



Date of first service for current series/symptom/illness.




Claim may be reconsidered at a future date.




Claim was processed as adjustment to previous claim.



Other Carrier Claim filing indicator is missing or invalid


                                                                         Page 356 of 378
                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Date of the last x-ray.




Missing or invalid information.




Amount must be greater than zero




Principle Procedure Date



Submitted charges.



Hospital s room rate.




Principle Procedure Date




Facility point of origin and destination - ambulance.




Number of miles patient was transported.




Claim was processed as adjustment to previous claim.




                                                                    Page 357 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Duplicate of an existing claim/line, awaiting processing.




Other payer's Explanation of Benefits/payment information.




Processed according to plan provisions.




Claim submitted to incorrect payer.



Entity not primary.



Entity's specialty code.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.




Admitting diagnosis.




Procedure code for services rendered.




                                                                         Page 358 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Procedure code for services rendered.




Supporting documentation.




Processed according to plan provisions.




Entity not eligible for benefits for submitted dates of service.



Missing or invalid information




Authorization/certification number.




Procedure code for services rendered.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




                                                                               Page 359 of 378
                                                  39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Processed according to plan provisions.




Days/units for procedure/revenue code.




Place of service.




Processed according to plan provisions.




Processed according to plan provisions.




Duplicate of a previously processed claim/line.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.



Missing or invalid information




                                                              Page 360 of 378
                                                            39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Missing or invalid information



One or more originally submitted procedure code have been
modified.




Entity's Medicaid provider id.




Type of service.




Entity's state license number.




Claim was processed as adjustment to previous claim.




Hospital admission date.




Processed according to plan provisions.




Processed according to plan provisions.




Supporting documentation.




                                                                        Page 361 of 378
                                                                   39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Other payer's Explanation of Benefits/payment information.



Cannot process HMO claims




Claim may be reconsidered at a future date.



Diagnosis code.



Claim submitted to incorrect payer.




Processed according to plan provisions.




Entity not eligible for benefits for submitted dates of service.




Claim may be reconsidered at a future date.




                                                                               Page 362 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.



Processed according to plan provisions.




Claim



Diagnosis and patient gender mismatch.



Processed according to plan provisions.



Entity's Medicaid provider id.



Entity's Medicaid provider id.


                                                      Page 363 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Missing or invalid information



Missing/invalid data prevents payer from processing claim.



Entity's Medicaid provider id.



Entity's Medicaid provider id.




Entity's address.



Missing or invalid information.



Entity's address.



Entity's tax id.



Charges pending provider audit.




Entity's date of birth



Entity's date of death




                                                                         Page 364 of 378
                                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Other insurance coverage information (health, liability, auto, etc.).



Submitted charges.



Entity not eligible.



Source of payment is not valid



Source of payment is not valid


Is injury due to auto accident?



Is accident/illness/condition employment related?


Covered Day(s)




NUBC Occurrence Span Code(s) and Date(s)




NUBC Occurrence Span Code(s) and Date(s)



NUBC Occurrence Code(s) and Date(s)


NUBC Occurrence Code(s) and Date(s)



                                                                                    Page 365 of 378
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Prescription number.


NUBC Condition Code(s)




Tooth number or letter.



Referral/authorization.



Dental information.



Were services related to an emergency


Dental information.




Processed according to plan provisions.




Processed according to plan provisions.



Claim may be reconsidered at a future date.


Submitted charges.


Missing or invalid information.




Was durable medical equipment purchased new or used?

                                                                   Page 366 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Source of payment is not valid


Source of payment is not valid


Entity's name.


Entity's name.



Ambulance Run Sheet


Entity's date of death


Entities Original Signature



Processed according to plan provisions.



Date patient last examined by entity



Missing/invalid data prevents payer from processing claim.



Missing/invalid data prevents payer from processing claim.


Missing/invalid data prevents payer from processing claim.




Missing/invalid data prevents payer from processing claim.




                                                                         Page 367 of 378
                                                               39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Missing/invalid data prevents payer from processing claim.



Missing/invalid data prevents payer from processing claim.



Missing/invalid data prevents payer from processing claim.


Entity's qualification degree/designation (e.g. RN, PhD, MD)




Missing/invalid data prevents payer from processing claim.


Type of service.


Diagnosis code pointer is missing or invalid



Other Carrier Claim filing indicator is missing or invalid


Missing/invalid data prevents payer from processing claim.




Claim submitted to incorrect payer.




Processed according to plan provisions.



                                                                           Page 368 of 378
                                                             39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Supporting documentation.


Date of most recent medical event necessitating service(s)




Entity not eligible/not approved for dates of service.



Claim.




Claim submitted to incorrect payer.




For more detailed information, see remittance advice.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.



                                                                         Page 369 of 378
                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.



For more detailed information, see remittance advice.




Processed according to plan provisions.




Entity's National Provider Identifier (NPI)


Entity's id number.


Entity's National Provider Identifier (NPI)


Entity's id number.

Missing or invalid information.

Missing or invalid information.

Missing or invalid information.


Missing or invalid information.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.



                                                                    Page 370 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.




Date(s) of service.




Processed according to plan provisions.



No payment will be made for this claim.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.




                                                                   Page 371 of 378
                                                        39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Processed according to plan provisions.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.



Processed according to plan provisions.




For more detailed information, see remittance advice.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




                                                                    Page 372 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls



Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.



                                                                   Page 373 of 378
                                          39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.




Processed according to plan provisions.



Processed according to plan provisions.


                                                      Page 374 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.


Vouchers/explanation of benefits (EOB).




Claim was processed as adjustment to previous claim.




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.




                                                                   Page 375 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Processed according to plan provisions.



Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




Cannot provide further status electronically.




Claim was processed as adjustment to previous claim.



Processed according to plan provisions.



Processed according to plan provisions.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




                                                                   Page 376 of 378
                                                       39337c9a-a58d-4821-8d8b-90dd110df8e3.xls




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Claim was processed as adjustment to previous claim.




Processed according to plan provisions.




Processed according to plan provisions.




Claim was processed as adjustment to previous claim.



Internal review/audit.



Submitted charges.




                                                                   Page 377 of 378
                                               39337c9a-a58d-4821-8d8b-90dd110df8e3.xls


Submitted charges.



Hospital admission date.



Hospital discharge date.


Confinement dates.


Confinement dates.



Primary diagnosis code.



Admitting diagnosis.


NUBC Occurrence Span Code(s) and Date(s)



Hospital admission type.




Date(s) of service.



Diagnosis code pointer is missing or invalid




Claim/submission format is invalid.




                                                           Page 378 of 378

				
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