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					                                                            277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
0           CANNOT PROVIDE FURTHER STATUS ELECTRONICALLY.

1           FOR MORE DETAILED INFORMATION, SEE REMITTANCE ADVICE.
2           MORE DETAILED INFORMATION IN LETTER.

3           CLAIM HAS BEEN ADJUDICATED AND IS AWAITING PAYMENT CYCLE.
            THIS IS A SUBSEQUENT REQUEST FOR INFORMATION FROM THE
4           ORIGINAL REQUEST.
5           THIS IS A FINAL REQUEST FOR INFORMATION.
6           BALANCE DUE FROM THE SUBSCRIBER.
7           CLAIM MAY BE RECONSIDERED AT A FUTURE DATE.


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
8           NO PAYMENT DUE TO CONTRACT/PLAN PROVISIONS                      107 for new verbiage.
9           NO PAYMENT WILL BE MADE FOR THIS CLAIM.


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
10          ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED.    12 for new verbiage.


                                                                          Inactive as of ASC X12
                                                                          Version 4020. Refer to
11          SOME ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 12 for new verbiage.
            ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN
12          COMBINED.                                                       Changed as of 6/01


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
13          ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN MODIFIED.    15 for new verbiage.


                                                                            Inactive as of ASC X12
            SOME ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN         Version 4020. Refer to
14          MODIFIED.                                                       15 for new verbiage.
            ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN
15          MODIFIED.                                                       Changed as of 6/01
16          CLAIM/ENCOUNTER HAS BEEN FORWARDED TO ENTITY.
            CLAIM/ENCOUNTER HAS BEEN FORWARDED BY THIRD PARTY ENTITY TO
17          ENTITY.

18          ENTITY RECEIVED CLAIM/ENCOUNTER, BUT RETURNED INVALID STATUS.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
19          ENTITY ACKNOWLEDGES RECEIPT OF CLAIM/ENCOUNTER                  Changed as of 6/01
20          ACCEPTED FOR PROCESSING.                                        Changed as of 6/01
21          MISSING OR INVALID INFORMATION.                                 Changed as of 6/01

22          …BEFORE ENTERING THE ADJUDICATION SYSTEM.                       Inactive as of 01/01/08
23          RETURNED TO ENTITY.                                             Changed as of 6/01
24          ENTITY NOT APPROVED AS AN ELECTRONIC SUBMITTER.                 Changed as of 6/01
25          ENTITY NOT APPROVED.                                            Changed as of 6/01
26          ENTITY NOT FOUND.                                               Changed as of 6/01
27          POLICY CANCELED.                                                Changed as of 6/01


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
28          CLAIM SUBMITTED TO WRONG PAYER.                                 116 for new verbiage.

29          SUBSCRIBER AND POLICY NUMBER/CONTRACT NUMBER MISMATCHED.
30          SUBSCRIBER AND SUBSCRIBER ID MISMATCHED.
31          SUBSCRIBER AND POLICYHOLDER NAME MISMATCHED.

32          SUBSCRIBER AND POLICY NUMBER/CONTRACT NUMBER NOT FOUND.
33          SUBSCRIBER AND SUBSCRIBER ID NOT FOUND.
34          SUBSCRIBER AND POLICYHOLDER NAME NOT FOUND.
35          CLAIM/ENCOUNTER NOT FOUND.

37          PREDETERMINATION IS ON FILE, AWAITING COMPLETION OF SERVICES.
38          AWAITING NEXT PERIODIC ADJUDICATION CYCLE.
39          CHARGES FOR PREGNANCY DEFERRED UNTIL DELIVERY.
40          WAITING FOR FINAL APPROVAL.
41          SPECIAL HANDLING REQUIRED AT PAYER SITE.
42          AWAITING RELATED CHARGES.
44          CHARGES PENDING PROVIDER AUDIT.
45          AWAITING BENEFIT DETERMINATION.
46          INTERNAL REVIEW/AUDIT.
47          INTERNAL REVIEW/AUDIT - PARTIAL PAYMENT MADE.
48          REFERRAL/AUTHORIZATION.                                       Changed as of 2/01
49          PENDING PROVIDER ACCREDITATION REVIEW.
50          CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION.
51          INVESTIGATING OCCUPATIONAL ILLNESS/ACCIDENT.

52          INVESTIGATING EXISTENCE OF OTHER INSURANCE COVERAGE.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            CLAIM BEING RESEARCHED FOR INSURED ID/GROUP POLICY NUMBER
53          ERROR.
54          DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE.
55          CLAIM ASSIGNED TO AN APPROVER/ANALYST.
56          AWAITING ELIGIBILITY DETERMINATION.
57          PENDING COBRA INFORMATION REQUESTED.
59          NON-ELECTRONIC REQUEST FOR INFORMATION.
60          ELECTRONIC REQUEST FOR INFORMATION.
61          ELIGIBILITY FOR EXTENDED BENEFITS.
64          RE-PRICING INFORMATION.
65          CLAIM/LINE HAS BEEN PAID.
66          PAYMENT REFLECTS USUAL AND CUSTOMARY CHARGES.
67          PAYMENT MADE IN FULL.
68          PARTIAL PAYMENT MADE FOR THIS CLAIM.


                                                                           Inactive as of ASC X12
                                                                           Version 4020. Refer to
69          PAYMENT REFLECTS PLAN PROVISIONS.                              107 for new verbiage.


                                                                           Inactive as of ASC X12
                                                                           Version 4020. Refer to
70          PAYMENT REFLECTS CONTRACT PROVISIONS.                          107 for new verbiage.
71          PERIODIC INSTALLMENT RELEASED.
72          CLAIM CONTAINS SPLIT PAYMENT.

73          PAYMENT MADE TO ENTITY, ASSIGNMENT OF BENEFITS NOT ON FILE.

78          DUPLICATE OF AN EXISTING CLAIM/LINE, AWAITING PROCESSING.

81          CONTRACT/PLAN DOES NOT COVER PRE-EXISTING CONDITIONS.
83          NO COVERAGE FOR NEWBORNS.
84          SERVICE NOT AUTHORIZED.
85          ENTITY NOT PRIMARY.
86          DIAGNOSIS AND PATIENT GENDER MISMATCH.                         Changed as of 2/00
                                                                           Inactive as of
                                                                           01/01/2008. Refer to
87          DENIED: ENTITY NOT FOUND.                                      code 26.
            ENTITY NOT ELIGIBLE FOR BENEFITS FOR SUBMITTED DATES OF
88          SERVICE.
            ENTITY NOT ELIGIBLE FOR DENTAL BENEFITS FOR SUBMITTED DATES
89          OF SERVICE




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            ENTITY NOT ELIGIBLE FOR MEDICAL BENEFITS FOR SUBMITTED DATES
90          OF SERVICE.

91          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES OF SERVICE.

92          ENTITY DOES NOT MEET DEPENDENT OR STUDENT QUALIFICATION.
93          ENTITY IS NOT SELECTED PRIMARY CARE PROVIDER.

94          ENTITY NOT REFERRED BY SELECTED PRIMARY CARE PROVIDER.
95          REQUESTED ADDITIONAL INFORMATION NOT RECEIVED.
96          NO AGREEMENT WITH ENTITY.
97          PATIENT ELIGIBILITY NOT FOUND WITH ENTITY.
98          CHARGES APPLIED TO DEDUCTIBLE.
99          PRE-TREATMENT REVIEW.
100         PRE-CERTIFICATION PENALTY TAKEN.

101         CLAIM WAS PROCESSED AS ADJUSTMENT TO PREVIOUS CLAIM.
102         NEWBORN'S CHARGES PROCESSED ON MOTHER'S CLAIM.
103         CLAIM COMBINED WITH OTHER CLAIM(S).
104         PROCESSED ACCORDING TO PLAN PROVISIONS.
105         CLAIM/LINE IS CAPITATED.
106         THIS AMOUNT IS NOT ENTITY'S RESPONSIBILITY.
107         PROCESSED ACCORDING TO CONTRACT/PLAN PROVISIONS.               Changed as of 6/01
                                                                           Inactive as of
                                                                           01/01/2008. Refer to
108         COVERAGE HAS BEEN CANCELED FOR THIS ENTITY.                    code 27.
109         ENTITY NOT ELIGIBLE.
110         CLAIM REQUIRES PRICING INFORMATION.
            AT THE POLICYHOLDER'S REQUEST THESE CLAIMS CANNOT BE
111         SUBMITTED ELECTRONICALLY.
112         POLICYHOLDER PROCESSES THEIR OWN CLAIMS.
                                                                           Inactive as of
113         CANNOT PROCESS INDIVIDUAL INSURANCE POLICY CLAIMS.             07/01/2008.

114         CLAIM/SERVICE SHOULD BE PROCESSED BY ENTITY.                   Changed as of 07/01/2008.
                                                                           Inactive as of
115         CANNOT PROCESS HMO CLAIMS                                      07/01/2008.
116         CLAIM SUBMITTED TO INCORRECT PAYER.
117         CLAIM REQUIRES SIGNATURE-ON-FILE INDICATOR.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
                                                                            Inactive as   of
                                                                            01/01/2008.   Refer to
                                                                            code 21 and   125 with
118         TPO REJECTED CLAIM/LINE BECAUSE PAYER NAME IS MISSING.          entity code   IN.
                                                                            Inactive as of
            TPO REJECTED CLAIM/LINE BECAUSE CERTIFICATION INFORMATION IS    01/01/2008. Refer to
119         MISSING.                                                        code 21 and 252.
                                                                            Inactive as of
            TPO REJECTED CLAIM/LINE BECAUSE CLAIM DOES NOT CONTAIN          01/01/2008. Refer to
120         ENOUGH INFORMATION.                                             code 21.

121         SERVICE LINE NUMBER GREATER THAN MAXIMUM ALLOWABLE FOR PAYER.
                                                                            Inactive as of
                                                                            01/01/2008. Refer to
122         MISSING/INVALID DATA PREVENTS PAYER FROM PROCESSING CLAIM.      code 21.
123         ADDITIONAL INFORMATION REQUESTED FROM ENTITY.
124         ENTITY'S NAME, ADDRESS, PHONE AND ID NUMBER.
125         ENTITY'S NAME.
126         ENTITY'S ADDRESS.
127         ENTITY'S PHONE NUMBER.
128         ENTITY'S TAX ID.
129         ENTITY'S BLUE CROSS PROVIDER ID.
130         ENTITY'S BLUE SHIELD PROVIDER ID.
131         ENTITY'S MEDICARE PROVIDER ID.
132         ENTITY'S MEDICAID PROVIDER ID.
133         ENTITY'S UPIN.
134         ENTITY'S CHAMPUS PROVIDER ID.
135         ENTITY'S COMMERCIAL PROVIDER ID.
136         ENTITY'S HEALTH INDUSTRY ID NUMBER.
137         ENTITY'S PLAN NETWORK ID.
138         ENTITY'S SITE ID.
139         ENTITY'S HEALTH MAINTENANCE PROVIDER ID (HMO).
140         ENTITY'S PREFERRED PROVIDER ORGANIZATION ID (PPO).

141         ENTITY'S   ADMINISTRATIVE SERVICES ORGANIZATION ID (ASO).
142         ENTITY'S   LICENSE/CERTIFICATION NUMBER.
143         ENTITY'S   STATE LICENSE NUMBER.
144         ENTITY'S   SPECIALTY LICENSE NUMBER.

145         ENTITY'S SPECIALTY/TAXONOMY CODE.                               Changed as of 04/01/2008.
146         ENTITY'S ANESTHESIA LICENSE NUMBER.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES

147         ENTITY'S QUALIFICATION DEGREE/DESIGNATION (E.G. RN,PHD, MD)
148         ENTITY'S SOCIAL SECURITY NUMBER.
149         ENTITY'S EMPLOYER ID.
150         ENTITY'S DRUG ENFORCEMENT AGENCY (DEA) NUMBER.
152         PHARMACY PROCESSOR NUMBER.
153         ENTITY'S ID NUMBER.
154         RELATIONSHIP OF SURGEON & ASSISTANT SURGEON.
155         ENTITY'S RELATIONSHIP TO PATIENT.
156         PATIENT RELATIONSHIP TO SUBSCRIBER.
157         ENTITY'S GENDER.
158         ENTITY'S DATE OF BIRTH.
159         ENTITY'S DATE OF DEATH.
160         ENTITY'S MARITAL STATUS.
161         ENTITY'S EMPLOYMENT STATUS.
162         ENTITY'S HEALTH INSURANCE CLAIM NUMBER (HICN).
163         ENTITY'S POLICY NUMBER.
164         ENTITY'S CONTRACT/MEMBER NUMBER.
165         ENTITY'S EMPLOYER NAME, ADDRESS AND PHONE.
166         ENTITY'S EMPLOYER NAME.
167         ENTITY'S EMPLOYER ADDRESS.
168         ENTITY'S EMPLOYER PHONE NUMBER.
                                                                          Inactive for version
                                                                          004060. Duplicates code
169         ENTITY'S EMPLOYER ID.                                         149.
170         ENTITY'S EMPLOYEE ID.
            OTHER INSURANCE COVERAGE INFORMATION (HEALTH, LIABILITY,
171         AUTO, ETC).
172         OTHER EMPLOYER NAME, ADDRESS AND TELEPHONE NUMBER.

            ENTITY'S NAME, ADDRESS, PHONE, GENDER, DOB, MARITAL STATUS,
173         EMPLOYMENT STATUS AND RELATION TO SUBSCRIBER.                 Changed as of 2/00
174         ENTITY'S STUDENT STATUS.
175         ENTITY'S SCHOOL NAME.
176         ENTITY'S SCHOOL ADDRESS.
            TRANSPLANT RECIPIENT'S NAME, DATE OF BIRTH, GENDER,
177         RELATIONSHIP TO INSURED.                                      Changed as of 2/00
178         SUBMITTED CHARGES.
179         OUTSIDE LAB CHARGES.
180         HOSPITAL'S SEMI-PRIVATE ROOM RATE.
181         HOSPITAL'S ROOM RATE.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
182         ALLOWABLE/PAID FROM PRIMARY COVERAGE.
183         AMOUNT ENTITY HAS PAID.

184         PURCHASE PRICE FOR THE RENTED DURABLE MEDICAL EQUIPMENT.
185         RENTAL PRICE FOR DURABLE MEDICAL EQUIPMENT.

186         PURCHASE AND RENTAL PRICE OF DURABLE MEDICAL EQUIPMENT.
187         DATE(S) OF SERVICE.
188         STATEMENT FROM-THROUGH DATES.
189         HOSPITAL ADMISSION DATE.
190         HOSPITAL DISCHARGE DATE.
191         DATE OF LAST MENSTRUAL PERIOD (LMP).                           New as of 2/97

192         DATE OF FIRST SERVICE FOR CURRENT SERIES/SYMPTOM/ILLNESS.
193         FIRST CONSULTATION/EVALUATION DATE.                            New as of 2/97
194         CONFINEMENT DATES.
195         UNABLE TO WORK DATES.
196         RETURN TO WORK DATES.
197         EFFECTIVE COVERAGE DATE(S).
198         MEDICARE EFFECTIVE DATES.
199         DATE OF CONCEPTION AND EXPECTED DATE OF DELIVERY.
200         DATE OF EQUIPMENT RETURN.
201         DATE OF DENTAL APPLIANCE PRIOR PLACEMENT.

202         DATE OF DENTAL PRIOR REPLACEMENT/REASON FOR REPLACEMENT.
203         DATE OF DENTAL APPLIANCE PLACED.

204         DATE DENTAL CANAL(S) OPENED AND DATE SERVICE COMPLETED.

205         DATE(S) DENTAL ROOT CANAL THERAPY PREVIOUSLY PERFORMED.
            MOST RECENT DATE OF CURETTAGE, ROOT PLANNING, OR PERIODONTAL
206         SURGERY.
207         DENTAL IMPRESSION AND SEATING DATE.
208         MOST RECENT DATE PACEMAKER WAS IMPLANTED.
209         MOST RECENT PACEMAKER BATTERY CHANGE DATE.
210         DATE OF THE LAST X-RAY.
211         DATE(S) OF DIALYSIS TRAINING PROVIDED TO PATIENT.
212         DATE OF LAST ROUTINE DIALYSIS.
213         DATE OF FIRST ROUTINE DIALYSIS.
214         ORIGINAL DATE OF PRESCRIPTION/ORDERS/REFERRAL.                 New as of 2/97
215         DATE OF TOOTH EXTRACTION/EVOLUTION.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
216         DRUG INFORMATION.
217         DRUG NAME, STRENGTH AND DOSAGE FORM.
218         NDC NUMBER.
219         PRESCRIPTION NUMBER.
220         DRUG PRODUCTION ID NUMBER.
221         DRUG DAYS SUPPLY AND DOSAGE.

222         DRUG DISPENSING UNITS AND AVERAGE WHOLESALE PRICE (AWP).
223         ROUTINE OF DRUG/MYELOGRAM ADMINISTRATION.
224         ANATOMICAL LOCATION FOR JOINT INJECTION.
225         ANATOMICAL LOCATION.
226         JOINT INJECTION SITE.
227         HOSPITAL INFORMATION.
228         TYPE OF BILL FOR UB CLAIM.                                    Changed as of 6/01
229         HOSPITAL ADMISSION SOURCE.
230         HOSPITAL ADMISSION HOUR.
231         HOSPITAL ADMISSION TYPE.
232         ADMITTING DIAGNOSIS.
233         HOSPITAL DISCHARGE HOUR.
234         PATIENT DISCHARGE STATUS.
235         UNITS OF BLOOD FURNISHED.
236         UNITS OF BLOOD REPLACED.
237         UNITS OF DEDUCTIBLE BLOOD.
238         SEPARATE CLAIM FOR MOTHER/BABY CHARGES.
239         DENTAL INFORMATION.
240         TOOTH SURFACE(S) INVOLVED.
241         LIST OF ALL MISSING TEETH (UPPER AND LOWER).
242         TOOTH NUMBERS, SURFACES, AND/OR QUADRANTS INVOLVED.
243         MONTHS OF DENTAL TREATMENT REMAINING.
244         TOOTH NUMBER OR LETTER.
245         DENTAL QUADRANT/ARCH.
            TOTAL ORTHODONTIC SERVICE FEE, INITIAL APPLIANCE FEE,
246         MONTHLY FEE, LENGTH OF SERVICE.
247         LINE INFORMATION.
248         ACCIDENT DATE, STATE, DESCRIPTION AND CAUSE.
249         PLACE OF SERVICE.
250         TYPE OF SERVICE.
251         TOTAL ANESTHESIA MINUTES.
252         AUTHORIZATION/CERTIFICATION NUMBER.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
                                                                           Deleted as of 2/97.
                                                                           Please use codes 454 or
253         PROCEDURE/REVENUE CODE FOR SERVICES(S) RENDERED.               455.
254         PRIMARY DIAGNOSIS CODE.
255         DIAGNOSIS CODE.
256         DRG CODE(S).
257         ADSM-III-R CODE FOR SERVICES RENDERED.
258         DAYS/UNITS FOR PROCEDURE/REVENUE CODE.
259         FREQUENCY OF SERVICE.
260         LENGTH OF MEDICAL NECESSITY, INCLUDING BEGIN DATE.             New as of 2/97
261         OBESITY MEASUREMENTS.
            TYPE OF SURGERY/SERVICE FOR WHICH ANESTHESIA WAS
262         ADMINISTERED.
263         LENGTH OF TIME FOR SERVICES RENDERED.
            NUMBER OF LITERS/MINUTE & TOTAL HOURS/DAY FOR RESPIRATORY
264         SUPPORT.
265         NUMBER OF LESIONS EXCISED.

266         FACILITY POINT OF ORIGIN AND DESTINATION - AMBULANCE.
267         NUMBER OF MILES PATIENT WAS TRANSPORTED.
268         LOCATION OF DURABLE MEDICAL EQUIPMENT USE.
269         LENGTH/SIZE OF LACERATION/TUMOR.
270         SUBLUXATION LOCATION.
271         NUMBER OF SPINE SEGMENTS.
272         OXYGEN CONTENTS FOR OXYGEN SYSTEM RENTAL.
273         WEIGHT.
274         HEIGHT.
275         CLAIM.
276         UB-04/HCFA-1450/HCFA-1500 CLAIM FORM                           Changed as of 6/01
277         PAPER CLAIM.
278         SIGNED CLAIM FORM.
279         ITEMIZED CLAIM.
280         ITEMIZED CLAIM BY PROVIDER.
281         RELATED CONFINEMENT CLAIM.
282         COPY OF PRESCRIPTION.
            MEDICARE ENTITLEMENT INFORMATION IS REQUIRED TO DETERMINE
283         PRIMARY COVERAGE.                                              Changed as of 7/01/08.
284         COPY OF MEDICARE ID CARD.
285         VOUCHERS/EXPLANATION OF BENEFITS (EOB).

286         OTHER PAYER'S EXPLANATION OF BENEFITS/PAYMENT INFORMATION.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
287         MEDICAL NECESSITY FOR SERVICE.
288         REASON FOR LATE HOSPITAL CHARGES.
289         REASON FOR LATE DISCHARGE.
290         PRE-EXISTING INFORMATION.
291         REASON FOR TERMINATION OF PREGNANCY.
292         PURPOSE OF FAMILY CONFERENCE/THERAPY.
293         REASON FOR PHYSICAL THERAPY.
294         SUPPORTING DOCUMENTATION.
295         ATTENDING PHYSICIAN REPORT.
296         NURSE'S NOTES.
297         MEDICAL NOTES/REPORT.                                        New as of 2/97
298         OPERATIVE REPORT.
299         EMERGENCY ROOM NOTES/REPORT.
300         LAB/TEST REPORT/NOTES/RESULTS.                               New as of 2/97
301         MRI REPORT.

302         REFER TO CODES 300 FOR LAB NOTES AND 311 FOR PATHOLOGY NOTES. Removed prior to 2/97


                                                                         Deleted as of 2/97.
                                                                         Please use code 297:6O
303         PHYSICAL THERAPY NOTES.                                      (6 'OH' - not zero)
304         REPORTS FOR SERVICE.
305         X-RAY REPORTS/INTERPRETATION.
306         DETAILED DESCRIPTION OF SERVICE.
307         NARRATIVE WITH POCKET DEPTH CHART.
308         DISCHARGE SUMMARY.

309         CODE WAS DUPLICATE OF CODE 299.                              Removed prior to 2/97.

310         PROGRESS NOTES FOR THE SIX MONTHS PRIOR TO STATEMENT DATE.
311         PATHOLOGY NOTES/REPORTS.
312         DENTAL CHARTING.
313         BRIDGEWORK INFORMATION.
314         DENTAL RECORDS FOR THIS SERVICE.
315         PAST PERIO TREATMENT HISTORY.
316         COMPLETE MEDICAL HISTORY.
317         PATIENT'S MEDICAL RECORDS.
318         X-RAYS.
319         PRE/POST-OPERATIVE X-RAYS/PHOTOGRAPHS.                       New as of 2/97
320         STUDY MODELS.
321         RADIOGRAPHS OR MODELS.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
322         RECENT FM X-RAYS.
323         STUDY MODELS, X-RAYS, AND/OR NARRATIVE.
324         RECENT X-RAY OF TREATMENT AREA AND/OR NARRATIVE.
325         RECENT FM X-RAYS AND/OR NARRATIVE.
326         COPY OF TRANSPLANT ACQUISITION INVOICE.
            PERIODONTAL CASE TYPE DIAGNOSIS AND RECENT POCKET DEPTH
327         CHART WITH NARRATIVE.

                                                                          Deleted as of 2/97.
328         SPEECH THERAPY NOTES.                                         Please use code 297:6R
329         EXERCISE NOTES.
330         OCCUPATIONAL NOTES.
331         HISTORY AND PHYSICAL.

                                                                          Inactive as of 01/01/08.
332         AUTHORIZATION/CERTIFICATION (INCLUDE PERIOD COVERED).         Use code 252.
333         PATIENT RELEASE OF INFORMATION AUTHORIZATION.
334         OXYGEN CERTIFICATION.
335         DURABLE MEDICAL EQUIPMENT CERTIFICATION.
336         CHIROPRACTIC CERTIFICATION.
337         AMBULANCE CERTIFICATION/DOCUMENTATION.

                                                                          Deleted as of 2/97.
338         HOME HEALTH CERTIFICATION.                                    Please use code 332:4Y
339         ENTERAL/PARENTERAL CERTIFICATION.
340         PACEMAKER CERTIFICATION.
341         PRIVATE DUTY NURSING CERTIFICATION.
342         PODIATRIC CERTIFICATION.
            DOCUMENTATION THAT FACILITY IS STATE LICENSED AND MEDICARE
343         APPROVED AS A SURGICAL FACILITY.
            DOCUMENTATION THAT PROVIDER OF PHYSICAL THERAPY IS MEDICARE
344         PART B APPROVED.
345         TREATMENT PLAN FOR SERVICE/DIAGNOSIS.
346         PROPOSED TREATMENT PLAN FOR NEXT 6 MONTHS.

347         REFER TO CODE 345 FOR TREATMENT PLAN AND 282 FOR PRESCRIPTION Removed prior to 2/97

                                                                          Inactive as of 01/01/08.
348         CHIROPRACTIC TREATMENT PLAN.                                   Use code 345:QL.




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

                                                                           Deleted as of 2/97.
                                                                           Please use codes 345:5I,
                                                                           5J, 5K, 5L, 5M, 5N, 5O
349         PSYCHIATRIC TREATMENT PLAN.                                    (5 'OH' - not zero), 5P

                                                                           Deleted as of 2/97.
350         SPEECH PATHOLOGY TREATMENT PLAN.                               Please use code 345:6R


                                                                           Deleted as of 2/97.
                                                                           Please use codes 345:6O
351         PHYSICAL/OCCUPATIONAL THERAPY TREATMENT PLAN.                  (6 'OH' - not zero), 6N
352         DURATION OF TREATMENT PLAN.
353         ORTHODONTICS TREATMENT PLAN.

354         TREATMENT PLAN FOR REPLACEMENT OF REMAINING MISSING TEETH.
355         HAS CLAIM BEEN PAID?
356         WAS BLOOD FURNISHED?
357         HAS OR WILL BLOOD BE REPLACED?
358         DOES PROVIDER ACCEPT ASSIGNMENT OF BENEFITS?

359         IS THERE A RELEASE OF INFORMATION SIGNATURE ON FILE?

360         IS THERE AN ASSIGNMENT OF BENEFITS SIGNATURE ON FILE?
361         IS THERE OTHER INSURANCE?
362         IS THE DENTAL PATIENT COVERED BY MEDICAL INSURANCE?
363         WILL WORKER'S COMPENSATION COVER SUBMITTED CHARGES?
364         IS ACCIDENT/ILLNESS/CONDITION EMPLOYMENT RELATED?
365         IS SERVICE THE RESULT OF AN ACCIDENT?
366         IS INJURY DUE TO AUTO ACCIDENT?
            IS SERVICE PERFORMED FOR A RECURRING CONDITION OR NEW
367         CONDITION?
            IS MEDICAL DOCTOR (MD) OR DOCTOR OF OSTEOPATH (DO) ON STAFF
368         OF THIS FACILITY?

369         DOES PATIENT CONDITION PRECLUDE USE OF ORDINARY BED?
370         CAN PATIENT OPERATE CONTROLS OF BED?
371         IS PATIENT CONFINED TO ROOM?
372         IS PATIENT CONFINED TO BED?
373         IS PATIENT AN INSULIN DIABETIC?
374         IS PRESCRIBED LENSES A RESULT OF CATARACT SURGERY?




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
375         WAS REFRACTION PERFORMED?
376         WAS CHARGE FOR AMBULANCE FOR A ROUND-TRIP?

377         WAS DURABLE MEDICAL EQUIPMENT PURCHASED NEW OR USED?
378         IS PACEMAKER TEMPORARY OR PERMANENT?
379         WERE SERVICES PERFORMED SUPERVISED BY A PHYSICIAN?
            WERE SERVICES PERFORMED BY A CRNA UNDER APPROPRIATE MEDICAL
380         DIRECTION?                                                      Changed as of 10/99
381         IS DRUG GENERIC?

382         DID PROVIDER AUTHORIZE GENERIC OR BRAND NAME DISPENSING?
            WAS NERVE BLOCK USED FOR SURGICAL PROCEDURE OR PAIN
383         MANAGEMENT?
            IS PROSTHESIS/CROWN/INLAY PLACEMENT AN INITIAL PLACEMENT OR
384         A REPLACEMENT?
            IS APPLIANCE UPPER OR LOWER ARCH & IS APPLIANCE FIXED OR
385         REMOVABLE?
386         IS SERVICE FOR ORTHODONTIC PURPOSES?
387         DATE PATIENT LAST EXAMINED BY ENTITY.                           New as of 2/97
388         DATE POST-OPERATIVE CARE ASSUMED.                               New as of 2/97
389         DATE POST-OPERATIVE CARE RELINQUISHED.                          New as of 2/97

390         DATE OF   MOST RECENT MEDICAL EVENT NECESSITATING SERVICE(S).   New   as   of   2/97
391         DATE(S)   DIALYSIS CONDUCTED.                                   New   as   of   2/97
392         DATE(S)   OF BLOOD TRANSFUSION(S).                              New   as   of   2/97
393         DATE OF   PREVIOUS PACEMAKER                                    New   as   of   2/97

394         DATE(S) OF MOST RECENT HOSPITALIZATION RELATED TO SERVICE.      New   as   of   2/97
395         DATE ENTITY SIGNED CERTIFICATION/RECERTIFICATION                New   as   of   2/97
396         DATE HOME DIALYSIS BEGAN.                                       New   as   of   2/97
397         DATE OF ONSET/EXACERBATION OF ILLNESS/CONDITION.                New   as   of   2/97
398         VISUAL FIELD TEST RESULTS.                                      New   as   of   2/97
            REPORT OF PRIOR TESTING RELATED TO THIS SERVICE, INCLUDING
399         DATES.                                                          New   as   of   2/97
400         CLAIM IS OUT OF BALANCE.                                        New   as   of   2/97
401         SOURCE OF PAYMENT IS NOT VALID                                  New   as   of   2/97
402         AMOUNT MUST BE GREATER THAN ZERO.                               New   as   of   2/97
403         ENTITY REFERRAL NOTES/ORDERS/PRESCRIPTION.                      New   as   of   2/97
            SPECIFIC FINDINGS, COMPLAINTS, OR SYMPTOMS NECESSITATING
404         SERVICE.                                                        New as of 2/97
405         SUMMARY OF SERVICES.                                            New as of 2/97




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
406         BRIEF MEDICAL HISTORY AS RELATED TO SERVICES(S).                New as of 2/97
407         COMPLICATIONS/MITIGATING CIRCUMSTANCES.                         New as of 2/97
408         INITIAL CERTIFICATION.                                          New as of 2/97

409         MEDICATION LOGS/RECORDS (INCLUDING MEDICATION THERAPY).         New as of 2/97
            EXPLAIN DIFFERENCES BETWEEN TREATMENT PLAN AND PATIENT'S
410         CONDITION.                                                      New as of 2/97
411         MEDICAL NECESSITY FOR NON-ROUTINE SERVICES(S).                  New as of 2/97

412         MEDICAL RECORDS TO SUBSTANTIATE DECISION OF NON-COVERAGE.       New as of 2/97
            EXPLAIN/JUSTIFY DIFFERENCES BETWEEN TREATMENT PLAN AND
413         SERVICES RENDERED.                                              New as of 2/97
414         NEED FOR MORE THAN ONE PHYSICIAN TO TREAT PATIENT.              New as of 2/97
415         JUSTIFY SERVICES OUTSIDE COMPOSITE RATE.                        New as of 2/97
            VERIFICATION OF PATIENT'S ABILITY TO RETAIN AND USE
416         INFORMATION.                                                    New as of 2/97
            PRIOR TESTING, INCLUDING RESULT(S) AND DATE(S) AS RELATED TO
417         SERVICE(S).                                                     New as of 2/97
418         INDICATING WHY MEDICATIONS CANNOT BE TAKEN ORALLY.              New as of 2/97
            INDIVIDUAL TEST(S) COMPRISING THE PANEL AND THE CHARGES FOR
419         EACH TEST.                                                      New as of 2/97
            NAME, DOSAGE AND MEDICAL JUSTIFICATION OF CONTRAST MATERIAL
420         USED FOR RADIOLOGY PROCEDURE.                                   New as of 2/97

421         MEDICAL REVIEW ATTACHMENT/INFORMATION FOR SERVICE(S).           New as of 2/97
422         HOMEBOUND STATUS.                                               New as of 2/97


                                                                            Inactive for 004030,
                                                                            since 10/99. LOINC
                                                                            codes have the ability
423         PROGNOSIS.                                                      to ask for prognosis.
424         STATEMENT OF NON-COVERAGE INCLUDING ITEMIZED BILL.              New as of 2/97
425         ITEMIZE NON-COVERED SERVICES.                                   New as of 2/97
426         ALL CURRENT DIAGNOSES.                                          New as of 2/97
427         EMERGENCY CARE PROVIDED DURING TRANSPORT.                       New as of 2/97
428         REASON FOR TRANSPORT BY AMBULANCE.                              New as of 2/97
            LOADED MILES AND CHARGES FOR TRANSPORT TO NEAREST FACILITY
429         WITH APPROPRIATE SERVICES.                                      New as of 2/97
430         NEAREST APPROPRIATE FACILITY.                                   New as of 2/97

431         PROVIDE CONDITION/FUNCTIONAL STATUS AT TIME OF SERVICE.         New as of 2/97




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
432         DATE BENEFITS EXHAUSTED.                                       New as of 2/97
433         COPY OF PATIENT REVOCATION OF HOSPICE BENEFITS.                New as of 2/97

434         REASONS FOR MORE THAN ONE TRANSFER PER ENTITLEMENT PERIOD.     New   as   of   2/97
435         NOTICE OF ADMISSION.                                           New   as   of   2/97
436         SHORT TERM GOALS.                                              New   as   of   2/97
437         LONG TERM GOALS.                                               New   as   of   2/97
438         NUMBER OF PATIENTS ATTENDING SESSION.                          New   as   of   2/97
439         SIZE, DEPTH, AMOUNT, AND TYPE OF DRAINAGE WOUNDS.              New   as   of   2/97

440         WHY NON-SKILLED CAREGIVER HAS NOT BEEN TAUGHT PROCEDURE.       New   as   of   2/97
441         ENTITY PROFESSIONAL QUALIFICATION FOR SERVICE(S).              New   as   of   2/97
442         MODALITIES OF SERVICE.                                         New   as   of   2/97
443         INITIAL EVALUATION REPORT.                                     New   as   of   2/97
444         METHOD USED TO OBTAIN TEST SAMPLE.                             New   as   of   2/97

445         EXPLAIN WHY HEARING LOSS NOT CORRECTABLE BY HEARING AID.       New as of 2/97

446         DOCUMENTATION FROM PRIOR CLAIM(S) RELATED TO SERVICE(S).       New as of 2/97
447         PLAN OF TEACHING.                                              New as of 2/97


            INVALID BILLING COMBINATION. SEE STC12 FOR DETAILS. THIS
            CODE SHOULD ONLY BE USED TO INDICATE AN INCONSISTENCY
            BETWEEN TWO OR MORE DATA ELEMENTS ON THE CLAIM. A DETAILED
448         EXPLANATION IS REQUIRED IN STC12 WHEN THIS CODE IS USED.       New   as   of   2/97
449         PROJECTED DATE TO DISCONTINUE SERVICE(S).                      New   as   of   2/97
450         AWAITING SPEND DOWN DETERMINATION.                             New   as   of   2/97
451         PREOPERATIVE AND POST-OPERATIVE DIAGNOSIS.                     New   as   of   2/97
            TOTAL VISITS IN TOTAL NUMBER OF HOURS/DAY AND TOTAL NUMBER
452         OF HOURS/WEEK.                                                 New   as   of   2/97
453         PROCEDURE CODE MODIFIER(S) FOR SERVICE(S) RENDERED.            New   as   of   2/97
454         PROCEDURE CODE FOR SERVICES RENDERED.                          New   as   of   2/97
455         REVENUE CODE FOR SERVICES RENDERED.                            New   as   of   2/97
456         COVERED DAY(S).                                                New   as   of   2/97
457         NON-COVERED DAY(S).                                            New   as   of   2/97
458         COINSURANCE DAYS(S).                                           New   as   of   2/97
459         LIFETIME RESERVE DAY(S).                                       New   as   of   2/97
460         NUBC CONDITION CODE(S).                                        New   as   of   2/97
461         NUBC OCCURRENCE CODE(S) AND DATES(S)                           New   as   of   2/97
462         NUBC OCCURRENCE SPAN CODE(S) AND DATE(S).                      New   as   of   2/97
463         NUBC VALUE CODE(S) AND/OR AMOUNT(S).                           New   as   of   2/97




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

464         PAYER ASSIGNED CLAIM CONTROL NUMBER.                           Changed as of 10/31/04.
465         PRINCIPAL PROCEDURE CODE FOR SERVICE(S) RENDERED.              New as of 2/97
466         ENTITIES ORIGINAL SIGNATURE.                                   New as of 2/97
467         ENTITY SIGNATURE DATE.                                         New as of 2/97
468         PATIENT SIGNATURE SOURCE.                                      New as of 2/97
469         PURCHASE SERVICE CHARGE.                                       New as of 2/97
470         WAS SERVICE PURCHASED FROM ANOTHER ENTITY?                     New as of 2/97
471         WERE SERVICES RELATED TO AN EMERGENCY?                         New as of 2/97
472         AMBULANCE RUN SHEET.                                           New as of 2/97
473         MISSING OR INVALID LAB INDICATOR.                              New as of 2/97
474         PROCEDURE CODE AND PATIENT GENDER MISMATCH.                    Changed as of 2/00
475         PROCEDURE CODE NOT VALID FOR PATIENT AGE.                      Changed as of 2/00
476         MISSING OR INVALID UNITS OF SERVICE.                           New as of 6/98
477         DIAGNOSIS CODE POINTER IS MISSING OR INVALID.                  New as of 6/98
            CLAIM SUBMITTER'S IDENTIFIER (PATIENT ACCOUNT NUMBER) IS
478         MISSING.                                                       New as of 6/98
479         OTHER CARRIER PAYER ID IS MISSING OR INVALID.                  New as of 6/98

480         OTHER CARRIER CLAIM FILING INDICATOR IS MISSING OR INVALID.    New as of 6/98
481         CLAIM/SUBMISSION FORMAT IS INVALID.                            New as of 10/98
482         DATE ERROR, CENTURY MISSING.                                   New as of 2/99

483         MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD.    New as of 6/99
484         BUSINESS APPLICATION CURRENTLY NOT AVAILABLE.                  New as of 2/00

            MORE INFORMATION AVAILABLE THAN CAN BE RETURNED IN REAL TIME
485         MODE. NARROW YOU CURRENT SEARCH CRITERIA.                      New as of 2/01
486         PRINCIPLE PROCEDURE DATE.                                      New as of 10/01
            CLAIM NOT FOUND, CLAIM SHOULD HAVE BEEN SUBMITTED TO/THROUGH
487         'ENTITY'.                                                      New   as   of   2/02
488         DIAGNOSIS CODE(S) FOR THE SERVICES RENDERED.                   New   as   of   6/02
489         ATTACHMENT CONTROL NUMBER.                                     New   as   of   10/02
490         OTHER PROCEDURE CODE FOR SERVICE(S) RENDERED.                  New   as   of   2/03
491         ENTITY NOT ELIGIBLE FOR ENCOUNTER SUBMISSION.                  New   as   of   2/03
492         OTHER PROCEDURE DATE.                                          New   as   of   2/03
            VERSION/RELEASE/INDUSTRY ID CODE NOT CURRENTLY SUPPORTED BY
493         INFORMATION HOLDER.                                            New as of 2/03
            REAL-TIME REQUESTS NOT SUPPORTED BY THE INFORMATION HOLDER,
494         RESUBMIT AS BATCH REQUEST.                                     New as of 2/03




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            REQUESTS FOR RE-ADJUDICATION MUST REFERENCE THE NEWLY
            ASSIGNED PAYER CLAIM CONTROL NUMBER FOR THIS PREVIOUSLY
            ADJUSTED CLAIM. CORRECT THE PAYER CLAIM CONTROL NUMBER AND
495         RE-SUBMIT.                                                     New as of 9/03
            SUBMITTER NOT APPROVED FOR ELECTRONIC CLAIM SUBMISSIONS ON
496         BEHALF OF THIS ENTITY.                                         New as of 2/04
497         SALES TAX NOT PAID                                             New as of 6/04
498         MAXIMUM LEAVE DAYS EXHAUSTED.                                  New as of 6/04
            NO RATE ON FILE WITH THE PAYER FOR THIS SERVICE FOR THIS
499         ENTITY.                                                        New   as   of   6/04
500         ENTITY'S POSTAL/ZIP CODE                                       New   as   of   6/04
501         ENTITY'S STATE/PROVINCE                                        New   as   of   6/04
502         ENTITY'S CITY                                                  New   as   of   6/04
503         ENTITY'S STREET ADDRESS                                        New   as   of   6/04
504         ENTITY'S LAST NAME                                             New   as   of   6/04
505         ENTITY'S FIRST NAME                                            New   as   of   6/04

            ENTITY IS CHANGING PROCESSOR/CLEARINGHOUSE. THIS CLAIM MUST
506         BE SUBMITTED TO THE NEW PROCESSOR/CLEARINGHOUSE.               New   as   of   6/04
507         HCPCS                                                          New   as   of   10/04
508         ICD9                                                           New   as   of   10/04
509         E-CODE                                                         New   as   of   10/04
510         FUTURE DATE                                                    New   as   of   10/04
511         INVALID CHARACTER                                              New   as   of   10/04
512         LENGTH INVALID FOR RECEIVER'S APPLICATION SYSTEM               New   as   of   10/04
513         HIPPS RATE CODE FOR SERVICES RENDERED                          New   as   of   10/04
514         ENTITIES MIDDLE NAME                                           New   as   of   10/04
515         MANAGED CARE REVIEW                                            New   as   of   10/04
516         ADJUDICATION OR PAYMENT DATE                                   New   as   of   10/04
517         ADJUSTED REPRICED CLAIM REFERENCE NUMBER                       New   as   of   10/04
518         ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER                   New   as   of   10/04
519         ADJUSTMENT AMOUNT                                              New   as   of   10/04
520         ADJUSTMENT QUANTITY                                            New   as   of   10/04
521         ADJUSTMENT REASON CODE                                         New   as   of   10/04
522         ANESTHESIA MODIFYING UNITS                                     New   as   of   10/04
523         ANESTHESIA UNIT COUNT                                          New   as   of   10/04
524         ARTERIAL BLOOD GAS QUANTITY                                    New   as   of   10/04
525         BEGIN THERAPY DATE                                             New   as   of   10/04
526         BUNDLED OR UNBUNDLED LINE NUMBER                               New   as   of   10/04
527         CERTIFICATION CONDITION INDICATOR                              New   as   of   10/04
528         CERTIFICATION PERIOD PROJECTED VISIT COUNT                     New   as   of   10/04




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                              NOTES
529         CERTIFICATION REVISION DATE                                  New   as   of   10/04
530         CLAIM ADJUSTMENT INDICATOR                                   New   as   of   10/04
531         CLAIM DISPROPORTINATE SHARE AMOUNT                           New   as   of   10/04
532         CLAIM DRG AMOUNT                                             New   as   of   10/04
533         CLAIM DRG OUTLIER AMOUNT                                     New   as   of   10/04
534         CLAIM ESRD PAYMENT AMOUNT                                    New   as   of   10/04
535         CLAIM FREQUENCY CODE                                         New   as   of   10/04
536         CLAIM INDIRECT TEACHING AMOUNT                               New   as   of   10/04
537         CLAIM MSP PASS-THROUGH AMOUNT                                New   as   of   10/04
538         CLAIM OR ENCOUNTER IDENTIFIER                                New   as   of   10/04
539         CLAIM PPS CAPITAL AMOUNT                                     New   as   of   10/04
540         CLAIM PPS CAPITAL OUTLIER AMOUNT                             New   as   of   10/04
541         CLAIM SUBMISSION REASON CODE                                 New   as   of   10/04
542         CLAIM TOTAL DENIED CHARGE AMOUNT                             New   as   of   10/04
543         CLEARINGHOUSE OR VALUE ADDED NETWORK TRACE                   New   as   of   10/04
544         CLINICAL LABORATORY IMPROVEMENT AMENDMENT                    New   as   of   10/04
545         CONTRACT AMOUNT                                              New   as   of   10/04
546         CONTRACT CODE                                                New   as   of   10/04
547         CONTRACT PERCENTAGE                                          New   as   of   10/04
548         CONTRACT TYPE CODE                                           New   as   of   10/04
549         CONTRACT VERSION IDENTIFIER                                  New   as   of   10/04
550         COORDINATION OF BENEFITS CODE                                New   as   of   10/04
551         COORDINATION OF BENEFITS TOTAL SUBMITTED CHARGE              New   as   of   10/04
552         COST REPORT DAY COUNT                                        New   as   of   10/04
553         COVERED AMOUNT                                               New   as   of   10/04
554         DATE CLAIM PAID                                              New   as   of   10/04
555         DELAY REASON CODE                                            New   as   of   10/04
556         DEMONSTRATION PROJECT IDENTIFIER                             New   as   of   10/04
557         DIAGNOSIS DATE                                               New   as   of   10/04
558         DISCOUNT AMOUNT                                              New   as   of   10/04
559         DOCUMENT CONTROL IDENTIFIER                                  New   as   of   10/04
560         ENTITY'S ADDITIONAL/SECONDARY IDENTIFIER                     New   as   of   10/04
561         ENTITY'S CONTACT NAME                                        New   as   of   10/04
562         ENTITY'S NATIONAL PROVIDER IDENTIFIER (NPI)                  New   as   of   10/04
563         ENTITY'S TAX AMOUNT                                          New   as   of   10/04
564         EPSDT INDICATOR                                              New   as   of   10/04
565         ESTIMATED CLAIM DUE AMOUNT                                   New   as   of   10/04
566         EXCEPTION CODE                                               New   as   of   10/04
567         FACILITY CODE QUALIFIER                                      New   as   of   10/04
568         FAMILY PLANNING INDICATOR                                    New   as   of   10/04
569         FIXED FORMAT INFORMATION                                     New   as   of   10/04




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                              NOTES
570         FREE FORM MESSAGE TEXT                                       New   as   of   10/04
571         FREQUENCY COUNT                                              New   as   of   10/04
572         FREQUENCY PERIOD                                             New   as   of   10/04
573         FUNCTIONAL LIMITATION CODE                                   New   as   of   10/04
574         HCPCS PAYABLE AMOUNT HOME HEALTH                             New   as   of   10/04
575         HOMEBOUND INDICATOR                                          New   as   of   10/04
576         IMMUNIZATION BATCH NUMBER                                    New   as   of   10/04
577         INDUSTRY CODE                                                New   as   of   10/04
578         INSURANCE TYPE CODE                                          New   as   of   10/04
579         INVESTIGATIONAL DEVICE EXEMPTION IDENTIFIER                  New   as   of   10/04
580         LAST CERTIFICATION DATE                                      New   as   of   10/04
581         LAST WORKED DATE                                             New   as   of   10/04
582         LIFETIME PSYCHIATRIC DAYS COUNT                              New   as   of   10/04
583         LINE ITEM CHARGE AMOUNT                                      New   as   of   10/04
584         LINE ITEM CONTROL NUMBER                                     New   as   of   10/04

585         DENIED CHARGE OR NON-COVERED CHARGE                          Changed as of 07/09/07.
586         LINE NOTE TEXT                                               New as of 10/04
587         MEASUREMENT REFERENCE IDENTIFICATION CODE                    New as of 10/04
588         MEDICAL RECORD NUMBER                                        New as of 10/04
589         MEDICARE ASSIGNMENT CODE                                     New as of 10/04
590         MEDICARE COVERAGE INDICATOR                                  New as of 10/04
591         MEDICARE PAID AT 100% AMOUNT                                 New as of 10/04
592         MEDICARE PAID AT 80% AMOUNT                                  New as of 10/04
593         MEDICARE SECTION 4081 INDICATOR                              New as of 10/04
594         MENTAL STATUS CODE                                           New as of 10/04
595         MONTHLY TREATMENT COUNT                                      New as of 10/04
596         NON-COVERED CHARGE AMOUNT                                    New as of 10/04
597         NON-PAYABLE PROFESSIONAL COMPONENT AMOUNT                    New as of 10/04
598         NON-PAYABLE PROFESSIONAL COMPONENT BILLED AMOUNT             New as of 10/04
599         NOTE REFERENCE CODE                                          New as of 10/04
600         OXYGEN SATURATION QTY                                        New as of 10/04
601         OXYGEN TEST CONDITION CODE                                   New as of 10/04
602         OXYGEN TEST DATE                                             New as of 10/04
603         OLD CAPITAL AMOUNT                                           New as of 10/04
604         ORIGINATOR APPLICATION TRANSACTION IDENTIFIER                New as of 10/04
605         ORTHODONTIC TREATMENT MONTHS COUNT                           New as of 10/04
606         PAID FROM PART A MEDICARE TRUST FUND AMOUNT                  New as of 10/04
607         PAID FROM PART B MEDICARE TRUST FUND AMOUNT                  New as of 10/04
608         PAID SERVICE UNIT COUNT                                      New as of 10/04
609         PARTICIPATION AGREEMENT                                      New as of 10/04




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                             NOTES
610         PATIENT DISCHARGE FACILITY TYPE CODE                        New   as   of   10/04
611         PEER REVIEW AUTHORIZATION NUMBER                            New   as   of   10/04
612         PER DAY LIMIT AMOUNT                                        New   as   of   10/04
613         PHYSICIAN CONTACT DATE                                      New   as   of   10/04
614         PHYSICIAN ORDER DATE                                        New   as   of   10/04
615         POLICY COMPLIANCE CODE                                      New   as   of   10/04
616         POLICY NAME                                                 New   as   of   10/04
617         POSTAGE CLAIMED AMOUNT                                      New   as   of   10/04
618         PPS-CAPITAL DSH DRG AMOUNT                                  New   as   of   10/04
619         PPS-CAPITAL EXCEPTION AMOUNT                                New   as   of   10/04
620         PPS-CAPITAL FSP DRG AMOUNT                                  New   as   of   10/04
621         PPS-CAPITAL HSP DRG AMOUNT                                  New   as   of   10/04
622         PPS-CAPITAL IME AMOUNT                                      New   as   of   10/04
623         PPS-OPERATING FEDERAL SPECIFIC DRG AMOUNT                   New   as   of   10/04
624         PPS-OPERATING HOSPITAL SPECIFIC DRG AMOUNT                  New   as   of   10/04
625         PREDETERMINATION OF BENEFITS IDENTIFIER                     New   as   of   10/04
626         PREGNANCY INDICATOR                                         New   as   of   10/04
627         PRE-TAX CLAIM AMOUNT                                        New   as   of   10/04
628         PRICING METHODOLOGY                                         New   as   of   10/04
629         PROPERTY CASUALTY CLAIM NUMBER                              New   as   of   10/04
630         REFERRING CLIA NUMBER                                       New   as   of   10/04
631         REIMBURSEMENT RATE                                          New   as   of   10/04
632         REJECT REASON CODE                                          New   as   of   10/04
633         RELATED CAUSES CODE                                         New   as   of   10/04
634         REMARK CODE                                                 New   as   of   10/04
635         REPRICED APPROVED AMBULATORY PATIENT GROUP                  New   as   of   10/04
636         REPRICED LINE ITEM REFERENCE NUMBER                         New   as   of   10/04
637         REPRICED SAVING AMOUNT                                      New   as   of   10/04
638         REPRICING PER DIEM OR FLAT RATE AMOUNT                      New   as   of   10/04
639         RESPONSIBILITY AMOUNT                                       New   as   of   10/04
640         SALES TAX AMOUNT                                            New   as   of   10/04
641         SERVICE ADJUDICATION OR PAYMENT DATE                        New   as   of   10/04
642         SERVICE AUTHORIZATION EXCEPTION CODE                        New   as   of   10/04
643         SERVICE LINE PAID AMOUNT                                    New   as   of   10/04
644         SERVICE LINE RATE                                           New   as   of   10/04
645         SERVICE TAX AMOUNT                                          New   as   of   10/04
646         SHIP, DELIVERY OR CALENDAR PATTERN CODE                     New   as   of   10/04
647         SHIPPED DATE                                                New   as   of   10/04
648         SIMILAR ILLNESS OR SYMPTOM DATE                             New   as   of   10/04
649         SKILLED NURSING FACILITY INDICATOR                          New   as   of   10/04
650         SPECIAL PROGRAM INDICATOR                                   New   as   of   10/04




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
651         STATE INDUSTRIAL ACCIDENT PROVIDER NUMBER                      New   as   of   10/04
652         TERMS DISCOUNT PERCENTAGE                                      New   as   of   10/04
653         TEST PERFORMED DATE                                            New   as   of   10/04
654         TOTAL DENIED CHARGE AMOUNT                                     New   as   of   10/04
655         TOTAL MEDICARE PAID AMOUNT                                     New   as   of   10/04
656         TOTAL VISITS PROJECTED THIS CERTIFICATION COUNT                New   as   of   10/04
657         TOTAL VISITS RENDERED COUNT                                    New   as   of   10/04
658         TREATMENT CODE                                                 New   as   of   10/04
659         UNIT OR BASIS FOR MEASUREMENT CODE                             New   as   of   10/04
660         UNIVERSAL PRODUCT NUMBER                                       New   as   of   10/04
661         VISITS PRIOR TO RECERTIFICATION DATE COUNT CR702               New   as   of   10/04
662         X-RAY AVAILABILITY INDICATOR                                   New   as   of   10/04
663         ENTITY'S GROUP NAME                                            New   as   of   10/04
664         ORTHODONTIC BANDING DATE                                       New   as   of   10/04
665         SURGERY DATE                                                   New   as   of   10/04
666         SURGICAL PROCEDURE CODE                                        New   as   of   10/04
            REAL-TIME REQUESTS NOT SUPPORTED BY THE INFORMATION HOLDER,
667         DO NOT RESUBMIT                                                New as of 02/28/05

668         MISSING ENDODONTICS TREATMENT HISTORY AND PROGNOSIS.           New as of 06/30/05
669         DENTAL SERVICE NARRATIVE NEEDED.                               New as of 10/31/05


            FUNDS APPLIED FROM A CONSUMER SPENDING ACCOUNT SUCH AS
            CONSUMER DIRECTED/DRIVEN HEALTH PLAN (CDHP), HEALTH SAVING
670         ACCOUNT (H S A) AND OR OTHER SIMILAR ACCOUNTS                  New as of 06/30/06


            FUNDS MAY BE AVAILABLE FROM A CONSUMER SPENDING ACCOUNT SUCH
            AS CONSUMER DIRECTED/DRIVEN HEALTH PLAN (CDHP), HEALTH
671         SAVINGS ACCOUNT (H S A) AND OR OTHER SIMILAR ACCOUNTS          New   as   of   06/30/06
672         OTHER PAYER'S PAYMENT INFORMATION IS OUT OF BALANCE            New   as   of   10/31/06
673         PATIENT REASON FOR VISIT                                       New   as   of   10/31/06
674         AUTHORIZATION EXCEEDED                                         New   as   of   10/31/06
675         FACILITY ADMISSION THROUGH DISCHARGE DATES                     New   as   of   10/31/06
676         ENTITY POSSIBLY COMPENSATED BY FACILITY                        New   as   of   10/31/06
677         ENTITY NOT AFFILIATED                                          New   as   of   10/31/06
678         REVENUE CODE AND PATIENT GENDER MISMATCH                       New   as   of   10/31/06
679         SUBMIT NEWBORN SERVICES ON MOTHER'S CLAIM                      New   as   of   10/31/06
680         ENTITY'S COUNTRY                                               New   as   of   10/31/06
681         CLAIM CURRENCY NOT SUPPORTED                                   New   as   of   10/31/06
682         COSMETIC PROCEDURE                                             New   as   of   02/28/07
683         AWAITING ASSOCIATED HOSPITAL CLAIMS                            New   as   of   02/28/07




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277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

            REJECTED. SYNTAX ERROR NOTED FOR THIS CLAIM/SERVICE/INQUIRY.
             SEE FUNCTIONAL OR IMPLEMENTATION ACKNOWLEDGEMENT FOR
            DETAILS. (NOTE: ONLY FOR USE TO REJECT CLAIMS OR STATUS
            REQUESTS IN TRANSACTIONS THAT WERE 'ACCEPTED WITH ERRORS' ON
684         A 997 OR 999 ACKNOWLEDGEMENT.)                                 New as of 11/05/07

            CLAIM COULD NOT COMPLETE ADJUDICATION IN REAL TIME. CLAIM
685         WILL CONTINUE PROCESSING IN A BATCH MODE. DO NOT RESUBMIT.     New as of 01/27/08
            THE CLAIM/ENCOUNTER HAS COMPLETED THE ADJUDICATION CYCLE AND
686         THE ENTIRE CLAIM HAS BEEN VOIDED.                              New as of 01/27/08
            CLAIM ESTIMATION CAN NOT BE COMPLETETED IN REAL TIME. DO NOT
687         RESUBMIT.                                                      New as of 01/27/08
            PRESENT ON ADMISSION INDICATOR FOR REPORTED DIAGNOSIS
688         CODE(S).                                                       New as of 01/27/08




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                                    835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                       NOTES
1           DEDUCTIBLE AMOUNT.
2           COINSURANCE AMOUNT.
3           CO-PAYMENT AMOUNT.
            THE PROCEDURE CODE IS INCONSISTENT WITH THE MODIFIER USED OR
4           A REQUIRED MODIFIER IS MISSING.
            THE PROCEDURE CODE/BILL TYPE IS INCONSISTENT WITH THE PLACE
5           OF SERVICE.
            THE PROCEDURE/REVENUE CODE IS INCONSISTENT WITH THE
6           PATIENT'S AGE.                                                  Changed as of 6/02
            THE PROCEDURE/REVENUE CODE IS INCONSISTENT WITH THE
7           PATIENT'S GENDER.                                               Changed as of 6/02
            THE PROCEDURE CODE IS INCONSISTENT WITH THE PROVIDER
8           TYPE/SPECIALTY (TAXONOMY).                                      Changed as of 6/02

9           THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE.

10          THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S GENDER.        Changed as of 2/00
11          THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE.

12          THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER TYPE.
13          THE DATE OF DEATH PRECEDES THE DATE OF SERVICE.
14          THE DATE OF BIRTH FOLLOWS THE DATE OF SERVICE.
            THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT
15          APPLY TO THE BILLED SERVICES OR PROVIDER.                       Changed as of 4/1/08.



                                                                            Changed as of 2/02, at
                                                                            least one remark code
            CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR             or NCPDP reject reason
16          ADJUDICATION.                                                   code must be provided.



                                                                            Modified. 4/1/08. At
                                                                            least one Remittance
                                                                            Advice Remark Code or
            REQUESTED INFORMATION WAS NOT PROVIDED OR WAS                   NCPDP Reject Reason
17          INSUFFICIENT/INCOMPLETE.                                        Code must be provided.
18          DUPLICATE CLAIM/SERVICE.
            THIS IS A WORK-RELATED INJURY/ILLNESS AND THUS THE LIABILITY
19          OF THE WORKER'S COMPENSATION CARRIER.                           Changed as of 4/1/08.

20          THIS INJURY/ILLNESS IS COVERED BY THE LIABILITY CARRIER.        Changed as of 4/1/08.

21          THIS INJURY/ILLNESS IS THE LIABILITY OF THE NO-FAULT CARRIER. Changed as of 4/1/08.
            THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COORDINATION
22          OF BENEFITS.                                                    Changed as of 4/1/08.
            THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS
23          AND/OR ADJUSTMENTS.                                             Changed as of 4/1/08.
            CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED
24          CARE PLAN.                                                      Changed as of 4/1/08.

25          PAYMENT DENIED.   YOUR STOP LOSS DEDUCTIBLE HAS NOT BEEN MET.   Inactive as of 4/1/08.
26          EXPENSES INCURRED PRIOR TO COVERAGE.




6/16/2011                                     Page 23
                                      835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
27          EXPENSES INCURRED AFTER COVERAGE TERMINATED.


                                                                           Inactive for 004010,
                                                                           since 6/98. Redundant
28          COVERAGE NOT IN EFFECT AT THE TIME THE SERVICE WAS PROVIDED.   to codes 26 & 27.
29          THE TIME LIMIT FOR FILING HAS EXPIRED.
            PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE
            REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY
30          REQUIREMENTS.                                                  Inactive as of 2/1/06.

31          PATIENT CANNOT BE IDENTIFIED AS OUR INSURED.                   Changed as of 4/1/08.
            OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE
32          DEPENDENT AS DEFINED.

33          INSURED HAS NO DEPENDENT COVERAGE.                             Changed as of 4/1/08.

34          INSURED HAS NO COVERAGE FOR NEWBORNS.                          Changed as of 4/1/08.
35          LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED.
                                                                           Inactive as of
36          BALANCE DOES NOT EXCEED CO-PAYMENT AMOUNT.                     10/16/03.
                                                                           Inactive as of
37          BALANCE DOES NOT EXCEED DEDUCTIBLE.                            10/16/03.
            SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED
38          (NETWORK/PRIMARY CARE) PROVIDERS.                              Changed as of 6/03
            SERVICES DENIED AT THE TIME AUTHORIZATION/PRE-CERTIFICATION
39          WAS REQUESTED.

40          CHARGES DO NOT MEET QUALIFICATIONS FOR EMERGENT/URGENT CARE.
                                                                           Inactive as of
41          DISCOUNT AGREED TO IN PREFERRED PROVIDER CONTRACT.             10/16/03.
                                                                           Inactive as of
                                                                           10/31/06. Use reason
42          CHARGES EXCEED OUR FEE SCHEDULE OR MAXIMUM ALLOWABLE AMOUNT.   code 45.

43          GRAMM-RUDMAN REDUCTION.                                        Inactive as of 7/1/06.
44          PROMPT-PAY DISCOUNT.
            CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR
            CONTRACTED/LEGISLATED FEE ARRANGMENT. (USE GROUPE CODES PR
45          OR CO DEPENDING ON LIABILITY).                                 Modified. 10/31/06.

                                                                           Inactive as of
46          THIS (THESE) SERVICE(S) IS (ARE) NOT COVERED.                  10/16/03. Use code 96.
            THIS (THESE) DIAGNOSIS(ES) IS (ARE) NOT COVERED, MISSING, OR
47          ARE INVALID.                                                   Inactive as of 2/1/06.

                                                                           Inactive as of
48          THIS (THESE) PROCEDURE(S) IS (ARE) NOT COVERED.                10/16/03. Use code 96.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS A ROUTINE
            EXAM OR SCREENING PROCEDURE DONE IN CONJUNCTION WITH A
49          ROUTINE EXAM.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A
50          'MEDICAL NECESSITY' BY THE PAYER.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS A PRE-
51          EXISTING CONDITION.



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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES

            THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE
52          TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED.           Inactive as of 02/1/06.
            SERVICES BY AN IMMEDIATE RELATIVE OR A MEMBER OF THE SAME
53          HOUSEHOLD ARE NOT COVERED.

54          MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN THIS CASE.
            PROCEDURE/TREATMENT IS DEEMED EXPERIMENTAL/INVESTIGATIONAL
55          BY THE PAYER.                                                  Changed as of 4/1/08.
            PROCEDURE/TREATMENT HAS NOT BEEN DEEMED 'PROVEN TO BE
56          EFFECTIVE' BY THE PAYER.                                       Changed as of 4/1/08.


            PAYMENT DENIED/REDUCED BECAUSE THE PAYER DEEMS THE             Inactive as of
            INFORMATION SUBMITTED DOES NOT SUPPORT THIS LEVEL OF           6/30/07. Split into
            SERVICE, THIS MANY SERVICES, THIS LENGTH OF SERVICE, THIS      codes 150, 151, 152,
57          DOSAGE, OR THIS DAY'S SUPPLY.                                  153 and 154.

            TREATMENT WAS DEEMED BY THE PAYER TO HAVE BEEN RENDERED IN
58          AN INAPPROPRIATE OR INVALID PLACE OF SERVICE.                  Changed as of 4/1/08.
            PROCESSED BASED ON MULTIPLE OR CONCURRENT PROCEDURE RULES.
            (FOR EXAMPLE MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
59          CONCURRENT ANESTHESIA.)                                        Changed as of 4/1/08.
            CHARGES FOR OUTPATIENT SERVICES WITH THIS PROXIMITY TO
60          INPATIENT SERVICES ARE NOT COVERED.

61          PENALTY FOR FAILURE TO OBTAIN SECOND SURGICAL OPINION.         Changed as of 4/1/08.
            PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-
62          CERTIFICATION/AUTHORIZATION.                                   Inactive as of 4/1/07.
                                                                           Inactive as of
63          CORRECTION TO A PRIOR CLAIM.                                   10/16/03.
                                                                           Inactive as of
64          DENIAL REVERSED PER MEDICAL REVIEW.                            10/16/03.
            PROCEDURE CODE WAS INCORRECT.   THIS PAYMENT REFLECTS THE      Inactive as of
65          CORRECT CODE.                                                  10/16/03.
66          BLOOD DEDUCTIBLE.
                                                                           Inactive as of
67          LIFETIME RESERVE DAYS. (HANDLED IN QTY, QTY01=LA)              10/16/03.
                                                                           Inactive as of
68          DRG WEIGHT.   (HANDLED IN CLP12)                               10/16/03.
69          DAY OUTLIER AMOUNT.

70          COST OUTLIER - ADJUSTMENT TO COMPENSATE FOR ADDITIONAL COSTS. Changed as of 6/01

                                                                           Deleted as of 6/30/00.
71          PRIMARY PAYER AMOUNT.                                           Use code 23.
                                                                           Inactive as of
72          COINSURANCE DAY.    (HANDLED IN QTY, QTY01=CD)                 10/16/03.
                                                                           Inactive as of
73          ADMINISTRATIVE DAYS.                                           10/16/03.
74          INDIRECT MEDICAL EDUCATION ADJUSTMENT.
75          DIRECT MEDICAL EDUCATION ADJUSTMENT.
76          DISPROPORTIONATE SHARE ADJUSTMENT.
                                                                           Inactive as of
77          COVERED DAYS.   (HANDLED IN QTY, QTY01=CA)                     10/16/03.



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                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
78          NON-COVERED DAYS/ROOM CHARGE ADJUSTMENT.
                                                                           Inactive as of
79          COST REPORT DAYS.   (HANDLED IN MIA15)                         10/16/03.
                                                                           Inactive as of
80          OUTLIER DAYS.   (HANDLED IN QTY, QTY01=OU)                     10/16/03.
                                                                           Inactive as of
81          DISCHARGES.                                                    10/16/03.
                                                                           Inactive as of
82          PIP DAYS.                                                      10/16/03.
                                                                           Inactive as of
83          TOTAL VISITS.                                                  10/16/03.
                                                                           Inactive as of
84          CAPITAL ADJUSTMENT.   (HANDLED IN MIA)                         10/16/03.

85          PATIENT INTEREST ADJUSTMENT (USE ONLY GROUP CODE PR)           Modified as of 7/9/07.


                                                                           Inactive as of
                                                                           10/16/03. Duplicative
86          STATUTORY ADJUSTMENT.                                          of code 45.
87          TRANSFER AMOUNT.
            ADJUSTMENT AMOUNT REPRESENTS COLLECTION AGAINST RECEIVABLE
88          CREATED IN PRIOR OVERPAYMENT.                                  Inactive as of 6/30/07.
89          PROFESSIONAL FEES REMOVED FROM CHARGES.
90          INGREDIENT COST ADJUSTMENT.
91          DISPENSING FEE ADJUSTMENT.
                                                                           Inactive as of
92          CLAIM PAID IN FULL.                                            10/16/03.


                                                                           Inactive as of
                                                                           10/16/03. In 004010,
                                                                           CAS at the claim level
93          NO CLAIM LEVEL ADJUSTMENTS.                                    is optional.
94          PROCESSED IN EXCESS OF CHARGES.

95          PLAN PROCEDURES NOT FOLLOWED.                                  Modified as of 4/1/08.
                                                                           At least one
                                                                           Remittance Advice
                                                                           Remark Code or NCPDP
                                                                           Reject Reason Code
96          NON-COVERED CHARGE(S).                                         must be provided.
            THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE
            PAYMENT/ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE THAT HAS
97          ALREADY BEEN ADJUDICATED.                                      Modified as of 4/1/08.
            THE HOSPITAL MUST FILE THE MEDICARE CLAIM FOR THIS INPATIENT   Inactive as of
98          NON-PHYSICIAN SERVICE.                                         10/16/03.
                                                                           Inactive as of
99          MEDICARE SECONDARY PAYER ADJUSTMENT AMOUNT.                    10/16/03.

100         PAYMENT MADE TO PATIENT/INSURED/RESPONSIBLE PARTY/EMPLOYER.    Modified as of 1/27/08.
            PREDETERMINATION: ANTICIPATED PAYMENT UPON COMPLETION OF
101         SERVICES OR CLAIM ADJUDICATION.                                Changed as of 2/99
102         MAJOR MEDICAL ADJUSTMENT.




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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            PROVIDER PROMOTIONAL DISCOUNT (E.G., SENIOR CITIZEN
103         DISCOUNT).                                                     Changed as of 6/01
104         MANAGED CARE WITHHOLDING.
105         TAX WITHHOLDING.
106         PATIENT PAYMENT OPTION/ELECTION NOT IN EFFECT.
            THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT IDENTIFIED
107         ON THIS CLAIM.                                                 Changed as of 9/30/07.

108         RENT/PURCHASE GUIDELINES WERE NOT MET.                         Changed as of 9/30/07.

            CLAIM NOT COVERED BY THIS PAYER/CONTRACTOR.   YOU MUST SEND
109         THE CLAIM TO THE CORRECT PAYER/CONTRACTOR.
110         BILLING DATE PREDATES SERVICE DATE.
111         NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT.
            SERVICE NOT FURNISHED DIRECTLY TO THE PATIENT AND/OR NOT
112         DOCUMENTED.                                                    Modified as of 4/1/08.


                                                                           Changed as of 2/01;
                                                                           Inactive as of
            PAYMENT DENIED BECAUSE SERVICE/PROCEDURE WAS PROVIDED          6/30/07. Use codes
113         OUTSIDE THE UNITED STATES OR AS A RESULT OF WAR.               157, 158 or 159.
            PROCEDURE/PRODUCT NOT APPROVED BY THE FOOD AND DRUG
114         ADMINISTRATION.

115         PROCEDURE POSTPONED, CANCELED, OR DELAYED.                     Modified as of 4/1/08.
            THE ADVANCE INDEMNIFICATION NOTICE SIGNED BY THE PATIENT DID
116         NOT COMPLY WITH REQUIREMENTS.                                  Modified as of 4/1/08.
            TRANSPORTATION IS ONLY COVERED TO THE CLOSEST FACILITY THAT
117         CAN PROVIDE THE NECESSARY CARE.                                Modified as of 4/1/08.

118         ESRD NETWORK SUPPORT ADJUSTMENT.                               Modified as of 4/1/08.
            BENEFIT MAXIMUM FOR THE TIME PERIOD OR OCCURRENCE HAS BEEN
119         REACHED.                                                       Changed as of 2/04

                                                                           Inactive as of
120         PATIENT IS COVERED BY A MANAGED CARE PLAN.                     6/30/07. Use code 24.
            INDEMNIFICATION ADJUSTMENT - COMPENSATION FOR OUTSTANDING
121         MEMBER RESPONSIBILITY.                                         Modified as of 4/1/08.
122         PSYCHIATRIC REDUCTION.


                                                                           Inactive as of
                                                                           6/30/07. Refer to
                                                                           implementation guide
                                                                           for proper handling of
123         PAYER REFUND DUE TO OVERPAYMENT.                               reversals.


                                                                           Inactive as of
                                                                           6/30/07. Refer to
                                                                           implementation guide
                                                                           for proper handling of
124         PAYER REFUND AMOUNT - NOT OUR PATIENT.                         reversals.




6/16/2011                                      Page 27
                                    835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES


                                                                           Modified. 4/1/08. At
                                                                           least one Remittance
                                                                           Advice Remark Code or
                                                                           NCPDP Reject Reason
125         SUBMISSION/BILLING ERROR(S).                                   Code must be provided.
                                                                           Inactive as of 4/1/08.
                                                                            Use group code PR and
126         DEDUCTIBLE -- MAJOR MEDICAL.                                   code 1.
                                                                           Inactive as of 4/1/08.
                                                                            Use group code PR and
127         COINSURANCE -- MAJOR MEDICAL                                   code 2.

128         NEWBORN'S SERVICES ARE COVERED IN THE MOTHER'S ALLOWANCE.      New as of 2/97

129         PRIOR PROCESSING INFORMATION APPEARS INCORRECT.                Modified as of 4/1/08.
130         CLAIM SUBMISSION FEE.                                          Changed as of 6/01
131         CLAIM SPECIFIC NEGOTIATED DISCOUNT.                            New as of 2/97
132         PREARRANGED DEMONSTRATION PROJECT ADJUSTMENT.                  New as of 2/97
            THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER
133         REVIEW.                                                        Changed as of 10/99
134         TECHNICAL FEES REMOVED FROM CHARGES.                           New as of 10/98

135         INTERIM BILLS CANNOT BE PROCESSED.                             Modified as of 4/1/08.
            FAILURE TO FOLLOW PRIOR PAYER'S COVERAGE RULES. (USE GROUP
136         CODE OA).                                                      Modified as of 9/30/07.
            REGULATORY SURCHARGES, ASSESSMENTS, ALLOWANCES OR HEALTH
137         RELATED TAXES.                                                 Modified as of 4/1/08.

138         APPEAL PROCEDURES NOT FOLLOWED OR TIME LIMITS NOT MET.         Modified as of 4/1/08.
            CONTRACTED FUNDING AGREEMENT - SUBSCRIBER IS EMPLOYED BY THE
139         PROVIDER OF SERVICES.                                          New as of 6/99
            PATIENT/INSURED HEALTH IDENTIFICATION NUMBER AND NAME DO NOT
140         MATCH.                                                         New as of 6/99

141         CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE.       Modified as of 4/1/08.

142         MONTHLY MEDICAID PATIENT LIABILITY AMOUNT.                     Modified as of 4/1/08.
143         PORTION OF PAYMENT DEFERRED.                                   New as of 2/01

144         INCENTIVE ADJUSTMENTS, E.G. PREFERRED PRODUCT/SERVICE.         New as of 6/01


                                                                           Deactivated as of
                                                                           4/1/08. Use group code
145         PREMIUM PAYMENT WITHHOLDING.                                   CO and code 45.

146         DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED.     Modified as of 4/1/08.

147         PROVIDER CONTRACTED/NEGOTIATED RATE EXPIRED OR NOT ON FILE.    New as of 6/02
            INFORMATION FROM ANOTHER PROVIDER WAS NOT PROVIDED OR WAS
148         INSUFFICIENT/INCOMPLETE.                                       Modified as of 4/1/08.
            LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED FOR THIS
149         SERVICE/BENEFIT CATEGORY.                                      New as of 10/02



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                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
150         LEVEL OF SERVICE.                                              Modified as of 4/1/08.

            PAYMENT ADJUSTED BECAUSE THE PAYER DEEMS THE INFORMATION
151         SUBMITTED DOES NOT SUPPORT THIS MANY/FREQUENCY OF SERVICES.    Changed as of 1/27/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
152         LENGTH OF SERVICE.                                             Modified as of 4/1/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
153         DOSAGE.                                                        Modified as of 4/1/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
154         DAY'S SUPPLY.                                                  Modified as of 4/1/08.

155         PATIENT REFUSED THE SERVICE/PROCEDURE.                         Modified as of 4/1/08.
156         FLEXIBLE SPENDING ACCOUNT PAYMENTS.                            New as of 9/03

157         SERVICE/PROCEDURE WAS PROVIDED AS A RESULT OF AN ACT OF WAR.   Modified as of 4/1/08.

158         SERVICE/PROCEDURE WAS PROVIDED OUTSIDE OF THE UNITED STATES.   Modified as of 4/1/08.

159         SERVICE/PROCEDURE WAS PROVIDED AS A RESULT OF TERRORISM.       Modified as of 4/1/08.
            INJURY/ILLNESS WAS THE RESULT OF AN ACTIVITY THAT IS A
160         BENEFIT EXCLUSION.                                             Modified as of 4/1/08.
161         PROVIDER PERFORMANCE BONUS.                                    New as of 2/04

            STATE-MANDATED REQUIREMENT FOR PROPERTY AND CASUALTY, SEE
162         CLAIM PAYMENT REMARKS CODE FOR SPECIFIC EXPLANATION.           New as of 2/04

163         ATTACHMENT REFERENCED ON THE CLAIM WAS NOT RECEIVED.           Modified as of 4/1/08.
            ATTACHMENT REFERENCED ON THE CLAIM WAS NOT RECEIVED IN A
164         TIMELY FASHION.                                                Modified as of 4/1/08.

165         REFERRAL ABSENT OR EXCEEDED.                                   Modified as of 4/1/08.

            THESE SERVICES WERE SUBMITTED AFTER THIS PAYERS
166         RESPONSIBILITY FOR PROCESSING CLAIMS UNDER THIS PLAN ENDED.    New as of 2/28/05
167         THIS (THESE) DIANOSIS(ES) IS (ARE) NOT COVERED.                New as of 6/30/05.

            SERVICE(S) HAVE BEEN CONSIDERED UNDER THE PATIENT'S MEDICAL
168         PLAN. BENEFITS ARE NOT AVAILABLE UNDER THIS DENTAL PLAN.       Modified 4/1/08.
169         ALTERNATE BENEFIT HAS BEEN PROVIDED.                           Modified 4/1/08.
            PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF
170         PROVIDER.                                                      New as of 6/30/05.
            PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF
171         PROVIDER IN THIS TYPE OF FACILITY.                             New as of 6/30/05.
            PAYMENT IS ADJUSTED WHEN PERFORMED/BILLED BY A PROVIDER OF
172         THIS SPECIALTY.                                                New as of 6/30/05.
173         SERVICE WAS NOT PRESCRIBED BY A PHYSICIAN.                     Modified 4/1/08.
174         SERVICE WAS NOT PRESCRIBED PRIOR TO DELIVERY.                  Modified 4/1/08.
175         PRESCRIPTION IS INCOMPLETE.                                    Modified 4/1/08.
176         PRESCRIPTION IS NOT CURRENT.                                   Modified 4/1/08.

177         PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY REQUIREMENTS.     Modified 4/1/08.




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                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES

178         PATIENT HAS NOT MET THE REQUIRED SPEND DOWN REQUIREMENTS.      Modified 4/1/08.

179         PATIENT HAS NOT MET THE REQUIRED WAITING REQUIREMENTS.         Modified 4/1/08.

180         PATIENT HAS NOT MET THE REQUIRED RESIDENCY REQUIREMENTS.       Modified 4/1/08.
181         PROCEDURE CODE WAS INVALID ON THE DATE OF SERVICE.             Modified 4/1/08.

182         PROCEDURE MODIFIER WAS INVALID ON THE DATE OF SERVICE.         Modified 4/1/08.
            THE REFERRING PROVIDER IS NOT ELIGIBLE TO REFER THE SERVICE
183         BILLED.                                                        New as of 6/30/05.
            THE PRESCRIBING/ORDERING PROVIDER IS NOT ELIGIBLE TO
184         PRESCRIBE/ORDER THE SERVICE BILLED.                            New as of 6/30/05.
            THE RENDERING PROVIDER IS NOT ELIGIBILE TO PERFORM THE
185         SERVICE BILLED.                                                New as of 6/30/05.

186         LEVEL OF CARE CHANGE ADJUSTMENT.                               Modified as of 9/30/07.
187         HEALTH SAVINGS ACCOUNT PAYMENTS.                               New as of 6/30/05.
            THIS PRODUCT/PROCEDURE IS ONLY COVERED WHEN USED ACCORDING
188         TO FDA RECOMMENDATIONS.                                        New as of 6/30/05.
            NOT OTHERWISE CLASSIFIED' OR 'UNLISTED' PROCEDURE CODE
            (CPT/HCPCS) WAS BILLED WHEN THERE IS A SPECIFIC PROCEDURE
189         CODE FOR THIS PROCEDURE/SERVICE.                               New as of 6/30/05.
            PAYMENT IS INCLUDED IN THE ALLOWANCE FOR A SKILLED NURSING
190         FACILITY (SNF) QUALIFIED STAY.                                 New as of 10/31/05.
            NOT A WORK RELATED INJURY/ILLNESS AND THUS NOT THE LIABILITY
191         OF THE WORKERS' COMPENSATION CARRIER.                          Modified 4/1/08.




                                                                           Modified 4/1/08. This
                                                                           code is only used when
                                                                           the non-standard code
                                                                           cannot be reasonably
                                                                           mapped to an existing
                                                                           Claims Adjustment
                                                                           Reason Code,
            NON STANDARD ADJUSTMENT CODE FROM PAPER REMITTANCE. NOTE:      specifically
            THIS CODE IS TO BE USED BY PROVIDERS/PAYERS PROVIDING          Deductible,
            COORDINATION OF BENEFITS INFORMATION TO ANOTHER RPAYER IN      Coinsurance and Co-
192         THE 837 TRANSACTION ONLY.                                      payment.

            ORIGINAL PAYMENT DECISION IS BEING MAINTAINED. UPON REVIEW,
193         IT WAS DETERMINED THAT THIS CLAIM WAS PROCESSED PROPERLY.      Modified as of 1/27/08.
            ANESTHESIA PERFORMED BY THE OPERATING PHYSICIAN, THE
194         ASSISTANT SURGEON OR THE ATTENDING PHYSICIAN.                  Modified 4/1/08.
            REFUND ISSUED TO AN ERRONEOUS PRIORITY PAYER FOR THIS
195         CLAIM/SERVICE.                                                 Modified 4/1/08.

            CLAIM/SERVICE DENIED BASED ON PRIOR PAYER'S COVERAGE           Deactivated as of
196         DETERMINATION.                                                 2/1/07. Use code 136
197         PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT.            Modified 4/1/08.
198         PRECERTIFICATION/AUTHORIZATION EXCEEDED.                       Modified 4/1/08.
199         REVENUE CODE AND PROCEDURE CODE DO NOT MATCH.                  New as of 10/31/06




6/16/2011                                      Page 30
                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
200         EXPENSES INCURRED DURING LAPSE IN COVERAGE.                    New as of 10/31/06


            WORKERS COMPENSATION CASE SETTLED. PATIENT IS RESPONSIBLE
            FOR AMOUNT OF THIS CLAIM/SERVICE THROUGH WC 'MEDICARE SET
201         ASIDE ARRANGEMENT' OR OTHER AGREEMENT. (USE GROUP CODE PR).    New as of 10/31/06

202         NON-COVERED PERSONAL COMFORT OR CONVENIENCE SERVICES.          Modified 4/1/08.
203         DISCONTINUED OR REDUCED SERVICE.                               Modified 4/1/08.
            THIS SERVICE/EQUIPMENT/DRUG IS NOT COVERED UNDER THE
204         PATIENT'S CURRENT BENEFIT PLAN.                                New as of 2/28/07
205         PHARMACY DISCOUNT CARD PROCESSING FEE.                         New as of 7/9/07
206         NATIONAL PROVIDER IDENTIFIER - MISSING.                        Modified 4/1/08.
                                                                           Deactivated as of
207         NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT.                 5/23/08.
208         NATIONAL PROVIDER IDENTIFIER - NOT MATCHED.                    Modified 4/1/08.


            PER REGULATORY OR OTHER AGREEMENT. THE PROVIDER CANNOT
            COLLECT THIS AMOUNT FROM THE PATIENT. HOWEVER, THIS AMOUNT
            MAY BE BILLED TO SUBSEQUENT PAYER. REFUND TO PATIENT IF
209         COLLECTED. (USE GROUP CODE OA).                                New as of 7/9/07.

            PAYMENT ADJUSTED BECAUSE PRE-CERTIFICATION/AUTHORIZATION NOT
210         RECEIVED IN A TIMELY FASHION.                                  New as of 7/9/07.
            NATIONAL DRUG CODES (NDC) NOT ELIGIBLE FOR REBATE, ARE NOT
211         COVERED.                                                       New as of 7/9/07.
212         ADMINISTRATIVE SURCHARGES ARE NOT COVERED.                     New as of 11/05/07.
            NON-COMPLIANCE WITH THE PHYSICIAN SELF REFERRAL PROHIBITION
213         LEGISLATION OR PAYER POLICY.                                   New as of 1/27/08.


            WORKERS' COMPENSATION CLAIM ADJUDICATED AS NON-COMPENSABLE.
            THIS PAYER NOT LIABLE FOR CLAIM OR SERVICE/TREATMENT.
214         (NOTE: TO BE USED FOR WORKERS' COMPENSATION ONLY).             New as of 1/27/08.
215         BASED ON SUBROGATION OF A THIRD PARTY SETTLEMENT.              New as of 1/27/08.
216         BASED ON THE FINDINGS OF A REVIEW ORGANIZATION.                New as of 1/27/08.


            BASED ON PAYER REASONABLE AND CUSTOMARY FEES. NO MAXIMUM
            ALLOWABLE DEFINED BY LEGISLATED FEE ARRANGEMENT. (NOTE: TO
217         BE USED FOR WORKERS' COMPENSATION ONLY).                       New as of 1/27/08.
            BASED ON ENTITLEMENT TO BENEFITS (NOTE: TO BE USED FOR
218         WORKERS' COMPENSATION ONLY).                                   New as of 1/27/08.
            BASED ON EXTENT OF INJURY (NOTE: TO BE USED FOR WORKERS'
219         COMPENSATION ONLY).                                            New as of 1/27/08.


            THE APPLICABLE FEE SCHEDULE DOES NOT CONTAIN THE BILLED
            CODE. PLEASE RESUBMIT A BILL WITH THE APPROPRIATE FEE
            SCHEDULE CODE(S) THAT BEST DESCRIBE THE SERVICE(S) PROVIDED
            AND SUPPORTING DOCUMENTATION IF REQUIRED. (NOTE: TO BE USED
220         FOR WORKERS' COMPENSATION ONLY).                               New as of 1/27/08.
            WORKERS' COMPENSATION CLAIM IS UNDER INVESTIGATION. (NOTE:
            TO BE USED FOR WORKERS' COMPENSATION ONLY. CLAIM PENDING
221         FINAL RESOLUTION).                                             New as of 1/27/08.
A0          PATIENT REFUND AMOUNT.




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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                       NOTES

                                                                            At least one
                                                                            Remittance Advice
                                                                            Remark Code or NCPDP
                                                                            Reject Reason Code
A1          CLAIM DENIED CHARGES.                                           must be provided.



                                                                            Inactive as of 1/1/08.
                                                                            Use Code 45 with Group
                                                                            Code 'CO' or use
                                                                            another appropriate
                                                                            specific adjustment
A2          CONTRACTUAL ADJUSTMENT.                                         code.
                                                                            Inactive as of
A3          MEDICARE SECONDARY PAYER LIABILITY MET.                         10/16/03.

A4          MEDICARE CLAIM PPS CAPITAL DAY OUTLIER AMOUNT.                  Inactive as of 4/1/08.
A5          MEDICARE CLAIM PPS CAPITAL COST OUTLIER AMOUNT.

A6          PRIOR HOSPITALIZATION OR 30 DAY TRANSFER REQUIREMENT NOT MET.
A7          PRESUMPTIVE PAYMENT ADJUSTMENT.

A8          UNGROUPABLE DRG.                                                Modified as of 4/1/08.
B1          NON-COVERED VISITS.
                                                                            Inactive as of
B2          COVERED VISITS.                                                 10/16/03.
                                                                            Inactive as of
B3          COVERED CHARGES.                                                10/16/03.
B4          LATE FILING PENALTY.

B5          COVERAGE/PROGRAM GUIDELINES WERE NOT MET OR WERE EXCEEDED.      Modified as of 4/1/08.


            THIS PAYMENT IS ADJUSTED WHEN PERFORMED/BILLED BY THIS TYPE
            OF PROVIDER, BY THIS TYPE OF PROVIDER IN THIS TYPE OF
B6          FACILITY, OR BY A PROVIDER OF THIS SPECIALTY.                   Inactive as of 2/1/06.

            THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
B7          PROCEDURE/SERVICE ON THIS DATE OF SERVICE.                      Changes as of 10/98
            ALTERNATIVE SERVICES WERE AVAILABLE, AND SHOULD HAVE BEEN
B8          UTILIZED.                                                       Modified as of 4/1/08.

B9          PATIENT IS ENROLLED IN A HOSPICE.                               Modified as of 4/1/08.
            ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE
            BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT
            LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC
B10         PROCEDURE/TEST.
            THE CLAIM/SERVICE HAS BEEN TRANSFERRED TO THE PROPER
            PAYER/PROCESSOR FOR PROCESSING. CLAIM/SERVICE NOT COVERED
B11         BY THIS PAYER/PROCESSOR.

B12         SERVICES NOT DOCUMENTED IN PATIENT'S MEDICAL RECORDS.
            PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE
B13         BEEN PROVIDED IN A PREVIOUS PAYMENT.



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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            ONLY ONE VISIT OR CONSULTATION PER PHYSICIAN PER DAY IS
B14         COVERED.                                                       Modified as of 4/1/08.


            THIS SERVICE/PROCEDURE REQUIRES THAT A QUALIFYING
            SERVICE/PROCEDURE BE RECEIVED AND COVERED. THE QUALIFYING
B15         OTHER SERVICE/PROCEDURE HAS NOT BEEN RECEIVED/ADJUDICATED.     Modified as of 4/1/08.

B16         NEW PATIENT' QUALIFICATIONS WERE NOT MET.                      Modified as of 4/1/08.
            PAYMENT ADJUSTED BECAUSE THIS SERVICE WAS NOT PRESCRIBED BY
            A PHYSICIAN, NOT PRESCRIBED PRIOR TO DELIVERY, THE
            PRESCRIPTION IS INCOMPLETE, OR THE PRESCRIPTION IS NOT
B17         CURRENT.                                                       Inactive as of 2/1/06.
            THIS PROCEDURE CODE AND MODIFIER WERE INVALID ON THE DATE OF
B18         SERVICE.                                                       Modified as of 4/1/08.
            CLAIM/SERVICE ADJUSTED BECAUSE OF THE FINDING OF A REVIEW
B19         ORGANIZATION.                                                  Inactive for 10/16/03.
            PROCEDURE/SERVICE WAS PARTIALLY OR FULLY FURNISHED BY
B20         ANOTHER PROVIDER.                                              Modified as of 4/1/08.
            THE CHARGES WERE REDUCED BECAUSE THE SERVICE/CARE WAS
B21         PARTIALLY FURNISHED BY ANOTHER PHYSICIAN.                      Inactive for 10/16/03.
B22         THIS PAYMENT IS ADJUSTED BASED ON THE DIAGNOSIS.               Changed as of 2/01

            PROCEDURE BILLED IS NOT AUTHORIZED PER YOUR CLINICAL
B23         LABORATORY IMPROVEMENT AMENDMENT (CLIA) PROFECIENCY TEST.      Modified as of 4/1/08.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED.   LEVEL OF SUBLUXATION IS MISSING OR     16 and remark codes if
D1          INADEQUATE.                                                    necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM LACKS THE NAME, STRENGTH, OR DOSAGE OF THE DRUG          16 and remark codes if
D2          FURNISHED.                                                     necessary.


                                                                           Inactive for 004010,
            CLAIM/SERVICE DENIED BECAUSE INFORMATION TO INDICATE IF THE    since 2/99. Use code
            PATIENT OWNS THE EQUIPMENT THAT REQUIRES THE PART OR SUPPLY    16 and remark codes if
D3          WAS MISSING.                                                   necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DOES NOT INDICATE THE PERIOD OF TIME FOR WHICH   16 and remark codes if
D4          THIS WILL BE NEEDED.                                           necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED.   CLAIM LACKS INDIVIDUAL LAB CODES       16 and remark codes if
D5          INCLUDED IN THE TEST.                                          necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM DID NOT INCLUDE PATIENT'S          16 and remark codes if
D6          MEDICAL RECORD FOR THE SERVICE.                                necessary.




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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                     NOTES

                                                                          Inactive for 004010,
                                                                          since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM LACKS DATE OF PATIENT'S MOST      16 and remark codes if
D7          RECENT PHYSICIAN VISIT.                                       necessary.


                                                                          Inactive for 004010,
                                                                          since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM LACKS INDICATOR THAT 'X-RAY IS    16 and remark codes if
D8          AVAILABLE FOR REVIEW'.                                        necessary.


                                                                          Inactive for 004010,
            CLAIM/SERVICE DENIED. CLAIM LACKS INVOICE OR STATEMENT        since 2/99. Use code
            CERTIFYING THE ACTUAL COST OF THE LENS, LESS DISCOUNTS OR     16 and remark codes if
D9          THE TYPE OF INTRAOCULAR LENS USED.                            necessary.
                                                                          Inactive for 003070,
            CLAIM/SERVICE DENIED. COMPLETED PHYSICIAN FINANCIAL           since 8/97. Use code
D10         RELATIONSHIP FORM NOT ON FILE.                                17.
                                                                          Inactive for 003070,
                                                                          since 8/97. Use code
D11         CLAIM LACKS COMPLETED PACEMAKER REGISTRATION FORM             17.
            CLAIM/SERVICE DENIED. CLAIM DOES NOT IDENTIFY WHO PERFORMED   Inactive for 003070,
            THE PURCHASED DIAGNOSTIC TEST OR THE AMOUNT YOUR WERE         since 8/97. Use code
D12         CHARGED FOR THE TEST.                                         17.
            CLAIM/SERVICE DENIED. PERFORMED BY A FACILITY/SUPPLIER IN     Inactive for 003070,
            WHICH THE ORDERING/REFERRING PHYSICIAN HAS A FINANCIAL        since 8/97. Use code
D13         INTEREST.                                                     17.
                                                                          Inactive for 003070,
                                                                          since 8/97. Use code
D14         CLAIM LACKS INDICATION THAT PLAN OF TREATMENT IS ON FILE.     17.
                                                                          Inactive for 003070,
            CLAIM LACKS INDICATION THAT SERVICE WAS SUPERVISED OR         since 8/97. Use code
D15         EVALUATED BY A PHYSICIAN.                                     17.


                                                                          Inactive as of version
                                                                          5010. Use code 16
                                                                          with appropriate claim
                                                                          payment remark code
D16         CLAIM LACKS PRIOR PAYER PAYMENT INFORMATION                   [N4].


                                                                          Inactive as of version
                                                                          5010. Use code 16
                                                                          with appropriate claim
                                                                          payment remard code
D17         CLAIM/SERVICE HAS INVALID NON-COVERED DAYS.                   [M32, M33].


                                                                          Inactive as of version
                                                                          5010. use code 16
                                                                          with appropriate claim
                                                                          payment remark code
D18         CLAIM/SERVICE HAS MISSING DIAGNOSIS INFORMATION.              [MA63, MA65].




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835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES


                                                                           Inactive as of version
                                                                           5010. Use code 16
                                                                           with appropriate claim
            CLAIM/SERVICE LACKS PHYSICIAN/OPERATIVE OR OTHER SUPPORTING    payment remark code
D19         DOCUMENTATION.                                                 [M29, M30, M35, M66].



                                                                           Inactive as of version
                                                                           5010. Use code 16
                                                                           with appropriate claim
                                                                           payment remark code
D20         CLAIM/SERVICE MISSING SERVICE/PRODUCT INFORMATION.             [M20, M67, M19, MA67].

D21         THIS (THESE) DIAGNOSIS(ES) IS (ARE) MISSING OR ARE INVALID.    Inactive as of 6/30/07


            REIMBURSEMENT WAS ADJUSTED FOR THE REASONS TO BE PROVIDED IN
            SEPARATE CORRESPONDENCE. (NOTE: TO BE USED FOR WORKERS'
            COMPENSATION ONLY) - TEMPORARY CODE TO BE ADDED FOR
            TIMEFRAME ONLY UNTIL 01/01/2009. ANOTHER CODE TO BE
            ESTABLISHED AND/OR FOR 6/2008 MEETING FOR A REVISED CODE TO    Inactive as of
D22         REPLACE OR STRATEGY TO USE ANOTHER EXISTING CODE.              01/01/09.
W1          WORKERS COMPENSATION STATE FEE SCHEDULE ADJUSTMENT.            New as of 2/00




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            X-RAY NOT TAKEN WITHIN THE PAST 12 MONTHS OR NEAR ENOUGH TO
M1          THE START OF TREATMENT.

M2          NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT.
            EQUIPMENT IS THE SAME OR SIMILAR TO EQUIPMENT ALREADY BEING
M3          USED.
            ALERT: THIS IS THE LAST MONTHLY INSTALLMENT PAYMENT FOR THIS   Modified
M4          DURABLE MEDICAL EQUIPMENT.                                     04/01/07.


            MONTHLY RENTAL PAYMENTS CAN CONTINUE UNTIL THE EARLIER OF
            THE 15TH MONTH FROM THE FIRST RENTAL MONTH, OR THE MONTH
M5          WHEN THE EQUIPMENT IS NO LONGER NEEDED.

            ALERT: YOU MUST FURNISH AND SERVICE THIS ITEM FOR AS LONG AS
            THE PATIENT CONTINUES TO NEED IT. WE CAN PAY FOR
            MAINTENANCE AND/OR SERVICING FOR EVERY 6 MONTH PERIOD AFTER
            THE END OF THE 15TH PAID RENTAL MONTH OR THE END OF THE        Modified
M6          WARRANTY PERIOD.                                               04/01/07.

            NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE
M7          TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE.
            WE DO NOT ACCEPT BLOOD GAS TESTS RESULTS WHEN THE TEST WAS
            CONDUCTED BY A MEDICAL SUPPLIER OR TAKEN WHILE THE PATIENT
M8          IS ON OXYGEN.
            ALERT: THIS IS THE TENTH RENTAL MONTH. YOU MUST OFFER THE
            PATIENT THE CHOICE OF CHANGING THE RENTAL TO A PURCHASE        Modified
M9          AGREEMENT.                                                     04/01/07.
            EQUIPMENT PURCHASES ARE LIMITED TO THE FIRST OR THE TENTH
M10         MONTH OF MEDICAL NECESSITY.

            DME, ORTHOTICS AND PROSTHETICS MUST BE BILLED TO THE DME
M11         CARRIER WHO SERVICES THE PATIENT'S ZIP CODE.

            DIAGNOSTIC TESTS PERFORMED BY A PHYSICIAN MUST INDICATE
M12         WHETHER PURCHASED SERVICES ARE INCLUDED ON THE CLAIM.
            ONLY ONE INITIAL VISIT IS COVERED PER SPECIALTY PER MEDICAL    (Modified
M13         GROUP.                                                         6/30/03)


            NO SEPARATE PAYMENT FOR AN INJECTION ADMINISTERED DURING AN
            OFFICE VISIT, AND NO PAYMENT FOR A FULL OFFICE VISIT IF THE
M14         PATIENT ONLY RECEIVED AN INJECTION.
            SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY
            ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE
M15         PAYMENT IS NOT ALLOWED.

            ALERT: PLEASE SEE OUR WEB SITE, MAILING, OR BULLETINS FOR      Modified
M16         MORE DETAILS CONCERNING THIS POLICY/PROCEDURE/DECISION.        04/01/07.


            ALERT: PAYMENT APPROVED AS YOU DID NOT KNOW, AND COULD NOT
            REASONABLY HAVE BEEN EXPECTED TO KNOW, THAT THIS WOULD NOT
            NORMALLY HAVE BEEN COVERED FOR THIS PATIENT. IN THE FUTURE,
            YOU WILL BE LIABLE FOR CHARGES FOR THE SAME SERVICE(S) UNDER   Modified
M17         THE SAME OR SIMILAR CONDITIONS.                                04/01/07.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            CERTAIN SERVICES MAY BE APPROVED FOR HOME USE. NEITHER A
            HOSPITAL NOR A SKILLED NURSING FACILITY (SNF) IS CONSIDERED    (Modified
M18         TO BE A PATIENT'S HOME.                                        6/30/03)
                                                                           (Modified
M19         MISSING OXYGEN CERTIFICATION/RE-CERTIFICATION.                 2/28/03)
                                                                           (Modified
M20         MISSING/INCOMPLETE/INVALID HCPCS.                              2/28/03)
            MISSING/INCOMPLETE/INVALID PLACE OF RESIDENCE FOR THIS         (Modified
M21         SERVICE/ITEM PROVIDED IN A HOME.                               2/28/03)
                                                                           (Modified
M22         MISSING/INCOMPLETE/INVALID NUMBER OF MILES TRAVELED.           2/28/03)
                                                                           Modified
M23         MISSING INVOICE.                                               08/01/05.
                                                                           (Modified
M24         MISSING/INCOMPLETE/INVALID NUMBER OF DOSES PER VIAL.           2/28/03)




            THE INFORMATION FURNISHED DOES NOT SUBSTANTIATE THE NEED FOR
            THIS LEVEL OF SERVICE. IF YOU BELIEVE THE SERVICE SHOULD
            HAVE BEEN FULLY COVERED AS BILLED, OR IF YOU DID NOT KNOW
            AND COULD NOT REASONABLY HAVE BEEN EXPECTED TO KNOW THAT WE
            WOULD NOT PAY FOR THIS LEVEL OF SERVICE, OR IF YOU NOTIFIED
            THE PATIENT IN WRITING IN ADVANCE THAT WE WOULD NOT PAY FOR
            THIS LEVEL OF SERVICE AND HE/SHE AGREED IN WRITING TO PAY,
            ASK US TO REVIEW YOUR CLAIM WITHIN 120 DAYS OF THE DATE OF
            THIS NOTICE. IF YOU DO NOT REQUEST A APPEAL, WE WILL, UPON     (Modified
            APPLICATION FROM THE PATIENT, REIMBURSE HIM/HER FOR THE        10/1/02,
            AMOUNT YOU HAVE COLLECTED FROM HIM/HER IN EXCESS OF ANY        6/30/03,
            DEDUCTIBLE AND COINSURANCE AMOUNTS. WE WILL RECOVER THE        8/1/05,
M25         REIMBURSEMENT FROM YOU AS AN OVERPAYMENT.                      11/5/07)




            THE INFORMATION FURNISHED DOES NOT SUBSTANTIATE THE NEED FOR
            THIS LEVEL OF SERVICE. IF YOU HAVE COLLECTED ANY AMOUNT
            FROM THE PATIENT FOR THIS LEVEL OF SERVICE/ANY AMOUNT THAT
            EXCEEDS THE LIMITING CHARGE FOR THE LESS EXTENSIVE SERVICE,
            THE LAW REQUIRES YOU TO REFUND THAT AMOUNT TO THE PATIENT
            WITHIN 30 DAYS OF RECEIVING THIS NOTICE. THE REQUIREMENTS
            FOR REFUND ARE IN 1824(I) OF THE SOCIAL SECURITY ACT AND
            42CFR411.408. THE SECTION SPECIFIES THAT PHYSICIANS WHO        (Modified
            KNOWINGLY AND WILLFULLY FAIL TO MAE APPROPRIATE REFUNDS MAY    10/1/02,
            BE SUBJECT TO CIVIL MONETARY PENALTIES AND/OR EXCLUSION FROM   6/30/03,
            THE PROGRAM. IF YOU HAVE ANY QEUSTIONS ABOUT THIS NOTICE,      8/1/05,
M26         PLEASE CONTACT THIS OFFICE.                                    11/5/07)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES



            ALERT: THE PATIENT HAS BEEN RELIEVED OF LIABILITY OF PAYMENT
            OF THESE ITEMS AND SERVICES UNDER THE LIMITATION OF
            LIABILITY PROVISION OF THE LAW. THE PROVIDER IS ULTIMATELY
            LIABLE FOR THE PATIENT'S WAIVED CHARGES, INCLUDING ANY
            CHARGES FOR COINSURANCE, SINCE THE ITEMS OR SERVICES WERE
            NOT REASONABLE AND NECESSARY OR CONSTITUTED CUSTODIAL CARE,
            AND YOU KNEW OR COULD REASONABLY HAVE BEEN EXPECTED TO KNOW,
            THAT THEY WERE NOT COVERED. YOU MAY APPEAL THIS                (Modified
            DETERMINATION AND THE ISSUE OF WHETHER YOU EXERCISED DUE       10/1/02,
            CARE. THE APPEAL REQUEST MUST BE FILED WITHIN 120 DAYS OF      8/1/05,
            THE DATE YOU RECEIVE THIS NOTICE. YOU MUST MAKE THE REQUEST    4/1/07,
M27         THROUGH THIS OFFICE.                                           8/1/07)

            THIS DOES NOT QUALIFY FOR PAYMENT UNDER PART B WHEN PART A
M28         COVERAGE IS EXHAUSTED OR NOT OTHERWISE AVAILABLE.
                                                                           (Modified
M29         MISSING OPERATIVE REPORT.                                      2/28/03)
                                                                           (Modified
M30         MISSING PATHOLOGY REPORT.                                      2/28/03)
                                                                           (Modified
M31         MISSING RADIOLOGY REPORT.                                      2/28/03)


            ALERT: THIS IS A CONDITIONAL PAYMENT MADE PENDING A DECISION
            ON THIS SERVICE BY THE PATIENT'S PRIMARY PAYER. THIS PAYMENT
            MAY BE SUBJECT TO REFUND UPON YOUR RECEIPT OF ANY ADDITIONAL
            PAYMENT FOR THIS SERVICE FROM ANOTHER PAYER. YOU MUST
            CONTACT THIS OFFICE IMMEDIATELY UPON RECEIPT OF AN             Modified
M32         ADDITIONAL PAYMENT FOR THIS SERVICE.                           04/01/07.



                                                                           (Modified
                                                                           2/28/03;
                                                                           Deactivated
            MISSING/INCOMPLETE/INVALID UPIN FOR THE                        eff. 8/1/04.
M33         ORDERING/REFERRING/PERFORMING PROVIDER.                        Refer to M68)


                                                                           (Deactivated
                                                                           eff. 8/1/04.
                                                                           Refer to
M34         CLAIM LACKS THE CLIA CERTIFICATION NUMBER.                     MA120)


                                                                           Deactivated
                                                                           eff.
            MISSING/INCOMPLETE/INVALID PRE-OPERATIVE PHOTOS OR VISUAL      02/05/05.
M35         FIELD RESULTS.                                                 Refer to N178.


            THIS IS THE 11TH RENTAL MONTH. WE CANNOT PAY FOR THIS UNTIL
            YOU INDICATE THAT THE PATIENT HAS BEEN GIVEN THE OPTION OF
M36         CHANGING THE RENTAL TO A PURCHASE.

M37         SERVICE NOT COVERED WHEN THE PATIENT IS UNDER AGE 35.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            THE PATIENT IS LIABLE FOR THE CHARGES FOR THIS SERVICE AS
            YOU INFORMED THE PATIENT IN WRITING BEFORE THE SERVICE WAS
            FURNISHED THAT WE WOULD NOT PAY FOR IT, AND THE PATIENT
M38         AGREED TO PAY.


            ALERT: THE PATIENT IS NOT LIABLE FOR PAYMENT FOR THIS
            SERVICE AS THE ADVANCE NOTICE OF NON-COVERAGE YOU PROVIDED     (Modified
M39         THE PATIENT DID NOT COMPLY WITH PROGRAM REQUIREMENTS.          4/1/07)
            CLAIM MUST BE ASSIGNED AND MUST BE FILED BY THE
M40         PRACTITIONER'S EMPLOYER.
            WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL
M41         OBLIGATION TO PAY FOR THIS.
            THE MEDICAL NECESSITY FORM MUST BE PERSONALLY SIGNED BY THE
M42         ATTENDING PHYSICIAN.


                                                                           (Deactivated
                                                                           eff. 1/31/04.
                                                                           Refer to
            PAYMENT FOR THIS SERVICE PREVIOUSLY ISSUED TO YOU OR ANOTHER   Reason Code
M43         PROVIDER BY ANOTHER CARRIER/INTERMEDIARY.                      23)
                                                                           (Modified
M44         MISSING/INCOMPLETE/INVALID CONDITION CODE.                     2/28/03)
                                                                           (Modified
M45         MISSING/INCOMPLETE/INVALID OCCURRENCE CODES.                   12/02/04)
                                                                           (Modified
M46         MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN CODE.               12/02/04)
            MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL        (Modified
M47         NUMBER.                                                        2/28/03)


            PAYMENT FOR SERVICES FURNISHED TO HOSPITAL INPATIENTS (OTHER
            THAN PROFESSIONAL SERVICES OF PHYSICIANS) CAN ONLY BE MADE     (Deactivated
            TO THE HOSPITAL. YOU MUST REQUEST PAYMENT FROM THE HOSPITAL    eff. 1/31/04.
M48         RATHER THAN THE PATIENT FOR THIS SERVICE.                      Refer to M97)
                                                                           (Modified
M49         MISSING/INCOMPLETE/INVALID VALUE CODE(S) OR AMOUNT(S).         2/28/03)
                                                                           (Modified
M50         MISSING/INCOMPLETE/INVALID REVENUE CODE(S).                    2/28/03)
                                                                           (Modified
M51         MISSING/INCOMPLETE/INVALID PROCEDURE CODE(S).                  12/02/04)
                                                                           (Modified
M52         MISSING/INCOMPLETE/INVALID “FROM” DATE(S) OF SERVICE.          2/28/03)
                                                                           (Modified
M53         MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE.           2/28/03)
                                                                           (Modified
M54         MISSING/INCOMPLETE/INVALID TOTAL CHARGES.                      2/28/03)

            WE DO NOT PAY FOR SELF-ADMINISTERED ANTI-EMETIC DRUGS THAT
M55         ARE NOT ADMINISTERED WITH A COVERED ORAL ANTI-CANCER DRUG.
                                                                           (Modified
M56         MISSING/INCOMPLETE/INVALID PAYER IDENTIFIER.                   2/28/03)

                                                                           Deactivated
M57         MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER.                as of 6/2/05.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            MISSING/INCOMPLETE/INVALID CLAIM INFORMATION.   RESUBMIT       Deactivated
M58         CLAIM AFTER CORRECTIONS.                                       as of 2/5/05.
                                                                           (Modified
M59         MISSING/INCOMPLETE/INVALID “TO” DATE(S) OF SERVICE.            2/28/03)
                                                                           (Modified
M60         MISSING CERTIFICATE OF MEDICAL NECESSITY.                      8/1/04)
            WE CANNOT PAY FOR THIS AS THE APPROVAL PERIOD FOR THE FDA
M61         CLINICAL TRIAL HAS EXPIRED.
                                                                           (Modified
M62         MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION CODE.       2/28/03)



                                                                           (Deactivated
                                                                           eff. 1/31/04.
M63         WE DO NOT PAY FOR MORE THAN ONE OF THESE ON THE SAME DAY.      Refer to M86)
                                                                           (Modified
M64         MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS.                    2/28/03)


            ONE INTERPRETING PHYSICIAN CHARGE CAN BE SUBMITTED PER CLAIM
            WHEN A PURCHASED DIAGNOSTIC TEST IS INDICATED. PLEASE SUBMIT
M65         A SEPARATE CLAIM FOR EACH INTERPRETING PHYSICIAN.


            OUR RECORDS INDICATE THAT YOU BILLED DIAGNOSTIC TESTS
            SUBJECT TO PRICE LIMITATIONS AND THE PROCEDURE CODE
            SUBMITTED INCLUDES A PROFESSIONAL COMPONENT. ONLY THE
            TECHNICAL COMPONENT IS SUBJECT TO PRICE LIMITATIONS. PLEASE
            SUBMIT THE TECHNICAL AND PROFESSIONAL COMPONENTS OF THIS
M66         SERVICE AS SEPARATE LINE ITEMS.
                                                                           (Modified
M67         MISSING/INCOMPLETE/INVALID OTHER PROCEDURE CODE(S).            12/2/04)

            MISSING/INCOMPLETE/INVALID ATTENDING, ORDERING, RENDERING,     Deactivated
M68         SUPERVISING OR REFERRING PHYSICIAN IDENTIFICATION.             as of 6/2/05.

            PAID AT THE REGULAR RATE AS YOU DID NOT SUBMIT DOCUMENTATION   (Modified
M69         TO JUSTIFY THE MODIFIED PROCEDURE CODE.                        2/1/04)


            ALERT: THE NDC CODE SUBMITTED FOR THIS SERVICE WAS
            TRANSLATED TO A HCPCS CODE FOR PROCESSING, BUT PLEASE          Modified
M70         CONTINUE TO SUBMIT THE NDC ON FUTURE CLAIMS FOR THIS ITEM.     8/1/07.

M71         TOTAL PAYMENT REDUCED DUE TO OVERLAP OF TESTS BILLED.


                                                                           (Deactivated
                                                                           eff.
                                                                           10/16/2003.
                                                                           C149 Refer to
M72         DID NOT ENTER FULL 8-DIGIT DATE (MM/DD/CCYY).                  MA52)


            THE HPSA/PHYSICIAN SCARCITY BONUS CAN ONLY BE PAID ON THE
            PROFESSIONAL COMPONENT OF THIS SERVICE. REBILL AS SEPARATE     Modified
M73         PROFESSIONAL AND TECHNICAL COMPONENTS.                         8/1/04.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                       NOTES
            THIS SERVICE DOES NOT QUALIFY FOR A HPSA/PHYSICIAN SCARCITY      Modified
M74         BONUS PAYMENT.                                                   12/2/04.
            MULTIPLE AUTOMATED MULTICHANNEL TESTS PERFORMED ON THE SAME      Modified
M75         DAY COMBINED FOR PAYMENT.                                        11/5/07.
                                                                             (Modified
M76         MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION.               2/28/03)
                                                                             (Modified
M77         MISSING/INCOMPLETE/INVALID PLACE OF SERVICE.                     2/28/03)


                                                                             Deactivated
                                                                             eff.
                                                                             05/18/06.
                                                                             Consider
                                                                             using Reason
M78         MISSING/INCOMPLETE/INVALID HCPCS MODIFIER.                       Code 4.
                                                                             (Modified
M79         MISSING/INCOMPLETE/INVALID CHARGE.                               2/28/03)

            NOT COVERED WHEN PERFORMED DURING THE SAME SESSION/DATE AS A     (Modified
M80         PREVIOUSLY PROCESSED SERVICE FOR THE PATIENT.                    10/31/02)
                                                                          (Modified
M81         YOU ARE REQUIRED TO CODE TO THE HIGHEST LEVEL OF SPECIFICITY. 2/1/04)

M82         SERVICE IS NOT COVERED WHEN PATIENT IS UNDER AGE 50.
            SERVICE IS NOT COVERED UNLESS THE PATIENT IS CLASSIFIED AS
M83         AT HIGH RISK.
            MEDICAL CODE SETS USED MUST BE THE CODES IN EFFECT AT THE        (Modified
M84         TIME OF SERVICE.                                                 2/1/04)
            SUBJECTED TO REVIEW OF PHYSICIAN EVALUATION AND MANAGEMENT
M85         SERVICES.
            SERVICE DENIED BECAUSE PAYMENT ALREADY MADE FOR SAME/SIMILAR     (Modified
M86         PROCEDURE WITHIN SET TIME FRAME.                                 6/30/03)

M87         CLAIM/SERVICE(S) SUBJECTED TO CFO-CAP PREPAYMENT REVIEW.


                                                                             (Deactivated
                                                                             eff.8/1/04.
                                                                             Refer to
            WE CANNOT PAY FOR LABORATORY TESTS UNLESS BILLED BY THE          Reason Code
M88         LABORATORY THAT DID THE WORK.                                    B20)
M89         NOT COVERED MORE THAN ONCE UNDER AGE 40.
M90         NOT COVERED MORE THAN ONCE IN A 12 MONTH PERIOD.
            LAB PROCEDURES WITH DIFFERENT CLIA CERTIFICATION NUMBERS
M91         MUST BE BILLED ON SEPARATE CLAIMS.

            SERVICES SUBJECTED TO REVIEW UNDER THE HOME HEALTH MEDICAL       (Deactivated
M92         REVIEW INITIATIVE.                                               eff. 8/1/04.)

            INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. A NEW
M93         CAPPED RENTAL PERIOD BEGAN WITH DELIVERY OF THIS EQUIPMENT.

            INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY.    A
M94         NEW CAPPED RENTAL PERIOD WILL NOT BEGIN.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                      NOTES
            SERVICES SUBJECTED TO HOME HEALTH INITIATIVE MEDICAL
M95         REVIEW/COST REPORT AUDIT.


            THE TECHNICAL COMPONENT OF A SERVICE FURNISHED TO AN
            INPATIENT MAY ONLY BE BILLED BY THAT INPATIENT FACILITY. YOU
            MUST CONTACT THE INPATIENT FACILITY FOR TECHNICAL COMPONENT
            REIMBURSEMENT. IF NOT ALREADY BILLED, YOU SHOULD BILL US
M96         FOR THE PROFESSIONAL COMPONENT ONLY.
            NOT PAID TO PRACTITIONER WHEN PROVIDED TO PATIENT IN THIS
            PLACE OF SERVICE. PAYMENT INCLUDED IN THE REIMBURSEMENT
M97         ISSUED THE FACILITY.
                                                                            (Deactivated
            BEGIN TO REPORT THE UNIVERSAL PRODUCT NUMBER ON CLAIMS FOR      eff.
            ITEMS OF THIS TYPE. WE WILL SOON BEGIN TO DENY PAYMENT FOR      1/31/2004.
M98         ITEMS OF THIS TYPE IF BILLED WITHOUT THE CORRECT UPN.           Use M99)
            MISSING/INCOMPLETE/INVALID UNIVERSAL PRODUCT NUMBER/SERIAL      (Modified
M99         NUMBER.                                                         2/28/03)


            WE DO NOT PAY FOR AN ORAL ANTI-EMETIC DRUG THAT IS NOT
            ADMINISTERED FOR USE IMMEDIATELY BEFORE, AT, OR WITHIN 48
M100        HOURS OF ADMINISTRATION OF A COVERED CHEMOTHERAPY DRUG.
                                                                            (Deactivated
            BEGIN TO REPORT A G1-G5 MODIFIER WITH THIS HCPCS. WE WILL       eff.
            SOON BEGIN TO DENY PAYMENT FOR THIS SERVICE IF BILLED           1/31/2004.
M101        WITHOUT A G1-G5 MODIFIER.                                       Use M78)
            SERVICE NOT PERFORMED ON EQUIPMENT APPROVED BY THE FDA FOR
M102        THIS PURPOSE.


            INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. HOWEVER,
            THE MEDICAL INFORMATION WE HAVE FOR THIS PATIENT DOES NOT
            SUPPORT THE NEED FOR THIS ITEM AS BILLED. WE HAVE APPROVED
            PAYMENT FOR THIS ITEM AT A REDUCED LEVEL, AND A NEW CAPPED
M103        RENTAL PERIOD WILL BEGIN WITH THE DELIVERY OF THIS EQUIPMENT.


            INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. A NEW
            CAPPED RENTAL PERIOD WILL BEGIN WITH DELIVERY OF THE
            EQUIPMENT. THIS IS THE MAXIMUM APPROVED UNDER THE FEE
M104        SCHEDULE FOR THIS ITEM OR SERVICE.


            INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY.
            THE MEDICAL INFORMATION WE HAVE FOR THIS PATIENT DOES NOT
            SUPPORT THE NEED FOR THIS ITEM AS BILLED. WE HAVE APPROVED
            PAYMENT FOR THIS ITEM AT A REDUCED LEVEL, AND A NEW CAPPED
M105        RENTAL PERIOD WILL NOT BEGIN.
                                                                            (Deactivated
            INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY. A     eff.
            NEW CAPPED RENTAL PERIOD WILL NOT BEGIN. THIS IS THE MAXIMUM    1/31/2004.
M106        APPROVED UNDER THE FEE SCHEDULE FOR THIS ITEM OR SERVICE.       Use MA31)
            PAYMENT REDUCED AS 90-DAY ROLLING AVERAGE HEMATOCRIT FOR
M107        ESRD PATIENT EXCEEDED 36.5%.

            MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE          Deactivated
M108        PROVIDER WHO INTERPRETED THE DIAGNOSTIC TEST.                   eff. 06/02/05.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            WE HAVE PROVIDED YOU WITH A BUNDLED PAYMENT FOR A
            TELECONSULTATION. YOU MUST SEND 25 PERCENT OF THE
M109        TELECONSULTATION PAYMENT TO THE REFERRING PRACTITIONER.

            MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE         Deactivated
M110        PROVIDER FROM WHOM YOU PURCHASED INTERPRETATION SERVICES.      eff. 06/02/05.

            WE DO NOT PAY FOR CHIROPRACTIC MANIPULATIVE TREATMENT WHEN
M111        THE PATIENT REFUSES TO HAVE AN X-RAY TAKEN.


            THE APPROVED AMOUNT IS BASED ON THE SINGLE PAYMENT AMOUNT
            REQUIRED UNDER THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR      Modified
M112        THE AREA WHERE THE PATIENT RESIDES.                            11/5/07.
            OUR RECORDS INDICATE THAT THIS PATIENT BEGAN USING THIS
            SERVICE(S) PRIOR TO THE CURRENT CONTRACT PERIOD FOR THE        Modified
M113        DMEPOS COMPETITIVE BIDDING PROGRAM.                            11/5/07.


            THIS SERVICE WAS PROCESSED IN ACCORDANCE WITH RULES AND
            GUIDELINES UNDER THE DMEPOS COMPETITIVE BIDDING PROGRAM OR A
            DEMONSTRATION PROJECT. FOR MORE INFORMATION REGARDING THESE    Modified
M114        PROJECTS, CONTACT YOUR LOCAL CONTRACTOR.                       11/5/07.
            THIS ITEM IS DENIED WHEN PROVIDED TO THIS PATIENT BY A NON-
M115        DEMONSTRATION SUPPLIER.
            PAID UNDER THE COMPETITIVE BIDDING DEMONSTRATION PROJECT.
            PROJECT IS ENDING, AND FUTURE SERVICES MAY NOT BE PAID UNDER   (Modified
M116        THIS PROJECT.                                                  2/1/04)
                                                                           (Modified
M117        NOT COVERED UNLESS SUBMITTED VIA ELECTRONIC CLAIM.             6/30/03)
                                                                           Modified
M118        ALERT: LETTER TO FOLLOW CONTAINING FURTHER INFORMATION.        4/1/07
                                                                           (Modified
            MISSING/INCOMPLETE/INVALID/DEACTIVATED/WITHDRAWN NATIONAL      2/28/03,
M119        DRUG CODE (NDC).                                               4/1/04)


            MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE
            SUBSTITUTING PHYSICIAN WHO FURNISHED THE SERVICE(S) UNDER A    (Modified
M120        RECIPROCAL BILLING OR LOCUM TENENS ARRANGEMENT.                2/28/03)
            WE PAY FOR THIS SERVICE ONLY WHEN PERFORMED WITH A COVERED
M121        CRYOSURGICAL ABLATION.
                                                                           (Modified
M122        MISSING/INCOMPLETE/INVALID LEVEL OF SUBLUXATION.               2/28/03)
            MISSING/INCOMPLETE/INVALID NAME, STRENGTH, OR DOSAGE OF THE    (Modified
M123        DRUG FURNISHED.                                                2/28/03)
            MISSING INDICATION OF WHETHER THE PATIENT OWNS THE EQUIPMENT   (Modified
M124        THAT REQUIRES THE PART OR SUPPLY.                              2/28/03)

            MISSING/INCOMPLETE/INVALID INFORMATION ON THE PERIOD OF TIME   (Modified
M125        FOR WHICH THE SERVICE/SUPPLY/EQUIPMENT WILL BE NEEDED.         2/28/03)
            MISSING/INCOMPLETE/INVALID INDIVIDUAL LAB CODES INCLUDED IN    (Modified
M126        THE TEST.                                                      2/28/03)
            MISSING/INCOMPLETE/INVALID PATIENT MEDICAL RECORD FOR THIS     (Modified
M127        SERVICE.                                                       2/28/03)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            MISSING/INCOMPLETE/INVALID DATE OF THE PATIENT’S LAST          (Modified
M128        PHYSICIAN VISIT.                                               2/28/03)
                                                                           (Modified
            MISSING/INCOMPLETE/INVALID INDICATOR OF X-RAY AVAILABILITY     2/28/03,
M129        FOR REVIEW.                                                    6/30/03)
            MISSING INVOICE OR STATEMENT CERTIFYING THE ACTUAL COST OF
            THE LENS, LESS DISCOUNTS, AND/OR THE TYPE OF INTRAOCULAR       (Modified
M130        LENS USED.                                                     2/28/03)
                                                                           (Modified
M131        MISSING PHYSICIAN FINANCIAL RELATIONSHIP FORM.                 2/28/03)
                                                                           (Modified
M132        MISSING PACEMAKER REGISTRATION FORM.                           2/28/03)

            CLAIM DID NOT IDENTIFY WHO PERFORMED THE PURCHASED
M133        DIAGNOSTIC TEST OR THE AMOUNT YOU WERE CHARGED FOR THE TEST.
            PERFORMED BY A FACILITY/SUPPLIER IN WHICH THE PROVIDER HAS A   (Modified
M134        FINANCIAL INTEREST.                                            6/30/03)
                                                                           (Modified
M135        MISSING/INCOMPLETE/INVALID PLAN OF TREATMENT.                  2/28/03)
            MISSING/INCOMPLETE/INVALID INDICATION THAT THE SERVICE WAS     (Modified
M136        SUPERVISED OR EVALUATED BY A PHYSICIAN.                        2/28/03)
M137        PART B COINSURANCE UNDER A DEMONSTRATION PROJECT.
            PATIENT IDENTIFIED AS A DEMONSTRATION PARTICIPANT BUT THE
            PATIENT WAS NOT ENROLLED IN THE DEMONSTRATION AT THE TIME
            SERVICES WERE RENDERED. COVERAGE IS LIMITED TO
M138        DEMONSTRATION PARTICIPANTS.
            DENIED SERVICES EXCEED THE COVERAGE LIMIT FOR THE
M139        DEMONSTRATION.


                                                                           (Deactivated
                                                                           eff.
            SERVICE NOT COVERED UNTIL AFTER THE PATIENT’S 50TH BIRTHDAY,   1/30/2004.
M140        I.E., NO COVERAGE PRIOR TO THE DAY AFTER THE 50TH BIRTHDAY     Refer to M82)
                                                                           (Modified
M141        MISSING PHYSICIAN CERTIFIED PLAN OF CARE.                      2/28/03)
            MISSING AMERICAN DIABETES ASSOCIATION CERTIFICATE OF           (Modified
M142        RECOGNITION.                                                   2/28/03)
                                                                           MODIFIED
M143        THE PROVIDER MUST UPDATE LICENSE INFORMATION WITH THE PAYER.   12/1/2006
            PRE-/POST-OPERATIVE CARE PAYMENT IS INCLUDED IN THE
M144        ALLOWANCE FOR THE SURGERY/PROCEDURE.


            ALERT: IF YOU DO NOT AGREE WITH WHAT WE APPROVED FOR THESE
            SERVICES, YOU MAY APPEAL OUR DECISION. TO MAKE SURE THAT WE
            ARE FAIR TO YOU, WE REQUIRE ANOTHER INDIVIDUAL THAT DID NOT
            PROCESS YOUR INITIAL CLAIM TO CONDUCT THE REVIEW. HOWEVER,     (Modified
            IN ORDER TO BE ELIGIBLE FOR AN APPEAL YOU MUST WRITE TO US     10/31/02,
            WITHIN 120 DAYS OF THE DATE OF THIS NOTICE, UNLESS YOU HAVE    6/30/03,
MA01        A GOOD REASON FOR BEING LATE.                                  4/1/07)
                                                                           (Modified
            ALERT: IF YOU DO NOT AGREE WITH THIS DETERMINATION, YOU HAVE   10/31/02,
            THE RIGHT TO APPEAL. YOU MUST FILE A WRITTEN REQUEST FOR AN    6/30/03,
MA02        APPEAL WITHIN 180 DAYS OF THE DATE YOU RECEIVE THIS NOTICE.    4/1/07)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES


            IF YOU DO NOT AGREE WITH THE APPROVED AMOUNTS AND $100 OR
            MORE IS IN DISPUTE (LESS DEDUCTIBLE AND COINSURANCE), YOU
            MAY ASK FOR A HEARING WITHIN SIX MONTHS OF THE DATE OF THIS
            NOTICE. TO MEET THE $100, YOU MAY COMBINE AMOUNTS ON OTHER
            CLAIMS THAT HAVE BEEN DENIED, INCLUDING REOPENED APPEALS IF    Deactivated
            YOU RECEIVED A REVISED DECISION. YOU MUST APPEAL EACH CLAIM    eff. 10/1/06.
MA03        ON TIME.                                                       Refer to MA02.


            SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY
            OF OR PAYMENT INFORMATION FROM THE PRIMARY PAYER. THE
MA04        INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE.


                                                                           (Deactivated
                                                                           eff.
                                                                           10/16/2003.
                                                                           Refer to MA30
            INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL        or MA40 or
MA05        ENTRY ON CLAIM.                                                MA43.)



                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
                                                                           eff. 8/1/04.
MA06        MISSING/INCOMPLETE/INVALID BEGINNING AND/OR ENDING DATE(S).    Refer to MA31)
            ALERT: THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO        Modified
MA07        MEDICAID FOR REVIEW.                                           4/1/07.
            ALERT: CLAIM INFORMATION WAS NOT FORWARDED BECAUSE THE
            SUPPLEMENTAL COVERAGE IS NOT WITH A MEDIGAP PLAN, OR YOU DO    Modified
MA08        NOT PARTICIPATE IN MEDICARE.                                   4/1/07.

            CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED. YOU
MA09        AGREED TO ACCEPT ASSIGNMENT FOR ALL CLAIMS.

            ALERT: THE PATIENT'S PAYMENT WAS IN EXCESS OF THE AMOUNT       Modified
MA10        OWED. YOU MUST REFUND THE OVERPAYMENT TO THE PATIENT.          4/1/07.


            PAYMENT IS BEING ISSUED ON A CONDITIONAL BASIS. IF NO-FAULT
            INSURANCE, LIABILITY INSURANCE, WORKERS' COMPENSATION,
            DEPARTMENT OF VETERANS AFFAIRS, OR A GROUP HEALTH PLAN FOR     (Deactivated
            EMPLOYEES AND DEPENDENTS ALSO COVERS THIS CLAIM, A REFUND      eff.
            MAY BE DUE US. PLEASE CONTACT US IF THE PATIENT IS COVERED     1/31/2004.
MA11        BY ANY OF THESE SOURCES.                                       Refer to M32)


            YOU HAVE NOT ESTABLISHED THAT YOU HAVE THE RIGHT UNDER THE
            LAW TO BILL FOR SERVICES FURNISHED BY THE PERSON(S) THAT
MA12        FURNISHED THIS (THESE) SERVICE(S).
            ALERT: YOU MAY BE SUBJECT TO PENALTIES IF YOU BILL THE
            PATIENT FOR AMOUNTS NOT REPORTED WITH THE PR (PATIENT          Modified
MA13        RESPONSIBILITY) GROUP CODE.                                    4/1/07.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                      NOTES

            ALERT: THE PATIENT IS A MEMBER OF AN EMPLOYER-SPONSORED
            PREPAID HEALTH PLAN. SERVICES FROM OUTSIDE THAT HEALTH PLAN
            ARE NOT COVERED. HOWEVER, AS YOU WERE NOT PREVIOUSLY
            NOTIFIED OF THIS, WE ARE PAYING THIS TIME. IN THE FUTURE,       Modified
MA14        WE WILL NOT PAY YOU FOR NON-PLAN SERVICES.                      8/1/07.
            ALERT: YOUR CLAIM HAS BEEN SEPARATED TO EXPEDITE HANDLING.
            YOU WILL RECEIVE A SEPARATE NOTICE FOR THE OTHER SERVICES       Modified
MA15        REPORTED.                                                       4/1/07.


            THE PATIENT IS COVERED BY THE BLACK LUNG PROGRAM. SEND THIS
            CLAIM TO THE DEPARTMENT OF LABOR, FEDERAL BLACK LUNG
MA16        PROGRAM, P.O. BOX 828, LANHAM-SEABROOK MD 20703.


            WE ARE THE PRIMARY PAYER AND HAVE PAID AT THE PRIMARY RATE.
            YOU MUST CONTACT THE PATIENT'S OTHER INSURER TO REFUND ANY
MA17        EXCESS IT MAY HAVE PAID DUE TO ITS ERRONEOUS PRIMARY PAYMENT.


            ALERT: THE CLAIM INFORMATION IS ALSO BEING FORWARDED TO THE
            PATIENT'S SUPPLEMENTAL INSURER. SEND ANY QUESTIONS REGARDING    Modified
MA18        SUPPLEMENTAL BENEFITS TO THEM.                                  4/1/07.


            ALERT: INFORMATION WAS NOT SENT TO THE MEDIGAP INSURER DUE
            TO INCORRECT/INVALID INFORMATION YOU SUBMITTED CONCERNING
            THAT INSURER. PLEASE VERIFY YOUR INFORMATION AND SUBMIT YOUR    Modified
MA19        SECONDARY CLAIM DIRECTLY TO THAT INSURER.                       4/1/07.


            SKILLED NURSING FACILITY (SNF) STAY NOT COVERED WHEN CARE IS
            PRIMARILY RELATED TO THE USE OF AN URETHRAL CATHETER FOR        (Modified
MA20        CONVENIENCE OR THE CONTROL OF INCONTINENCE.                     6/30/03)
MA21        SSA RECORDS INDICATE MISMATCH WITH NAME AND SEX.
MA22        PAYMENT OF LESS THAN $1.00 SUPPRESSED.
MA23        DEMAND BILL APPROVED AS RESULT OF MEDICAL REVIEW.
            CHRISTIAN SCIENCE SANITARIUM/SKILLED NURSING FACILITY (SNF)     (Modified
MA24        BILL IN THE SAME BENEFIT PERIOD.                                6/30/03)
            A PATIENT MAY NOT ELECT TO CHANGE A HOSPICE PROVIDER MORE
MA25        THAN ONCE IN A BENEFIT PERIOD.
            ALERT: OUR RECORDS INDICATE THAT YOU WERE PREVIOUSLY            Modified
MA26        INFORMED OF THIS RULE.                                          4/1/07.
            MISSING/INCOMPLETE/INVALID ENTITLEMENT NUMBER OR NAME SHOWN     (Modified
MA27        ON THE CLAIM.                                                   2/28/03)


            ALERT: RECEIPT OF THIS NOTICE BY A PHYSICIAN OR SUPPLIER WHO
            DID NOT ACCEPT ASSIGNMENT IS FOR INFORMATION ONLY AND DOES
            NOT MAKE THE PHYSICIAN OR SUPPLIER A PARTY TO THE
            DETERMINATION. NO ADDITIONAL RIGHTS TO APPEAL THIS
            DECISION, ABOVE THOSE RIGHTS ALREADY PROVIDED FOR BY
            REGULATION/INSTRUCTION, ARE CONFERRED BY RECEIPT OF THIS        Modified
MA28        NOTICE.                                                         4/1/07.
            MISSING/INCOMPLETE/INVALID PROVIDER NAME, CITY, STATE, OR       (Modified
MA29        ZIP CODE.                                                       2/28/03)
                                                                            (Modified
MA30        MISSING/INCOMPLETE/INVALID TYPE OF BILL.                        2/28/03)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE   (Modified
MA31        PERIOD BILLED.                                                 2/28/03)
            MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE   (Modified
MA32        BILLING PERIOD.                                                2/28/03)
            MISSING/INCOMPLETE/INVALID NONCOVERED DAYS DURING THE          (Modified
MA33        BILLING PERIOD.                                                2/28/03)
            MISSING/INCOMPLETE/INVALID NUMBER OF COINSURANCE DAYS DURING   (Modified
MA34        THE BILLING PERIOD.                                            2/28/03)
                                                                           (Modified
MA35        MISSING/INCOMPLETE/INVALID NUMBER OF LIFETIME RESERVE DAYS.    2/28/03)
                                                                           (Modified
MA36        MISSING/INCOMPLETE/INVALID PATIENT NAME.                       2/28/03)
                                                                           (Modified
MA37        MISSING/INCOMPLETE/INVALID PATIENT'S ADDRESS.                  2/28/03)
                                                                           (Modified
MA38        MISSING/INCOMPLETE/INVALID BIRTH DATE.                         2/28/03)
                                                                           (Modified
MA39        MISSING/INCOMPLETE/INVALID GENDER.                             2/28/03)
                                                                           (Modified
MA40        MISSING/INCOMPLETE/INVALID ADMISSION DATE.                     2/28/03)
                                                                           (Modified
MA41        MISSING/INCOMPLETE/INVALID ADMISSION TYPE.                     2/28/03)
                                                                           (Modified
MA42        MISSING/INCOMPLETE/INVALID ADMISSION SOURCE.                   2/28/03)
                                                                           (Modified
MA43        MISSING/INCOMPLETE/INVALID PATIENT STATUS.                     2/28/03)
                                                                           Modified
MA44        ALERT: NO APPEAL RIGHTS. ADJUDICATIVE DECISION BASED ON LAW.   4/1/07.
            ALERT: AS PREVIOUSLY ADVISED, A PORTION OR ALL OF YOUR         Modified
MA45        PAYMENT IS BEING HELD IN A SPECIAL ACCOUNT.                    4/1/07.
            THE NEW INFORMATION WAS CONSIDERED, HOWEVER, ADDITIONAL
            PAYMENT CANNOT BE ISSUED. PLEASE REVIEW THE INFORMATION
MA46        LISTED FOR THE EXPLANATION.


            OUR RECORDS SHOW YOU HAVE OPTED OUT OF MEDICARE, AGREEING
            WITH THE PATIENT NOT TO BILL MEDICARE FOR
            SERVICES/TESTS/SUPPLIES FURNISHED. AS RESULT, WE CANNOT PAY
MA47        THIS CLAIM. THE PATIENT IS RESPONSIBLE FOR PAYMENT.
            MISSING/INCOMPLETE/INVALID NAME OR ADDRESS OF RESPONSIBLE      (Modified
MA48        PARTY OR PRIMARY PAYER.                                        2/28/03)



                                                                           (Modified
                                                                           2/28/03.
            MISSING/INCOMPLETE/INVALID SIX-DIGIT PROVIDER IDENTIFIER FOR   Deactivated
            HOME HEALTH AGENCY OR HOSPICE FOR PHYSICIAN(S) PERFORMING      eff. 8/1/04.
MA49        CARE PLAN OVERSIGHT SERVICES.                                  Refer to MA76)

            MISSING/INCOMPLETE/INVALID INVESTIGATIONAL DEVICE EXEMPTION    (Modified
MA50        NUMBER FOR FDA-APPROVED CLINICAL TRIAL SERVICES.               2/28/03)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           Deactivated
                                                                           eff.
                                                                           02/05/05.
            MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER FOR       Refer to
MA51        LABORATORY SERVICES BILLED BY PHYSICIAN OFFICE LABORATORY.     MA120.

                                                                           Deactivated
MA52        MISSING/INCOMPLETE/INVALID DATE.                               eff. 06/02/05.
            MISSING/INCOMPLETE/INVALID COMPETITIVE BIDDING DEMONSTRATION   (Modified
MA53        PROJECT IDENTIFICATION.                                        2/1/04)
            PHYSICIAN CERTIFICATION OR ELECTION CONSENT FOR HOSPICE CARE
MA54        NOT RECEIVED TIMELY.


            NOT COVERED AS PATIENT RECEIVED MEDICAL HEALTH CARE
            SERVICES, AUTOMATICALLY REVOKING HIS/HER ELECTION TO RECEIVE
MA55        RELIGIOUS NON-MEDICAL HEALTH CARE SERVICES.


            OUR RECORDS SHOW YOU HAVE OPTED OUT OF MEDICARE, AGREEING
            WITH THE PATIENT NOT TO BILL MEDICARE FOR
            SERVICES/TESTS/SUPPLIES FURNISHED. AS RESULT, WE CANNOT PAY
            THIS CLAIM. THE PATIENT IS RESPONSIBLE FOR PAYMENT, BUT
            UNDER FEDERAL LAW, YOU CANNOT CHARGE THE PATIENT MORE THAN
MA56        THE LIMITING CHARGE AMOUNT.

            PATIENT SUBMITTED WRITTEN REQUEST TO REVOKE HIS/HER ELECTION
MA57        FOR RELIGIOUS NON-MEDICAL HEALTH CARE SERVICES.
                                                                           (Modified
MA58        MISSING/INCOMPLETE/INVALID RELEASE OF INFORMATION INDICATOR.   2/28/03)


            ALERT: THE PATIENT OVERPAID YOU FOR THESE SERVICES. YOU MUST
            ISSUE THE PATIENT A REFUND WITHIN 30 DAYS FOR THE DIFFERENCE
            BETWEEN HIS/HER PAYMENT AND THE TOTAL AMOUNT SHOWN AS          Modified
MA59        PATIENT RESPONSIBILITY ON THIS NOTICE.                         4/1/07.
                                                                           (Modified
MA60        MISSING/INCOMPLETE/INVALID PATIENT RELATIONSHIP TO INSURED.    2/28/03)
            MISSING/INCOMPLETE/INVALID SOCIAL SECURITY NUMBER OR HEALTH    (Modified
MA61        INSURANCE CLAIM NUMBER.                                        2/28/03)
                                                                           Modified
MA62        ALERT: THIS IS A TELEPHONE REVIEW DECISION.                    8/1/07.
                                                                           (Modified
MA63        MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS.                2/28/03)
            OUR RECORDS INDICATE THAT WE SHOULD BE THE THIRD PAYER FOR
            THIS CLAIM. WE CANNOT PROCESS THIS CLAIM UNTIL WE HAVE
            RECEIVED PAYMENT INFORMATION FROM THE PRIMARY AND SECONDARY
MA64        PAYERS.
                                                                           (Modified
MA65        MISSING/INCOMPLETE/INVALID ADMITTING DIAGNOSIS.                2/28/03)
                                                                           (Modified
MA66        MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE CODE.           12/2/04)
MA67        CORRECTION TO A PRIOR CLAIM.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            ALERT: WE DID NOT CROSSOVER THIS CLAIM BECAUSE THE SECONDARY
            INSURANCE INFORMATION ON THE CLAIM WAS INCOMPLETE. PLEASE
            SUPPLY COMPLETE INFORMATION OR USE THE PLANID OF THE INSURER
MA68        TO ASSURE CORRECT AND TIMELY ROUTING OF THE CLAIM.
                                                                           (Modified
MA69        MISSING/INCOMPLETE/INVALID REMARKS.                            2/28/03)
                                                                          (Modified
MA70        MISSING/INCOMPLETE/INVALID PROVIDER REPRESENTATIVE SIGNATURE. 2/28/03)
            MISSING/INCOMPLETE/INVALID PROVIDER REPRESENTATIVE SIGNATURE   (Modified
MA71        DATE.                                                          2/28/03)


            ALERT: THE PATIENT OVERPAID YOU FOR THESE ASSIGNED SERVICES.
             YOU MUST ISSUE THE PATIENT A REFUND WITHIN 30 DAYS FOR THE
            DIFFERENCE BETWEEN HIS/HER PAYMENT TO YOU AND THE TOTAL OF
            THE AMOUNT SHOWN AS PATIENT RESPONSIBILITY AND AS PAID TO      Modified
MA72        THE PATIENT ON THIS NOTICE.                                    4/1/07.


            INFORMATIONAL REMITTANCE ASSOCIATED WITH A MEDICARE
            DEMONSTRATION. NO PAYMENT ISSUED UNDER FEE-FOR-SERVICE
MA73        MEDICARE AS PATIENT HAS ELECTED MANAGED CARE.
            THIS PAYMENT REPLACES AN EARLIER PAYMENT FOR THIS CLAIM THAT
MA74        WAS EITHER LOST, DAMAGED OR RETURNED.
            MISSING/INCOMPLETE/INVALID PATIENT OR AUTHORIZED               (Modified
MA75        REPRESENTATIVE SIGNATURE.                                      2/28/03)
            MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR HOME        (Modified
            HEALTH AGENCY OR HOSPICE WHEN PHYSICIAN IS PERFORMING CARE     2/28/03,
MA76        PLAN OVERSIGHT SERVICES.                                       2/1/04)


            ALERT: THE PATIENT OVERPAID YOU. YOU MUST ISSUE THE PATIENT
            A REFUND WITHIN 30 DAYS FOR THE DIFFERENCE BETWEEN THE
            PATIENT’S PAYMENT LESS THE TOTAL OF OUR AND OTHER PAYER
            PAYMENTS AND THE AMOUNT SHOWN AS PATIENT RESPONSIBILITY ON     Modified
MA77        THIS NOTICE.                                                   4/1/07.


                                                                           (Deactivated
            THE PATIENT OVERPAID YOU. YOU MUST ISSUE THE PATIENT A         eff.
            REFUND WITHIN 30 DAYS FOR THE DIFFERENCE BETWEEN OUR ALLOWED   1/31/2004.
MA78        AMOUNT TOTAL AND THE AMOUNT PAID BY THE PATIENT.               Refer to MA59)
MA79        BILLED IN EXCESS OF INTERIM RATE.
            INFORMATIONAL NOTICE. NO PAYMENT ISSUED FOR THIS CLAIM WITH
            THIS NOTICE. PAYMENT ISSUED TO THE HOSPITAL BY ITS
            INTERMEDIARY FOR ALL SERVICES FOR THIS ENCOUNTER UNDER A
MA80        DEMONSTRATION PROJECT.
                                                                           (Modified
MA81        MISSING/INCOMPLETE/INVALID PROVIDER/SUPPLIER SIGNATURE.        2/28/03)
            MISSING/INCOMPLETE/INVALID PROVIDER/SUPPLIER BILLING
            NUMBER/IDENTIFIER OR BILLING NAME, ADDRESS, CITY, STATE, ZIP   Deactivated
MA82        CODE, OR PHONE NUMBER.                                         eff. 6/2/05.
            DID NOT INDICATE WHETHER WE ARE THE PRIMARY OR SECONDARY       Modified
MA83        PAYER.                                                         8/1/05.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            PATIENT IDENTIFIED AS PARTICIPATING IN THE NATIONAL
            EMPHYSEMA TREATMENT TRIAL BUT OUR RECORDS INDICATE THAT THIS
            PATIENT IS EITHER NOT A PARTICIPANT, OR HAS NOT YET BEEN
            APPROVED FOR THIS PHASE OF THE STUDY. CONTACT JOHNS HOPKINS
            UNIVERSITY, THE STUDY COORDINATOR, TO RESOLVE IF THERE WAS A
MA84        DISCREPANCY.


            OUR RECORDS INDICATE THAT A PRIMARY PAYER EXISTS (OTHER THAN
            OURSELVES); HOWEVER, YOU DID NOT COMPLETE OR ENTER             (Deactivated
            ACCURATELY THE INSURANCE PLAN/GROUP/PROGRAM NAME OR            eff. 8/1/04.
MA85        IDENTIFICATION NUMBER. ENTER THE PLANID WHEN EFFECTIVE.        Refer to MA92)



                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
            MISSING/INCOMPLETE/INVALID GROUP OR POLICY NUMBER OF THE       eff. 8/1/04.
MA86        INSURED FOR THE PRIMARY COVERAGE.                              Refer to MA92)



                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
            MISSING/INCOMPLETE/INVALID INSURED'S NAME FOR THE PRIMARY      eff. 8/1/04.
MA87        PAYER.                                                         Refer to MA92)
            MISSING/INCOMPLETE/INVALID INSURED'S ADDRESS AND/OR            (Modified
MA88        TELEPHONE NUMBER FOR THE PRIMARY PAYER.                        2/28/03)
            MISSING/INCOMPLETE/INVALID PATIENT'S RELATIONSHIP TO THE       (Modified
MA89        INSURED FOR THE PRIMARY PAYER.                                 2/28/03)
            MISSING/INCOMPLETE/INVALID EMPLOYMENT STATUS CODE FOR THE      (Modified
MA90        PRIMARY INSURED.                                               2/28/03)

MA91        THIS DETERMINATION IS THE RESULT OF THE APPEAL YOU FILED.
                                                                           (Modified
            MISSING/INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER          2/28/03,
MA92        INSURANCE.                                                     2/1/04)
                                                                           (Modified
MA93        NON-PIP (PERIODIC INTERIM PAYMENT) CLAIM.                      6/30/03)


            DID NOT ENTER THE STATEMENT “ATTENDING PHYSICIAN NOT HOSPICE
            EMPLOYEE” ON THE CLAIM TO CERTIFY THAT THE RENDERING           Modified
MA94        PHYSICIAN IS NOT AN EMPLOYEE OF THE HOSPICE.                   8/1/05.
                                                                           (Modified
MA95        DE-ACTIVATE AND REFER TO M51.                                  2/28/03)
            CLAIM REJECTED. CODED AS A MEDICARE MANAGED CARE
            DEMONSTRATION BUT PATIENT IS NOT ENROLLED IN A MEDICARE
MA96        MANAGED CARE PLAN.
            MISSING/INCOMPLETE/INVALID MEDICARE MANAGED CARE               (Modified
MA97        DEMONSTRATION CONTRACT NUMBER.                                 2/28/03)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           (Deactivated
                                                                           eff.
            CLAIM REJECTED. DOES NOT CONTAIN THE CORRECT MEDICARE          10/16/2003.
            MANAGED CARE DEMONSTRATION CONTRACT NUMBER FOR THIS            Refer to MA
MA98        BENEFICIARY.                                                   97)
                                                                           (Modified
MA99        MISSING/INCOMPLETE/INVALID MEDIGAP INFORMATION.                2/28/03)
            MISSING/INCOMPLETE/INVALID DATE OF CURRENT ILLNESS, INJURY     (Modified
MA100       OR PREGNANCY.                                                  2/28/03)
            A SKILLED NURSING FACILITY (SNF) IS RESPONSIBLE FOR PAYMENT
            OF OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES TO    (Modified
MA101       RESIDENTS.                                                     6/30/03)



                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
            MISSING/INCOMPLETE/INVALID NAME OR PROVIDER IDENTIFIER FOR     eff. 8/1/04.
MA102       THE RENDERING/REFERRING/ORDERING/SUPERVISING PROVIDER.         Refer to M68)
MA103       HEMOPHILIA ADD ON.

                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
                                                                           eff.
                                                                           1/31/2004.
            MISSING/INCOMPLETE/INVALID DATE THE PATIENT WAS LAST SEEN OR   Use M128 or
MA104       THE PROVIDER IDENTIFIER OF THE ATTENDING PHYSICIAN.            M57)
            MISSING/INCOMPLETE/INVALID PROVIDER NUMBER FOR THIS PLACE OF   (Modified
MA105       SERVICE.                                                       2/28/03)
                                                                           (Modified
MA106       PIP (PERIODIC INTERIM PAYMENT) CLAIM.                          6/30/03)
            PAPER CLAIM CONTAINS MORE THAN THREE SEPARATE DATA ITEMS IN
MA107       FIELD 19.

MA108       PAPER CLAIM CONTAINS MORE THAN ONE DATA ITEM IN FIELD 23.
            CLAIM PROCESSED IN ACCORDANCE WITH AMBULATORY SURGICAL
MA109       GUIDELINES.


            MISSING/INCOMPLETE/INVALID INFORMATION ON WHETHER THE
            DIAGNOSTIC TEST(S) WERE PERFORMED BY AN OUTSIDE ENTITY OR IF   (Modified
MA110       NO PURCHASED TESTS ARE INCLUDED ON THE CLAIM.                  2/28/03)

            MISSING/INCOMPLETE/INVALID PURCHASE PRICE OF THE TEST(S)       (Modified
MA111       AND/OR THE PERFORMING LABORATORY'S NAME AND ADDRESS.           2/28/03)
                                                                           (Modified
MA112       MISSING/INCOMPLETE/INVALID GROUP PRACTICE INFORMATION.         2/28/03)


            INCOMPLETE/INVALID TAXPAYER IDENTIFICATION NUMBER (TIN)
            SUBMITTED BY YOU PER THE INTERNAL REVENUE SERVICE. YOUR
            CLAIMS CANNOT BE PROCESSED WITHOUT YOUR CORRECT TIN, AND YOU
            MAY NOT BILL THE PATIENT PENDING CORRECTION OF YOUR TIN.
            THERE ARE NO APPEAL RIGHTS FOR UNPROCESSABLE CLAIMS, BUT YOU
            MAY RESUBMIT THIS CLAIM AFTER YOU HAVE NOTIFIED THIS OFFICE
MA113       OF YOUR CORRECT TIN.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            MISSING/INCOMPLETE/INVALID INFORMATION ON WHERE THE SERVICES   (Modified
MA114       WERE FURNISHED.                                                2/28/03)


            MISSING/INCOMPLETE/INVALID PHYSICAL LOCATION (NAME AND
            ADDRESS, OR PIN) WHERE THE SERVICE(S) WERE RENDERED IN A       (Modified
MA115       HEALTH PROFESSIONAL SHORTAGE AREA (HPSA).                      2/28/03)
            DID NOT COMPLETE THE STATEMENT "HOMEBOUND" ON THE CLAIM TO
            VALIDATE WHETHER LABORATORY SERVICES WERE PERFORMED AT HOME    (Reactivated
MA116       OR IN AN INSTITUTION.                                          4/1/04)
MA117       THIS CLAIM HAS BEEN ASSESSED A $1.00 USER FEE.


            COINSURANCE AND/OR DEDUCTIBLE AMOUNTS APPLY TO A CLAIM FOR
            SERVICES OR SUPPLIES FURNISHED TO A MEDICARE-ELIGIBLE
            VETERAN THROUGH A FACILITY OF THE DEPARTMENT OF VETERANS
MA118       AFFAIRS. NO MEDICARE PAYMENT ISSUED.


                                                                           Deactivated
                                                                           eff. 5/1/08.
                                                                           Refer to
            PROVIDER LEVEL ADJUSTMENT FOR LATE CLAIM FILING APPLIES TO     Reason Code
MA119       THIS CLAIM.                                                    B4.
                                                                           (Modified
MA120       MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER.          2/28/03)
                                                                           (Modified
                                                                           2/28/03,
                                                                           6/30/03,
MA121       MISSING/INCOMPLETE/INVALID X-RAY DATE.                         2/1/04)
                                                                           (Modified
                                                                           2/28/03,
MA122       MISSING/INCOMPLETE/INVALID INITIAL TREATMENT DATE.             12/2/04)

            YOUR CENTER WAS NOT SELECTED TO PARTICIPATE IN THIS STUDY,
MA123       THEREFORE, WE CANNOT PAY FOR THESE SERVICES.

                                                                           (Deactivated
                                                                           eff.
                                                                           1/31/2004.
                                                                           Refer to
                                                                           Reason Code
MA124       PROCESSED FOR IME ONLY.                                        74)
            PER LEGISLATION GOVERNING THIS PROGRAM, PAYMENT CONSTITUTES
MA125       PAYMENT IN FULL.
            PANCREAS TRANSPLANT NOT COVERED UNLESS KIDNEY TRANSPLANT       (New Code
MA126       PERFORMED.                                                     10/12/01)

                                                                           Deactivated
MA127       RESERVED FOR FUTURE USE.                                       eff. 6/2/05.
                                                                           (Modified
                                                                           2/28/03,
MA128       MISSING/INCOMPLETE/INVALID FDA APPROVAL NUMBER.                3/30/05)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

                                                                           (Modified
                                                                           2/28/03.
                                                                           Deactivated
                                                                           eff
                                                                           1/31/2004.
                                                                           Refer to
                                                                           MA120 and
            THIS PROVIDER WAS NOT CERTIFIED FOR THIS PROCEDURE ON THIS     Reason Code
MA129       DATE OF SERVICE.                                               B7)
            YOUR CLAIM CONTAINS INCOMPLETE AND/OR INVALID INFORMATION,
            AND NO APPEAL RIGHTS ARE AFFORDED BECAUSE THE CLAIM IS
            UNPROCESSABLE. PLEASE SUBMIT A NEW CLAIM WITH THE
MA130       COMPLETE/CORRECT INFORMATION.
            PHYSICIAN ALREADY PAID FOR SERVICES IN CONJUNCTION WITH THIS
            DEMONSTRATION CLAIM. YOU MUST HAVE THE PHYSICIAN WITHDRAW
            THAT CLAIM AND REFUND THE PAYMENT BEFORE WE CAN PROCESS YOUR
MA131       CLAIM.
MA132       ADJUSTMENT TO THE PRE-DEMONSTRATION RATE.
            CLAIM OVERLAPS INPATIENT STAY. REBILL ONLY THOSE SERVICES
MA133       RENDERED OUTSIDE THE INPATIENT STAY.
            MISSING/INCOMPLETE/INVALID PROVIDER NUMBER OF THE FACILITY
MA134       WHERE THE PATIENT RESIDES.


            ALERT: YOU MAY APPEAL THIS DECISION IN WRITING WITHIN THE
            REQUIRED TIME LIMITS FOLLOWING RECEIPT OF THIS NOTICE BY       (Modified
            FOLLOWING THE INSTRUCTIONS INCLUDED IN YOUR CONTRACT OR PLAN   2/28/03,
N1          BENEFIT DOCUMENTS.                                             4/1/07)

            THIS ALLOWANCE HAS BEEN MADE IN ACCORDANCE WITH THE MOST
N2          APPROPRIATE COURSE OF TREATMENT PROVISION OF THE PLAN.
                                                                           (Modified
N3          MISSING CONSENT FORM.                                          2/28/03)
                                                                           (Modified
N4          MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER EOB.        2/28/03)

N5          EOB RECEIVED FROM PREVIOUS PAYER.    CLAIM NOT ON FILE.
            UNDER FEHB LAW (U.S.C. 8904(B)), WE CANNOT PAY MORE FOR
            COVERED CARE THAN THE AMOUNT MEDICARE WOULD HAVE ALLOWED IF
            THE PATIENT WERE ENROLLED IN MEDICARE PART A AND/OR MEDICARE   (Modified
N6          PART B.                                                        2/28/03)
            PROCESSING OF THIS CLAIM/SERVICE HAS INCLUDED CONSIDERATION
N7          UNDER MAJOR MEDICAL PROVISIONS.


            CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM
            DATA NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO
N8          PROVIDE ADEQUATE DATA FOR ADJUDICATION.
            ADJUSTMENT REPRESENTS THE ESTIMATED AMOUNT A PREVIOUS PAYER    Modified
N9          MAY PAY.                                                       11/18/05.
            CLAIM/SERVICE ADJUSTED BASED ON THE FINDINGS OF A REVIEW
            ORGANIZATION/PROFESSIONAL CONSULT/MANUAL                       (Modified
N10         ADJUDICATION/MEDICAL OR DENTAL ADVISOR.                        10/31/02)
N11         DENIAL REVERSED BECAUSE OF MEDICAL REVIEW.




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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            POLICY PROVIDES COVERAGE SUPPLEMENTAL TO MEDICARE. AS MEMBER
            DOES NOT APPEAR TO BE ENROLLED IN THE APPLICABLE PART OF
            MEDICARE, THE MEMBER RESPONSIBLE FOR PAYMENT OF THE PORTION    Modified
N12         OF THE CHARGE THAT WOULD HAVE BEEN COVERED BY MEDICARE.        8/1/07.
            PAYMENT BASED ON PROFESSIONAL/TECHNICAL COMPONENT
N13         MODIFIER(S).


                                                                           Deactivated
                                                                           eff. 10/1/07.
                                                                           Refer to
            PAYMENT BASED ON A CONTRACTUAL AMOUNT OR AGREEMENT, FEE        reason code
N14         SCHEDULE, OR MAXIMUM ALLOWABLE AMOUNT.                         45.
N15         SERVICES FOR A NEWBORN MUST BE BILLED SEPARATELY.
            FAMILY/MEMBER OUT-OF-POCKET MAXIMUM HAS BEEN MET. PAYMENT
N16         BASED ON A HIGHER PERCENTAGE.



                                                                           (Deactivated
                                                                           eff. 8/1/04.
                                                                           Refer to
N17         PER ADMISSION DEDUCTIBLE.                                      Reason Code 1)


                                                                           (Deactivated
                                                                           eff.
                                                                           1/31/2004.
N18         PAYMENT BASED ON THE MEDICARE ALLOWED AMOUNT.                  Refer to N14)
N19         PROCEDURE CODE INCIDENTAL TO PRIMARY PROCEDURE.
            SERVICE NOT PAYABLE WITH OTHER SERVICE RENDERED ON THE SAME
N20         DATE.
            ATTN: YOUR LINE ITEM HAS BEEN SEPARATED INTO MULTIPLE LINES    Modified
N21         TO EXPEDITE HANDLING.                                          4/1/07.
                                                                           (Modified
            THIS PROCEDURE CODE WAS ADDED/CHANGED BECAUSE IT MORE          10/31/02,
N22         ACCURATELY DESCRIBES THE SERVICES RENDERED.                    2/28/03)
            PATIENT LIABILITY MAY BE AFFECTED DUE TO COORDINATION OF
            BENEFITS WITH OTHER CARRIERS AND/OR MAXIMUM BENEFIT            (Modified
N23         PROVISIONS.                                                    8/13/01)
            MISSING/INCOMPLETE/INVALID ELECTRONIC FUNDS TRANSFER (EFT)     (Modified
N24         BANKING INFORMATION.                                           2/28/03)


            THIS COMPANY HAS BEEN CONTRACTED BY YOUR BENEFIT PLAN TO
            PROVIDE ADMINISTRATIVE CLAIMS PAYMENT SERVICES ONLY. THIS
            COMPANY DOES NOT ASSUME FINANCIAL RISK OR OBLIGATION WITH
N25         RESPECT TO CLAIMS PROCESSED ON BEHALF OF YOUR BENEFIT PLAN.
                                                                           (Modified
N26         MISSING ITEMIZED BILL.                                         2/28/03)
                                                                           (Modified
N27         MISSING/INCOMPLETE/INVALID TREATMENT NUMBER.                   2/28/03)
N28         CONSENT FORM REQUIREMENTS NOT FULFILLED.
                                                                           (Modified
            MISSING/INCOMPLETE/INVALID                                     2/28/03,
N29         DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART.               8/1/05)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           (Modified
N30         PATIENT INELIGIBLE FOR THIS SERVICE.                           6/30/03)
                                                                           (Modified
                                                                           2/28/03,
N31         MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER.    12/2/04)
            CLAIM MUST BE SUBMITTED BY THE PROVIDER WHO RENDERED THE       (Modified
N32         SERVICE.                                                       6/30/03)

N33         NO RECORD OF HEALTH CHECK PRIOR TO INITIATION OF TREATMENT.
                                                                           Modified
N34         INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE.                  11/18/05.
N35         PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION.
            CLAIM MUST MEET PRIMARY PAYER’S PROCESSING REQUIREMENTS
N36         BEFORE WE CAN CONSIDER PAYMENT.
                                                                           (Modified
N37         MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER.                2/28/03)



                                                                           Deactivated
                                                                           eff. 2/5/05.
N38         MISSING/INCOMPLETE/INVALID PLACE OF SERVICE.                   Refer to M77.

N39         PROCEDURE CODE IS NOT COMPATIBLE WITH TOOTH NUMBER/LETTER.
                                                                           (Modified
                                                                           2/28/03,
                                                                           6/30/03,
N40         MISSING X-RAY.                                                 2/1/04)

                                                                           (Deactivated
                                                                           eff.
                                                                           10/16/2003.
                                                                           Refer to
                                                                           Reason Code
N41         AUTHORIZATION REQUEST DENIED.                                  39)
N42         NO RECORD OF MENTAL HEALTH ASSESSMENT.
N43         BED HOLD OR LEAVE DAYS EXCEEDED.

                                                                           (Deactivated
                                                                           eff.
                                                                           10/16/2003.
            PAYER’S SHARE OF REGULATORY SURCHARGES, ASSESSMENTS,           Refer to
            ALLOWANCES OR HEALTH CARE-RELATED TAXES PAID DIRECTLY TO THE   Reason Code
N44         REGULATORY AUTHORITY.                                          137)
N45         PAYMENT BASED ON AUTHORIZED AMOUNT.
N46         MISSING/INCOMPLETE/INVALID ADMISSION HOUR.
N47         CLAIM CONFLICTS WITH ANOTHER INPATIENT STAY.
            CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED
N48         FROM OTHER INSURANCE CARRIER.

N49         COURT ORDERED COVERAGE INFORMATION NEEDS VALIDATION.
                                                                           (Modified
N50         MISSING/INCOMPLETE/INVALID DISCHARGE INFORMATION.              2/28/03)
            ELECTRONIC INTERCHANGE AGREEMENT NOT ON FILE FOR
N51         PROVIDER/SUBMITTER.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            PATIENT NOT ENROLLED IN THE BILLING PROVIDER'S MANAGED CARE
N52         PLAN ON THE DATE OF SERVICE.
                                                                           (Modified
N53         MISSING/INCOMPLETE/INVALID POINT OF PICK-UP ADDRESS.           2/28/03)
            CLAIM INFORMATION IS INCONSISTENT WITH PRE-
N54         CERTIFIED/AUTHORIZED SERVICES.

            PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING
N55         PROVIDERS WERE NOT FOLLOWED.
            PROCEDURE CODE BILLED IS NOT CORRECT/VALID FOR THE SERVICES    (Modified
N56         BILLED OR THE DATE OF SERVICE BILLED.                          2/28/03)
                                                                           (Modified
                                                                           2/28/03,
N57         MISSING/INCOMPLETE/INVALID PRESCRIBING DATE.                   12/2/04)
                                                                           (Modified
N58         MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT.           2/28/03)
            ATTN: PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL      Modified
N59         PROGRAM AND PROVIDER INFORMATION.                              4/1/07.


                                                                           (Deactivated
                                                                           eff.
            A VALID NDC IS REQUIRED FOR PAYMENT OF DRUG CLAIMS EFFECTIVE   1/31/2004.
N60         OCTOBER 02.                                                    Refer to M119)
N61         REBILL SERVICES ON SEPARATE CLAIMS.
            INPATIENT ADMISSION SPANS MULTIPLE RATE PERIODS.   RESUBMIT
N62         SEPARATE CLAIMS.
N63         REBILL SERVICES ON SEPARATE CLAIM LINES.
N64         THE “FROM” AND “TO” DATES MUST BE DIFFERENT.

            PROCEDURE CODE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED,   (Modified
N65         OR WAS NOT ON FILE, FOR THE DATE OF SERVICE/PROVIDER.          2/28/03)



                                                                           Deactivated
                                                                           eff. 2/5/05.
                                                                           Refer to N29
N66         MISSING/INCOMPLETE/INVALID DOCUMENTATION.                      or N225.




            PROFESSIONAL PROVIDER SERVICES NOT PAID SEPARATELY.
            INCLUDED IN FACILITY PAYMENT UNDER A DEMONSTRATION PROJECT.
            APPLY TO THAT FACILITY FOR PAYMENT, OR RESUBMIT YOUR CLAIM
            IF: THE FACILITY NOTIFIES YOU THE PATIENT WAS EXCLUDED FROM
            THIS DEMONSTRATION; OR IF YOU FURNISHED THESE SERVICES IN
            ANOTHER LOCATION ON THE DATE OF THE PATIENT’S ADMISSION OR
            DISCHARGE FROM A DEMONSTRATION HOSPITAL. IF SERVICES WERE
            FURNISHED IN A FACILITY NOT INVOLVED IN THE DEMONSTRATION ON
            THE SAME DATE THE PATIENT WAS DISCHARGED FROM OR ADMITTED TO
            A DEMONSTRATION FACILITY, YOU MUST REPORT THE PROVIDER ID
N67         NUMBER FOR THE NON-DEMONSTRATION FACILITY ON THE NEW CLAIM.




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES


            PRIOR PAYMENT BEING CANCELLED AS WE WERE SUBSEQUENTLY
            NOTIFIED THIS PATIENT WAS COVERED BY A DEMONSTRATION PROJECT
            IN THIS SITE OF SERVICE. PROFESSIONAL SERVICES WERE
            INCLUDED IN THE PAYMENT MADE TO THE FACILITY. YOU MUST
            CONTACT THE FACILITY FOR YOUR PAYMENT. PRIOR PAYMENT MADE
            TO YOU BY THE PATIENT OR ANOTHER INSURER FOR THIS CLAIM MUST
N68         BE REFUNDED TO THE PAYER WITHIN 30 DAYS.

            PPS (PROSPECTIVE PAYMENT SYSTEM) CODE CHANGED BY CLAIMS        (Modified
N69         PROCESSING SYSTEM. INSUFFICIENT VISITS OR THERAPIES.           6/30/03)
                                                                           (Modified
                                                                           2/28/02,
N70         CONSOLIDATED BILLING AND PAYMENT APPLIES.                      11/5/07)


            YOUR UNASSIGNED CLAIM FOR A DRUG OR BIOLOGICAL, CLINICAL
            DIAGNOSTIC LABORATORY SERVICES OR AMBULANCE SERVICE WAS        (Modified
            PROCESSED AS AN ASSIGNED CLAIM. YOU ARE REQUIRED BY LAW TO     2/21/02,
N71         ACCEPT ASSIGNMENT FOR THESE TYPES OF CLAIMS.                   6/30/03)

            PPS (PROSPECTIVE PAYMENT SYSTEM) CODE CHANGED BY MEDICAL       (Modified
N72         REVIEWERS. NOT SUPPORTED BY CLINICAL RECORDS.                  6/30/03)



                                                                           (Modified
                                                                           7/24/01,
                                                                           2/28/03.
                                                                           Deactivated
                                                                           eff. 1/31/04.
            A SKILLED NURSING FACILITY IS RESPONSIBLE FOR PAYMENT OF       Refer to
            OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES UNDER    MA101 and
N73         ARRANGEMENT TO ITS RESIDENTS.                                  N200)
            RESUBMIT WITH MULTIPLE CLAIMS, EACH CLAIM COVERING SERVICES
N74         PROVIDED IN ONLY ONE CALENDAR MONTH.
                                                                           (Modified
N75         MISSING/INCOMPLETE/INVALID TOOTH SURFACE INFORMATION.          2/28/03)
                                                                           (Modified
N76         MISSING/INCOMPLETE/INVALID NUMBER OF RIDERS.                   2/28/03)
                                                                           (Modified
N77         MISSING/INCOMPLETE/INVALID DESIGNATED PROVIDER NUMBER.         2/28/03)
            THE NECESSARY COMPONENTS OF THE CHILD AND TEEN CHECKUP
N78         (EPSDT) WERE NOT COMPLETED.
            SERVICE BILLED IS NOT COMPATIBLE WITH PATIENT LOCATION
N79         INFORMATION.
                                                                           (Modified
N80         MISSING/INCOMPLETE/INVALID PRENATAL SCREENING INFORMATION.     2/28/03)

N81         PROCEDURE BILLED IS NOT COMPATIBLE WITH TOOTH SURFACE CODE.
            PROVIDER MUST ACCEPT INSURANCE PAYMENT AS PAYMENT IN FULL
            WHEN A THIRD PARTY PAYER CONTRACT SPECIFIES FULL
N82         REIMBURSEMENT.
            NO APPEAL RIGHTS. ADJUDICATIVE DECISION BASED ON THE
N83         PROVISIONS OF A DEMONSTRATION PROJECT.
                                                                           Modified
N84         ALERT: FURTHER INSTALLMENT PAYMENTS FORTHCOMING.               8/1/07




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           Modified
N85         ALERT: THIS IS THE FINAL INSTALLMENT PAYMENT.                  8/1/07


            A FAILED TRIAL OF PELVIC MUSCLE EXERCISE TRAINING IS
            REQUIRED IN ORDER FOR BIOFEEDBACK TRAINING FOR THE TREATMENT
N86         OF URINARY INCONTINENCE TO BE COVERED.
N87         HOME USE OF BIOFEEDBACK THERAPY IS NOT COVERED.



            ALERT: THIS PAYMENT IS BEING MADE CONDITIONALLY. AN HHA
            EPISODE OF CARE NOTICE HAS BEEN FILED FOR THIS PATIENT. WHEN
            A PATIENT IS TREATED UNDER A HHA EPISODE OF CARE,
            CONSOLIDATED BILLING REQUIRES THAT CERTAIN THERAPY SERVICES
            AND SUPPLIES, SUCH AS THIS, BE INCLUDED IN THE HHA'S
            PAYMENT. THIS PAYMENT WILL NEED TO BE RECOUPED FROM YOU IF
            WE ESTABLISH THAT THE PATIENT IS CONCURRENTLY RECEIVING        Modified
N88         TREATMENT UNDER A HHA EPISODE OF CARE.                         4/1/07.
            ALERT: PAYMENT INFORMATION FOR THIS CLAIM HAS BEEN FORWARDED
            TO MORE THAN ONE OTHER PAYER, BUT FORMAT LIMITATIONS PERMIT
            ONLY ONE OF THE SECONDARY PAYERS TO BE IDENTIFIED IN THIS      Modified
N89         REMITTANCE ADVICE.                                             4/1/07.

N90         COVERED ONLY WHEN PERFORMED BY THE ATTENDING PHYSICIAN.
N91         SERVICES NOT INCLUDED IN THE APPEAL REVIEW.

N92         THIS FACILITY IS NOT CERTIFIED FOR DIGITAL MAMMOGRAPHY.
            A SEPARATE CLAIM MUST BE SUBMITTED FOR EACH PLACE OF
            SERVICE. SERVICES FURNISHED AT MULTIPLE SITES MAY NOT BE
N93         BILLED IN THE SAME CLAIM.
            CLAIM/SERVICE DENIED BECAUSE A MORE SPECIFIC TAXONOMY CODE
N94         IS REQUIRED FOR ADJUDICATION.
                                                                           (New code
                                                                           7/31/01,
            THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS        Modified
N95         SERVICE.                                                       2/28/03)


            PATIENT MUST BE REFRACTORY TO CONVENTIONAL THERAPY
            (DOCUMENTED BEHAVIORAL, PHARMACOLOGIC AND/OR SURGICAL
            CORRECTIVE THERAPY) AND BE AN APPROPRIATE SURGICAL CANDIDATE   (New code
N96         SUCH THAT IMPLANTATION WITH ANESTHESIA CAN OCCUR.              8/24/01)


            PATIENTS WITH STRESS INCONTINENCE, URINARY OBSTRUCTION, AND
            SPECIFIC NEUROLOGIC DISEASES (E.G., DIABETES WITH PERIPHERAL
            NERVE INVOLVEMENT) WHICH ARE ASSOCIATED WITH SECONDARY         (New code
N97         MANIFESTATIONS OF THE ABOVE THREE INDICATIONS ARE EXCLUDED.    8/24/01)



            PATIENT MUST HAVE HAD A SUCCESSFUL TEST STIMULATION IN ORDER
            TO SUPPORT SUBSEQUENT IMPLANTATION. BEFORE A PATIENT IS
            ELIGIBLE FOR PERMANENT IMPLANTATION, HE/SHE MUST DEMONSTRATE
            A 50 PERCENT OR GREATER IMPROVEMENT THROUGH TEST              (New code
N98         STIMULATION. IMPROVEMENT IS MEASURED THROUGH VOIDING DIARIES. 8/24/01)




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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            PATIENT MUST BE ABLE TO DEMONSTRATE ADEQUATE ABILITY TO
            RECORD VOIDING DIARY DATA SUCH THAT CLINICAL RESULTS OF THE    (New code
N99         IMPLANT PROCEDURE CAN BE PROPERLY EVALUATED.                   8/24/01)
                                                                           (New code
                                                                           9/14/01.
            PPS (PROSPECT PAYMENT SYSTEM) CODE CORRECTED DURING            Modified
N100        ADJUDICATION.                                                  6/30/03)


            ADDITIONAL INFORMATION IS NEEDED IN ORDER TO PROCESS THIS
            CLAIM. PLEASE RESUBMIT THE CLAIM WITH THE IDENTIFICATION       (New code
            NUMBER OF THE PROVIDER WHERE THIS SERVICE TOOK PLACE. THE      10/16/01.
            MEDICARE NUMBER OF THE SITE OF SERVICE PROVIDER SHOULD BE      Deactivated
            PRECEDED WITH THE LETTERS "HSP" AND ENTERED INTO ITEM #32 ON   eff. 1/31/04.
            THE CLAIM FORM. YOU MAY BILL ONLY ONE SITE OF SERVICE          Refer to
N101        PROVIDER NUMBER PER CLAIM.                                     MA105))
            THIS CLAIM HAS BEEN DENIED WITHOUT REVIEWING THE MEDICAL
            RECORD BECAUSE THE REQUESTED RECORDS WERE NOT RECEIVED OR      (New code
N102        WERE NOT RECEIVED TIMELY.                                      10/31/01)



            SOCIAL SECURITY RECORDS INDICATE THAT THIS PATIENT WAS A
            PRISONER WHEN THE SERVICE WAS RENDERED. THIS PAYER DOES NOT
            COVER ITEMS AND SERVICES FURNISHED TO AN INDIVIDUAL WHILE
            THEY ARE IN STATE OR LOCAL CUSTODY UNDER A PENAL AUTHORITY,    (New code
            UNLESS UNDER STATE OR LOCAL LAW, THE INDIVIDUAL IS             12/05/01,
            PERSONALLY LIABLE FOR THE COST OF HIS OR HER HEALTH CARE       Modified
            WHILE INCARCERATED AND THE STATE OR LOCAL GOVERNMENT PURSUES   4/8/02,
            SUCH DEBT IN THE SAME WAY AND WITH THE SAME VIGOR AS ANY       2/28/03,
N103        OTHER DEBT.                                                    6/30/03)
            THIS CLAIM/SERVICE IS NOT PAYABLE UNDER OUR CLAIMS             (New code
            JURISDICTION AREA. YOU CAN IDENTIFY THE CORRECT MEDICARE       1/29/02,
            CONTRACTOR TO PROCESS THIS CLAIM/SERVICE THROUGH THE CMS       Modified
N104        WEBSITE AT WWW.CMS.HHS.GOV.                                    10/31/02)


            THIS IS A MISDIRECTED CLAIM/SERVICE FOR AN RRB BENEFICIARY.
            SUBMIT PAPER CLAIMS TO THE RRB CARRIER: PALMETTO GBA, P.O.
            BOX 10066, AUGUSTA, GA 30999. CALL 866-749-4301 FOR RRB EDI    (New code
N105        INFORMATION FOR ELECTRONIC CLAIMS PROCESSING.                  1/29/02)


            PAYMENT FOR SERVICES FURNISHED TO SKILLED NURSING FACILITY
            (SNF) INPATIENTS (EXCEPT FOR EXCLUDED SERVICES) CAN ONLY BE
            MADE TO THE SNF. YOU MUST REQUEST PAYMENT FROM THE SNF         (New code
N106        RATHER THAN THE PATIENT FOR THIS SERVICE.                      1/31/02)


            SERVICES FURNISHED TO SKILLED NURSING FACILITY (SNF)
            INPATIENTS MUST BE BILLED ON THE INPATIENT CLAIM. THEY         (New code
N107        CANNOT BE BILLED SEPARATELY AS OUTPATIENT SERVICES.            1/31/02)
                                                                           (Modified
N108        MISSING/INCOMPLETE/INVALID UPGRADE INFORMATION.                2/28/03)
            THIS CLAIM WAS CHOSEN FOR COMPLEX REVIEW AND WAS DENIED        (New Code
N109        AFTER REVIEWING THE MEDICAL RECORDS.                           2/26/02)
                                                                           (New Code
N110        THIS FACILITY IS NOT CERTIFIED FOR FILM MAMMOGRAPHY.           2/28/02)




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835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            NO APPEAL RIGHT EXCEPT DUPLICATE CLAIM/SERVICE ISSUE. THIS
            SERVICE WAS INCLUDED IN A CLAIM THAT HAS BEEN PREVIOUSLY       (New Code
N111        BILLED AND ADJUDICATED.                                        2/28/02)
            THIS CLAIM IS EXCLUDED FROM YOUR ELECTRONIC REMITTANCE         (New Code
N112        ADVICE.                                                        2/28/02)
                                                                           (New Code
                                                                           4/16/02.
            ONLY ONE INITIAL VISIT IS COVERED PER PHYSICIAN, GROUP         Modified
N113        PRACTICE OR PROVIDER.                                          6/30/03)


            DURING THE TRANSITION TO THE AMBULANCE FEE SCHEDULE, PAYMENT
            IS BASED ON THE LESSER OF A BLENDED AMOUNT CALCULATED USING
            A PERCENTAGE OF THE REASONABLE CHARGE/COST AND FEE SCHEDULE
            AMOUNTS, OR THE SUBMITTED CHARGE FOR THE SERVICE. YOU WILL
            BE NOTIFIED YEARLY WHAT THE PERCENTAGES FOR THE BLENDED        (New Code
N114        PAYMENT CALCULATION WILL BE.                                   5/30/02)


            THIS DECISION WAS BASED ON A LOCAL MEDICAL REVIEW POLICY
            (LMRP) OR LOCAL COVERAGE DETERMINATION (LCD). AN LMRP/LCD      (New Code
            PROVIDES A GUIDE TO ASSIST IN DETERMINING WHETHER A            6/26/02.
            PARTICULAR ITEM OR SERVICE IS COVERED. A COPY OF THIS          Modified
            POLICY IS AVAILABLE AT HTTP://WWW.CMS.HHS.GOV/MCD, OR IF YOU   9/16/02,
            DO NOT HAVE WEB ACCESS, YOU MAY CONTACT THE CONTRACTOR TO      6/30/03,
N115        REQUEST A COPY OF THE LMRP/LCD.                                4/4/04)



            THIS PAYMENT IS BEING MADE CONDITIONALLY BECAUSE THE SERVICE
            WAS PROVIDED IN THE HOME, AND IT IS POSSIBLE THAT THE
            PATIENT IS UNDER A HOME HEALTH EPISODE OF CARE. WHEN A
            PATIENT IS TREATED UNDER A HOME HEALTH EPISODE OF CARE,
            CONSOLIDATED BILLING REQUIRES THAT CERTAIN THERAPY SERVICES
            AND SUPPLIES, SUCH AS THIS, BE INCLUDED IN THE HOME HEALTH
            AGENCY’S (HHA’S) PAYMENT. THIS PAYMENT WILL NEED TO BE
            RECOUPED FROM YOU IF WE ESTABLISH THAT THE PATIENT IS
            CONCURRENTLY RECEIVING TREATMENT UNDER AN HHA EPISODE OF       (New Code
N116        CARE.                                                          6/30/02)
                                                                           (New Code
                                                                           7/30/02.
                                                                           Modified
N117        THIS SERVICE IS PAID ONLY ONCE IN A PATIENT'S LIFETIME.        6/30/03)
            THIS SERVICE IS NOT PAID IF BILLED MORE THAN ONCE EVERY 28     (New Code
N118        DAYS.                                                          7/30/02)


            THIS SERVICE IS NOT PAID IF BILLED ONCE EVERY 28 DAYS, AND     (New Code
            THE PATIENT HAS SPENT 5 OR MORE CONSECUTIVE DAYS IN ANY        7/30/02.
            INPATIENT OR SKILLED/NURSING FACILITY (SNF) WITHIN THOSE 28    Modified
N119        DAYS.                                                          6/30/03)
                                                                           (New Code
            PAYMENT IS SUBJECT TO HOME HEALTH PROSPECTIVE PAYMENT SYSTEM   8/9/02.
            PARTIAL EPISODE PAYMENT ADJUSTMENT. PATIENT WAS                Modified
N120        TRANSFERRED/DISCHARGED/READMITTED DURING PAYMENT EPISODE.      6/30/03)

                                                                           (New Code
                                                                           9/9/02.
            MEDICARE PART B DOES NOT PAY FOR ITEMS OR SERVICES PROVIDED    Modified
            BY THIS TYPE OF PRACTITIONER FOR BENEFICIARIES IN A MEDICARE   6/30/03,
N121        PART A COVERED SKILLED NURSING FACILITY (SNF) STAY.            8/1/04)



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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           (New Code
                                                                           9/12/02,
N122        ADD-ON CODE CANNOT BE BILLED BY ITSELF.                        8/1/05)
            THIS IS A SPLIT SERVICE AND REPRESENTS A PORTION OF THE        (New Code
N123        UNITS FROM THE ORIGINALLY SUBMITTED SERVICE.                   9/24/02)




            PAYMENT HAS BEEN DENIED FOR THE/MADE ONLY FOR A LESS
            EXTENSIVE SERVICE/ITEM BECAUSE THE INFORMATION FURNISHED
            DOES NOT SUBSTANTIATE THE NEED FOR THE (MORE EXTENSIVE)
            SERVICE/ITEM. THE PATIENT IS LIABLE FOR THE CHARGES FOR THIS
            SERVICE/ITEM AS YOU INFORMED THE PATIENT IN WRITING BEFORE
            THE SERVICE/ITEM WAS FURNISHED THAT WE WOULD NOT PAY FOR IT,   (New Code
N124        AND THE PATIENT AGREED TO PAY.                                 9/26/02)




            PAYMENT HAS BEEN (DENIED FOR THE/MADE ONLY FOR A LESS
            EXTENSIVE) SERVICE/ITEM BECAUSE THE INFORMATION FURNISHED
            DOES NOT SUBSTANTIATE THE NEED FOR THE (MORE EXTENSIVE)
            SERVICE/ITEM. IF YOU HAVE COLLECTED ANY AMOUNT FROM THE
            PATIENT, YOU MUST REFUND THAT AMOUNT TO THE PATIENT WITHIN
            30 DAYS OF RECEIVING THIS NOTICE. THE REQUIREMENTS FOR A
            REFUND ARE IN 1834(A)(18) OF THE SOCIAL SECURITY ACT (AND IN
            1834(J)(4) AND 1879(H) BY CROSS-REFERENCE TO 1834(A)(18)).
            SECTION 1834(A)(18)(B) SPECIFIES THAT SUPPLIERS WHICH
            KNOWINGLY AND WILLFULLY FAIL TO MAKE APPROPRIATE REFUNDS MAY
            BE SUBJECT TO CIVIL MONEY PENALTIES AND/OR EXLUSION FROM THE   New Code
            MEDICARE PROGRAM. IF YOU HAVE ANY QUESTIONS ABOUT THIS         9/26/02,
N125        NOTICE, PLEASE CONTACT THIS OFFICE.                            8/1/05)


            SOCIAL SECURITY RECORDS INDICATE THAT THIS INDIVIDUAL HAS
            BEEN DEPORTED. THIS PAYER DOES NOT COVER ITEMS AND SERVICES    (New Code
N126        FURNISHED TO INDIVIDUALS WHO HAVE BEEN DEPORTED.               10/17/02)
            THIS IS A MISDIRECTED CLAIM/SERVICE FOR A UNITED MINE          (New Code
            WORKERS OF AMERICA (UMWA) BENEFICIARY. PLEASE SUBMIT CLAIMS    10/31/02,
N127        TO THEM.                                                       8/1/04)
            THIS AMOUNT REPRESENTS THE PRIOR TO COVERAGE PORTION OF THE    (New Code
N128        ALLOWANCE.                                                     10/31/02)
                                                                           (New Code
                                                                           10/31/02,
N129        NOT ELIGIBLE DUE TO THE PATIENT'S AGE.                         8/1/07)
                                                                           (New Code
            ALERT: CONSULT PLAN BENEFIT DOCUMENTS FOR INFORMATION ABOUT    10/31/02,
N130        RESTRICTIONS FOR THIS SERVICE.                                 4/1/07)
            TOTAL PAYMENTS UNDER MULTIPLE CONTRACTS CANNOT EXCEED THE      (New Code
N131        ALLOWANCE FOR THIS SERVICE.                                    10/31/02)


            ALERT: PAYMENTS WILL CEASE FOR SERVICES RENDERED BY THIS US    (New Code
            GOVERNMENT DEBARRED OR EXCLUDED PROVIDER AFTER THE 30 DAY      10/31/02,
N132        GRACE PERIOD AS PREVIOUSLY NOTIFIED.                           4/1/07)
                                                                           (New Code
            ALERT: SERVICES FOR PREDETERMINATION AND SERVICES REQUESTING   10/31/02,
N133        PAYMENT ARE BEING PROCESSED SEPARATELY.                        4/1/07)




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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
            ALERT: THIS REPRESENTS YOUR SCHEDULED PAYMENT FOR THIS         (New Code
            SERVICE. IF TREATMENT HAS BEEN DISCONTINUED, PLEASE CONTACT    10/31/02,
N134        CUSTOMER SERVICE.                                              4/1/07)
            RECORD FEES ARE THE PATIENT'S RESPONSIBILITY AND LIMITED TO    (New Code
N135        THE SPECIFIED CO-PAYMENT.                                      10/31/02)


            ALERT: TO OBTAIN INFORMATION ON THE PROCESS TO FILE AN         (New Code
            APPEAL IN ARIZONA, CALL THE DEPARTMENT'S CONSUMER ASSISTANCE   10/31/02,
N136        OFFICE AT (602) 912-8444 OR (800) 325-2548.                    4/1/07)




            ALERT: THE PROVIDER ACTING ON THE MEMBER'S BEHALF, MAY FILE
            AN APPEAL WITH THE PAYER. THE PROVIDER ACTING ON THE
            MEMBER'S BEHALF, MAY FILE A COMPLAINT WITH THE STATE
            REGULATORY AUTHORITY WITHOUT FIRST FILING AN APPEAL, IF THE
            COVERAGE DECISION INVOLVES AN URGENT CONDITION FOR WHICH       (New Code
            CARE HAS NOT BEEN RENDERED. THE ADDRESS MAY BE OBTAINED FROM   10/31/02,
N137        THE STATE INSURANCE REGULATORY AUTHORITY.                      4/1/07)


            ALERT: IN THE EVENT YOU DISAGREE WITH THE DENTAL ADVISOR'S
            OPINION AND HAVE ADDITIONAL INFORMATION RELATIVE TO THE
            CASE, YOU MAY SUBMIT RADIOGRAPHS TO THE DENTAL ADVISOR UNIT    (New Code
            AT THE SUBSCRIBER'S DENTAL INSURANCE CARRIER FOR A SECOND      10/31/02,
N138        INDEPENDENT DENTAL ADVISOR REVIEW.                             4/1/07)




            ALERT: UNDER THE CODE OF FEDERAL REGULATIONS, CHAPTER 32,
            SECTION 199.13 A NON-PARTICIPATING PROVIDER IS NOT AN
            APPROPRIATE APPEALING PARTY. THEREFORE, IF YOU DISAGREE WITH
            THE DENTAL ADVISOR'S OPINION, YOU MAY APPEAL THE
            DETERMINATION IF APPOINTED IN WRITING, BY THE BENEFICIARY,
            TO ACT AS HIS/HER REPRESENTATIVE. SHOULD YOU BE APPOINTED AS
            A REPRESENTATIVE, SUBMIT A COPY OF THIS LETTER, A SIGNED
            STATEMENT EXPLAINING THE MATTER IN WHICH YOU DISAGREE, AND
            ANY RADIOGRAPHS AND RELEVANT INFORMATION TO THE SUBSCRIBER'S   (New Code
            DENTAL INSURANCE CARRIER WITHIN 90 DAYS FROM THE DATE OF       10/31/02,
N139        THIS LETTER.                                                   4/1/07)




            ALERT: YOU HAVE NOT BEEN DESIGNATED AS AN AUTHORIZED OCONUS
            PROVIDER THEREFORE ARE NOT CONSIDERED AN APPROPRIATE
            APPEALING PARTY. IF THE BENEFICIARY HAS APPOINTED YOU, IN
            WRITING, TO ACT AS HIS/HER REPRESENTATIVE AND YOU DISAGREE
            WITH THE DENTAL ADVISOR'S OPINION, YOU MAY APPEAL BY
            SUBMITTING A COPY OF THIS LETTER, A SIGNED STATEMENT
            EXPLAINING THE MATTER IN WHICH YOU DISAGREE, AND ANY           (New Code
            RELEVANT INFORMATION TO THE SUBSCRIBER'S DENTAL INSURANCE      10/31/02,
N140        CARRIER WITHIN 90 DAYS FROM THE DATE OF THIS LETTER.           4/1/07)

            THE PATIENT WAS NOT RESIDING IN A LONG-TERM CARE FACILITY      (New Code
N141        DURING ALL OR PART OF THE SERVICE DATES BILLED.                10/31/02)
            THE ORIGINAL CLAIM WAS DENIED.   RESUBMIT A NEW CLAIM, NOT A   (New Code
N142        REPLACEMENT CLAIM.                                             10/31/02)
            THE PATIENT WAS NOT IN A HOSPICE PROGRAM DURING ALL OR PART    (New Code
N143        OF THE SERVICE DATES BILLED.                                   10/31/02)



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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES
                                                                           New Code
N144        THE RATE CHANGED DURING THE DATES OF SERVICE BILLED.           10/31/02)

            MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THIS        Deactivated
N145        PLACE OF SERVICE.                                              eff. 6/2/05.
                                                                           (New Code
                                                                           10/31/02,
N146        MISSING SCREENING DOCUMENT.                                    8/1/04)


            LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE
            DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING,           (New Code
N147        INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST.              10/31/02)
                                                                           (New Code
N148        MISSING/INCOMPLETE/INVALID DATE OF LAST MENSTRUAL PERIOD.      10/31/02)
                                                                           (New Code
N149        REBILL ALL APPLICABLE SERVICES ON A SINGLE CLAIM.              10/31/02)
                                                                           (New Code
N150        MISSING/INCOMPLETE/INVALID MODEL NUMBER.                       10/31/02)
            TELEPHONE CONTACT SERVICES WILL NOT BE PAID UNTIL THE FACE-    (New Code
N151        TO-FACE CONTACT REQUIREMENT HAS BEEN MET.                      10/31/02)
                                                                           (New Code
N152        MISSING/INCOMPLETE/INVALID REPLACEMENT CLAIM INFORMATION.      10/31/02)
                                                                           (New Code
N153        MISSING/INCOMPLETE/INVALID ROOM AND BOARD RATE.                10/31/02)
                                                                           (New Code
            ALERT: THIS PAYMENT WAS DELAYED FOR CORRECTION OF PROVIDER'S   10/31/02,
N154        MAILING ADDRESS.                                               4/1/07)
            ALERT: OUR RECORDS DO NOT INDICATE THAT OTHER INSURANCE IS     (New Code
            ON FILE. PLEASE SUBMIT OTHER INSURANCE INFORMATION FOR OUR     10/31/02,
N155        RECORDS.                                                       4/1/07)
                                                                           (New Code
            ALERT: THE PATIENT IS RESPONSIBLE FOR THE DIFFERENCE BETWEEN   10/31/02,
N156        THE APPROVED TREATMENT AND THE ELECTIVE TREATMENT.             4/1/07)
                                                                           (New Code
                                                                           2/28/03.
                                                                           Modified
N157        TRANSPORTATION TO/FROM THIS DESTINATION IS NOT COVERED.        2/1/04)
            TRANSPORTATION IN A VEHICLE OTHER THAN AN AMBULANCE IS NOT     (New Code
N158        COVERED.                                                       2/28/03)
            PAYMENT DENIED/REDUCED BECAUSE MILEAGE IS NOT COVERED WHEN     (New Code
N159        THE PATIENT IS NOT IN THE AMBULANCE.                           2/28/03)
                                                                           (New Code
                                                                           2/28/03.
            THE PATIENT MUST CHOOSE AN OPTION BEFORE A PAYMENT CAN BE      Modified
N160        MADE FOR THIS PROCEDURE/EQUIPMENT/SUPPLY/SERVICE.              2/1/04)
            THIS DRUG/SERVICE/SUPPLY IS COVERED ONLY WHEN THE ASSOCIATED   (New Code
N161        SERVICE IS COVERED.                                            2/28/03)

            ALERT: ALTHOUGH YOUR CLAIM WAS PAID, YOU HAVE BILLED FOR A
            TEST/SPECIALTY NOT INCLUDED IN YOUR LABORATORY
            CERTIFICATION. YOUR FAILURE TO CORRECT THE LABORATORY          (New Code
            CERTIFICATION INFORMATION WILL RESULT IN A DENIAL OF PAYMENT   2/28/03,
N162        IN THE NEAR FUTURE.                                            4/1/07)
            MEDICAL RECORD DOES NOT SUPPORT CODE BILLED PER THE CODE       (New Code
N163        DEFINITION.                                                    2/28/03)




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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES


                                                                           (New Code
                                                                           2/28/03.
                                                                           Deactivated
                                                                           eff. 1/31/04.
N164        TRANSPORTATION TO/FROM THIS DESTINATION IS NOT COVERED.        Refer to N157)



                                                                           (New Code
                                                                           2/28/03.
                                                                           Deactivated
            TRANSPORTATION IN A VEHICLE OTHER THAN AN AMBULANCE IS NOT     eff. 1/31/04.
N165        COVERED.                                                       Refer to N158)



                                                                           (New Code
                                                                           2/28/03.
                                                                           Deactivated
            PAYMENT DENIED/REDUCED BECAUSE MILEAGE IS NOT COVERED WHEN     eff. 1/31/04.
N166        THE PATIENT IS NOT IN THE AMBULANCE.                           Refer to N159)
                                                                           (New Code
N167        CHARGES EXCEED THE POST-TRANSPLANT COVERAGE LIMIT.             2/28/03)



                                                                           (New Code
                                                                           2/28/03.
                                                                           Deactivated
            THE PATIENT MUST CHOOSE AN OPTION BEFORE A PAYMENT CAN BE      eff. 1/31/04.
N168        MADE FOR THIS PROCEDURE/EQUIPMENT/SUPPLY/SERVICE.              Refer to N160)



                                                                           (New Code
                                                                           2/28/03.
                                                                           Deactivated
            THIS DRUG/SERVICE/SUPPLY IS COVERED ONLY WHEN THE ASSOCIATED   eff. 1/31/04.
N169        SERVICE IS COVERED.                                            Refer to N161)
            A NEW/REVISED/RENEWED CERTIFICATE OF MEDICAL NECESSITY IS      (New Code
N170        NEEDED.                                                        2/28/03)
            PAYMENT FOR REPAIR OR REPLACEMENT IS NOT COVERED OR HAS        (New Code
N171        EXCEEDED THE PURCHASE PRICE.                                   2/28/03)
            THE PATIENT IS NOT LIABLE FOR THE DENIED/ADJUSTED CHARGE(S)    (New Code
N172        FOR RECEIVING ANY UPDATED SERVICE/ITEM.                        2/28/03)
            NO QUALIFYING HOSPITAL STAY DATES WERE PROVIDED FOR THIS       (New Code
N173        EPISODE OF CARE.                                               2/28/03)


            THIS IS NOT A COVERED SERVICE/PROCEDURE/ EQUIPMENT/BED,
            HOWEVER PATIENT LIABILITY IS LIMITED TO AMOUNTS SHOWN IN THE   (New Code
N174        ADJUSTMENTS UNDER GROUP 'PR'.                                  2/28/03)
                                                                           (New Code
                                                                           2/28/03,
N175        MISSING REVIEW ORGANIZATION APPROVAL.                          2/29/08)




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REMARK CODE 835 REMITTANCE REMARK CODE                                     NOTES

            SERVICES PROVIDED ABOARD A SHIP ARE COVERED ONLY WHEN THE
            SHIP IS OF UNITED STATES REGISTRY AND IS IN UNITED STATES
            WATERS. IN ADDITION, A DOCTOR LICENSED TO PRACTICE IN THE      (New Code
N176        UNITED STATES MUST PROVIDE THE SERVICE.                        2/28/03)

                                                                           (New Code
                                                                           2/28/03.
            ALERT: WE DID NOT SEND THIS CLAIM TO PATIENT’S OTHER           Modified
            INSURER. THEY HAVE INDICATED NO ADDITIONAL PAYMENT CAN BE      6/30/03,
N177        MADE.                                                          4/1/07)
                                                                           (New Code
                                                                           2/28/03,
N178        MISSING PRE-OPERATIVE PHOTOS OR VISUAL FIELD RESULTS.          8/1/04)
            ADDITIONAL INFORMATION HAS BEEN REQUESTED FROM THE MEMBER.
            THE CHARGES WILL BE RECONSIDERED UPON RECEIPT OF THAT          (New Code
N179        INFORMATION.                                                   2/28/03)
            THIS ITEM OR SERVICE DOES NOT MEET THE CRITERIA FOR THE        (New Code
N180        CATEGORY UNDER WHICH IT WAS BILLED.                            2/28/03)
                                                                           (New Code
            ADDITIONAL INFORMATION HAS BEEN REQUESTED FROM ANOTHER         2/28/03,
N181        PROVIDER INVOLVED IN THIS SERVICE.                             12/1/06)
            THIS CLAIM/SERVICE MUST BE BILLED ACCORDING TO THE SCHEDULE    (New Code
N182        FOR THIS PLAN.                                                 2/28/03)


            ALERT: THIS IS A PREDETERMINATION ADVISORY MESSAGE, WHEN
            THIS SERVICE IS SUBMITTED FOR PAYMENT ADDITIONAL               (New Code
            DOCUMENTATION AS SPECIFIED IN PLAN DOCUMENTS WILL BE           2/28/03,
N183        REQUIRED TO PROCESS BENEFITS.                                  4/1/07)
                                                                           (New Code
N184        REBILL TECHNICAL AND PROFESSIONAL COMPONENTS SEPARATELY.       2/28/03)
                                                                           (New Code
                                                                           2/28/03,
N185        ALERT: DO NOT RESUBMIT THIS CLAIM/SERVICE.                     4/1/07)
            NON-AVAILABILITY STATEMENT (NAS) REQUIRED FOR THIS SERVICE.
            CONTACT THE NEAREST MILITARY TREATMENT FACILITY (MTF) FOR      (New Code
N186        ASSISTANCE.                                                    2/28/03)
            ALERT: YOU MAY REQUEST A REVIEW IN WRITING WITHIN THE
            REQUIRED TIME LIMITS FOLLOWING RECEIPT OF THIS NOTICE BY       (New Code
            FOLLOWING THE INSTRUCTIONS INCLUDED IN YOUR CONTRACT OR PLAN   2/28/03,
N187        BENEFIT DOCUMENTS.                                             4/1/07)
            THE APPROVED LEVEL OF CARE DOES NOT MATCH THE PROCEDURE CODE   (New Code
N188        SUBMITTED.                                                     2/28/03)
                                                                           (New Code
            ALERT: THIS SERVICE HAS BEEN PAID AS A ONE-TIME EXCEPTION TO   2/28/03,
N189        THE PLAN'S BENEFIT RESTRICTIONS.                               4/1/07)
                                                                           (New Code
                                                                           2/28/03,
N190        MISSING CONTRACT INDICATOR.                                    8/1/04)
            THE PROVIDER MUST UPDATE INSURANCE INFORMATION DIRECTLY WITH   (New Code
N191        PAYER.                                                         2/28/03)
                                                                           (New Code
N192        PATIENT IS A MEDICAID/QUALIFIED MEDICARE BENEFICIARY.          2/28/03)
            SPECIFIC FEDERAL/STATE/LOCAL PROGRAM MAY COVER THIS SERVICE    (New Code
N193        THROUGH ANOTHER PAYER.                                         2/28/03)




6/16/2011                                    Page 65
                                  835 Remittance Remark Master




835 REMIT
REMARK CODE 835 REMITTANCE REMARK CODE                                  NOTES
            TECHNICAL COMPONENT NOT PAID IF PROVIDER DOES NOT OWN THE   (New Code
N194        EQUIPMENT USED.                                             2/28/03)
                                                                        (New Code
N195        THE TECHNICAL COMPONENT MUST BE BILLED SEPARATELY.          2/28/03)
                                                                        (New Code
            ALERT: PATIENT ELIGIBLE TO APPLY FOR OTHER COVERAGE WHICH   2/28/03,
N196        MAY BE PRIMARY.                                             4/1/07)
            THE SUBSCRIBER MUST UPDATE INSURANCE INFORMATION DIRECTLY   (New Code
N197        WITH PAYER.                                                 2/28/03)
            RENDERING PROVIDER MUST BE AFFILIATED WITH THE PAY-TO       (New Code
N198        PROVIDER.                                                   2/28/03)
                                                                        (New Code
            ADDITIONAL PAYMENT/RECOUPMENT APPROVED BASED ON PAYER-      2/28/03,
N199        INITIATED REVIEW/AUDIT.                                     8/1/06)
                                                                        (New Code
N200        THE PROFESSIONAL COMPONENT MUST BE BILLED SEPARATELY.       2/28/03)
            A MENTAL HEALTH FACILITY IS RESPONSIBLE FOR PAYMENT OF
            OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES TO    (New Code
N201        RESIDENTS.                                                  2/28/03)




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                                                                               EOB TO 277 & 835



                                       835                                               835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                               STATUS
001   DETAIL FROM DATE OF SERVICE      16       CLAIM/SERVICE LACKS INFORMATION WHICH    M52      MISSING/INCOMPLETE/INVALID “FROM”         188
      MISSING/ INVALID                          IS NEEDED FOR ADJUDICATION.                       DATE(S) OF SERVICE.
002   THE ADMITTING DATE OF SERVICE    16       CLAIM/SERVICE LACKS INFORMATION WHICH    MA40     MISSING/INCOMPLETE/INVALID ADMISSION      189
      IS MISSING OR INVALID.                    IS NEEDED FOR ADJUDICATION.                       DATE.

003   THE TO SERVICE DATE IS INVALID. 16        CLAIM/SERVICE LACKS INFORMATION WHICH    M59      MISSING/INCOMPLETE/INVALID “TO” DATE(S)   188
                                                IS NEEDED FOR ADJUDICATION.                       OF SERVICE.
004   DATES OF SERVICE SPAN STATE      A1       CLAIM DENIED CHARGES.                    MA31     MISSING/INCOMPLETE/INVALID BEGINNING      187
      FISCAL YEAR. PLEASE SUBMIT 2                                                                AND ENDING DATES OF THE PERIOD BILLED.
      SEPARATE BILLS.


005   DATE OF DELIVERY/SURGERY DOES    16       CLAIM/SERVICE LACKS INFORMATION WHICH    MA31     MISSING/INCOMPLETE/INVALID BEGINNING      187
      NOT CORRESPOND WITH HOSPITAL              IS NEEDED FOR ADJUDICATION.                       AND ENDING DATES OF THE PERIOD BILLED.
      STAY
006   THE DISCHARGE DATE OF SERVICE    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N50      MISSING/INCOMPLETE/INVALID DISCHARGE      190
      IS MISSING OR INVALID.                    IS NEEDED FOR ADJUDICATION.                       INFORMATION.

007   TOTAL DAYS NOT EQUAL TO THE                                                        MA32     MISSING/INCOMPLETE/INVALID NUMBER OF      188
      DIFFERENCE BETWEEN THE "FROM"                                                               COVERED DAYS DURING THE BILLING PERIOD.
      AND "TO" DATES.
008   THIS REQUEST FOR PAYMENT WAS     29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                      9
      RECEIVED BEYOND 185 DAYS
      MEDICAL BILLING LIMITATION.


009   THIS CLAIM WAS RECEIVED BEYOND   29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                      9
      THE 12 MONTH CLAIM SUBMISSION
      LIMITATION.
010   LEAVE OF ABSENCE DAYS NOT        96       NON-COVERED CHARGE(S).                   N43      BED HOLD OR LEAVE DAYS EXCEEDED.          498
      COVERED
011   MEDICARE PAID DATE INVALID.      129      PRIOR PROCESSING INFORMATION APPEARS                                                        21
                                                INCORRECT.
012   INPATIENT CLAIM MISSING A        16       CLAIM/SERVICE LACKS INFORMATION WHICH    M44      MISSING/INCOMPLETE/INVALID CONDITION      460
      REQUIRED CONDITION CODE.                  IS NEEDED FOR ADJUDICATION.                       CODE.
      REQUIRED CONDITION CODES ARE
      AB, AN, OR AX.
013   SERVICE INCLUDED IN FEE FOR      97       THE BENEFIT FOR THIS SERVICE IS                                                             247
      HOSPITAL VISIT                            INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


014   CLAIM STILL IN PROCESS.                                                            N185     DO NOT RESUBMIT THIS CLAIM/SERVICE.       20
      PLEASE DO NOT REBILL.
015   STATE RECORDS INDICATE LEVEL    16        CLAIM/SERVICE LACKS INFORMATION WHICH    N188     THE APPROVED LEVEL OF CARE DOES NOT
      OF CARE (LOC) AS --. TAKE NO              IS NEEDED FOR ADJUDICATION.                       MATCH THE PROCEDURE CODE SUBMITTED.
      ACTION IF CHANGE HAS BEEN MADE.


016   LOA CODE IS MISSING OR INVALID. 16        CLAIM/SERVICE LACKS INFORMATION WHICH    N225     INCOMPLETE/INVALID                       21
                                                IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                               STATUS
017   INSUFFICIENT OR INVALID DATA     16       CLAIM/SERVICE LACKS INFORMATION WHICH      M44      MISSING/INCOMPLETE/INVALID CONDITION      460
      FOR THE CONDITION CODE AB/80.             IS NEEDED FOR ADJUDICATION.                         CODE.
      INDICATES MISSING OR INVALID
      TYPE OF RECIPIENT SEX, AGE
      RANGE OF RECIPIENT, OR DIAG.
      CODES.


018   DUPLICATE NUTRITIONAL FORMULA    18       DUPLICATE CLAIM/SERVICE.                                                                      54
      PROCEDURES NOT REIMBURSEABLE
      ON THE SAME OR OVERLAPPING
      DATES OF SERVICE.


019   DOCUMENTATION INADEQUATE.        16       CLAIM/SERVICE LACKS INFORMATION WHICH      N29      MISSING/INCOMPLETE/INVALID               21
                                                IS NEEDED FOR ADJUDICATION.                         DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                    T/CHART.
020   NO LINE ITEMS PRESENT ON THE     16       CLAIM/SERVICE LACKS INFORMATION WHICH      N26      MISSING ITEMIZED BILL.                    247
      CLAIM.                                    IS NEEDED FOR ADJUDICATION.
021   TPL AMOUNT PRESENT ON THE        16       CLAIM/SERVICE LACKS INFORMATION WHICH      MA92     MISSING/INCOMPLETE/INVALID PLAN           171
      CLAIM; NO INSURANCE COMPANY               IS NEEDED FOR ADJUDICATION.                         INFORMATION FOR OTHER INSURANCE.
      INFORMATION PRESENT.


022   COVERED DAYS FORMAT INVALID.                                                         MA32     MISSING/INCOMPLETE/INVALID NUMBER OF      456
                                                                                                    COVERED DAYS DURING THE BILLING PERIOD.

023   LEAVE OF ABSENCE DAYS CUTBACK                                                        N43      BED HOLD OR LEAVE DAYS EXCEEDED.          456
      TO ALLOWED NUMBER OF DAYS PER
      STATE GUIDELINES.


024   TOTAL BILLED DOES NOT EQUAL                                                          M54      MISSING/INCOMPLETE/INVALID TOTAL          400
      SUM OF DETAILS                                                                                CHARGES.
025   PATIENT STATUS CODE IS MISSING   16       CLAIM/SERVICE LACKS INFORMATION WHICH      MA43     MISSING/INCOMPLETE/INVALID PATIENT        234
      OR INVALID.                               IS NEEDED FOR ADJUDICATION.                         STATUS.
026   ENTER TOS 8 IN FIELD C WHEN      16       CLAIM/SERVICE LACKS INFORMATION WHICH      MA67     CORRECTION TO A PRIOR CLAIM.              250
      BILLING FOR ASSISTANT SURGEON.            IS NEEDED FOR ADJUDICATION.

027   REPORT ATTACHED DOES NOT         16       CLAIM/SERVICE LACKS INFORMATION WHICH      N225     INCOMPLETE/INVALID                       294
      DESCRIBE PROCEDURE BILLED.                IS NEEDED FOR ADJUDICATION.                         DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                    T/CHART.
028   PRIOR AUTHORIZATION IS          197       PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                      252
      REQUIRED FOR ASSISTANT SURGEON.           ION ABSENT.

029   THIS AMOUNT WILL BE DEDUCTED     23       THE IMPACT OF PRIOR PAYER(S)
      FROM FUTURE CLAIMS PROCESSING             ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                ADJUSTMENTS.
030   RECOUPMENT OF OUR PRIOR          23       THE IMPACT OF PRIOR PAYER(S)                                                                  101
      PAYMENT HAS BEEN MADE.                    ADJUDICATION INCLUDING PAYMENTS AND/OR
      RESUBMIT THE CLAIM WITH A COPY            ADJUSTMENTS.
      OF THE MEDICARE EXPLANATION OF
      BENEFITS.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                              STATUS
031   PA WAS REQUESTED FOR INCORRECT   15       THE AUTHORIZATION NUMBER IS MISSING,                                                         84
      PROCEDURE CODE - PLEASE                   INVALID, OR DOES NOT APPLY TO THE
      CONTACT UTILIZATION REVIEW,               BILLED SERVICES OR PROVIDER.
      ADEMS
032   INVALID DATA FOR THE CONDITION 16         CLAIM/SERVICE LACKS INFORMATION WHICH      M44      MISSING/INCOMPLETE/INVALID CONDITION     460
      CODE AN. THE ADMISSION DATA               IS NEEDED FOR ADJUDICATION.                         CODE.
      IS NOT EQUAL TO THE BIRTH DATE.


033   THIS PAYMENT, SUPPLEMENTED BY    22       THIS CARE MAY BE COVERED BY ANOTHER                                                          65
      A PREVIOUS PAYMENT MADE BY                PAYER PER COORDINATION OF BENEFITS.
      MEDICARE, CONSTITUTES THE
      TOTAL PAYMENT.


034   SERVICE NOT PAYABLE TO POST                                                          N30      PATIENT INELIGIBLE FOR THIS SERVICE.     109
      STERILIZED RECIPIENTS
035   VERIFY UNITS OF SERVICE ON       154      PAYER DEEMS THE INFORMATION SUBMITTED      M53      MISSING/INCOMPLETE/INVALID DAYS OR       476
      CLAIM FORM                                DOES NOT SUPPORT THIS DAY'S SUPPLY.                 UNITS OF SERVICE.

036   UNITS OF SERVICE ARE INCORRECT   16       CLAIM/SERVICE LACKS INFORMATION WHICH      M53      MISSING/INCOMPLETE/INVALID DAYS OR       476
      ON CLAIM FORM                             IS NEEDED FOR ADJUDICATION.                         UNITS OF SERVICE.
037   STAND BY FOR ANESTHESIA SHOULD   125      SUBMISSION/BILLING ERROR(S).               MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL     84
      BE BILLED AS DETENTION TIME,                                                                  PROCEDURE CODE.
      NOT AS ANESTHESIA


038   WAIVER SERVICES PROCEDURES                                                           MA31     MISSING/INCOMPLETE/INVALID BEGINNING     188
      BEGIN/END DATES NOT SAME MONTH                                                                AND ENDING DATES OF THE PERIOD BILLED.

039   INAPPROPRIATE CLAIM FORM FOR                                                         N34      INCORRECT CLAIM FORM/FORMAT FOR THIS     481
      PROCEDURE CODE                                                                                SERVICE.
040   TYPE OF SERVICE IS MISSING OR    16       CLAIM/SERVICE LACKS INFORMATION WHICH      MA67     CORRECTION TO A PRIOR CLAIM.             250
      INVALID.                                  IS NEEDED FOR ADJUDICATION. ADDITIONAL
                                                INFORMATION IS SUPPLIED USING
                                                REMITTANCE ADVICE REMARKS CODES
                                                WHENEVER APPROPRIATE.


041   TYPE OF SERVICE OR PROCEDURE     16       CLAIM/SERVICE LACKS INFORMATION WHICH      N56      PROCEDURE CODE BILLED IS NOT             250
      IS INVALID.                               IS NEEDED FOR ADJUDICATION. ADDITIONAL              CORRECT/VALID FOR THE SERVICES BILLED
                                                INFORMATION IS SUPPLIED USING                       OR THE DATE OF SERVICE BILLED.
                                                REMITTANCE ADVICE REMARKS CODES
                                                WHENEVER APPROPRIATE.


042   PLEASE DO NOT REBILL. CLAIM IS   133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                        46
      BEING REVIEWED BY MEDICAL                 IS PENDING FURTHER REVIEW.
      CONSULTANT.
043   PA REQUIRED FOR UNITS            197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                     252
      EXCEEDING 64 PER MONTH                    ION ABSENT.
044   OTHER INSURANCE AMOUNT IS        23       THE IMPACT OF PRIOR PAYER(S)                                                                 171
      GREATER THAN THE TOTAL BILLED.            ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                ADJUSTMENTS.




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                                                                               EOB TO 277 & 835



                                       835                                                835                                             277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                            STATUS
045   MEDICARE DENIED THIS CLAIM. IF                                                      N45      PAYMENT BASED ON AUTHORIZED AMOUNT.    481
      THE SERVICE IS COVERED BY
      ARKANSAS MEDICAID, YOU MAY
      SUBMIT A MEDICAID CLAIM TO EDS


046   EMERGENCY DEPARTMENT SUPPLIES,   40       CHARGES DO NOT MEET QUALIFICATIONS FOR                                                    84
      DRUGS AND INJECTIONS ARE NOT              EMERGENT/URGENT CARE.
      ALLOWED WITHOUT AN EMERGENCY
      DEPARTMENT ROOM CHARGE ON THE
      SAME DATE.


047   PATIENTS UNMET LIABILITY         142      MONTHLY MEDICAID PATIENT LIABILITY                                                        106
      EXCEEDS CLAIM ALLOWED AMOUNT              AMOUNT.

048   CLAIM PAYMENT REDUCED DUE TO     142      MONTHLY MEDICAID PATIENT LIABILITY                                                        68
      RECIPIENTS' UNMET LIABILITY               AMOUNT.
      AMOUNT
049   EPSDT INTER/PERIODIC SCREEN      B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                      107
      NON-PAYABLE 7 DAYS                        MET OR WERE EXCEEDED.
      BEFORE/AFTER FULL MEDICAL
      SCREEN
050   FULL MEDICAL SCREEN NON-         B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                      107
      PAYABLE 7 DAYS BEFORE/AFTER               MET OR WERE EXCEEDED.
      EPSDT INTER/PERIODIC SCREEN


051   EXCEEDS LIMIT OF 60 SERVICE      B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                      483
      COORDINATION PER STATE FISCAL             MET OR WERE EXCEEDED.
      YEAR
052   EXCEEDS LIMIT OF 16 SERVICE      B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                      483
      PLAN UPDATING UNITS PER STATE             MET OR WERE EXCEEDED.
      FISCAL YEAR


053   POST-OP VISITS FOR SAME                                                             M144     PRE-/POST-OPERATIVE CARE PAYMENT IS    107
      PRIMARY DETAIL DX AS THIS                                                                    INCLUDED IN THE ALLOWANCE FOR THE
      SURGICAL PROCEDURE HAVE BEEN                                                                 SURGERY/PROCEDURE.
      PAID TO SAME/DIFFERENT
      PROVIDER; SUBMIT ADJUSTMENT IF
      APPLICABLE


054   PROCEDURE NOT COVERED FOR        96       NON-COVERED CHARGE(S).                    MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL   475
      RECIPIENTS AGE 21 OR OLDER                                                                   PROCEDURE CODE.
055   FACILITY PROVIDER ID MISSING     171      PAYMENT IS DENIED WHEN PERFORMED/BILLED                                                   132
      OR INVALID                                BY THIS TYPE OF PROVIDER IN THIS TYPE
                                                OF FACILITY.


056   PERS LIMITED TO 31 UNITS PER     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      MONTH.                                    OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                   Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
057   ADULT FOSTER CARE LIMITED TO      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      31 UNITS PER MONTH.                        OCCURRENCE HAS BEEN REACHED.

058   CLAIM IN ADJUDICATION.   PLEASE                                                     N185     DO NOT RESUBMIT THIS CLAIM/SERVICE.      3
      DO NOT REBILL.
059   CLAIM BEING REVIEWED BY           133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                      46
      PHARMACY CONSULTANT. PLEASE                IS PENDING FURTHER REVIEW.
      DO NOT REBILL.
060   SPANNING DOS. DOS MUST BE                                                           N61      REBILL SERVICES ON SEPARATE CLAIMS.      187
      SPECIFIC TO DAY SERVICE
      RENDERED. PLEASE RESUBMIT.


061   PAID IN FULL BY MEDICAID.                                                           N45      PAYMENT BASED ON AUTHORIZED AMOUNT.      67

062   ADULT SERVICES - LIMITED TO       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      155 UNITS PER CALENDAR MONTH               OCCURRENCE HAS BEEN REACHED.

063   MEDICAL SUPPLIES OR DIAPERS/                                                        N74      RESUBMIT WITH MULTIPLE CLAIMS, EACH      187
      UNDERPADS CANNOT SPAN CALENDAR                                                               CLAIM COVERING SERVICES PROVIDED IN
      MONTHS                                                                                       ONLY ONE CALENDAR MONTH.


064   EXCEEDS BENEFIT LIMIT OF TWO      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ULTRASOUND PROCEDURES PER                  OCCURRENCE HAS BEEN REACHED.
      NINE-MONTH PERIOD.


065   RESPITE CARE CUT BACK TO 14       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     456
      CONSECUTIVE DAYS                           OCCURRENCE HAS BEEN REACHED.

066   ARKIDS FIRST-B PARTICIPANT        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      CUMULATIVE ALLOWED EXCEEDS                 OCCURRENCE HAS BEEN REACHED.
      $500 PER STATE FISCAL YEAR
      FOR DME.
067   ARKIDS FIRST-B PARTICIPANT        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EXCEEDED $125 LIMIT FOR                    OCCURRENCE HAS BEEN REACHED.
      MEDICAL SUPPLIES.


068   EXCEEDS BENEFIT LIMIT OF FIVE     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      FETAL NON-STRESS TESTS PER                 OCCURRENCE HAS BEEN REACHED.
      NINE-MONTH PERIOD.


069   EXCEEDS PROGRAM LIMITATIONS.      B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                       483
                                                 MET OR WERE EXCEEDED.
070   NOT IN ACCORD WITH MEDICAL        96       NON-COVERED CHARGE(S).                   M16      ALERT: PLEASE SEE OUR WEB SITE,          9
      POLICY GUIDELINES.                                                                           MAILING, OR BULLETINS FOR MORE DETAILS
                                                                                                   CONCERNING THIS
                                                                                                   POLICY/PROCEDURE/DECISION.
071   EXCEEDS LIMIT OF FOUR UNITS     119        BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER WEEK FOR INDIVIDUAL OUTPT -            OCCURRENCE HAS BEEN REACHED.
       THERAPY SESSION




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
072   ONLY ONE PSYCHOTHERAPY VISIT     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      ALLOWED PER DATE OF SERVICE               OCCURRENCE HAS BEEN REACHED.
      PER RECIPIENT
073   LACKS JUSTIFICATION FOR          29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                       9
      WAITING TIME.
074   VENIPUNCTURE NON-PAYABLE SAME    97       THE BENEFIT FOR THIS SERVICE IS           M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    107
      DATE OF SERVICE AS LAB TEST               INCLUDED IN THE PAYMENT/ALLOWANCE FOR              MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                ANOTHER SERVICE/PROCEDURE THAT HAS                 SET TIME FRAME.
                                                ALREADY BEEN ADJUDICATED.


075   EXCEEDED 720 UNITS PER 12        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    N182     THIS CLAIM/SERVICE MUST BE BILLED        483
      MONTH PERIOD FOR RESPITE CARE             OCCURRENCE HAS BEEN REACHED.                       ACCORDING TO THE SCHEDULE FOR THIS PLAN.

076   EXCEEDED 12 PROFESSIONAL         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       483
      OUTPATIENT HOSPITAL VISITS FOR            OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR


077   THERAPY SERVICES INDICATOR       16       CLAIM/SERVICE LACKS INFORMATION WHICH     MA114    MISSING/INCOMPLETE/INVALID INFORMATION    21
      AND/OR SCHOOL DISTRICT LEA                IS NEEDED FOR ADJUDICATION.                        ON WHERE THE SERVICES WERE FURNISHED.
      CODE MISSING/INVALID


078   BREASTCARE CLIENT - BREASTCARE   125      SUBMISSION/BILLING ERROR(S).              N182     THIS CLAIM/SERVICE MUST BE BILLED        9
      SERVICES MUST BE BILLED ON                                                                   ACCORDING TO THE SCHEDULE FOR THIS PLAN.
      BREASTCARE CLAIM.


079   BILLING PROVIDER - BREASTCARE    125      SUBMISSION/BILLING ERROR(S).              N182     THIS CLAIM/SERVICE MUST BE BILLED        9
      SERVICES MUST BE BILLED ON                                                                   ACCORDING TO THE SCHEDULE FOR THIS PLAN.
      BREASTCARE CLAIM.


080   PAID TO PHYSICIAN PROVIDING                                                         N32      CLAIM MUST BE SUBMITTED BY THE PROVIDER   65
      SERVICE.                                                                                     WHO RENDERED THE SERVICE.

081   DUPLICATE CHARGE. NO             18       DUPLICATE CLAIM/SERVICE.                  M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    54
      JUSTIFICATION TO SHOW MEDICAL                                                                MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      NECESSITY                                                                                    SET TIME FRAME.
082   PERFORMING PROVIDER -            125      SUBMISSION/BILLING ERROR(S).              N182     THIS CLAIM/SERVICE MUST BE BILLED        9
      BREASTCARE SERVICES MUST BE                                                                  ACCORDING TO THE SCHEDULE FOR THIS PLAN.
      BILLED ON BREASTCARE CLAIM.


083   EVALUATION LIMITED TO FOUR PER   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    483
      STATE FISCAL YEAR.                        OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
084   TRANSPORTATION SERVICES          107      THE RELATED OR QUALIFYING CLAIM/SERVICE                                                      42
      ALLOWED ONLY WHEN BILLED IN               WAS NOT IDENTIFIED ON THIS CLAIM.
      CONJUNCTION WITH A0370 OR
      A0427.
085   LEAVE OF ABSENCE DENIED PER      96       NON-COVERED CHARGE(S).                    N43      BED HOLD OR LEAVE DAYS EXCEEDED.          457
      MEDICAL GUIDELINES.




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                                                                               EOB TO 277 & 835



                                       835                                               835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                               STATUS
086   PA REQUIRED FOR ARKIDS FIRST-B   197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT M62      MISSING/INCOMPLETE/INVALID TREATMENT      483
      PARTICIPANTS EXCEEDING $500               ION ABSENT.                                       AUTHORIZATION CODE.
      LIMIT PER STATE FISCAL YEAR
      FOR MENTAL HEALTH SERVICES.


087   OPERATIVE REPORT THAT WAS                                                          M29      MISSING OPERATIVE REPORT.                 298
      ATTACHED DID NOT DESCRIBE THE
      PROCEDURE THAT WAS BILLED ON
      YOUR CLAIM.
088   ARKIDS FIRST-B PARTICIPANTS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EXCEEDED $2500 LIMIT PER STATE            OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR FOR MENTAL HEALTH
      SERVICES.


089   DIAGNOSIS/EVALUATION EXCEEDS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TWO PER STATE FISCAL YEAR                 OCCURRENCE HAS BEEN REACHED.

090   DAY OF DISCHARGE NOT COVERED.    96       NON-COVERED CHARGE(S).                   N50      MISSING/INCOMPLETE/INVALID DISCHARGE      190
                                                                                                  INFORMATION.
091   THERAPY SERVICES INDICATOR       16       CLAIM/SERVICE LACKS INFORMATION WHICH    N129     NOT ELIGIBLE DUE TO THE PATIENT'S AGE.    21
      INVALID FOR RECIPIENT'S AGE               IS NEEDED FOR ADJUDICATION.

092   THERAPY SERVICES INDICATOR       16       CLAIM/SERVICE LACKS INFORMATION WHICH    N95      THIS PROVIDER TYPE/PROVIDER SPECIALTY     21
      INVALID FOR PROVIDER TYPE                 IS NEEDED FOR ADJUDICATION.                       MAY NOT BILL THIS SERVICE.

093   EXCEEDS LIMIT OF FOUR            119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       483
      TREATMENTS PER STATE FISCAL               OCCURRENCE HAS BEEN REACHED.
      YEAR
094   SERVICES EXCEED LIMIT OF         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       483
      $75.00 PER DATE OF SERVICE                OCCURRENCE HAS BEEN REACHED.

095   THIS SERVICE WAS REVIEWED BY                                                       N10      CLAIM/SERVICE ADJUSTED BASED ON THE       107
      OUR MEDICAL CONSULTANT AND WAS                                                              FINDINGS OF A REVIEW
      DENIED.                                                                                     ORGANIZATION/PROFESSIONAL
                                                                                                  CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                  DENTAL ADVISOR.


096   THIS CLAIM TYPE CAN ONLY BE                                                        M117     NOT COVERED UNLESS SUBMITTED VIA          481
      BILLED USING AEVCS                                                                          ELECTRONIC CLAIM.
097   RECIPIENT HAS MEDICARE HMO.      109      CLAIM NOT COVERED BY THIS                MA04     SECONDARY PAYMENT CANNOT BE CONSIDERED    116
      BENEFITS LIMITED TO COPAYMENT             PAYER/CONTRACTOR. YOU MUST SEND THE               WITHOUT THE IDENTITY OF OR PAYMENT
      AMOUNTS ONLY. PLEASE FILE                 CLAIM TO THE CORRECT PAYER/CONTRACTOR.            INFORMATION FROM THE PRIMARY PAYER.
      MEDICARE HMO FIRST.                                                                         THE INFORMATION WAS EITHER NOT REPORTED
                                                                                                  OR WAS ILLEGIBLE.


098   SERVICE NOT PROVIDED UNDER THE   96       NON-COVERED CHARGE(S).                   N425     STATUTORILY EXCLUDED SERVICE(S).          107
      MEDICAID PROGRAM.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                             STATUS
099   CLAIM DENIED. VALID DATE OF      57       PAYMENT DENIED/REDUCED BECAUSE THE        N301     MISSING/INCOMPLETE/INVALID PROCEDURE    187
      SERVICE REQUIRED ON EACH                  PAYER DEEMS THE INFORMATION SUBMITTED              DATE(S).
      DETAIL.                                   DOES NOT SUPPORT THIS LEVEL OF SERVICE,
                                                THIS MANY SERVICES, THIS LENGTH OF
                                                SERVICE, THIS DOSAGE, OR THIS DAY'S
                                                SUPPLY.


100   SERVICES ARE NOT PAYABLE IN      A1       CLAIM DENIED CHARGES.                     N351     SERVICE DATE OUTSIDE OF THE APPROVED    9
      ADVANCE.                                                                                     TREATMENT PLAN SERVICE DATES.

101   JUSTIFICATION REQUIRED FOR       16       CLAIM/SERVICE LACKS INFORMATION WHICH     MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR   294
      SERVICES RENDERED.                        IS NEEDED FOR ADJUDICATION.                        INVALID INFORMATION, AND NO APPEAL
                                                                                                   RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                   IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                   CLAIM WITH THE COMPLETE/CORRECT
                                                                                                   INFORMATION.


102   THIS REQUEST FOR PAYMENT WAS     29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                     9
      RECEIVED BEYOND THE 185 DAYS
      LIMITATION FOR MEDICAID
      BILLING.
103   THIS CLAIM WAS RECEIVED BEYOND   29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                     9
      THE 12 MONTH SUBMISSION
      LIMITATION.
104   DIAGNOSIS/EVALUATION EXCEEDS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EIGHT PER STATE FISCAL YEAR               OCCURRENCE HAS BEEN REACHED.

105   DIAGNOSIS/EVALUATION EXCEEDS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      SIX PER STATE FISCAL YEAR                 OCCURRENCE HAS BEEN REACHED.

106   DIAGNOSIS/     EVALUATION        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EXCEEDS FOUR PER STATE FISCAL             OCCURRENCE HAS BEEN REACHED.
      YEAR
107   CHMS PROVIDERS CAN NOT BILL                                                         N61      REBILL SERVICES ON SEPARATE CLAIMS.     252
      SPANNING DATES OF SERVICE FOR
       RECIPIENTS REQUIRING AFMC
      PRIOR AUTHORIZATION FOR PART
      OF THE SERVICES BILLED.
      PLEASE SUBMIT AS SEPARATE
      DETAILS.


108   DETAIL BEGIN/END DATES MUST BE                                                      MA31     MISSING/ INCOMPLETE/INVALID BEGINNING   187
      IN SAME MONTH AND EQUAL NUMBER                                                               AND ENDING DATES OF SERVICE
      OF UNITS BILLED EACH DAY FOR
      SPAN DATES OF SERVICE


109   TIME NOT EQUAL TO UNITS,                                                            M53      MISSING/INCOMPLETE/INVALID DAYS OR      251
      CORRECT AND REFILE                                                                           UNITS OF SERVICE.




                                                                                                                                                    Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                                835                                                277
                                        ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB    EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
110    MEDICARE PAYMENT EXCEEDS         45       CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM      N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       9
       MEDICAID MAX ALLOWED FOR                  ALLOWABLE OR CONTRACTED/LEGISLTATED FEE
       PROCEDURE.RECIPIENT NOT                   ARRANGMENT. (USE GROUPE CODES PR OR CO
       RESPONSIBLE.                              DEPENDING ON LIABILITY).


111    PAYMENT AMOUNT ADDED TO CLAIMS   97       THE BENEFIT FOR THIS SERVICE IS                                                              65
       PAYMENT.                                  INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                 ALREADY BEEN ADJUDICATED.


112    RECOUPMENT - THIS AMOUNT IS      23       THE IMPACT OF PRIOR PAYER(S)                                                                 101
       WITHHELD FROM YOUR CHECK.                 ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                 ADJUSTMENTS.
113    REFUND CHECK AMOUNT CREDITED
       TO YOUR IRS YEAR TOTAL.

114    RETURNED CHECK AMOUNT CREDITED
       TO YOUR IRS YEAR TOTAL

115    PAYMENT APPLIED TO RECEIVABLE.   97       THE BENEFIT FOR THIS SERVICE IS                                                              65
                                                 INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                 ALREADY BEEN ADJUDICATED.


116    CLAIM IN PROCESS DUE TO REVIEW   133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                        20
       OF CLAIM HISTORY. PLEASE DO               IS PENDING FURTHER REVIEW.
       NOT RESUBMIT.
 117   INVALID NCCI BILLING             96       NON-COVERED CHARGE(S).                    N59      ATTN: PLEASE REFER TO YOUR PROVIDER       54
       COMBINATIONS - CMS ALLOWS                                                                    MANUAL FOR ADDITIONAL PROGRAM AND
       APPEAL.                                                                                      PROVIDER INFORMATION.
118    DENIED BY MEDICARE.                                                                                                                    9

119    NOT COVERED UNDER THE PROGRAM    96       NON-COVERED CHARGE(S).                    N78      THE NECESSARY COMPONENTS OF THE CHILD     107
       EXCEPT UNDER EPSDT.                                                                          AND TEEN CHECKUP (EPSDT) WERE NOT
                                                                                                    COMPLETED.
120    PROVIDER TYPE CAN ONLY BE A                                                         N32      CLAIM MUST BE SUBMITTED BY THE PROVIDER   84
       PERFORMING PROVIDER.                                                                         WHO RENDERED THE SERVICE.

121    THIS NEW BALANCE IS A                                                                                                                  101
       RECOUPMENT STILL OUTSTANDING.

122    INVALID/MULTIPLE PROVIDER        B7       THIS PROVIDER WAS NOT                     N55      PROCEDURES FOR BILLING WITH               145
       DISCIPLINE FOR PROVIDER                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS             GROUP/REFERRING/PERFORMING PROVIDERS
       SPECIALTY                                 PROCEDURE/SERVICE ON THIS DATE OF                  WERE NOT FOLLOWED.
                                                 SERVICE.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                               STATUS
123   INVALID DATA FOR THE CONDITION   17       REQUESTED INFORMATION WAS NOT PROVIDED     M44      MISSING/INCOMPLETE/INVALID CONDITION      460
      CODE AX/82. INDICATES INVALID             OR WAS INSUFFICINET/INCOMPLETE.                     CODE.
      TYPE OF RECIPIENT SEX, AGE
      RANGE OF RECIPIENT, DIAGNOSIS
      CODE, OR BIRTH DATE NOT EQUAL
      TO THE ADMISSION DATE.




124   ARKIDS FIRST-B PARTICIPANT       197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                      483
      CUMULATIVE ALLOWED AMOUNT                 ION ABSENT.
      EXCEEDS$500 PER SFY '98 FOR
      OUTPATIENT MENTAL AND
      BEHAVIORAL HEALTH SERVICES.
      PRIOR AUTHORIZATION REQUIRED.




125   THE TOOTH NUMBER IS MISSING OR   16       CLAIM/SERVICE LACKS INFORMATION WHICH      N37      MISSING/INCOMPLETE/INVALID TOOTH          244
      INVALID.                                  IS NEEDED FOR ADJUDICATION.                         NUMBER/LETTER.
126   THE TOOTH SURFACE CODE IS        16       CLAIM/SERVICE LACKS INFORMATION WHICH      N75      MISSING/INCOMPLETE/INVALID TOOTH          240
      MISSING OR INVALID                        IS NEEDED FOR ADJUDICATION.                         SURFACE INFORMATION.
127   PRIOR AUTHORIZATION REQUIRED     197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT N54        CLAIM INFORMATION IS INCONSISTENT WITH    483
      FOR OUTPATIENT MENTAL HEALTH              ION ABSENT.                                         PRE-CERTIFIED/AUTHORIZED SERVICES.
      VISITS OVER FOUR


128   PROC REQUIRES A VALID TOOTH     16        CLAIM/SERVICE LACKS INFORMATION WHICH      N37      MISSING/INCOMPLETE/INVALID TOOTH          244
      NO. PROC D1351/01351 REQUIRES             IS NEEDED FOR ADJUDICATION.                         NUMBER/LETTER.
      A TOOTH NO. OF
      2,3,14,15,18,19,30 OR 31. ALL
      OTHER PROC REQUIRE A TOOTH NO.
      BETWEEN 1-9,10-32,51-82,A-T,AS-
      TS.


129   EXCEEDS LIMIT OF 1 WHEELCHAIR    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                        483
      PER 2 YEAR PERIOD                         OCCURRENCE HAS BEEN REACHED.

130   PUBLIC TRANSPORTATION LIMITED   119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR     N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       483
      TO 30 UNITS PER DATE OF SERVICE           OCCURRENCE HAS BEEN REACHED.

131   NON-COVERED TRANSPORTATION       96       NON-COVERED CHARGE(S).                     N157     TRANSPORTATION TO/FROM THIS DESTINATION   84
      SERVICE BASED ON RECIPIENT'S                                                                  IS NOT COVERED.
      COUNTY OF RESIDENCE


132   SUBMISSION DATE DOES NOT MEET    29       THE TIME LIMIT FOR FILING HAS EXPIRED.     N102     THIS CLAIM HAS BEEN DENIED WITHOUT        9
      TIMELY FILING REQUIREMENTS.                                                                   REVIEWING THE MEDICAL RECORD BECAUSE
                                                                                                    THE REQUESTED RECORDS WERE NOT RECEIVED
                                                                                                    OR WERE NOT RECEIVED TIMELY.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
133   INDICATE ON YOUR INVOICE IF      16       CLAIM/SERVICE LACKS INFORMATION WHICH     N225     INCOMPLETE/INVALID                       21
      THIS LENS IS INVESTIGATIONAL              IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      OR FDA APPROVED                                                                              T/CHART.


134   MORE MEDICAL INFORMATION         16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               123
      NECESSARY                                 IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.
135   PROCEDURE CODE LIMITED TO        96       NON-COVERED CHARGE(S).                    N30      RECIPIENT INELIGIBLE FOR THIS SERVICE.    84
      RECIPIENTS IN AID CATEGORY 69
      ONLY
136   PLACE OF SERVICE MISSING OR      16       CLAIM/SERVICE LACKS INFORMATION WHICH     M77      MISSING/INCOMPLETE/INVALID PLACE OF       249
      INVALID                                   IS NEEDED FOR ADJUDICATION.                        SERVICE.
137   PAID CLAIM FOR SAME DOS IN       45       CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM      N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       107
      RELATED HISTORY PAYMENT CUT               ALLOWABLE OR CONTRACTED/LEGISLTATED FEE
      BACK TO MAX ALLOWABLE.                    ARRANGMENT. (USE GROUPE CODES PR OR CO
                                                DEPENDING ON LIABILITY).


138   DIAGNOSIS CODE INVALID FOR       11       THE DIAGNOSIS IS INCONSISTENT WITH THE    M50      MISSING/INCOMPLETE/INVALID REVENUE        488
      REVENUE CODE                              PROCEDURE.                                         CODE(S).
139   SURGICAL/OBSTETRICAL PROCEDURE   B18      THIS PROCEDURE CODE AND MODIFIER WERE     N65      PROCEDURE CODE OR PROCEDURE RATE COUNT    454
      NOT ON FILE.                              INVALID ON THE DATE OF SERVICE.                    CANNOT BE DETERMINED, OR WAS NOT ON
                                                                                                   FILE, FOR THE DATE OF SERVICE/PROVIDER.


140   MODIFIER MISSING OR INVALID      4        THE PROCEDURE CODE IS INCONSISTENT WITH   M78      MISSING/INCOMPLETE/INVALID HCPCS          453
      FOR PROCEDURE CODE/TOS                    THE MODIFIER USED OR A REQUIRED                    MODIFIER.
                                                MODIFIER IS MISSING.


141   PROSTHETIC DEVICE(S) EXCEEDS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M90      NOT COVERED MORE THAN ONCE IN A 12        483
      $20,000 PER STATE FISCAL YEAR             OCCURRENCE HAS BEEN REACHED.                       MONTH PERIOD.

142   PROSTHETICS DEVICE LIMITED TO    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      ONE PER FIVE YEARS                        OCCURRENCE HAS BEEN REACHED.

143   ORTHOTIC APPLIANCE EXCEEDS       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M90      NOT COVERED MORE THAN ONCE IN A 12        483
      $3,000 PER STATE FISCAL YEAR              OCCURRENCE HAS BEEN REACHED.                       MONTH PERIOD.

144   ORTHOTIC APPLIANCE LIMITED TO    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M90      NOT COVERED MORE THAN ONCE IN A 12        483
      ONE PER 12 MONTH PERIOD                   OCCURRENCE HAS BEEN REACHED.                       MONTH PERIOD.

145   DIAGNOSIS INVALID FOR            11       THE DIAGNOSIS IS INCONSISTENT WITH THE    M64      MISSING/INCOMPLETE/INVALID OTHER          488
      PROCEDURE CODE                            PROCEDURE.                                         DIAGNOSIS.
146   PROVIDER IS NOT CERTIFIED FOR    B7       THIS PROVIDER WAS NOT                     MA120    MISSING/INCOMPLETE/INVALID CLIA           109
      PROCEDURE                                 CERTIFIED/ELIGIBLE TO BE PAID FOR THIS             CERTIFICATION NUMBER.
                                                PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
147   PROCEDURE/NDC/REVENUE CODE       47       THIS (THESE) DIAGNOSIS(ES) IS (ARE) NOT   M20      MISSING/INCOMPLETE/INVALID HCPCS.         454
      MISSING OR INVALID.                       COVERED, MISSING, OR ARE INVALID.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
148   PROCEDURE INAPPROPRIATE FOR      5        THE PROCEDURE CODE/BILL TYPE IS           M77      MISSING/INCOMPLETE/INVALID PLACE OF      249
      PLACE OF SERVICE.                         INCONSISTENT WITH THE PLACE OF SERVICE.            SERVICE.

149   PROCEDURE INAPPROPRIATE FOR      6        THE PROCEDURE/REVENUE CODE IS                                                               475
      THE RECIPIENT'S AGE.                      INCONSISTENT WITH THE PATIENT'S AGE.

150   THIS PROCEDURE IS INVALID FOR    7        THE PROCEDURE/REVENUE CODE IS             MA39     MISSING/INCOMPLETE/INVALID GENDER.       474
      THE RECIPIENT'S SEX.                      INCONSISTENT WITH THE PATIENT'S GENDER.

151   PROCEDURE/NDC INVALID FOR DATE   B18      THIS PROCEDURE CODE AND MODIFIER WERE                                                       454
      OF SERVICE.                               INVALID ON THE DATE OF SERVICE.

152   NDC/PROCEDURE/REVENUE CODES                                                         M51      MISSING/INCOMPLETE/INVALID PROCEDURE     454
      ARE NOT ON FILE                                                                              CODE(S).
153   NON-COVERED SERVICE FOR THE      11       THE DIAGNOSIS IS INCONSISTENT WITH THE                                                      488
      DIAGNOSIS.                                PROCEDURE.
154   AMBULANCE ATTACHMENT REQUIRED    16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               337
      ON AMBULANCE BILLINGS                     IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.
155   UNITS FIELD INDICATES MILEAGE    16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               21
      BUT THE OUTSIDE CITY LIMITS               IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      INDICATOR IS NOT PRESENT.                                                                    T/CHART.


156   THE OUTSIDE CITY LIMITS          16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               21
      INDICATOR IS PRESENT BUT THE              IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      UNITS FIELD IS BLANK.                                                                        T/CHART.
157   DIAGNOSIS INVALID FOR            11       THE DIAGNOSIS IS INCONSISTENT WITH THE                                                      488
      PROCEDURE CODE                            PROCEDURE.
158   PROVIDER NOT CERTIFIED TO BILL   B7       THIS PROVIDER WAS NOT                                                                       88
      THIS PROCEDURE ON THIS DATE               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      OF SERVICE.                               PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
159   ONLY ONE POST STERILIZATION      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      VISIT PER STATE FISCAL YEAR               OCCURRENCE HAS BEEN REACHED.

160   PROCEDURE REQUIRES A VALID       17       REQUESTED INFORMAITON WAS NOT PROVIDED    N75      MISSING/INCOMPLETE/INVALID TOOTH         240
      TOOTH SURFACE CODE.                       OR WAS INSUFFICIENT/INCOMPLETE.                    SURFACE INFORMATION.

161   TYPE OF PROVIDER INAPPROPRIATE   B7       THIS PROVIDER WAS NOT                     MA120    MISSING/INCOMPLETE/INVALID CLIA          454
      FOR THIS PROCEDURE.                       CERTIFIED/ELIGIBLE TO BE PAID FOR THIS             CERTIFICATION NUMBER.
                                                PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
162   UNITS BILLED EXCEED MAX          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      258
      ALLOWED PER DAY. UNITS CUT                OCCURRENCE HAS BEEN REACHED.
      BACK TO MAX ALLOWED FOR
      PROCEDURE.
163   LAB NOT CERTIFIED FOR            170      PAYMENT IS DENIED WHEN PERFORMED/BILLED                                                     454
      PROCEDURE.                                BY THIS TYPE OF PROVIDER.




                                                                                                                                                     Effective 10/22/10
                                                                                 EOB TO 277 & 835



                                        835                                                 835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                                REMARK   DESCRIPTION                              STATUS
164   TOS INVALID TO PROCEDURE CODE                                                         N56      PROCEDURE CODE BILLED IS NOT             250
                                                                                                     CORRECT/VALID FOR THE SERVICES BILLED
                                                                                                     OR THE DATE OF SERVICE BILLED.


165   INPATIENT SERVICES ARE NOT        96       NON-COVERED CHARGE(S).                     N30      RECIPIENT INELIGIBLE FOR THIS SERVICE.   88
      COVERED FOR PW-PE (PREGNANT
      WOMEN PRESUMPTIVE ELIGIBILITY)
      CATEGORY OF ELIGIBILITY


166   INVALID MEDICARE TYPE OF          16       CLAIM/SERVICE LACKS INFORMATION WHICH      M51      MISSING/INCOMPLETE/INVALID PROCEDURE     454
      SERVICE OR INVALID MEDICARE                IS NEEDED FOR ADJUDICATION.                         CODE(S).
      PROCEDURE CODE.
167   CONSENT FORM NOT SIGNED BY                                                            N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 466
      PATIENT.
168   PROCEDURE CODE/MODIFIER           4        THE PROCEDURE CODE IS INCONSISTENT WITH                                                      453
      COMBINATION INVALID                        THE MODIFIER USED OR A REQUIRED
                                                 MODIFIER IS MISSING.


169   NON-EMERGENCY PROCEDURE BILLED                                                        MA30     MISSING/INCOMPLETE/INVALID TYPE OF BILL. 454
      TO AN EMERGENCY-INDICATED
      CLAIM.
170   EMERGENCY PROCEDURE BILLED        17       REQUESTED INFORMAITON WAS NOT PROVIDED                                                       454
      WITHOUT EMERGENCY INDICATOR.               OR WAS INSUFFICIENT/INCOMPLETE.

171   PROCEDURES BEGIN/END DATES NOT                                                        MA31     MISSING/INCOMPLETE/INVALID BEGINNING     187
      SAME MONTH                                                                                     AND ENDING DATES OF THE PERIOD BILLED.

172   OB DISCOUNT POLICY IN EFFECT      95       PLAN PROCEDURES NOT FOLLOWED.                                                                107
      AS OF JULY 15, 1997. CLAIM
      DISCOUNTED BY 15%.


173   SEE MEDICAID BILLING MANUAL                                                           N59      ALERT: PLEASE REFER TO YOUR PROVIDER
      CONCERNING FAMILY PLANNING                                                                     MANUAL FOR ADDITIONAL PROGRAM AND
      BILLING PROCEDURES.                                                                            PROVIDER INFORMATION.


174   HOME HEALTH PROCEDURE'S                                                               MA31     MISSING/INCOMPLETE/INVALID BEGINNING     187
      BEGIN/END DATES NOT SAME MONTH.                                                                AND ENDING DATES OF THE PERIOD BILLED.

175   PERSONAL CARE PROCEDURE'S                                                             MA31     MISSING/INCOMPLETE/INVALID BEGINNING     187
      BEGIN/END DATES NOT SAME MONTH.                                                                AND ENDING DATES OF THE PERIOD BILLED.

176   ARKIDS FIRST-B PARTICIPANT                                                            MA92     MISSING PLAN INFORMATION FOR OTHER       171
      IDENTIFIED WITH COMPREHENSIVE                                                                  INSURANCE.
      MEDICAL COVERAGE. BILL OTHER
      INSURANCE.


177   ADMISSION DATE OUTSIDE PA         197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                     189
      BEGIN AND END DATES                        ION ABSENT.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
178   OCCUPATIONAL THERAPY EVAL        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMITED TO FOUR PER STATE                 OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
179   SERVICES ASSOCIATED WITH         B7       THIS PROVIDER WAS NOT                                                                       454
      PROVIDER SPECIALTY LIMITED TO             CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      ARKIDS 1ST PARTICIPANT ONLY.              PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
180   PERSONAL CARE SERVICES           96       NON-COVERED CHARGE(S).                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      PROVIDED THROUGH WAIVER                                                                      RENDERED ON THE SAME DATE.
      PROGRAM NOT ALLOWED SAME DATES
      OF SERVICE AS PERSONAL CARE
      SERVICES PROVIDED THROUGH
      MEDICAID

181   RSPMI SERVICE OR RELATED         B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                          107
      SERVICE HAS BEEN SUBMITTED AND            FULLY FURNISHED BY ANOTHER PROVIDER.
      PAID TO ANOTHER RSPMI PROVIDER
      FOR THIS DATE OF SERVICE.


182   PRIVATE ROOM REVENUE CODE ON                                                        M44      MISSING/INCOMPLETE/INVALID CONDITION     460
      UB-92 REQUIRES ENTERING                                                                      CODE.
      APPROPRIATE CONDITION CODE (38
      OR 39) IN FORM LOCATOR 24-30.


183   RSPMI DAILY BENEFIT LIMIT        B20      PROCEDURE/SERVICE WAS PARTIALLY OR        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      REACHED.                                  FULLY FURNISHED BY ANOTHER PROVIDER.               MADE FOR SIMILAR PROCEDURE WITHIN SET
                                                                                                   TIME FRAME.
184   ACCOMODATION UNITS (LOC 46 OR    150      PAYER DEEMS THE INFORMATION SUBMITTED                                                       258
      52) DO NOT EQUAL COVERED DAYS             DOES NOT SUPPORT THIS LEVEL OF SERVICE.
      (LOC 7 OR 23).


185   DURABLE MEDICAL SUPPLIES -                                                          N26      MISSING ITEMIZED BILL.                   279
      ITEMIZED LIST REQUIRED
186   RSPMI SFY BENEFIT LIMIT          B20      PROCEDURE/SERVICE WAS PARTIALLY OR        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      REACHED.                                  FULLY FURNISHED BY ANOTHER PROVIDER.               MADE FOR SIMILAR PROCEDURE WITHIN SET
                                                                                                   TIME FRAME.
187   PARTICIPANT NOT ELIGIBLE FOR                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.     109
      BILLED SERVICES UNDER ARKIDS
      FIRST-B PROGRAM.
188   SECONDARY HEADER DIAGNOSIS       17       REQUESTED INFORMAITON WAS NOT PROVIDED    M64      MISSING/INCOMPLETE/INVALID OTHER         255
      CODE INVALID. LENGTH OF STAY              OR WAS INSUFFICIENT/INCOMPLETE.                    DIAGNOSIS.
      CALCULATED AS SINGLE DIAGNOSIS
      CODE. CORRECT AND RESUBMIT AN
      ADJUSTMENT REQUEST.


189   SECONDARY DIAGNOSIS CODE         17       REQUESTED INFORMAITON WAS NOT PROVIDED    M64      MISSING/INCOMPLETE/INVALID OTHER         255
      INVALID. PLEASE RESUBMIT WITH             OR WAS INSUFFICIENT/INCOMPLETE.                    DIAGNOSIS.
      CORRECT DIAGNOSIS CODE AND
      ADJUSTMENT REQUEST FORM.




                                                                                                                                                     Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                                835                                              277
                                        ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                               REMARK   DESCRIPTION                             STATUS
190   CLAIM DIAGNOSIS CODE IS           146      DIAGNOSIS WAS INVALID FOR THE DATE(S)     M64      MISSING/INCOMPLETE/INVALID OTHER        254
      MISSING OR INVALID.                        OF SERVICE REPORTED.                               DIAGNOSIS.
191   SECONDARY HEADER DIAGNOSIS        11       THE DIAGNOSIS IS INCONSISTENT WITH THE    M64      MISSING/INCOMPLETE/INVALID OTHER        255
      CODE INVALID.                              PROCEDURE.                                         DIAGNOSIS.
192   PRIMARY/SECONDARY DIAGNOSIS       9        THE DIAGNOSIS IS INCONSISTENT WITH THE    MA63     MISSING/INCOMPLETE/INVALID PRINCIPAL    426
      CODE INVALID FOR THE                       PATIENT'S AGE.                                     DIAGNOSIS.
      RECIPIENT'SAGE
193   INVALID SECONDARY DIAGNOSIS       9        THE DIAGNOSIS IS INCONSISTENT WITH THE    M64      MISSING/INCOMPLETE/INVALID OTHER        255
      CODE FOR THIS PATIENT'S AGE.               PATIENT'S AGE.                                     DIAGNOSIS.

194   PRIMARY DIAGNOSIS CODE INVALID    10       THE DIAGNOSIS IS INCONSISTENT WITH THE    MA63     MISSING/INCOMPLETE/INVALID PRINCIPAL    86
      FOR PATIENT'S SEX.                         PATIENT'S GENDER.                                  DIAGNOSIS.
195   SECONDARY DIAGNOSIS CODE          10       THE DIAGNOSIS IS INCONSISTENT WITH THE    M64      MISSING/INCOMPLETE/INVALID OTHER        86
      INVALID FOR PATIENT'S SEX.                 PATIENT'S GENDER.                                  DIAGNOSIS.
196   SERVICE IS INCONSISTENT WITH    11         THE DIAGNOSIS IS INCONSISTENT WITH THE    M64      MISSING/INCOMPLETE/INVALID OTHER        488
      THE DIAGNOSIS CODE ON THE CLAIM            PROCEDURE.                                         DIAGNOSIS.

197   PHYSICAL THERAPY EVAL LIMITED     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TO FOUR PER STATE FISCAL YEAR              OCCURRENCE HAS BEEN REACHED.

198   $5,000 SFY LIMITATION FOR         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      FAMILY SUPPORT SERVICES HAS                OCCURRENCE HAS BEEN REACHED.
      BEEN EXCEEDED.
199   PARTICIPANT'S AGE IS                                                                                                                  109
      INAPPROPRIATE FOR ARKIDS FIRST-
      B PROGRAM.
200   RECOUPED PAID CLAIM.              B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                          101
      RESTORATIONS COMBINED AND PAID             CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
      AT MAX ALLOWED.                            A PREVIOUS PAYMENT.
201   DETAIL DIAGNOSIS CODE NOT ON      146      DIAGNOSIS WAS INVALID FOR THE DATE(S)                                                      255
      FILE.                                      OF SERVICE REPORTED.
202   ADMITTING DIAGNOSIS CODE          146      DIAGNOSIS WAS INVALID FOR THE DATE(S)                                                      232
      MISSING, INVALID, OR NOT ON                OF SERVICE REPORTED.
      FILE.
203   EXCEEDED ONE PREVENTATIVE         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      DENTAL SCREEN APPROPRIATE PER              OCCURRENCE HAS BEEN REACHED.
      150 DAYS.
204   PROVIDER SPECIALTY INVALID FOR    96       NON-COVERED CHARGE(S).                    N95      THIS PROVIDER TYPE/PROVIDER SPECIALTY   145
      RECIPIENT'S AGE.                                                                              MAY NOT BILL THIS SERVICE.
205   ONLY ONE EYE EXAM PER 12          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      MONTHS FOR PARTICIPANT UNDER               OCCURRENCE HAS BEEN REACHED.
      19.
206   DETAIL DIAGNOSIS CODE IS          10       THE DIAGNOSIS IS INCONSISTENT WITH THE                                                     86
      INVALID FOR PATIENT'S SEX.                 PATIENT'S GENDER.
207   DETAIL DIAGNOSIS CODE INVALID     9        THE DIAGNOSIS IS INCONSISTENT WITH THE                                                     255
      FOR PATIENT'S AGE.                         PATIENT'S AGE.
208   RECIPIENT AID CATEGORY 69         96       NON-COVERED CHARGE(S).                    N30      PATIENT INELIGIBLE FOR THIS SERVICE.    109
      LIMITED TO FAMILY PLANNING
         SERVICES




                                                                                                                                                     Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
209   MAXIMUM PAYMENT OF 72 UNITS       96       NON-COVERED CHARGE(S).                   N362     THE NUMBER OF DAYS OR UNITS OF SERVICE   483
      PERSONAL CARE NOT PREVIOUSLY                                                                 EXCEEDS OUR ACCEPTABLE MAXIMUM.
       BILLED FOR DDS WAIVER
      RECIPIENT.
210   DETAIL DIAGNOSIS CODE NOT         146      DIAGNOSIS WAS INVALID FOR THE DATE(S)                                                      255
      ALLOWED.                                   OF SERVICE REPORTED.
211   CLAIM "TO" DATE OF SERVICE        29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                     9
      OVER TWO YEARS OLD
212   ONLY ONE PAIR OF GLASSES PER      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      12 MONTHS FOR PARTICIPANT                  OCCURRENCE HAS BEEN REACHED.
      UNDER 19.
213   MEALS DISALLOWED SAME DOS AS                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.     107
      ADC, ADHC OR IN-HOME RESPITE
      CARE.
214   FACILITY RESPITE CARE LIMITED     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TO 600 UNITS PER SFY                       OCCURRENCE HAS BEEN REACHED.

215   PRIVATE DUTY NURSING MEDICAL                                                        N26      MISSING ITEMIZED BILL.                   279
      SUPPLIES ITEMIZED LIST REQUIRED

216   DATES OF SERVICE SPAN PROVIDER                                                      N61      REBILL SERVICES ON SEPARATE CLAIMS.      187
      FISCAL YEAR.
217   MEDICARE - DAYS NOT COVERED BY    96       NON-COVERED CHARGE(S).                   N18      PAYMENT BASED ON THE MEDICARE ALLOWED    457
      MEDICAID.                                                                                    AMOUNT.
218   BENEFITS FOR QUALIFIED            96       NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      MEDICARE BENEFICIARIES DO NOT
      INCLUDE OUTPATIENT
      PRESCRIPTION DRUGS, OR ROUTINE
      DENTAL SERVICES. BEN ARE LIM
      TO COST SHARING EXPENSES FOR
      SVCS CVRD BY MDCARE


219   BENEFITS FOR QUALIFIED            96       NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.     171
      MEDICARE BENEFICIARIES ARE
      LIMITED TO MEDICARE DEDUCTIBLE
      AND COINSURANCE PAYMENTS.
      PLEASE FILE MEDICARE COVERED
      SERVICES WITH MEDICARE FIRST.




220   PROCEDURE MAY BE PERFORMED        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ONLY 6 TIMES PER FFY                       OCCURRENCE HAS BEEN REACHED.

221   PROVIDER DECEASED WHEN            B7       THIS PROVIDER WAS NOT                                                                      91
      SERVICES WERE PERFORMED.                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
                                                 PROCEDURE/SERVICE ON THIS DATE OF
                                                 SERVICE.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
222   PROVIDER NOT ELIGIBLE-PROVIDER   B7       THIS PROVIDER WAS NOT                                                                      91
      CANCELLED ON DATE OF SERVICE.             CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
                                                PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
223   THE PROVIDER IS NOT ELIGIBLE     B7       THIS PROVIDER WAS NOT                                                                      91
      ON DATE OF SERVICE. PLEASE                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      CONTACT STATE PROVIDER                    PROCEDURE/SERVICE ON THIS DATE OF
      ENROLLMENT UNIT IF ANY                    SERVICE.
      QUESTIONS.


224   AGE INVALID FOR INPATIENT                                                          N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      PSYCHE SERVICE.
225   INVALID NCCI BILLING             96       NON-COVERED CHARGE(S).                   N59      ATTN: PLEASE REFER TO YOUR PROVIDER      107
      COMBINATIONS - CMS DOES NOT                                                                 MANUAL FOR ADDITIONAL PROGRAM AND
      ALLOW                                                                                       PROVIDER INFORMATION.
226   PRIOR AUTHORIZATION VALID FOR                                                      N54      CLAIM INFORMATION IS INCONSISTENT WITH   252
      CMS NON-MEDICAID SERVICES                                                                   PRE-CERTIFIED/AUTHORIZED SERVICES.
      ONLY
227   EPSDT CONDITION (REASON) CODE    125      SUBMISSION/BILLING ERROR(S).             MA58     MISSING/INCOMPLETE/INVALID RELEASE OF    21
      REQUIRED                                                                                    INFORMATION INDICATOR.
228   THE PROVIDER IS NOT ELIGIBLE     B7       THIS PROVIDER WAS NOT                                                                      91
      FOR DATE(S) OF SERVICE.                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      PLEASE CONTACT THE STATE                  PROCEDURE/SERVICE ON THIS DATE OF
      PROVIDER ENROLLMENT UNIT IF               SERVICE.
      THERE ARE ANY QUESTIONS.


229   NO OTHER ACCOMMODATION REVENUE                                                     M80      NOT COVERED WHEN PERFORMED DURING THE    455
      CODE ALLOWED ON THE SAME CLAIM                                                              SAME SESSION/DATE AS A PREVIOUSLY
      WITH REVENUE CODE 128.                                                                      PROCESSED SERVICE FOR THE PATIENT.


230   ATTENDING PHYSICIAN NAME, NON-   B7       THIS PROVIDER WAS NOT                                                                      142
      PARTTICIPATING OR LICENSE                 CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      NUMBER NOT INDICATED                      PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
231   EXCEEDS BENEFIT LIMIT OF TWO     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      FETAL NON-STRESS TESTS PER                OCCURRENCE HAS BEEN REACHED.
      NINE-MONTH PERIOD.


232   SERVICES NOT COVERED BY          96       NON-COVERED CHARGE(S).                   M20      MISSING/INCOMPLETE/INVALID HCPCS.        84
      MEDICAID.
233   DENIED BY UTILIZATION REVIEW     50       THESE ARE NON-COVERED SERVICES BECAUSE                                                     287
      FOR MEDICAL NECESSITY.                    THIS IS NOT DEEMED A 'MEDICAL
                                                NECESSITY' BY THE PAYER.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
234   PERFORMING PROVIDER IS NOT       B7       THIS PROVIDER WAS NOT                                                                      91
      ENROLLED UNDER THE BILLING                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      GROUP NUMBER FOR DATES OF                 PROCEDURE/SERVICE ON THIS DATE OF
      SERVICE BILLED. CONTACT                   SERVICE.
      PROVIDER        ENROLLMENT
      WITH QUESTIONS AT 1-800-482-
      1141

235   PROCEDURE CODE NON-PAYABLE FOR   B18      THIS PROCEDURE CODE AND MODIFIER WERE    M20      MISSING/INCOMPLETE/INVALID HCPCS.        84
      DATE OF SERVICE. CHECK                    INVALID ON THE DATE OF SERVICE.
      MANUAL FOR CORRECT CODE


236   PERFORMING PROVIDER IS NOT       B7       THIS PROVIDER WAS NOT                                                                      91
      ENROLLED UNDER THE BILLING                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      GROUP PROVIDER NUMBER ON THE              PROCEDURE/SERVICE ON THIS DATE OF
      CLAIM. CONTACT PROVIDER                   SERVICE.
      ENROLLMENT   WITH QUESTIONS AT
      1-800-482-1141.




237   PERFORMING PROVIDER NUMBER IS    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N77      MISSING/INCOMPLETE/INVALID DESIGNATED    153
      INVALID, MISSING, OR                      IS NEEDED FOR ADJUDICATION.                       PROVIDER NUMBER.
      PERFORMING PROVIDER IS
      CANCELLED.
238   ATTENDING PHYSICIAN'S                                                              N55      PROCEDURES FOR BILLING WITH              153
      INDIVIDUAL PROVIDER NUMBER WAS                                                              GROUP/REFERRING/PERFORMING PROVIDERS
      USED    RATHER THAN CLINIC                                                                  WERE NOT FOLLOWED.
      NUMBER.
239   PROVIDER ELIGIBILITY                                                                                                                 56
      DETERMINATION IS BEING MADE.
      PLEASE    DO NOT REBILL.


240   REFERRING PHYSICIAN NAME, NON-   B7       THIS PROVIDER WAS NOT                                                                      153
      PARTICIPATING, OR MEDICAID                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      NUMBER INVALID.                           PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
241   RECIPIENT AID CATEGORY 69       96        NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      LIMITED TO FAMILY PLANNING NDC.

242   CLAIM TYPE MUST BE CROSS-OVER    125      SUBMISSION/BILLING ERROR(S).             N34      INCORRECT CLAIM FORM/FORMAT FOR THIS     481
      ONLY.                                                                                       SERVICE.
243   FORMULAS NOT PAYABLE WITH                                                          M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DIFFERENT TYPES OF SERVICE IN                                                               MADE FOR SIMILAR PROCEDURE WITHIN SET
      THE SAME CALENDAR MONTH                                                                     TIME FRAME.


244   CLAIMS MUST BE BILLED                                                              M117     NOT COVERED UNLESS SUBMITTED VIA         481
      ELECTRONICALLY.                                                                             ELECTRONIC CLAIM.
245   NOT PAYABLE ON THIS CLAIM                                                          N34      INCORRECT CLAIM FORM/FORMAT FOR THIS     481
      TYPE. PLEASE BILL ON                                                                        SERVICE.
      APPROPRIATE CLAIM FORM AND
      RESUBMIT.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                             STATUS
246   FLU VACCINE LIMITED TO ONE PER   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      STATE FISCAL YEAR.                        OCCURRENCE HAS BEEN REACHED.

247   PNEUMONIA VACCINE LIMITED TO     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      ONE EVERY TEN YEARS.                      OCCURRENCE HAS BEEN REACHED.

248   PAYMENT OF YOUR CLAIM WAS                                                          N55      PROCEDURES FOR BILLING WITH             153
      DELAYED BECAUSE ANY PHYSICIAN                                                               GROUP/REFERRING/PERFORMING PROVIDERS
         PRACTICING IN A GROUP WHO                                                                WERE NOT FOLLOWED.
      BILLS USING THE GROUP PROVIDER
         NUMBER MUST ALSO PUT
      PERFORMING PHYSICIAN NAME AND
      #.


249   PAYMENT OF CLAIM WAS DELAYED     16       CLAIM/SERVICE LACKS INFORMATION WHICH    N382     MISSING/INCOMPLETE/INVALID PATIENT      153
      BECAUSE RECIPIENT ID#                     IS NEEDED FOR ADJUDICATION.                       IDENTIFIER.
      SUBMITTED WAS INVALID FOR THE
      CLAIM DATE(S) OF SERVICE.


250   RECIPIENT NOT LISTED UNDER ID    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N382     MISSING/INCOMPLETE/INVALID PATIENT      153
      # SUBMITTED. CORRECT ID # AND             IS NEEDED FOR ADJUDICATION.                       IDENTIFIER.
      RESUBMIT A COMPLETED AND
      SIGNED CLAIM FOR PROCESSING.


251   GROUND TRANSPORT EXCEEDS        119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      $1000.00 PER ROUND TRIP PER DAY           OCCURRENCE HAS BEEN REACHED.

252   MEDICAID ID NUMBER SUBMITTED     140      PATIENT/INSURED HEALTH IDENTIFICATION                                                     124
      DOES NOT MATCH PATIENT'S NAME             NUMBER AND NAME DO NOT MATCH.
      ON MEDICAID ID CARD. PLEASE
      VERIFY CARD AND REBILL WITH
      CORRECT INFORMATION.



253   PATIENT DECEASED-NOT ELIGIBLE    13       THE DATE OF DEATH PRECEDES THE DATE OF                                                    91
      FOR SERVICE.                              SERVICE.
254   RECIPIENT IS NOT ELIGIBLE FOR    26       EXPENSES INCURRED PRIOR TO COVERAGE.                                                      91
      MEDICAID ON DATE OF SERVICE.

255   LEVEL OF CARE IS INVALID.        16       CLAIM/SERVICE LACKS INFORMATION WHICH    MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR   21
                                                IS NEEDED FOR ADJUDICATION.                       INVALID INFORMATION, AND NO APPEAL
                                                                                                  RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                  IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                  CLAIM WITH THE COMPLETE/CORRECT
                                                                                                  INFORMATION.




                                                                                                                                                   Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
256   RECIPIENT PARTIALLY OR TOTALLY   141      CLAIM SPANS ELIGIBLE AND INELIGIBLE                                                          91
      INELIGIBLE FOR WAIVER SERVICES            PERIODS OF COVERAGE.
      ON DATES OF SERVICE BILLED


257   FOR REPAYMENT, REBILL CLAIM                                                         M117     NOT COVERED UNLESS SUBMITTED VIA
      ELECTRONICALLY.                                                                              ELECTRONIC CLAIM.
258   CLAIM PAYMENT AMOUNT INCLUDES
      $96.00 ADDITIONAL PAYMENT FOR
      NEWBORN PHYSIOLOGICAL
      BILATERAL HEARING SCREEN.


259   UNABLE TO DETERMINE RECIPIENT                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.      109
      ELIGIBILITY.
260   RECIPIENT ELIGIBILITY                                                               N185     ALERT: DO NOT RESUBMIT THIS               56
      DETERMINATION IS BEING MADE.                                                                 CLAIM/SERVICE.
      PLEASE DONOT REBILL.
261   PATIENT DECEASED. NOT            13       THE DATE OF DEATH PRECEDES THE DATE OF                                                       88
      ELIGIBLE FOR SERVICE.                     SERVICE.
262   DATES OF SERVICE SPAN FEDERAL                                                                                                          187
      FISCAL YEAR. PLEASE SUBMIT TWO
      SEPARATE BILLS.


263   THE RECIPIENT IS NOT ELIGIBLE    96       NON-COVERED CHARGE(S).                    N30      PATIENT INELIGIBLE FOR THIS SERVICE.      91
      ON DATE OF SERVICE.

264   PAYMENT REDUCED BECAUSE OUR      150      PAYER DEEMS THE INFORMATION SUBMITTED     MA32     MISSING/INCOMPLETE/INVALID NUMBER OF      457
      RECORDS SHOW RECIPIENT WAS NOT            DOES NOT SUPPORT THIS LEVEL OF SERVICE.            COVERED DAYS DURING THE BILLING PERIOD.
       IN FACILITY FOR ALL OF TOTAL
      BILLED DAYS.


265   RECIPIENT ID NUMBER IS MISSING   16       CLAIM/SERVICE LACKS INFORMATION WHICH     N382     MISSING/INCOMPLETE/INVALID PATIENT        153
      OR INVALID.                               IS NEEDED FOR ADJUDICATION.                        IDENTIFIER.
266   (TAPE CROSSOVERS ONLY.)          22       THIS CARE MAY BE COVERED BY ANOTHER       MA92     MISSING PLAN INFORMATION FOR OTHER        286
      PARTIAL MEDCAID ELIGIBILITY               PAYER PER COORDINATION OF BENEFITS.                INSURANCE.
      FOR    DATES OF SERVICE
      LISTED. REBILL HARDCOPY CLAIM
      WITH        MEDICARE
      EXPLANATION OF BENEFITS.


267   PARTIALLY OR TOTALLY            141       CLAIM SPANS ELIGIBLE AND INELIGIBLE                                                          88
      INELIGIBLE FOR DATES OF                   PERIODS OF COVERAGE.
      SERVICE LISTED.PLEASE CHECK
      DATES RECIPIENT IS ELIGIBLE
      AND BILL           ACCORDINGLY.


268   PATIENT ON REVIEW. CHARGE(S)     133      THE DISPOSITION OF THIS CLAIM/SERVICE     N35      PROGRAM INTEGRITY/UTILIZATION REVIEW      46
      DENIED PER SUR ANALYST REVIEW.            IS PENDING FURTHER REVIEW.                         DECISION.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
269   RECIPIENT NOT 21 YRS OLD AT                                                        N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 467
      TIME OF SIGNATURE ON CONSENT.

270   RECIPIENT NOT ELIGIBLE FOR                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      NURSING HOME CARE.
271   INVALID LOA CODE FOR FACILITY    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N225     INCOMPLETE/INVALID                       21
      CLASS                                     IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
272   AUTHORIZED LEVEL OF CARE NOT     16       CLAIM/SERVICE LACKS INFORMATION WHICH    N54      CLAIM INFORMATION IS INCONSISTENT WITH   84
      ON FILE FOR DATE OF SERVICE               IS NEEDED FOR ADJUDICATION.                       PRE-CERTIFIED/AUTHORIZED SERVICES.
      BILLED
273   BENEFICIARY TURNS 21 DURING                                                        N61      REBILL SERVICES ON SEPARATE CLAIMS.      481
      INPATIENT STAY. PLEASE SPLIT
      BILL AND RESUBMIT.
274   NOT ELIGIBLE FOR NURSING HOME                                                      N30      PATIENT INELIGIBLE FOR THIS SERVICE.     91
      CARE FOR THESE DATES OF
      SERVICE.
275   RECIPIENT NOT ELIGIBLE FOR       125      SUBMISSION/BILLING ERROR(S).             N30      PATIENT INELIGIBLE FOR THIS SERVICE.     91
      NURSING HOME CARE FOR THESE
      DATESOF SERVICE DUE TO
      PROVIDER BILLING ERROR.
276   THE BILLED LOC REPORTED ON THE   16       CLAIM/SERVICE LACKS INFORMATION WHICH    N225     INCOMPLETE/INVALID                       65
      TAD IS DIFFERENT FROM THE                 IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      LOCON THE LTC RECIPIENT FILE.                                                               T/CHART.
      THE CLAIM WAS PAID ACCORDING
      TO THE LOC ON FILE.


277   RECIPIENT PARTIALLLY OR          96       NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.     91
      TOTALLY INELIGIBLE FOR WAIVER
           SERVICES FOR DATES OF
      SERVICE BILLED
278   RECIPIENT WAS RECEIVING CARE                                                       MA134    MISSING/INCOMPLETE/INVALID PROVIDER      84
      IN ANOTHER FACILITY                                                                         NUMBER OF THE FACILITY WHERE THE
                                                                                                  PATIENT RESIDES.
279   ADJUSTMENT RESULTING FROM A      142      MONTHLY MEDICAID PATIENT LIABILITY                                                         101
      CHANGE IN THE PATIENT                     AMOUNT.
      LIABILITY AMOUNT.
280   RECIPIENT HAS OTHER MEDICAL      22       THIS CARE MAY BE COVERED BY ANOTHER      MA92     MISSING/INCOMPLETE/INVALID PLAN          171
      COVERAGE BILL OTHER INSURANCE             PAYER PER COORDINATION OF BENEFITS.               INFORMATION FOR OTHER INSURANCE.
       FIRST
281   SURGERY INFORMATION IS           17       REQUESTED INFORMATION WAS NOT PROVIDED   MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR    21
      INCOMPLETE                                OR WAS INSUFFICINET/INCOMPLETE.                   INVALID INFORMATION, AND NO APPEAL
                                                                                                  RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                  IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                  CLAIM WITH THE COMPLETE/CORRECT
                                                                                                  INFORMATION.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
282   UNDER AGE 65. HAS MEDICARE       B11      THE CLAIM/SERVICE HAS BEEN TRANSFERRED    N196     ALERT: PATIENT ELIGIBLE TO APPLY FOR      116
      COVERAGE. BILL MEDICARE FIRST.            TO THE PROPER PAYER/PROCESSOR FOR                  OTHER COVERAGE WHICH MAY BE PRIMARY.
                                                PROCESSING. CLAIM/SERVICE NOT COVERED
                                                BY THIS PAYER/PROCESSOR.


283   FRAGMENTED IMMUNIZATION CODES                                                       M51      MISSING/INCOMPLETE/INVALID PROCEDURE      84
      SHOULD BE BILLED.                                                                            CODE(S).
284   HAS MEDICARE COVERAGE. BILL      22       THIS CARE MAY BE COVERED BY ANOTHER                                                          116
      MEDICARE FIRST.                           PAYER PER COORDINATION OF BENEFITS.

285   GLOBAL OB PROCEDURE REQUIRED                                                        N182     THIS CLAIM/SERVICE MUST BE BILLED        263
      MINIMUM 2 MONTHS CARE.                                                                       ACCORDING TO THE SCHEDULE FOR THIS PLAN.

286   CLAIM DENIED DUE TO INJURY       20       THIS INJURY/ILLNESS IS COVERED BY THE                                                        255
      DIAGNOSIS. PLEASE INVESTIGATE             LIABILITY CARRIER.
        POSSIBLE THIRD PARTY
      INVOLVEMENT.
287   THIS CLAIM PAYMENT WAS                                                                                                                 101
      RECOUPED PER YOUR ADJUSTMENT
      REQUEST.
288   CLAIM BILLED BY MEDICARE TAPE                                                       MA64     OUR RECORDS INDICATE THAT WE SHOULD BE    116
      CROSSOVER. RECIPIENT'S OTHER                                                                 THE THIRD PAYER FOR THIS CLAIM. WE
      MEDICAL COVERAGE MUST BE                                                                     CANNOT PROCESS THIS CLAIM UNTIL WE HAVE
      BILLED PRIOR TO MEDICAID.                                                                    RECEIVED PAYMENT INFORMATION FROM THE
                                                                                                   PRIMARY AND SECONDARY PAYERS.



289   PSRO DATE ARE MISSING/INVALID.   16       CLAIM/SERVICE LACKS INFORMATION WHICH     MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR     21
                                                IS NEEDED FOR ADJUDICATION.                        INVALID INFORMATION, AND NO APPEAL
                                                                                                   RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                   IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                   CLAIM WITH THE COMPLETE/CORRECT
                                                                                                   INFORMATION.


290   PROVIDER TO RECIPIENT MISMATCH   170      PAYMENT IS DENIED WHEN PERFORMED/BILLED                                                      109
      FOR SCHOOL DISTRICT OUTREACH              BY THIS TYPE OF PROVIDER.
      SERVICES.


291   MAXIMUM OF 24 PAID INPATIENT     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      HOSPITAL DAYS PER SFY.                    OCCURRENCE HAS BEEN REACHED.

292   DISALLOWED BY VISUAL CARE        216      BASED ON THE FINDINGS OF A REVIEW                                                            84
      CONSULTANT.                               ORGANIZATION.
293   CMS NON-MEDICAID SERVICES FOR                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.      475
      UNDER AGE 18 ONLY.
294   ELECTRONIC FUNDS TRANSFER IS                                                        N24      MISSING/INCOMPLETE/INVALID ELECTRONIC     24
      REQUIRED FOR PAYMENT OF                                                                      FUNDS TRANSFER (EFT) BANKING
      NON-MEDICAID SERVICES.                                                                       INFORMATION.




                                                                                                                                                      Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                                277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                               STATUS
295   DUE TO NO PAID DETAILS ON                                                                                                              9
      CLAIM, ARKIDS FIRST-B COPAY
      WAS   NOT WITHHELD.
296   RECIPIENT, PROVIDER OR BOTH       B7       THIS PROVIDER WAS NOT                                                                       84
      ARE INELIGIBLE FOR DDS                     CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
       NON-MEDICAID SERVICES.                    PROCEDURE/SERVICE ON THIS DATE OF
                                                 SERVICE.
297   DIAGNOSIS CODE AND                11       THE DIAGNOSIS IS INCONSISTENT WITH THE                                                      488
      PRESCRIPTION SERVICE CONFLICT.             PROCEDURE.

298   YOUR CHARGES WERE COMBINED TO                                                                                                          247
      FACILITE PROCESSING.

299   SERVICE NON-PAYABLE FOR THIS                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.      84
      INDEPENDENT CHOICES CLIENT.

300   FEE ADJUSTED TO MAXIMUM           B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                        65
      ALLOWABLE.                                 MET OR WERE EXCEEDED.
301   THIS CLAIM IS AN ADJUSTMENT       142      MONTHLY MEDICAID PATIENT LIABILITY       N23      ALERT: PATIENT LIABILITY MAY BE           101
      RESULTING FROM A CHANGE IN THE             AMOUNT.                                           AFFECTED DUE TO COORDINATION OF
       RECIPIENT LIABILITY.                                                                        BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                                   MAXIMUM BENEFIT PROVISIONS.


302   DAYS BILLED CUTBACK TO 'PRO'      197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT N10      CLAIM/SERVICE ADJUSTED BASED ON THE
      CERTIFIED DAYS.                            ION ABSENT.                                       FINDINGS OF A REVIEW
                                                                                                   ORGANIZATION/PROFESSIONAL
                                                                                                   CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                   DENTAL ADVISOR.


303   YOUR CLAIM/CHARGE HAS BEEN                                                          MA15     YOUR CLAIM HAS BEEN SEPARATED TO
      SPLIT TO FACILITATE PROCESSING.                                                              EXPEDITE HANDLING. YOU WILL RECEIVE A
                                                                                                   SEPARATE NOTICE FOR THE OTHER SERVICES
                                                                                                   REPORTED.
304   ADJUSTMENT TO REFLECT AN          154      PAYER DEEMS THE INFORMATION SUBMITTED                                                       101
      INCREASE IN RECIPIENT                      DOES NOT SUPPORT THIS DAY'S SUPPLY.
      RESOURCES    APPLIED TO
      ORIGINAL BILL.
305   ADJUSTMENT REFLECTING PATIENT     23       THE IMPACT OF PRIOR PAYER(S)                                                                101
      THIRD PARTY LIABILITY APPLIED              ADJUDICATION INCLUDING PAYMENTS AND/OR
      TO ORIGINAL BILL.                          ADJUSTMENTS.


306   THIRD PARTY LIABILITY SUSPECT.    109      CLAIM NOT COVERED BY THIS                MA64     OUR RECORDS INDICATE THAT WE SHOULD BE    171
                                                 PAYER/CONTRACTOR. YOU MUST SEND THE               THE THIRD PAYER FOR THIS CLAIM. WE
                                                 CLAIM TO THE CORRECT PAYER/CONTRACTOR.            CANNOT PROCESS THIS CLAIM UNTIL WE HAVE
                                                                                                   RECEIVED PAYMENT INFORMATION FROM THE
                                                                                                   PRIMARY AND SECONDARY PAYERS.



307   AN ADJUSTMENT RESULTING FROM A    125      SUBMISSION/BILLING ERROR(S).             MA67     CORRECTION TO A PRIOR CLAIM.              101
      CLERICAL ERROR.




                                                                                                                                                      Effective 10/22/10
                                                                              EOB TO 277 & 835



                                      835                                                835                                              277
                                      ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                 REASON   DESCRIPTION                               REMARK   DESCRIPTION                             STATUS
308   PROCEDURE NUMBER CHANGED TO     189      NOT OTHERWISE CLASSIFIED' OR 'UNLISTED'   N22      THIS PROCEDURE CODE WAS ADDED/CHANGED   454
      MATCH DESCRIPTION.                       PROCEDURE CODE (CPT/HCPCS) WAS BILLED              BECAUSE IT MORE ACCURATELY DESCRIBES
                                               WHEN THERE IS A SPECIFIC PROCEDURE CODE            THE SERVICES RENDERED.
                                               FOR THIS PROCEDURE/SERVICE.


309   A MATH ERROR IN YOUR BILLING    125      SUBMISSION/BILLING ERROR(S).              MA67     CORRECTION TO A PRIOR CLAIM.            400
      HAS BEEN CORRECTED.

310   DISCHARGE. PATIENT DECEASED.    13       THE DATE OF DEATH PRECEDES THE DATE OF    N30      PATIENT INELIGIBLE FOR THIS SERVICE.    88
      NOTIFY IF INCORRECT.                     SERVICE.

311   CORRECTED PAYMENT PER           119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     101
      ADJUSTMENT REQUEST. SEE                  OCCURRENCE HAS BEEN REACHED.
      FINANCIAL    ITEMS FOR RECOUP
      OF INCORRECT PAYMENT.


312   YOU BILLED IMPROPER NUMBER OF   17       REQUESTED INFORMATION WAS NOT PROVIDED    M53      MISSING/INCOMPLETE/INVALID DAYS OR      456
      DAYS FOR MONTH.                          OR WAS INSUFFICIENT/INCOMPLETE.                    UNITS OF SERVICE.

313   MULTIPLE RESTORATION FOR SAME   97       THE BENEFIT FOR THIS SERVICE IS                                                            483
      TOOTH COMBINED.                          INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                               ANOTHER SERVICE/PROCEDURE THAT HAS
                                               ALREADY BEEN ADJUDICATED.


314   ONLY ONE RESTORATION PER        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      SURFACE ALLOWED.                         OCCURRENCE HAS BEEN REACHED.

315   PANOGRAPHIC SURVEY INCLUDES     97       THE BENEFIT FOR THIS SERVICE IS           N40      MISSING X-RAY.                          318
      NECESSARY BW X-RAYS.                     INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                               ANOTHER SERVICE/PROCEDURE THAT HAS
                                               ALREADY BEEN ADJUDICATED.


316   PAYMENT OF YOUR CLAIM WAS       125      SUBMISSION/BILLING ERROR(S).              M54      MISSING/INCOMPLETE/INVALID TOTAL        400
      DELAYED BECAUSE YOUR CHARGES                                                                CHARGES.
         WERE NOT TOTALED.


317   CODE CHANGED TO MATCH           189      NOT OTHERWISE CLASSIFIED' OR 'UNLISTED'                                                    15
      SURGEON'S CLAIM.                         PROCEDURE CODE (CPT/HCPCS) WAS BILLED
                                               WHEN THERE IS A SPECIFIC PROCEDURE CODE
                                               FOR THIS PROCEDURE/SERVICE.


318   ADJUSTED TO MAXIMUM ALLOWABLE   B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                       66
      NOT EXCEEDING THE USUAL                  MET OR WERE EXCEEDED.
      CUSTOMARY CHARGE ORIGINALLY
      BILLED.
319   INCORRECT PROVIDER NUMBER       16       CLAIM/SERVICE LACKS INFORMATION WHICH     N257     MISSING/INCOMPLETE/INVALID BILLING      153
      SUBMITTED - PAYMENT DELAYED.             IS NEEDED FOR ADJUDICATION.                        PROVIDER/SUPPLIER PRIMARY IDENTIFIER.




                                                                                                                                                   Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
320   DAYS BILLED CUTBACK TO THE       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    MA33     MISSING/INCOMPLETE/INVALID NONCOVERED    483
      NUMBER OF DAYS IN THE SERVICE             OCCURRENCE HAS BEEN REACHED.                       DAYS DURING THE BILLING PERIOD.
        MONTH.
321   REDUCED TO ESTABLISHED PATIENT                                                                                                        454
      CPT CODE.
322   SURGERY PROVIDER NUMBER          16       CLAIM/SERVICE LACKS INFORMATION WHICH     M51      MISSING/INCOMPLETE/INVALID PROCEDURE     454
      PRESENT/SURGERY PROCEDURE                 IS NEEDED FOR ADJUDICATION.                        CODE(S).
      MISSING. PAYMENT OF CLAIM
      DELAYED.
323   PROCEDURE NUMBER CHANGED BY      216      BASED ON THE FINDINGS OF A REVIEW         N10      CLAIM/SERVICE ADJUSTED BASED ON THE      454
      MEDICAL CONSULTANT.                       ORGANIZATION.                                      FINDINGS OF A REVIEW
                                                                                                   ORGANIZATION/PROFESSIONAL
                                                                                                   CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                   DENTAL ADVISOR.


324   NUMBER CHANGED PER DENTAL        B5       COVERAGE/PROGRAM GUIDELINES WERE NOT      N37      MISSING/INCOMPLETE/INVALID TOOTH         454
      POLICY GUIDELINES.                        MET OR WERE EXCEEDED.                              NUMBER/LETTER.
325   PROCEDURE NUMBER CHANGED BY      216      BASED ON THE FINDINGS OF A REVIEW         N10      CLAIM/SERVICE ADJUSTED BASED ON THE      454
      DENTAL CONSULTANT REVIEW.                 ORGANIZATION.                                      FINDINGS OF A REVIEW
                                                                                                   ORGANIZATION/PROFESSIONAL
                                                                                                   CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                   DENTAL ADVISOR.


326   DATE OF DISCHARGE NOT PAID.      96       NON-COVERED CHARGE(S).                    N50      MISSING/INCOMPLETE/INVALID DISCHARGE     190
                                                                                                   INFORMATION.
327   ADJUSTMENT RESULTING FROM        125      SUBMISSION/BILLING ERROR(S).              MA67     CORRECTION TO A PRIOR CLAIM.             101
      INCORRECT ORIGINAL BILL.
328   PAID IN ACCORDANCE WITH                                                             N10      CLAIM/SERVICE ADJUSTED BASED ON THE      65
      MEDICAL CONSULTANT'S REVIEW.                                                                 FINDINGS OF A REVIEW
                                                                                                   ORGANIZATION/PROFESSIONAL
                                                                                                   CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                   DENTAL ADVISOR.


329   PAYMENT REDUCED                  119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      65
      PROPORTIONATELY TO COMPLY WITH            OCCURRENCE HAS BEEN REACHED.
      MEDICAL      POLICY QUANTITY
      LIMITATION.
330   AN ADJUSTMENT FROM A CHANGE IN   B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                        101
      PATIENT'S DAYS STAY.                      MET OR WERE EXCEEDED.

331   PAYMENT REDUCED BY AMOUNT        B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                           65
      PREVIOUSLY PAID. POST OP                  CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
         INCLUDED IN PROCEDURE.                 A PREVIOUS PAYMENT.


332   PAID IN ACCORD WITH MEDICAL      B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                        65
      POLICY GUIDELINES.                        MET OR WERE EXCEEDED.
333   THIS IS AN ADJUSTMENT            125      SUBMISSION/BILLING ERROR(S).              MA67     CORRECTION TO A PRIOR CLAIM.             101
      RESULTING FROM A CLERICAL
      ERROR.




                                                                                                                                                     Effective 10/22/10
                                                                                EOB TO 277 & 835



                                       835                                                 835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                              STATUS
334   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      OCCUPATIONAL THERAPY                      OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER    STATE FISCAL
      YEAR.
335   LACKS REPORT TO JUSTIFY HIGHER   16       CLAIM/SERVICE LACKS INFORMATION WHICH      N29      MISSING/INCOMPLETE/INVALID               294
      FEE.                                      IS NEEDED FOR ADJUDICATION.                         DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                    T/CHART.
336   ADJUSTMENT TO SERVICES           B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                            101
      PREVIOUSLY PAID OR DENIED.                CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
                                                A PREVIOUS PAYMENT.
337   BILLED DAYS CUTBACK SINCE        17       REQUESTED INFORMATION WAS NOT PROVIDED     N50      MISSING/INCOMPLETE/INVALID DISCHARGE     456
      DISCHARGE TIME NOT CODED ON               OR WAS INSUFFICIENT/INCOMPLETE.                     INFORMATION.
      TAD.
338   DAYS REDUCED PER MEDICAL                                                             N10      CLAIM/SERVICE ADJUSTED BASED ON THE      456
      CONSULTANT COMMENT.                                                                           FINDINGS OF A REVIEW
                                                                                                    ORGANIZATION/PROFESSIONAL
                                                                                                    CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                    DENTAL ADVISOR.


339   NEGATIVE ADJUSTMENT -
      RECOUPMENT WILL FOLLOW.
340   REPORT DOES NOT JUSTIFY HIGHER   16       CLAIM/SERVICE LACKS INFORMATION WHICH      N29      MISSING/INCOMPLETE/INVALID               294
      FEE.                                      IS NEEDED FOR ADJUDICATION.                         DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                    T/CHART.
341   FEE REDUCED/PROCEDURE            97       THE BENEFIT FOR THIS SERVICE IS                                                              107
      CODE/UNITS CHANGE TO ALLOW                INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      STATE      MAXIMUM PER DENTAL             ANOTHER SERVICE/PROCEDURE THAT HAS
      POLICY.                                   ALREADY BEEN ADJUDICATED.


342   PROCEDURE/FEE PAID IN            95       PLAN PROCEDURES NOT FOLLOWED.                                                                107
      ACCORDANCE WITH AUDIT.
343   PAID AS BILLED.                                                                                                                        67
344   CLAIM DATES OF SERVICE ARE       B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                         187
      OUTSIDE THE PSRO APPROVED                 MET OR WERE EXCEEDED.
      DATES.
345   PAID IN ACCORD WITH DENTAL       95       PLAN PROCEDURES NOT FOLLOWED.                                                                107
      POLICY GUIDELINES.
346   SERVICES REDUCED PER MEDICAL                                                         N10      CLAIM/SERVICE ADJUSTED BASED ON THE      107
      CONSULTANT COMMENT.                                                                           FINDINGS OF A REVIEW
                                                                                                    ORGANIZATION/PROFESSIONAL
                                                                                                    CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                    DENTAL ADVISOR.


347   NON ALLOWABLE CHARGES DELETED.   96       NON-COVERED CHARGE(S).                     M79      MISSING/INCOMPLETE/INVALID CHARGE.       84

348   ROOM CHARGES REDUCED TO SEMI     78       NON-COVERED DAYS/ROOM CHARGE ADJUSTMENT.                                                     180
      PRIVATE RATE.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                               STATUS
349   RECIPIENT RESOURCE   REPORTING   177      PATIENT HAS NOT MET THE REQUIRED                                                            21
      ON THE TAD DIFFERS   FROM THE             ELIGIBILITY REQUIREMENTS.
      RECIPIENT RESOURCE   CONTAINED
      ON THE ELIGIBILITY   FILE.



350   NDC HAS BEEN CHANGED TO          17       REQUESTED INFORMATION WAS NOT PROVIDED   M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      CURRENT NUMBER.                           OR WAS INSUFFICIENT/INCOMPLETE.                   ITHDRAWN NATIONAL DRUG CODE (NDC).

351   LIMIT EXCEEDED FOR ONE PAID      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EYE GLASSES EVERY 24 MONTHS               OCCURRENCE HAS BEEN REACHED.
      FOR RECIPIENTS 21 AND OLDER.


352   ONLY ONE DISPENSING FEE          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      222
      ALLOWED PER MONTH.                        OCCURRENCE HAS BEEN REACHED.

353   DIAGNOSIS CODE CHANGED TO        B22      THIS PAYMENT IS ADJUSTED BASED ON THE                                                       488
      MATCH DESCRIPTION.                        DIAGNOSIS.
354   YOUR CLAIM WAS DELAYED BECAUSE                                                     M50      MISSING/INCOMPLETE/INVALID REVENUE        455
      ONE OR MORE OF THE REVENUE                                                                  CODE(S).
      CODES THAT WERE USED WERE NOT
      ACCEPTABLE IN OUR SYSTEM.


355   NO CO-INSURANCE OR DEDUCTIBLE                                                                                                         9
      DUE BY MEDICAID
356   RECOUPMENT OF PAYMENT WHICH      B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                          101
      BELONGS TO ANOTHER PROVIDER.              FULLY FURNISHED BY ANOTHER PROVIDER.

357   RECOUPMENT OF PAYMENT MADE FOR                                                                                                        101
      WRONG RECIPIENT. PLEASE
      RESUBMIT YOUR CLAIM.


358   RECOUPMENT OF PAYMENT MADE FOR                                                                                                        101
      WRONG RECIPIENT. YOUR CLAIM
      IS BEING REPROCESSED.


359   RECOUPMENT OF PAID CLAIM WHICH                                                                                                        101
      WAS INCORRECTLY PROCESSED.
      CLAIM IS BEING REPROCESSED. DO
      NOT RESUBMIT CLAIM.


360   PAID IN PART BY MEDICARE.        23       THE IMPACT OF PRIOR PAYER(S)                                                                182
                                                ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                ADJUSTMENTS.
361   RATE NOT VALID FOR DATES OF      147      PROVIDER CONTRACTED/NEGOTIATED RATE      N65      PROCEDURE CODE OR PROCEDURE RATE COUNT    187
      SERVICE.                                  EXPIRED OR NOT ON FILE.                           CANNOT BE DETERMINED, OR WAS NOT ON
                                                                                                  FILE, FOR THE DATE OF SERVICE/PROVIDER.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                           277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                          STATUS
362   THE CLAIM PATIENT LIABILITY      142      MONTHLY MEDICAID PATIENT LIABILITY                                                      65
      AMOUNT HAS BEEN DEDUCTED FROM             AMOUNT.
       THE CLAIM PAYABLE AMOUNT.


363   ADDITIONAL PAYMENT CANNOT BE     23       THE IMPACT OF PRIOR PAYER(S)                                                            182
      MADE ON THE CLAIM AS THE                  ADJUDICATION INCLUDING PAYMENTS AND/OR
      RECIPIENT'S PRIVATE INSURANCE             ADJUSTMENTS.
      PAID AN AMOUNT GREATER THAN
      OREQUAL TO THE CLAIM'S
      MEDICAID ALLOWED AMOUNT.


364   MEDICAID ALLOWED AMOUNT          23       THE IMPACT OF PRIOR PAYER(S)                                                            182
      REDUCED BY OTHER INSURANCE                ADJUDICATION INCLUDING PAYMENTS AND/OR
      PAYMENT                                   ADJUSTMENTS.
365   FEE ADJUSTED TO MAXIMUM          45       CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM                                                    65
      ALLOWABLE.                                ALLOWABLE OR CONTRACTED/LEGISLTATED FEE
                                                ARRANGMENT. (USE GROUPE CODES PR OR CO
                                                DEPENDING ON LIABILITY).


366   OTHER INSURANCE PAID AN AMOUNT   23       THE IMPACT OF PRIOR PAYER(S)                                                            182
      GREATER THAN OR EQUAL TO OUR              ADJUDICATION INCLUDING PAYMENTS AND/OR
      ALLOWED AMOUNT. MEDICAID                  ADJUSTMENTS.
      CANNOT MAKE ANY ADDITIONAL
         PAYMENT.


367   EYE EXAM EXCEEDS ONE EVERY 24    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  483
      MONTHS FOR RECIPIENTS AGE 21              OCCURRENCE HAS BEEN REACHED.
      AND OLDER.


368   LOCK IN SERVICES TO BE ORDERED                                                                                                    84
      BY PRIMARY PHYSICIAN.

369   SUBMITTED LINE ITEM CHARGE       16       CLAIM/SERVICE LACKS INFORMATION WHICH     M79      MISSING/INCOMPLETE/INVALID CHARGE.   247
      MISSING OR INVALID.                       IS NEEDED FOR ADJUDICATION.
370   QUARTERLY AMOUNT FOR FUND CODE   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  483
      BILLED WAS EXCEEDED.                      OCCURRENCE HAS BEEN REACHED.

371   PATIENT LIABILITY EXCEEDS        142      MONTHLY MEDICAID PATIENT LIABILITY                                                      182
      ALLOWED AMOUNT.                           AMOUNT.
372   PAID IN FULL BY OTHER            23       THE IMPACT OF PRIOR PAYER(S)                                                            182
      INSURANCE.                                ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                ADJUSTMENTS.
373   MUST BE INCLUDED IN FLAT FEE     97       THE BENEFIT FOR THIS SERVICE IS                                                         39
      FOR MATERNITY.                            INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.




                                                                                                                                                 Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
374   REPAYMENT PORTION OF THIS                                                                                                             101
      ADJUSTMENT HAS BEEN DENIED.
         RECOUPMENT IS UNDER
      FINANCIAL ITEMS.
375   ONLY ONE THIN PAP SMEAR           119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ALLOWED PER SFY                            OCCURRENCE HAS BEEN REACHED.

376   INCLUDED IN FEE FOR OFFICE        97       THE BENEFIT FOR THIS SERVICE IS                                                            9
      CALL.                                      INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                 ALREADY BEEN ADJUDICATED.


377   $2.00 DIFFERENTIAL DISPENSING                                                                                                         103
      FEE INCLUDED IN PAID AMOUNT

378   INCLUDED IN FEE FOR LABORATORY    97       THE BENEFIT FOR THIS SERVICE IS                                                            103
      SERVICE.                                   INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                 ALREADY BEEN ADJUDICATED.


379   PAID IN FULL BY OTHER             23       THE IMPACT OF PRIOR PAYER(S)                                                               182
      INSURANCE. NO ADDL' PMT CAN BE             ADJUDICATION INCLUDING PAYMENTS AND/OR
      MADE.                                      ADJUSTMENTS.
380   RECIPIENT SPENDDOWN REDUCED       91       DISPENSING FEE ADJUSTMENT.
      AMT/ADD $2 FOR DIF DISPENSING
      FEE.
381   ADJUSTMENT RESULTING FROM                                                           M53      MISSING/INCOMPLETE/INVALID DAYS OR       101
      INCORRECT AMOUNT OF                                                                          UNITS OF SERVICE.
      DOLLAR/SERVICE UNITS ON
      ORIGINAL CLAIM.
382   ADJUSTMENT RESULTING FROM         17       REQUESTED INFORMATION WAS NOT PROVIDED   MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR    101
      INCORRECT RECIPIENT ID# ON                 OR WAS INSUFFICIENT/INCOMPLETE.                   INVALID INFORMATION, AND NO APPEAL
         ORIGINAL CLAIM.                                                                           RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                   IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                   CLAIM WITH THE COMPLETE/CORRECT
                                                                                                   INFORMATION.


383   ADJUSTMENT RESULTING FROM                                                           N30      PATIENT INELIGIBLE FOR THIS SERVICE.     101
      OVERPAYMENT -- PATIENT EXPIRED.

384   ADJUSTMENT RESULTING FROM A                                                         M53      MISSING/INCOMPLETE/INVALID DAYS OR       101
      CHANGE IN THE UNITS OF SERVICE.                                                              UNITS OF SERVICE.

385   ADJUSTMENT --- ORIGINAL CLAIM     125      SUBMISSION/BILLING ERROR(S).             N377     PAYMENT BASED ON A PROCESSED             101
      PAID TO WRONG PROVIDER.                                                                      REPLACEMENT CLAIM.

386   ADJUSTMENT RESULTING FROM A                                                         M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 101
      CHANGE IN THE NDC NUMBER.                                                                    ITHDRAWN NATIONAL DRUG CODE (NDC).




                                                                                                                                                     Effective 10/22/10
                                                                              EOB TO 277 & 835



                                      835                                                 835                                            277
                                      ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   EDS DESCRIPTION                 REASON   DESCRIPTION                                REMARK   DESCRIPTION                           STATUS
387   EFFECTIVE 07-01-88 IF PRIOR     197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      AUTHORIZATION NUMBER OMITTED             ION ABSENT.
       CLAIM WILL BE DENIED


388   EXCEEDS LIMIT OF ONE PHYSICAL   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      THERAPY EVALUATION PER                   OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR.


389   PRIOR AUTHORIZATION/PRE-        197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      CERTIFICATION NUMBER NOT ON              ION ABSENT.
      FILE.
390   CLAIM PROVIDER NUMBER IS NOT    15       THE AUTHORIZATION NUMBER IS MISSING,                                                      252
      ON PRIOR AUTHORIZATION/                  INVALID, OR DOES NOT APPLY TO THE
      PRE-CERTIFICATION FILE.                  BILLED SERVICES OR PROVIDER.


391   ARKIDS FIRST-B CLAIM EXCEEDED                                                       N61      REBILL SERVICES ON SEPARATE CLAIMS.   121
      28 DETAILS. PLEASE SPLIT BILL
      AND RESUBMIT.


392   PRIOR AUTHORIZATION/PRE-        15       THE AUTHORIZATION NUMBER IS MISSING,                                                      252
      CERTIFICATION UNITS HAVE BEEN            INVALID, OR DOES NOT APPLY TO THE
           EXHAUSTED.                          BILLED SERVICES OR PROVIDER.


393   CLAIM RECIPIENT ID# DOES NOT    140      PATIENT/INSURED HEALTH IDENTIFICATION                                                     252
      MATCH P.A. RECIPIENT ID#.                NUMBER AND NAME DO NOT MATCH.

394   TOOTH NUMBER MUST BE PRIOR      15       THE AUTHORIZATION NUMBER IS MISSING,                                                      252
      AUTHORIZED.                              INVALID, OR DOES NOT APPLY TO THE
                                               BILLED SERVICES OR PROVIDER.


395   OUT-OF-STATE CARE NOT           197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  84
      PREAUTHORIZED.                           ION ABSENT.
396   PRIOR AUTHORIZATION HAS NOT     197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      BEEN ISSUED FOR THE ASSISTANT            ION ABSENT.
       SURGEON.
397   PRIOR AUTHORIZATION/PRE-        197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      CERTIFICATION NUMBER IS                  ION ABSENT.
      MISSING OR INVALID.
398   PRIOR AUTHORIZATION/PRE-        197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      CERTIFICATION NUMBER HAS                 ION ABSENT.
      EXPIRED.
399   PRIOR AUTHORIZATION/PRE-        197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                  252
      CERTIFICATION REQUIRED.                  ION ABSENT.
400   NO PAYMENT ALLOWED FOR          59       PROCESSED BASED ON MULTIPLE OR                                                            9
      INCIDENTAL SURGERY.                      CONCURRENT PROCEDURE RULES (FOR EXAMPLE
                                               MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
                                               CONCURRENT ANESTHESIA.)




                                                                                                                                                  Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
401   THIS PROCEDURE IS INCLUDED IN    97       THE BENEFIT FOR THIS SERVICE IS                                                             107
      THE FEE FOR THE PRIMARY                   INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      PROCEDURE.                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


402   THIS SERVICE WAS REVIEWED BY     A1       CLAIM DENIED CHARGES.                     N10      CLAIM/SERVICE ADJUSTED BASED ON THE      9
      OUR MEDICAL CONSULTANT AND WAS                                                               FINDINGS OF A REVIEW
      DENIED.                                                                                      ORGANIZATION/PROFESSIONAL
                                                                                                   CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                   DENTAL ADVISOR.


403   PRICED AS MULTIPLE SURGERY.      59       PROCESSED BASED ON MULTIPLE OR                                                              65
                                                CONCURRENT PROCEDURE RULES (FOR EXAMPLE
                                                MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
                                                CONCURRENT ANESTHESIA.)


404   THIS SERVICE WAS PREVIOUSLY      B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                           54
      SUBMITTED AND PAID.                       CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
                                                A PREVIOUS PAYMENT.
405   CLIA CERTIFICATION REQUIRED                                                         MA120    MISSING/INCOMPLETE/INVALID CLIA          142
      FOR LAB PROCEDURE.                                                                           CERTIFICATION NUMBER.

406   EXCEEDED ONE PREVENTATIVE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      DENTAL SCREEN APPROPRIATE FOR             OCCURRENCE HAS BEEN REACHED.
         NEWBORN TO 12 MONTHS.


407   EXCEEDS LIMIT OF ONE EYE EXAM    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      IN A 12 MONTH PERIOD                      OCCURRENCE HAS BEEN REACHED.

408   TAX RECOUPMENT FROM VOIDED
      CHECK CREDITED NET 1099 AMOUNT

409   ARKIDS FIRST-B PARTICIPANT       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EXCEEDED BENEFIT LIMIT FOR                OCCURRENCE HAS BEEN REACHED.
        AGE APPROPRIATE PREVENTATIVE
      HEALTH SCREEN.



410   RESPITE CARE PROVIDED MORE       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      THAN 14 CONSECUTIVE DAYS                  OCCURRENCE HAS BEEN REACHED.

411   TWO EPSDT HEARING SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      APPROPRIATE PER YEAR                      OCCURRENCE HAS BEEN REACHED.

412   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      HEARING SCREENS PAYABLE FROM              OCCURRENCE HAS BEEN REACHED.
      16YRSTHRU 17YRS




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                   277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE   CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                  STATUS
413   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      HEARING SCREENS PAYABLE FROM              OCCURRENCE HAS BEEN REACHED.
      18YRSTHRU 20YRS
414   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      HEARING SCREENS PAYABLE FROM              OCCURRENCE HAS BEEN REACHED.
      12YRSTHRU 15 YRS
415   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      VISION SCREENS PAYABLE FROM 6             OCCURRENCE HAS BEEN REACHED.
      YRS THRU 9 YEARS
416   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      VISION SCREENS PAYABLE FROM 10            OCCURRENCE HAS BEEN REACHED.
      YRSTHRU 11 YEARS
417   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      VISION SCREENS PAYABLE FROM 12            OCCURRENCE HAS BEEN REACHED.
      YRSTHRU 15 YRS
418   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      VISION SCREENS PAYABLE FROM 16            OCCURRENCE HAS BEEN REACHED.
      YRSTHRU 17 YRS
419   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      VISION SCREENS PAYABLE FROM 18            OCCURRENCE HAS BEEN REACHED.
      YRSTHRU 20 YRS
420   ADJUSTMENT RESULTING FROM A                                                                                              101
      CHANGE IN THE TYPE OF SERVICE.

421   ADJUSTMENT RESULTING FROM A                                                                                              101
      CHANGE IN THE PROCEDURE CODE.

422   CROSSOVER ADJUSTMENT RESULTING   B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                           101
      FROM AN ADJUSTMENT MADE BY                MET OR WERE EXCEEDED.
      MEDICARE.


423   ADJUSTMENT RESULTING FROM A     58        TREATMENT WAS DEEMED BY THE PAYER TO                                           101
      CHANGE IN THE PLACE OF SERVICE.           HAVE BEEN RENDERED IN AN INAPPROPRIATE
                                                OR INVALID PLACE OF SERVICE.


424   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      HEARING SCREENS PAYABLE FROM              OCCURRENCE HAS BEEN REACHED.
      NEW- BORN TO 5 YEARS
425   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                         483
      HEARING SCREENS PAYABLE FROM 8            OCCURRENCE HAS BEEN REACHED.
      YRSTO 11 YRS
426   GROUP I OUTPATIENT DENTAL        97       THE BENEFIT FOR THIS SERVICE IS                                                107
      SURGERY NOT PAYABLE SAME DOS              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      GROUP II OUTPATIENT DENTAL                ANOTHER SERVICE/PROCEDURE THAT HAS
      SURGERY.                                  ALREADY BEEN ADJUDICATED.


427   $5.00 ENROLLMENT FEE DEDUCTED
      FROM PAYMENT.




                                                                                                                                        Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                             STATUS
428   EXCEEDS TWO NORPLANT SYSTEMS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      WITHIN 5 YEAR PERIOD                      OCCURRENCE HAS BEEN REACHED.

429   EXCEEDS TWO NORPLANT            119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      INSERTIONS WITHIN 5 YEAR PERIOD           OCCURRENCE HAS BEEN REACHED.

430   $2.00 DISPENSING FEE             91       DISPENSING FEE ADJUSTMENT.
      INCLUDED/$5.00 ENROLLMENT FEE
      DEDUCTED.
431   EXCEEDS LIMIT OF ONE DIAGNOSIS   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      - PSYCHOLOGICAL TEST                      OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER STATE FISCAL
      YEAR
432   RECIPIENT LIMITED TO TB                                                            N30      PATIENT INELIGIBLE FOR THIS SERVICE.    84
      RELATED SERVICES ONLY.
433   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      INTERPRETATION OF DIAGNOSIS               OCCURRENCE HAS BEEN REACHED.
      PER STATE FISCAL YEAR


434   EXCEEDED LIMIT OF 48 CRISIS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      MANAGEMENT SERVICE UNITS PER              OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR


435   EXCEEDS LIMIT OF SIX UNITS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      FAMILY THERAPY/MARITAL PER WEEK           OCCURRENCE HAS BEEN REACHED.

436   EXCEEDS LIMIT OF TWELVE UNITS   119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      INDIVIDUAL OUTPATIENT -                   OCCURRENCE HAS BEEN REACHED.
      COLLATERAL SERVICES PER 90 DAYS



437   NEW BIRTH STANDBY NON-PAYABLE    97       THE BENEFIT FOR THIS SERVICE IS                                                           107
      SAME DATE OF SERVICE AS                   INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      PHYSICIAN STANDBY SERVICE.                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


438   UNITS * UNIT COST IS FOUR OR     154      PAYER DEEMS THE INFORMATION SUBMITTED                                                     483
      MORE TIMES GREATER THAN BILLED            DOES NOT SUPPORT THIS DAY'S SUPPLY.
      AMOUNT. REBILL USING CORRECT
      UNITS.


439   UNITS * UNIT COST IS LESS THAN   154      PAYER DEEMS THE INFORMATION SUBMITTED    M53      MISSING/INCOMPLETE/INVALID DAYS OR      476
      HALF OF THE BILLED AMOUNT.                DOES NOT SUPPORT THIS DAY'S SUPPLY.               UNITS OF SERVICE.
      REBILL USING CORRECT UNITS.


440   NON-COVERED SERVICES MUST BE     96       NON-COVERED CHARGE(S).                   N78      THE NECESSARY COMPONENTS OF THE CHILD   84
      RESULT OF EPSDT REFERRAL                                                                    AND TEEN CHECKUP (EPSDT) WERE NOT
                                                                                                  COMPLETED.




                                                                                                                                                   Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
441   CLAIMS RELATED TO ORGAN          109      CLAIM NOT COVERED BY THIS                 N59      ALERT: PLEASE REFER TO YOUR PROVIDER      23
      TRANSPLANT MUST BE SUBMITTED              PAYER/CONTRACTOR. YOU MUST SEND THE                MANUAL FOR ADDITIONAL PROGRAM AND
      DIRECT-LY TO UTILIZATION                  CLAIM TO THE CORRECT PAYER/CONTRACTOR.             PROVIDER INFORMATION.
      REVIEW WITHIN SIXTY DAYS OF
      THE PROCEDURE. INSTRUCTION
      FOR FILING CLAIMS MAY BE FOUND
      IN PROV MANUAL.


442   THE CENSUS RECORD FOR THE        16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               21
      MONTH JUST BEFORE THE FROM                IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      DATE OF SERVICE HAS NOT BEEN                                                                 T/CHART.
      RECIEVED. PLEASE SUBMIT THE
      APPROPRIATE CENSUS DATA AND
      RESUBMIT THE CLAIM.


443   CLAIM IN EXCESS OF THE MAXIMUM   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      5 CONSECUTIVE DAYS HOSPITAL               OCCURRENCE HAS BEEN REACHED.
      LEAVE FROM THE NURSING HOME.


444   ABSENCE OF RESTORATIVE CODE      107      THE RELATED OR QUALIFYING CLAIM/SERVICE   M20      MISSING/INCOMPLETE/INVALID HCPCS.         42
      PREVENTS PAYMENT OF CLAIM                 WAS NOT IDENTIFIED ON THIS CLAIM.

445   INVALID NCCI BILLING             97       THE BENEFIT FOR THIS SERVICE IS                                                              107
      COMBINATIONS - DENIED DUE TO              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      RELATED PROCEDURE PAID IN                 ANOTHER SERVICE/PROCEDURE THAT HAS
      HISTORY. CMS DOES NOT ALLOW               ALREADY BEEN ADJUDICATED.
      APPEAL.

446   CLAIM SPLIT INTO SEPARATE        178      PATIENT HAS NOT MET THE REQUIRED SPEND    N63      REBILL SERVICES ON SEPARATE CLAIM LINES. 247
      DETAILS TO ACCOMMODATE THE                DOWN REQUIREMENTS.
         SPENDDOWN REQUIREMENTS.


447   UNITS OF SERVICE DO NOT          178      PATIENT HAS NOT MET THE REQUIRED SPEND                                                       476
      CORRESPOND TO THE DATES BILLED            DOWN REQUIREMENTS.
      FOR SPENDDOWN
448   SERVICE INCLUDED IN CRITICAL     97       THE BENEFIT FOR THIS SERVICE IS           M15      SEPARATELY BILLED SERVICES/TESTS HAVE     107
      CARE CODE.                                INCLUDED IN THE PAYMENT/ALLOWANCE FOR              BEEN BUNDLED AS THEY ARE CONSIDERED
                                                ANOTHER SERVICE/PROCEDURE THAT HAS                 COMPONENTS OF THE SAME PROCEDURE.
                                                ALREADY BEEN ADJUDICATED.                          SEPARATE PAYMENT IS NOT ALLOWED.


449   DIAGNOSIS NOT ON INSTITUTIONAL   146      DIAGNOSIS WAS INVALID FOR THE DATE(S)     M81      YOU ARE REQUIRED TO CODE TO THE HIGHEST   255
      CRITERIA FOR PAS DAYS.                    OF SERVICE REPORTED.                               LEVEL OF SPECIFICITY.

450   REFILE WITH COPY OF PROGRESS     16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               294
      NOTES.                                    IS NEEDED FOR ADJUDICATION.                        DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.




                                                                                                                                                      Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
451   INVALID NCCI BILLING              97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      COMBINATIONS - DENIED DUE TO               INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      RELATED PROCEDURE PAID IN                  ANOTHER SERVICE/PROCEDURE THAT HAS
      HISTORY. CMS ALLOWS APPEAL                 ALREADY BEEN ADJUDICATED.


452   CLAIM IN EXCESS OF THE MAXIMUM    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      14 CONSECUTIVE DAY HOME                    OCCURRENCE HAS BEEN REACHED.
      LEAVE FROM THE NURSING HOME.


453   CLAIM CUT BACK TO BENEFIT LIMIT 119        BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
                                                 OCCURRENCE HAS BEEN REACHED.

454   PROCEDURE CODE CAN BE BILLED      B18      THIS PROCEDURE CODE AND MODIFIER WERE                                                      454
      ON DATE OF BIRTH ONLY                      INVALID ON THE DATE OF SERVICE.

455   PROCEDURE CODE CANNOT BE          B18      THIS PROCEDURE CODE AND MODIFIER WERE                                                      454
      BILLED ON DATE OF BIRTH                    INVALID ON THE DATE OF SERVICE.

456   MAXIMUM OF 20 PAID INPATIENT      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      HOSPITAL DAYS PER SFY                      OCCURRENCE HAS BEEN REACHED.

457   BENEFITS EXHAUSTED                119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
                                                 OCCURRENCE HAS BEEN REACHED.

458   MAXIMUM OF 30 PAID REHAB          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      HOSPITAL DAYS OPTION PER                   OCCURRENCE HAS BEEN REACHED.
      CURRENT   SFY
459   MAX TRANSPLANT REIMBURSEMENT      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      AMOUNT OF 150,000.00 HAS BEEN              OCCURRENCE HAS BEEN REACHED.
      EXCEEDED.


460   SERVICES COVERED ONLY FOR                                                           N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      ASSISTED LIVING WAIVER CLIENTS.

461   EXCEEDED MAXIMUM OF THREE         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TREATMENTS PER WEEK FOR                    OCCURRENCE HAS BEEN REACHED.
      HEMODIALYSIS
462   LIMIT OF 3 UNITS PER DAY          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      WITHOUT BENEFIT EXTENSION                  OCCURRENCE HAS BEEN REACHED.

463   93543/93546 NOT ALLOWED SAME      B18      THIS PROCEDURE CODE AND MODIFIER WERE    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DOS AS CERTAIN COMPANION                   INVALID ON THE DATE OF SERVICE.                   MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      RADIOLOGICAL CODES                                                                           SET TIME FRAME.


464   READMISSION 96 HOURS FROM                                                                                                             189
      DISCHARGE, PAS DAYS USED.
465   UNITS OF SERVICE EXCEED NCCI      154      PAYER DEEMS THE INFORMATION SUBMITTED    M53      MISSING/INCOMPLETE/INVALID COMPETITIVE   476
      MEDICALLY UNLIKELY EDITS.                  DOES NOT SUPPORT THIS DAY'S SUPPLY.               BIDDING DEMONSTRATION PROJECT
                                                                                                   IDENTIFICATION.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
466   PROVIDER FILE SUSPENDED DUE TO                                                                                                       91
      NONPAYMENT OF TAXES, CONTACT
      THE DHS ACCOUNTS RECIEVABLE
      SECTION AT 682-6506/ 6508/
      6511.


467   PROVIDER FILE CANCELLED DUE TO                                                                                                       91
      NONPAYMENT OF TAXES, CONTACT
      THE DHS ACCOUNTS RECIEVABLE
      SECTION AT 682-6506/ 6508/
      6511.


468   TIER OF NEED FOR ASST LIVING                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      WVR SERV NOT APPROVED BY DAAS
      FOR THIS CLIENT.


469   DUPLICATE OF CLAIM NOT YET PAID 18        DUPLICATE CLAIM/SERVICE.                                                                   78

470   DUPLICATE OF CLAIM PAID          18       DUPLICATE CLAIM/SERVICE.                                                                   54

471   SERVICE IS A DUPLICATE OF        18       DUPLICATE CLAIM/SERVICE.                                                                   78
      SERVICE PAID ON SAME CLAIM.

472   SEALANT ONCE IN A LIFETIME FOR   35       LIFETIME BENEFIT MAXIMUM HAS BEEN                                                          483
      TOOTH.                                    REACHED.
473   PROCEDURE IS INCLUDED IN         97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      93543/93546 FOR SAME DOS                  INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


474   RENTAL WHEELCHAIR NON-PAYABLE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N417     THIS SERVICE IS ALLOWED 1 TIME IN A 5-   107
      WITHIN 5 YEARS OF PURCHASED               OCCURRENCE HAS BEEN REACHED.                      YEAR PERIOD.
      WHEELCHAIR
475   A PAID PANEL CODE OR ANOTHER     B18      THIS PROCEDURE CODE AND MODIFIER WERE    N61      REBILL SERVICES ON SEPARATE CLAIMS.      419
      PAID INDIVIDUAL TEST PREVENTS             INVALID ON THE DATE OF SERVICE.
      PAYMENT OF THIS CLAIM PLEASE
      ADJUST FOR PAID PROCEDURES AND
      REBILL USING HIGHEST PANEL OR
      PROFILE CODE APPLICABLE




476   CLAIM NOT SUBMITTED USING                                                          M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    419
      HIGHEST LAB PANEL OR PROFILE                                                                LAB CODES INCLUDED IN THE TEST.
      CODE APPLICABLE FOR SAME DOS
      RESUBMIT USING A SINGLE
      APPROPRIATE CODE




                                                                                                                                                    Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                                835                                                277
                                        ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
477   A PAID OR PENDING CLAIM FOR       45       CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM      N45      PAYMENT BASED ON AUTHORIZED AMOUNT.       419
      80019 REPRESENTS THE MAXIMUM               ALLOWABLE OR CONTRACTED/LEGISLTATED FEE
       ALLOWABLE PER DOS NO OTHER                ARRANGMENT. (USE GROUPE CODES PR OR CO
      INDIVIDUAL TESTS OR PANELS ARE             DEPENDING ON LIABILITY).
       ALLOWED IN CONJUNCTION WITH
      80019


478   93501-93529 NOT ALLOWED SAME                                                         N20      SERVICE NOT PAYABLE WITH OTHER SERVICE    107
      DOS AS CERTAIN COMPANION RADIO-                                                               RENDERED ON THE SAME DATE.
      LOGICAL CODES


479   PROCEDURE IS INCLUDED IN 93501- 97         THE BENEFIT FOR THIS SERVICE IS                                                              107
      93529 FOR SAME DOS                         INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                 ALREADY BEEN ADJUDICATED.


480   REFILE ON PAPER CLAIM WITH        16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29      MISSING/INCOMPLETE/INVALID               277
      APPROPRIATE DESCRIPTION AND/OR             IS NEEDED FOR ADJUDICATION. ADDITIONAL             DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
        ATTACHMENT.                              INFORMATION IS SUPPLIED USING                      T/CHART.
                                                 REMITTANCE ADVICE REMARKS CODES
                                                 WHENEVER APPROPRIATE.


481   PERSONAL CARE NOT ALLOWED TO                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.      84
      ASSISTED LIVING WAIVER CLIENTS.

482   PATIENT WAS ADMITTED ON SAME      60       CHARGES FOR OUTPATIENT SERVICES WITH      M2       NOT PAID SEPARATELY WHEN THE PATIENT IS   189
      DOS AS PAID OR PENDING CLAIM               THIS PROXIMITY TO INPATIENT SERVICES               AN INPATIENT.
      FOR OUTPATIENT SERVICES.                   ARE NOT COVERED.


483   PROCEDURE IS INCLUDED IN 93544    B15      THIS SERVICE/PROCEDURE REQUIRES THAT A    M15      SEPARATELY BILLED SERVICES/TESTS HAVE     107
      FOR SAME DOS                               QUALIFYING SERVICE/PROCEDURE BE                    BEEN BUNDLED AS THEY ARE CONSIDERED
                                                 RECEIVED AND COVERED. THE QUALIFYING               COMPONENTS OF THE SAME PROCEDURE.
                                                 OTHER SERVICE/PROCEDURE HAS NOT BEEN               SEPARATE PAYMENT IS NOT ALLOWED.
                                                 RECEIVED/ADJUDICATED.


484   THIS SERVICE HAS BEEN             B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                           65
      SUBMITTED AND PAID TO ANOTHER              FULLY FURNISHED BY ANOTHER PROVIDER.
      PROVIDERFOR THIS DATE OF
      SERVICE.
485   ONLY ONE HOSPITAL ADMISSION     B14        ONLY ONE VISIT OR CONSULTATION PER                                                           483
      VISIT ALLOWED PER HOSPITAL STAY            PHYSICIAN PER DAY IS COVERED.

486   NEONATAL INTENSIVE CARE CODE      B15      THIS SERVICE/PROCEDURE REQUIRES THAT A                                                       107
      NOT PAID IN CONJUNCTION TO                 QUALIFYING SERVICE/PROCEDURE BE
      PAID RELATED PROCEDURE                     RECEIVED AND COVERED. THE QUALIFYING
                                                 OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                 RECEIVED/ADJUDICATED.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
487   PROCEDURE INCLUDED IN CODE       B15      THIS SERVICE/PROCEDURE REQUIRES THAT A                                                     107
      99295-99297 FOR SAME DOS.                 QUALIFYING SERVICE/PROCEDURE BE
                                                RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


488   93548 NOT ALLOWED SAME DOS AS    B15      THIS SERVICE/PROCEDURE REQUIRES THAT A                                                     107
      CERTAIN COMPANION                         QUALIFYING SERVICE/PROCEDURE BE
      RADIOLOGICALCODES                         RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


489   PURCHASED WHEELCHAIR NON-        151      PAYMENT ADJUSTED BECAUSE THE PAYER                                                         107
      PAYABLE WITHIN 5 YEARS OF                 DEEMS THE INFORMATION SUBMITTED DOES
          RENTED WHEELCHAIR                     NOT SUPPORT THIS MANY/FREQUENCY OF
                                                SERVICES.
490   ROUTINE INFANT/CHILD HEALTH      49       THESE ARE NON-COVERED SERVICES BECAUSE                                                     481
      CHECK NOT PAYABLE ON CLAIM                THIS IS A ROUTINE EXAM OR SCREENING
      FORM BILLED                               PROCEDURE DONE IN CONJUNCTION WITH A
                                                ROUTINE EXAM.
491   93542 NOT ALLOWED SAME DOS AS    B15      THIS SERVICE/PROCEDURE REQUIRES THAT A   N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CERTAIN COMPANION                         QUALIFYING SERVICE/PROCEDURE BE                   RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                         RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


492   PROCEDURE IS INCLUDED IN 93542   97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      FOR SAME DOS                              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


493   93545 NOT ALLOWED SAME DOS AS    97       THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CERTAIN COMPANION                         INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                         ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


494   PROCEDURE IS INCLUDED IN 93545   97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      FOR SAME DOS                              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


495   EXCEEDED MAXIMUM OF 12           119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TREATMENTS PER MONTH FOR                  OCCURRENCE HAS BEEN REACHED.
      HEMODIALYSIS




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
496   EXACT DUPLICATE CROSSOVER        18       DUPLICATE CLAIM/SERVICE.                 N8       CROSSOVER CLAIM DENIED BY PREVIOUS       54
                                                                                                  PAYER AND COMPLETE CLAIM DATA NOT
                                                                                                  FORWARDED. RESUBMIT THIS CLAIM TO THIS
                                                                                                  PAYER TO PROVIDE ADEQUATE DATA FOR
                                                                                                  ADJUDICATION.


497   93547/93549 NOT ALLOWED SAME    B15       THIS SERVICE/PROCEDURE REQUIRES THAT A   N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      DOS AS CERTAIN COMPANION RADIO-           QUALIFYING SERVICE/PROCEDURE BE                   RENDERED ON THE SAME DATE.
      LOGICAL CODES                             RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


498   PROCEDURE INCLUDE IN             97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      93547/93549 FOR SAME DOS                  INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


499   93544 NOT ALLOWED SAME DOS AS    B15      THIS SERVICE/PROCEDURE REQUIRES THAT A   N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CERTAIN COMPANION                         QUALIFYING SERVICE/PROCEDURE BE                   RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                         RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


500   INCORRECT BILLING.               125      SUBMISSION/BILLING ERROR(S).             MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR    481
                                                                                                  INVALID INFORMATION, AND NO APPEAL
                                                                                                  RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                  IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                  CLAIM WITH THE COMPLETE/CORRECT
                                                                                                  INFORMATION.


501   REFILE WITH MORE LEGIBLE CLAIM                                                     N29      MISSING                                  294
      OR DOCUMENTATION.                                                                           DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
502   INDICATE TIME INVOLVED.                                                            M125     MISSING/INCOMPLETE/INVALID INFORMATION   263
                                                                                                  ON THE PERIOD OF TIME FOR WHICH THE
                                                                                                  SERVICE/SUPPLY/EQUIPMENT WILL BE NEEDED.



503   LIST TESTS INCLUDED IN PANEL.    16       CLAIM/SERVICE LACKS INFORMATION WHICH    M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    419
                                                IS NEEDED FOR ADJUDICATION.                       LAB CODES INCLUDED IN THE TEST.

504   INDICATE IF TEST WAS PERFORMED   16       CLAIM/SERVICE LACKS INFORMATION WHICH    N396     INCOMPLETE/INVALID LABORATORY REPORT.    473
      IN YOUR LAB.                              IS NEEDED FOR ADJUDICATION.
505   REFILE WITH COPY OF HISTORY      16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               331
      AND PHYSICAL.                             IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
506   REFILE WITH PROCEDURE REPORT.    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING                                  306
                                                IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
507   REFILE WITH PATHOLOGY REPORT.    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N30      PATIENT INELIGIBLE FOR THIS SERVICE.     311
                                                IS NEEDED FOR ADJUDICATION.
508   REFILE WITH COPY OF OPERATIVE    16       CLAIM/SERVICE LACKS INFORMATION WHICH    M29      MISSING OPERATIVE REPORT.                298
      REPORT.                                   IS NEEDED FOR ADJUDICATION.
509   REFILE WITH COPY OF ANESTHESIA   16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               262
      REPORT.                                   IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
510   REFILE WITH COPY OF DISCHARGE    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N50      MISSING/INCOMPLETE/INVALID DISCHARGE     308
      SUMMARY.                                  IS NEEDED FOR ADJUDICATION.                       INFORMATION.
511   INDICATE IF CHARGE IS FOR                                                          N249     MISSING/INCOMPLETE/INVALID ASSISTANT     414
      ASSISTANT SURGEON.                                                                          PRIMARY IDENTIFIER.
512   31 UNITS OF ASSISTED LIVING      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      WAIVER SERVICES ALLOWED PER               OCCURRENCE HAS BEEN REACHED.
      MONTH.
513   DENIED BY MEDICAL STAFF.         A1       CLAIM DENIED CHARGES.                    N10      CLAIM/SERVICE ADJUSTED BASED ON THE      9
                                                                                                  FINDINGS OF A REVIEW
                                                                                                  ORGANIZATION/PROFESSIONAL
                                                                                                  CONSULT/MANUAL ADJUDICATION/MEDICAL OR
                                                                                                  DENTAL ADVISOR.


514   VERIFY PROCEDURE                                                                   M51      MISSING/INCOMPLETE/INVALID PROCEDURE     454
      CODE/DESCRIPTION/CHARGE.                                                                    CODE(S).
515   INCORRECT PROCEDURE CODE.                                                          M51      MISSING/INCOMPLETE/INVALID PROCEDURE     454
      CONTACT THE STATE PROVIDER                                                                  CODE(S).
      COMMUNICATIONS UNIT AT 1-800-
      482-1141
516   INADEQUATE PROCEDURE                                                               M51      MISSING/INCOMPLETE/INVALID PROCEDURE     306
      DESCRIPTION.                                                                                CODE(S).
517   ONLY ONE CONSULTATION/OFFICE     B14      ONLY ONE VISIT OR CONSULTATION PER                                                         483
      VISIT PER DATE OF SERVICE PER             PHYSICIAN PER DAY IS COVERED.
      RECIPIENT PER PERFORMING
      PROVIDER.


518   REFILE WITH COPY OF              16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING                                  294
      MANUFACTURERS INVOICE.                    IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
519   LIST NAME OF DRUG AND DOSAGE.    16       CLAIM/SERVICE LACKS INFORMATION WHICH    M123     MISSING/INCOMPLETE/INVALID NAME,         217
                                                IS NEEDED FOR ADJUDICATION.                       STRENGTH, OR DOSAGE OF THE DRUG
                                                                                                  FURNISHED.
520   STERILITY ACKNOWLEDGE MENT       133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                      294
      SIGNED AFTER HYSTERECTOMY MUST            IS PENDING FURTHER REVIEW.
         CLEARLY STATE PATIENT WAS
      INFORMED PRIOR TO SURGERY THAT
      THE HYSTERECTOMY WOULD RENDER
      HER PERMANATELY STERILE.




                                                                                                                                                    Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
521   PLEASE ATTACH A COPY OF THE       133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                      311
      PATHOLOGY REPORT WHICH                     IS PENDING FURTHER REVIEW.
      VERIFIES A DIAGNOSIS OF CANCER
      OR SEVERE DYSPLASIA PRIOR TO
      THE HYSTERECTOMY BEING
      PERFORMED


522   STATEMENT SIGNED BY THE           133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                      294
      PATIENT ACKNOWLEDGING THAT THE             IS PENDING FURTHER REVIEW.
      HYSTERECTOMY WILL RENDER HER
      PERMANENTLY INCAPABLE OF
      REPRODUCING CHILDREN MUST
      ACCOMPANY CLAIM.


523   DEPARTMENT OF HUMAN SERVICES                                                        N3       MISSING CONSENT FORM.                    294
      APPROVED CONSENT FORM MUST BE
      COMPLETED AND ATTACHED TO
      CLAIM FOR STERILIZATION


524   ALL BLANKS MUST BE FILLED IN                                                        N3       MISSING CONSENT FORM.                    21
      AND LEGIBLE ON CONSENT FORM.

525   PATIENT'S SIGNATURE IS OMITTED                                                      N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 466
      OR ILLEGIBLE ON CONSENT FORM.

526   DATE PATIENT SIGNED CONSENT       17       REQUESTED INFORMATION WAS NOT PROVIDED   N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 467
      FORM IS OMITTED, INCORRECT, OR             OR WAS INSUFFICIENT/INCOMPLETE.
       ILLEGIBLE.
527   SIGNATURE AND/OR DATE OF                                                            N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 21
      PERSON OBTAINING CONSENT IS
      OMITTED, INCORRECT OR ILLEGIBLE


528   DATE PHYSICIAN SIGNED CONSENT                                                       N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 467
      FORM IS OMITTED OR ILLEGIBLE.

529   PHYSICIAN'S SIGNATURE IS                                                            MA70     MISSING/INCOMPLETE/INVALID PROVIDER      466
      OMITTED.                                                                                     REPRESENTATIVE SIGNATURE.

530   DATE PHYSICIAN'S STATEMENT IS     129      PRIOR PROCESSING INFORMATION APPEARS                                                       467
      SIGNED CANNOT BE MORE THAN                 INCORRECT.
      ONEWEEK PRIOR TO SURGERY.


531   BIRTHDATE IS OMITTED,                                                               N3       MISSING CONSENT FORM.                    158
      INCORRECT OR ILLEGIBLE ON
      CONSENT FORM.
532   PLEASE REFILE --- OMITTING THE    15       THE AUTHORIZATION NUMBER IS MISSING,                                                       84
      CHARGES FOR UNAUTHORIZED                   INVALID, OR DOES NOT APPLY TO THE
      STERILIZATION PROCEDURE.                   BILLED SERVICES OR PROVIDER.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
533   STERILIZATION WAS PERFORMED      116      THE ADVANCE INDEMNIFICATION NOTICE       N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 467
      BEFORE 30 DAYS FROM TIME                  SIGNED BY THE PATIENT DID NOT COMPLY
      CONSENTFORM WAS SIGNED BY                 WITH REQUIREMENTS.
      PATIENT.
534   STERILIZATION WAS PERFORMED      116      THE ADVANCE INDEMNIFICATION NOTICE       N28      CONSENT FORM REQUIREMENTS NOT FULFILLED. 467
      MORE THAN 180 DAYS AFTER                  SIGNED BY THE PATIENT DID NOT COMPLY
      CONSENT FORM WAS SIGNED BY THE            WITH REQUIREMENTS.
      PATIENT.
535   FAMILY PLANNING DIAGNOSIS NOT    11       THE DIAGNOSIS IS INCONSISTENT WITH THE                                                     255
      PRESENT WITH FAMILY PLANNING              PROCEDURE.
      PROCEDURE
536   EXCEEDS LIMIT OF ONE GROUP       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      OUTPATIENT GROUP THERAPY PER              OCCURRENCE HAS BEEN REACHED.
      WEEK
537   EXCEEDED BENEFIT LIMIT OF ONE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      GROUP OUTPATIENT-MEDICATION               OCCURRENCE HAS BEEN REACHED.
      MAINTENANCE PER 30 DAYS


538   EXCEEDED BENEFIT LIMIT OF ONE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PERITONEAL DIALYSIS FOR SEVEN             OCCURRENCE HAS BEEN REACHED.
      DAYS
539   EXCEEDED BENEFIT LIMIT OF                                                          M90      NOT COVERED MORE THAN ONCE IN A 12       483
      ONE(1) DIAGNOSIS AND                                                                        MONTH PERIOD.
      EVALUATION SERVICE PER 12
      MONTH PERIOD
540   CODED BY MEDICAL STAFF                                                                                                               454

541   SURGERY CHARGES COMBINED.                                                          M144     PRE-/POST-OPERATIVE CARE PAYMENT IS      12
                                                                                                  INCLUDED IN THE ALLOWANCE FOR THE
                                                                                                  SURGERY/PROCEDURE.
542   CLAIM CANNOT BE PROCESSED B/C    16       CLAIM/SERVICE LACKS INFORMATION WHICH    N30      PATIENT INELIGIBLE FOR THIS SERVICE.     25
      OF MISSING OR INVALID INFO IN             IS NEEDED FOR ADJUDICATION.
      THIS RECIPIENT'S MEDICAID
      FILE. PLEASE CONTACT THE EDS
      COMMUNICATIONS UNIT TO ASSIST
      US IN OBTAINING CURRENT RECIP
      INFO.


543   FUND CODE INVALID OR NOT ON      16       CLAIM/SERVICE LACKS INFORMATION WHICH    MA130    YOUR CLAIM CONTAINS INCOMPLETE AND/OR    21
      PROVIDER OR RECIPIENT PROFILE             IS NEEDED FOR ADJUDICATION.                       INVALID INFORMATION, AND NO APPEAL
                                                                                                  RIGHTS ARE AFFORDED BECAUSE THE CLAIM
                                                                                                  IS UNPROCESSABLE. PLEASE SUBMIT A NEW
                                                                                                  CLAIM WITH THE COMPLETE/CORRECT
                                                                                                  INFORMATION.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
544   93541-NOT ALLOWED SAME DOS AS    97       THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CERTAIN COMPANION                         INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                         ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


545   PROCEDURE IS INCLUDED IN 93541- 97        THE BENEFIT FOR THIS SERVICE IS                                                            107
      FOR SAME DOS                              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


546   PROVIDER/RECIPIENT INELIGIBLE    22       THIS CARE MAY BE COVERED BY ANOTHER                                                        109
      FOR MANAGED CARE NET SERVICES             PAYER PER COORDINATION OF BENEFITS.

547   PROCEDURE IS INCLUDED IN 93550   97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      FOR SAME DOS                              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


548   93551 NOT ALLOWED SAME DOS AS    97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      CERTAIN COMPANION                         INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      RADIOLOGICALCODES                         ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


549   PROCEDURE IS INCLUDED IN 93551   97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      FOR SAME DOS                              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


550   RECIPIENT HAS ALREADY RECIEVED   B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     N170     A NEW/REVISED/RENEWED CERTIFICATE OF     483
      PERIODIC EPSDT SCREENING FOR              MET OR WERE EXCEEDED.                             MEDICAL NECESSITY IS NEEDED.
      THIS AGE.IF SCREEN IS
      MEDICALLY NECESSARY PLEASE
      DOCUMENT ONCLAIM AND REBILL AS
      INTERPERIODIC SCREEN


551   EXCEEDED LIMIT OF 3 EPSDT        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      MEDICAL SCREENS FOR AGES 12               OCCURRENCE HAS BEEN REACHED.

552   ONE EPSDT MEDICAL SCREENS                                                          M90      NOT COVERED MORE THAN ONCE IN A 12       483
      PAYABLE FROM 2 YEARS 1 DAY TO                                                               MONTH PERIOD.
      3   YEARS
553   ONE EPSDT MEDICAL SCREENS                                                          M90      NOT COVERED MORE THAN ONCE IN A 12       483
      PAYABLE FROM 3 YEARS 1 DAY TO                                                               MONTH PERIOD.
      4   YEARS
554   ONE EPSDT MEDICAL SCREENS                                                          M90      NOT COVERED MORE THAN ONCE IN A 12       483
      PAYABLE FROM 4 YEARS 1 DAY TO                                                               MONTH PERIOD.
      5   YEARS




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                             STATUS
555   ONE EPSDT MEDICAL SCREENS                                                          M90      NOT COVERED MORE THAN ONCE IN A 12      483
      PAYABLE FROM 5 YEARS 1 DAY TO                                                               MONTH PERIOD.
      6   YEARS
556   TWO EPSDT MEDICAL SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      PAYABLE FROM 6 YEARS 1 DAY TO             OCCURRENCE HAS BEEN REACHED.
      8   YEARS
557   EXCEED LIMIT OF FOUR EPSDT       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      MEDICAL SCREENS FOR AGES 8                OCCURRENCE HAS BEEN REACHED.
      YEARS AND 1 DAY TO 10 YEARS.


558   TWO EPSDT MEDICAL SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      PAYABLE FROM 10 YEARS 1 DAY TO            OCCURRENCE HAS BEEN REACHED.
      12 YEARS
559   FILLING NOT ALLOWED ON TOOTH     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    107
      NUMBERS WITH CROWNS WITHIN ONE            OCCURRENCE HAS BEEN REACHED.
      YEAR PERIOD.
560   TWO EPSDT MEDICAL SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      PAYABLE FROM 14 YEARS 1 DAY TO            OCCURRENCE HAS BEEN REACHED.
      16 YEARS
561   TWO EPSDT MEDICAL SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      PAYABLE FROM 16 YEARS 1 DAY TO            OCCURRENCE HAS BEEN REACHED.
      18 YEARS
562   TWO EPSDT MEDICAL SCREENS        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                    483
      PAYABLE FROM 18 YEARS 1 DAY TO            OCCURRENCE HAS BEEN REACHED.
      21 YEARS
563   MEDICAID VISITS (OFFICE, ER,     97       THE BENEFIT FOR THIS SERVICE IS                                                           107
      HOSPITAL AND CONSULTS) ARE NON            INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      PAYABLE WHEN BILLED ON THE                ANOTHER SERVICE/PROCEDURE THAT HAS
      SAME DAY AS A PRIMARY                     ALREADY BEEN ADJUDICATED.
      PROCEDURE.


564   PAYMENT FOR A PRIMARY SURGICAL   97       THE BENEFIT FOR THIS SERVICE IS                                                           107
      PROCEDURE INCLUDES PAYMENT                INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      FOR INCIDENTAL SURGERY.                   ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


565   A PAID SERVICE ON THE SAME       18       DUPLICATE CLAIM/SERVICE.                                                                  54
      DATE DUPLICATES, OR INCLUDES,
      THIS SERVICE.
566   THE SYSTEM HAS REBUNDLED THIS                                                      M15      SEPARATELY BILLED SERVICES/TESTS HAVE   15
      PROCEDURE CODE INTO THE                                                                     BEEN BUNDLED AS THEY ARE CONSIDERED
      APPROPRIATE GLOBAL PROCEDURE                                                                COMPONENTS OF THE SAME PROCEDURE.
      CODE.                                                                                       SEPARATE PAYMENT IS NOT ALLOWED.




                                                                                                                                                   Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                             277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                            STATUS
567   PERS INSTALLATION NOT REQUIRED   B15      THIS SERVICE/PROCEDURE REQUIRES THAT A                                                     84
      ON CONNECTED PERS UNIT.                   QUALIFYING SERVICE/PROCEDURE BE
                                                RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


568   SURGICAL REVENUE CODE REQUIRES   16       CLAIM/SERVICE LACKS INFORMATION WHICH      M51      MISSING/INCOMPLETE/INVALID PROCEDURE   490
      A SURGICAL PROCEDURE CODE.                IS NEEDED FOR ADJUDICATION.                         CODE(S).

569   INVALID USE OF HOSPITAL PCP      16       CLAIM/SERVICE LACKS INFORMATION WHICH      M51      MISSING/INCOMPLETE/INVALID PROCEDURE   227
      ENROLLMENT PCODE.                         IS NEEDED FOR ADJUDICATION.                         CODE(S).
570   PROVIDER LIMITED TO CAPITATION   24       CHARGES ARE COVERED UNDER A CAPITATION                                                     105
      CLAIMS ONLY (REGION 22)                   AGREEMENT/MANAGED CARE PLAN.

571   EXCEEDS LIMIT OF FOUR            119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EMERGENCY HOME DELIVERED MEALS            OCCURRENCE HAS BEEN REACHED.
       PER STATE FISCAL YEAR.


572   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      INSTALLATION PER LIFETIME OR              OCCURRENCE HAS BEEN REACHED.
      PERIOD OF ELIGIBILITY.
573   HOME DELIVERED MEALS LIMITED     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TO 31 PER MONTH.                          OCCURRENCE HAS BEEN REACHED.

574   OUTPATIENT SERVICES ARE NOT      60       CHARGES FOR OUTPATIENT SERVICES WITH                                                       84
      PAYABLE ON THE SAME DATE OF               THIS PROXIMITY TO INPATIENT SERVICES
      SERVICE AS INPATIENT SERVICES.            ARE NOT COVERED.


575   PRE-SCHOOL SERVICES LIMITED TO   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      155 UNITS PER MONTH                       OCCURRENCE HAS BEEN REACHED.

576   EARLY INTERVENTION AND PRE-      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      SCHOOL I SERVICES LIMITED TO 1            OCCURRENCE HAS BEEN REACHED.
        UNIT PER DATE OF SERVICE


577   RECIPIENT ELIGIBLE FOR ONLY 2    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TELEMEDICINE CONSUTATIONS                 OCCURRENCE HAS BEEN REACHED.
      FROMJULY 1 THRU JUNE 30.


578   SPEECH THERAPY LIMITED TO 3      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      UNITS PER DATE OF SERVICE                 OCCURRENCE HAS BEEN REACHED.

579   OCCUPATIONAL INDIVIDUAL          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      THERAPY LIMITED TO 3 UNITS PER            OCCURRENCE HAS BEEN REACHED.
      DATE OF SERVICE.
580   PA REQUIRED FOR ALL DAYS AFTER   197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                   252
      RECIPIENT'S FIRST BIRTHDAY.               ION ABSENT.
      CLAIM CUT BACK TO MAX
      ALLOWABLE DAYS.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
581   PROVIDER MUST HAVE A PROVIDER  8          THE PROCEDURE CODE IS INCONSISTENT WITH                                                     145
      SPECIALTY OF WC, R1, RC                   THE PROVIDER TYPE/SPECIALTY (TAXONOMY).
      OR RH TO BILL REVENUE CODE
      128. CHECK FOR CORRECT BILLING


582   PROVIDER SPECIALITY WC MUST      8        THE PROCEDURE CODE IS INCONSISTENT WITH                                                     145
      BILL ONLY REV. CODE 128.                  THE PROVIDER TYPE/SPECIALTY (TAXONOMY).

583   RECIPIENT INELIGIBLE FOR W4                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      SERVICE ON DOS - CONTACT
      COUNTY OFFICE FOR WAIVER
      ELIGIBILITY STATUS.
584   ONLY ONE DAY TREATMENT SERVICE                                                      M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DATE OF SERVICE                                                                  MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
585   REHABILITATIVE DAY SERVICE       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMITED TO 192 UNITS PER WEEK             OCCURRENCE HAS BEEN REACHED.

586   PROVIDER LIMITED TO BILLING      8        THE PROCEDURE CODE IS INCONSISTENT WITH                                                     91
      FOR ARKANSAS BENEFIT SERVICES.            THE PROVIDER TYPE/SPECIALTY (TAXONOMY).

587   EXCEEDED BENEFIT LIMIT OF 224-   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      1/4 HOUR UNITS PER WEEK FOR               OCCURRENCE HAS BEEN REACHED.
      THERAPEUTIC DAY TREATMENT


588   DCFS RECIPIENTS/AID CATEGORY                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      02 AND 05 ELIGIBLE FOR
      ARKANSASBENEFIT PROGRAM ONLY.



589   SERVICES COVERED UNDER MORE                                                         N61      REBILL SERVICES ON SEPARATE CLAIMS.      481
      THAN ONE PROGRAM. PLEASE
      SPLIT CLAIM AND RE-BILL.


590   CLAIM/RECIPIENT NOT COVERED BY                                                      N30      PATIENT INELIGIBLE FOR THIS SERVICE.     91
      MENTAL HEALTH MANAGED CARE.

591   CHILD HEALTH MANAGEMENT          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      SERVICES NOT TO EXCEED $95.00             OCCURRENCE HAS BEEN REACHED.
           PER DATE OF SERVICE.


592   PERSONAL CARE SERVICES LIMITED   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TO 256 DETAIL UNITS                       OCCURRENCE HAS BEEN REACHED.

593   PERSONAL CARE AIDE FOR UNDER     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      21-96 DETAIL UNITS/DAY                    OCCURRENCE HAS BEEN REACHED.

594   EXCEEDS BENEFIT LIMIT OF ONE     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PER FIVE YEAR PERIOD                      OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                              STATUS
595   BENEFITS EXCEEDED MAXIMUM OF     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      $7500.00 PER LIFETIME.                    OCCURRENCE HAS BEEN REACHED.

596   DUPLICATE OR FRAGMENTED BILLING 18        DUPLICATE CLAIM/SERVICE.                                                                     54

597   EXCEEDS MAXIMUM HOME HEALTH      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      VISITS OF 50 FOR MEDICAID AND             OCCURRENCE HAS BEEN REACHED.
      10 FOR ARKIDS FIRST-B PER
      STATE FISCAL YEAR.


598   FRAGMENTED LAB CODES ARE         B15      THIS SERVICE/PROCEDURE REQUIRES THAT A     M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    12
      COMBINED TO PANEL FEE                     QUALIFYING SERVICE/PROCEDURE BE                     LAB CODES INCLUDED IN THE TEST.
      REIMBURSEMENT                             RECEIVED AND COVERED. THE QUALIFYING
                                                OTHER SERVICE/PROCEDURE HAS NOT BEEN
                                                RECEIVED/ADJUDICATED.


599   FRAGMENTED LAB CODES WERE                                                            M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    15
      REDUCED TO PANEL FEE                                                                          LAB CODES INCLUDED IN THE TEST.
      REIMBURSEMENT
600   EXTRACTIONS MAY BE PERFORMED     35       LIFETIME BENEFIT MAXIMUM HAS BEEN                                                            483
      ONLY ONCE IN A LIFETIME.                  REACHED.

601   INITIAL SET UP OF APNEA          35       LIFETIME BENEFIT MAXIMUM HAS BEEN                                                            483
      MONITOR LIMITED TO ONCE IN A              REACHED.
      LIFETIME.
602   HOME DELIVERED MEALS LIMITED     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      TO 23 MEALS PER MONTH                     OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
603   ADULT DAY HEALTH CARE MONTHLY    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      BENEFIT LIMIT REACHED.                    OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
604   PROCEDURE CODE TO PROVIDER       8        THE PROCEDURE CODE IS INCONSISTENT WITH    M51      MISSING/INCOMPLETE/INVALID PROCEDURE     145
      SPECIALTY INVALID.                        THE PROVIDER TYPE/SPECIALTY (TAXONOMY).             CODE(S).

605   FULL MOUTH X-RAYS ALLOWED ONLY   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ONCE PER THREE YEARS PER                  OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      ATTENDING PROVIDER WITHOUT                                                                    SET TIME FRAME.
      PRIOR AUTHORIZATION


606   CMS COPAY CODE PAYABLE ONLY IF   197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                     171
      RECIPIENT HAS TPL ON FILE.                ION ABSENT.

607   HOMEMAKER SERVICES MONTHLY       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      BENEFIT LIMIT REACHED.                    OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
608   CHORE SERVICES LIMITED TO 20     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      UNITS PER MONTH                           OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                               STATUS
609   ADULT DAY CARE MONTHLY BENEFIT   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    483
      LIMIT REACHED.                            OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
610                                    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    483
                                                OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
611   EXCEEDS LIMIT OF ONE PURCHASE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    483
      OF THIS DURABLE MEDICAL                   OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      EQUIPMENT PER YEAR.                                                                           SET TIME FRAME.


612   EXCEEDS LIMIT OF ONE PURCHASE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY    483
      OF THIS DME EVERY TWO YEARS.              OCCURRENCE HAS BEEN REACHED.                        MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
613   THIS DURABLE MEDICAL EQUIPMENT   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M7       NO RENTAL PAYMENTS AFTER THE ITEM IS      483
      MAY BE PURCHASED ONLY ONCE INA            OCCURRENCE HAS BEEN REACHED.                        PURCHASED, OR AFTER THE TOTAL OF ISSUED
      LIFETIME.                                                                                     RENTAL PAYMENTS EQUALS THE PURCHASE
                                                                                                    PRICE.
614   EXCEEDS LIMIT OF ONE PURCHASE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M7       NO RENTAL PAYMENTS AFTER THE ITEM IS      483
      OF THIS DURABLE MEDICAL                   OCCURRENCE HAS BEEN REACHED.                        PURCHASED, OR AFTER THE TOTAL OF ISSUED
      EQUIPMENT EVERY SIX MONTHS.                                                                   RENTAL PAYMENTS EQUALS THE PURCHASE
                                                                                                    PRICE.
615   CLAIM EXCEEDS MAXIMUM PURCHASE   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M5       MONTHLY RENTAL PAYMENTS CAN CONTINUE      483
      ALLOWANCE. MEDICAID ALLOWS                OCCURRENCE HAS BEEN REACHED.                        UNTIL THE EARLIER OF THE 15TH MONTH
      AMAXIMUM OF 455 UNITS (15                                                                     FROM THE FIRST RENTAL MONTH, OR THE
      MONTHS) OF RENTAL PAYMENTS                                                                    MONTH WHEN THE EQUIPMENT IS NO LONGER
      TOWARD THE PURCHASE OF THIS                                                                   NEEDED.
      DURABLE MEDICAL EQUIPMENT.


616   ONE EPSDT SCREEN PER YEAR FROM   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M13      ONLY ONE INITIAL VISIT IS COVERED PER     483
      BIRTH THROUGH 6 MONTHS.                   OCCURRENCE HAS BEEN REACHED.                        SPECIALTY PER MEDICAL GROUP.

617   ONLY ONE EPSDT SCREEN IS         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR     M13      ONLY ONE INITIAL VISIT IS COVERED PER     483
      PAYABLE FROM AGE 6 MONTHS                 OCCURRENCE HAS BEEN REACHED.                        SPECIALTY PER MEDICAL GROUP.
      THROUGH 1 YEAR.
618   DOCUMENTATION DOES NOT SUPPORT   54       MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT                                                        287
      THE MEDICAL NECESSITY OF                  COVERED IN THIS CASE.
      ASSISTANT SURGEON SERVICES.



619   THE PROCEDURE CODE REPRESENTS    96       NON-COVERED CHARGE(S).                     MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL      454
      AN OBSOLETE PROCEDURE.                                                                        PROCEDURE CODE.

620   MEDICAID DOES NOT COVER THIS     96       NON-COVERED CHARGE(S).                     MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL      84
      SERVICE.                                                                                      PROCEDURE CODE.
621   COSMETIC SURGICAL PROCEDURES     197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                      252
      REQUIRE PRIOR AUTHORIZATION.              ION ABSENT.




                                                                                                                                                       Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                                277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE                CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                               STATUS
622   ONE EPSDT SCREEN IS PAYABLE      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M13      ONLY ONE INITIAL VISIT IS COVERED PER     483
      FROM 10 - 12 YEARS OF AGE                 OCCURRENCE HAS BEEN REACHED.                       SPECIALTY PER MEDICAL GROUP.

623   THIS PROCEDURE CODE IS           6        THE PROCEDURE/REVENUE CODE IS             M51      MISSING/INCOMPLETE/INVALID PROCEDURE      475
      INAPPROPRIATE FOR THE                     INCONSISTENT WITH THE PATIENT'S AGE.               CODE(S).
      RECIPIENT'S    AGE.
624   ONE EPSDT SCREEN IS PAYABLE      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M13      ONLY ONE INITIAL VISIT IS COVERED PER     483
      FROM 16-20 YEARS OF AGE                   OCCURRENCE HAS BEEN REACHED.                       SPECIALTY PER MEDICAL GROUP.

625   UNITS CUTBACK TO MAX ALLOWED     151      PAYMENT ADJUSTED BECAUSE THE PAYER        M25      THE INFORMATION FURNISHED DOES NOT        65
      FOR THIS DURABLE MEDICAL                  DEEMS THE INFORMATION SUBMITTED DOES               SUBSTANTIATE THE NEED FOR THIS LEVEL OF
      EQUIPMENT.                                NOT SUPPORT THIS MANY/FREQUENCY OF                 SERVICE. IF YOU BELIEVE THE SERVICE
                                                SERVICES.                                          SHOULD HAVE BEEN FULLY COVERED AS
                                                                                                   BILLED OR IF YOU DID NO KNOW AND COULD
                                                                                                   NOT REASONABLY HAVE BEEN EXPECTED TO
                                                                                                   KNOW THAT WE WOULD NOT PAY FOR THIS
                                                                                                   LEVEL OF SERVICE, OR IF YOU NOTIFIED
                                                                                                   THE PATIENT IN WRITING IN ADVANCE THAT
                                                                                                   WE WOULD NOT PAY FOR THIS LEVEL OF
                                                                                                   SERVICE AND HE/SHE AGREED IN WRITING TO
                                                                                                   PAY, ASK US TO REVIEW YOUR CLAIM WITHIN
                                                                                                   120 DAYS OF THE DATE OF THIS NOTICE.
                                                                                                   IF YOU DO NOT REQUEST A APPEAL, WE
                                                                                                   WILL, UPON APPLICATION FROM THE
                                                                                                   PATIENT, REIMBURSE HIM/HER FOR THE
                                                                                                   AMOUNT YOU HAVE COLLECTED FROM HIM/HER
                                                                                                   IN EXCESS OF ANY DEDUCTIBLE AND
                                                                                                   COINSURANCE AMOUNTS. WE WILL RECOVER
                                                                                                   THE REIMBURSEMENT FROM YOU AS AN
                                                                                                   OVERPAYMENT.




626   X-RAYS LIMITED TO $52.00 PER 5   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      YEARS WITHOUT PRIOR                       OCCURRENCE HAS BEEN REACHED.
      AUTHORIZATION.
627   THIS PROCEDURE CODE IS           7        THE PROCEDURE/REVENUE CODE IS                                                                474
      INAPPROPRIATE FOR THE                     INCONSISTENT WITH THE PATIENT'S GENDER.
      PATIENT'S SEX.
628   OUTPATIENT SERVICES LIMITED TO   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                       483
      ONE ENCOUNTER PER CLAIM                   OCCURRENCE HAS BEEN REACHED.

629   THE SYSTEM REDUCED THE ALLOWED   59       PROCESSED BASED ON MULTIPLE OR                                                               107
      AMOUNT FOR THIS PROCEDURE                 CONCURRENT PROCEDURE RULES (FOR EXAMPLE
      CODE IN ACCORDANCE WITH                   MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
      ARKANSAS MEDICAID POLICY                  CONCURRENT ANESTHESIA.)
      REGARDING MULTIPLE SURGICAL
      PROCEDURES.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                 835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE                 REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                                REMARK   DESCRIPTION                             STATUS
630   MORE THAN THREE SIMPLE           197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT                                                    252
      EXTRACTIONS ON THE SAME DOS               ION ABSENT.
      REQUIRES PA.
631   DELETED PROCEDURE CODES ARE      96       NON-COVERED CHARGE(S).                     M51      MISSING/INCOMPLETE/INVALID PROCEDURE    84
      NON-PAYABLE.                                                                                  CODE(S).
632   DME SERVICES ARE LIMITED TO      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      $1000.00 WITHOUT PRIOR                    OCCURRENCE HAS BEEN REACHED.
      AUTHORIZATION
633   ONLY ONE DDS CASE MANAGEMENT     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      SERVICE PER MONTH.                        OCCURRENCE HAS BEEN REACHED.

634   EXCEEDED 80 ACUTE THERAPEUTIC    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      DAY TREAT SRV UNITS/STATE                 OCCURRENCE HAS BEEN REACHED.
      FISCAL YR
635   PC D2330-D2332 & D2335 WITH                                                          N39      PROCEDURE CODE IS NOT COMPATIBLE WITH   244
      TOS K MAY ONLY BE BILLED WITH                                                                 TOOTH NUMBER/LETTER.
      PERMANENT TOOTH NUMBERS 6-11 &
      22-27.


636   WAASDTEJ ERROR WITH 2 YEAR       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      AUDIT LOGIC - INTERNAL EDIT               OCCURRENCE HAS BEEN REACHED.
      346.
637   EXCEEDS BRIEF CONSULTATION       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      SERVICES LIMIT OF 24 PER 90               OCCURRENCE HAS BEEN REACHED.
      DAY P. A. CYCLE.


638   EXCEEDS LIMIT OF 2 DOS FOR      119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      DIAGNOSIS PER STATE FISCAL YEAR           OCCURRENCE HAS BEEN REACHED.

639   OUTPATIENT ER AND NON-ER         97       THE BENEFIT FOR THIS SERVICE IS                                                             107
      SERVICES INCLUDE ASSESSMENT.              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


640   EXCEEDS LIMIT OF 2 BATTERY       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TESTING SERVICES PER YEAR                 OCCURRENCE HAS BEEN REACHED.

641   ONLY PCP ENROLLMENT FEE IS       97       THE BENEFIT FOR THIS SERVICE IS                                                             107
      ALLOWED WITH EMERGENCY                    INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      DEPARTMENTASSESSMENT FEE                  ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


642   NO MEDICAL JUSTIFICATION         B14      ONLY ONE VISIT OR CONSULTATION PER                                                          287
      EXISTS FOR MORE THAN ONE VISIT            PHYSICIAN PER DAY IS COVERED.
      PER DATE OF SERVICE.
643   SERVICE HAS NOT BEEN             197      PRECERTIFICATION/AUTHORIZATION/NOTIFICAT M62        MISSING/INCOMPLETE/INVALID TREATMENT    84
      AUTHORIZED.                               ION ABSENT.                                         AUTHORIZATION CODE.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
644   LAB PROCEDURE NOT PERFORMED      29       THE TIME LIMIT FOR FILING HAS EXPIRED.                                                     107
      WITH 7 DAYS OF SCREENING

645   ARKIDS FIRST-B PARTICIPANT       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      CUMULATIVE ALLOWED AMOUNT                 OCCURRENCE HAS BEEN REACHED.
      EXCEEDS$500 FOR SFY '99 FOR
      OUTPATIENT MENTAL AND
      BEHAVIORAL       HEALTH
      SERVICES. PRIOR AUTHORIZATION
      REQUIRED.


646   ONLY ONE PROCEDURE ALLOWED PER   B14      ONLY ONE VISIT OR CONSULTATION PER       N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   483
      DOS PER ATTENDING PROVIDER                PHYSICIAN PER DAY IS COVERED.                     RENDERED ON THE SAME DATE.

647   THERAPY EXAM LIMITED TO ONCE     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER STATE FISCAL YEAR.                    OCCURRENCE HAS BEEN REACHED.

648   BENEFITS EXHAUSTED               119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
                                                OCCURRENCE HAS BEEN REACHED.

649   GLOBAL SURGERY CHARGES SHOULD    97       THE BENEFIT FOR THIS SERVICE IS          M15      SEPARATELY BILLED SERVICES/TESTS HAVE    263
      BE INCLUDED IN FEE FOR PRIMARY            INCLUDED IN THE PAYMENT/ALLOWANCE FOR             BEEN BUNDLED AS THEY ARE CONSIDERED
      PROCEDURE                                 ANOTHER SERVICE/PROCEDURE THAT HAS                COMPONENTS OF THE SAME PROCEDURE.
                                                ALREADY BEEN ADJUDICATED.                         SEPARATE PAYMENT IS NOT ALLOWED.


650   INDICATE IF MULTIPLE             16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               262
      ANESTHESIA PROCEDURES WERE                IS NEEDED FOR ADJUDICATION. ADDITIONAL            DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      DONE AT DIFFERENT SETTINGS.               INFORMATION IS SUPPLIED USING                     T/CHART.
                                                REMITTANCE ADVICE REMARKS CODES
                                                WHENEVER APPROPRIATE.


651   RECIPIENT IS BEING REIMBURSED    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N45      PAYMENT BASED ON AUTHORIZED AMOUNT.      107
      FOR STANDARD OR SPECIALIZED               OCCURRENCE HAS BEEN REACHED.
      WHEELCHAIR. RECIPIENT MAY NOT
      BE REIMBURSED FOR 2 WHEEL-
      CHAIRS CONCURRENTLY.



652   EXCEEDS LIMIT OF 12 OUTPATIENT   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      VISITS PER STATE FISCAL YEAR              OCCURRENCE HAS BEEN REACHED.

653   EXCEEDS LIMIT OF 12 PHYSICIAN    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      VISITS PER STATE FISCAL YEAR              OCCURRENCE HAS BEEN REACHED.

654   EXCEEDS 12 NURSE PRACTITIONER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      VISITS PER SFY                            OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
655   ONLY ONE SERVICE ALLOWED PER                                                       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      DOS                                                                                         MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
656   DENTAL SERVICES LIMITED TO       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ONCE PER STATE FISCAL YEAR.               OCCURRENCE HAS BEEN REACHED.

657   PHYSICIAN STANDBY SERVICE NON-   97       THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      PAYABLE SAME DATE OF SERVICE              INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
      AS NEW BIRTH STANDBY.                     ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


658   REBILL USING LAB PANEL CODE      16       CLAIM/SERVICE LACKS INFORMATION WHICH    M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    419
      FOR APPROPRIATE NUMBER OF                 IS NEEDED FOR ADJUDICATION.                       LAB CODES INCLUDED IN THE TEST.
      INDIV-IDUALS TESTS


659   IMMUNIZATION DPT AND             B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   490
      HEMOPHILIUS INFLUENZA B CANNOT            MET OR WERE EXCEEDED.                             RENDERED ON THE SAME DATE.
      BE BILLED ON THE SAME DOS.


660   ONLY ONE ADMISSION, HISTORY      B14      ONLY ONE VISIT OR CONSULTATION PER       N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   483
      AND PHYSICAL IS ALLOWED PER               PHYSICIAN PER DAY IS COVERED.                     RENDERED ON THE SAME DATE.
      DAY BY THE SAME OR DIFFERENT
      ATTENDING PROVIDER


661   NEW PATIENT VISIT PREVIOUSLY     B1       NON-COVERED VISITS.                      M13      ONLY ONE INITIAL VISIT IS COVERED PER    454
      BILLED WITHIN PAST 3 YEARS FOR                                                              SPECIALTY PER MEDICAL GROUP.
      THIS RECIPIENT. REBILL USING
      APPROPRIATE ESTABLISHED
      PATIENTCODE.


662   93552-93553 NOT ALLOWED SAME    97        THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      DOS AS CERTAIN COMPANION RADIO-           INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
      LOGICAL CODES                             ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


663   ONLY ONE DELIVERY IN A NINE      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      MONTH PERIOD.                             OCCURRENCE HAS BEEN REACHED.

664   PROCEDURE IS INCLUDED IN 93552- 97        THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      93553 FOR SAME DOS                        INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


665   ONLY ONE VISIT ALLOWED PER DAY. 119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
                                                OCCURRENCE HAS BEEN REACHED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
666   IV INSERTION INCLUDED IN         97       THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CHEMOTHERAPY.                             INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


667   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      OCCUPATIONAL THERAPY                      OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER STATE FISCAL
      YEAR.
668   CASE MANAGEMENT LIMITED TO 6     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      UNITS PER DATE OF SERVVICE PER            OCCURRENCE HAS BEEN REACHED.
      ATTENDING PROVIDER.


669   OUTPATIENT FACILITY FEE          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      LIMITED TO ONE PER DAY PER                OCCURRENCE HAS BEEN REACHED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      PROVIDER                                                                                    SET TIME FRAME.
670   CRISIS MANAGEMENT LIMITED TO 4   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      UNITS PER DATE OF SERVICE PER             OCCURRENCE HAS BEEN REACHED.
      ATTENDING PROVIDER.


671   FILL OUT ONLY ONE SECTION OF     17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      HYSTERECTOMY ACKNOWLEDGMENT               OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      FORM (DHS - 2606).                                                                          T/CHART.


672   EXCEEDS TWO PAID COMPLEX         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N54      CLAIM INFORMATION IS INCONSISTENT WITH   483
      VISITS PER STATE FISCAL YEAR              OCCURRENCE HAS BEEN REACHED.                      PRE-CERTIFIED/AUTHORIZED SERVICES.
      WITHOUT APPROVAL.
673   THE SYSTEM ADDED THIS DETAIL.                                                      M15      SEPARATELY BILLED SERVICES/TESTS HAVE    15
      THE BILLED AMOUNT SHOWN IS                                                                  BEEN BUNDLED AS THEY ARE CONSIDERED
      THE SUM OF THE CHARGES FOR THE                                                              COMPONENTS OF THE SAME PROCEDURE.
      DETAILS DENIED AS A RESULT                                                                  SEPARATE PAYMENT IS NOT ALLOWED.
      OF REBUNDLING.


674   DIAPERS AND UNDERPADS LIMITED    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      TO $130 PER CALENDAR MONTH.               OCCURRENCE HAS BEEN REACHED.

675   RECIPIENT EXCEEDS LIMIT OF       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      $4500.00 PER LIFETIME FOR APD             OCCURRENCE HAS BEEN REACHED.
        ENVIRONMENTAL ADAPTATIONS.


676   ONLY 12 NURSE PRACTITIONER       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      VISITS ALLOWED PER SFY.                   OCCURRENCE HAS BEEN REACHED.

677   INDIVIDUAL OUTPATIENT -          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      MEDICATION ADMIN. LIMITED TO 2            OCCURRENCE HAS BEEN REACHED.
      UNITSPER DATE OF SERVICE PER
      ATTENDING PROVIDER.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
678   OB DELIVERY DENIED AS NOT AN     40       CHARGES DO NOT MEET QUALIFICATIONS FOR                                                      84
      EMERGENCY.                                EMERGENT/URGENT CARE.

679   INVALID TYPE OF BILL. VALID                                                         MA30     MISSING/INCOMPLETE/INVALID TYPE OF BILL. 228
      INPATIENT TYPES OF BILL ARE
      111-114. VALID OUTPATIENT
      TYPES OF BILL ARE 131-134,
      141, 711-714.

680   UNITS CUT BACK TO MAX ALLOWED    B10      ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE   N45      PAYMENT BASED ON AUTHORIZED AMOUNT.      65
      FOR PROCEDURES                            A COMPONENT OF THE BASIC PROCEDURE/TEST
                                                WAS PAID. THE BENEFICIARY IS NOT
                                                LIABLE FOR MORE THAN THE CHARGE LIMIT
                                                FOR THE BASIC PROCEDURE/TEST.


681   WHEELCHAIR VAN EXCEEDS 50        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      UNITS PER DATE OF SERVICE.                OCCURRENCE HAS BEEN REACHED.

682   TRANSPORTATION SERVICES          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMITED TO 15 MILES PER DOS.              OCCURRENCE HAS BEEN REACHED.

683   PUBLIC TRANSPORTATION EXCEEDS    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMTI OF 30 MILES PER DATE OF             OCCURRENCE HAS BEEN REACHED.
      SERVICE.
684   EXCEEDS LIMIT OF 50 MILES PER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      DOS.                                      OCCURRENCE HAS BEEN REACHED.

685   UNITS CUT BACK TO MAX            151      PAYMENT ADJUSTED BECAUSE THE PAYER        N45      PAYMENT BASED ON AUTHORIZED AMOUNT.      483
      ALLOWABLE OF 224 UNITS FOR                DEEMS THE INFORMATION SUBMITTED DOES
      ADDITIONAL THERAPEUTIC DAY                NOT SUPPORT THIS MANY/FREQUENCY OF
      TREATMENT.                                SERVICES.
686   THIS PROCEDURE MAY BE            119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PERFORMED ONCE IN A LIFETIME.             OCCURRENCE HAS BEEN REACHED.

687   PRIVATE NON EMERGENCY            119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TRANSPORTATION PAYABLE ONLY               OCCURRENCE HAS BEEN REACHED.
      ONCE PER DATE OF SERVICE.


688   EXCEEDS LIMIT OF 12 ENCOUNTER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      SERVICES PER STATE FISCAL YEAR            OCCURRENCE HAS BEEN REACHED.

689   NON PROFIT NON EMERGENCY         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TRANSPORTATION/PAYABLE ONLY               OCCURRENCE HAS BEEN REACHED.
      ONCE PER DOS
690   HOME HEALTH SUPPLIES EXCEEDED    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMIT OF $100.00 PER MONTH                OCCURRENCE HAS BEEN REACHED.

691   DEDUCTIBLE LIMITED TO ONCE PER   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      60 DAY BENEFIT PERIOD.                    OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
692   EXCEEDS BENEFIT LIMIT FOR        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      CHIROPRACTIC X-RAY PER STATE              OCCURRENCE HAS BEEN REACHED.
         FISCAL YEAR
693   RECIPIENT AID CATEGORY                                                              N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      INELIGIBLE FOR PERSONAL CARE
      SERVICE.
694   INDIVIDUAL OCCUPATIONAL          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      THERAPY LIMITED TO 4 UNITS PER            OCCURRENCE HAS BEEN REACHED.
      DATE OF SERVICE.
695   REFILE WITH COPY OF CONSULTING                                                      N29      MISSING/INCOMPLETE/INVALID               294
      PHYSICIAN'S REPORT.                                                                          DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.
696   RECIPIENT ELIGIBLE FOR ONLY 12   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      VISITS FROM JULY 1 THRU                   OCCURRENCE HAS BEEN REACHED.
      JUNE 30.
697   RECIPIENT PARTIALLLY OR                                                             N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      TOTALLY INELIGIBLE FOR WAIVER
      SERVICES FOR DOS BILLED.
      CONTACT EDS AT 1-800-457-4455
      OR 376-2211 LOCALLY TO VERIFY
      ELIGIBILITY DATES.


698   AUGMENTATIVE COMMUNICATIVE       35       LIFETIME BENEFIT MAXIMUM HAS BEEN                                                           483
      DEVICES EXCEED $7500 LIFETIME             REACHED.
        BENEFIT.


699   ADDITIONAL THERAPEUTIC DAY       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      TREATMENT LIMITED TO 32 UNITS             OCCURRENCE HAS BEEN REACHED.
      PER DATE OF SERVICE PER
      ATTENDING PROVIDER.


700   HOME HEALTH SUPPLIES EXCEEDED    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMIT OF $ 250.00 PER MONTH.              OCCURRENCE HAS BEEN REACHED.

701   THERAPEUTIC DAY - ACUTE          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMITED TO 32 UNITS PER DATE              OCCURRENCE HAS BEEN REACHED.
      OF SERVICE PER ATTENDING
      PROVIDER.
702   EMERGENCY PROCEDURE CODE         5        THE PROCEDURE CODE/BILL TYPE IS                                                             454
      INVALID IN A NON-EMERGENCY                INCONSISTENT WITH THE PLACE OF SERVICE.
      SETTING.
703   EXCEEDS BENEFIT LIMIT OF        119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      $200.00 FOR DISPOSABLE DIAPERS.           OCCURRENCE HAS BEEN REACHED.

704   EXCEEDS LIMIT OF TWO             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EVALUATIONS PER STATE FISCAL              OCCURRENCE HAS BEEN REACHED.
      YEAR.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
705   WHEELCHAIR VAN/LIMITED TO 50     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      MILES PER DOS                             OCCURRENCE HAS BEEN REACHED.

706   INAPPROPRIATE BILLING OF         96       NON-COVERED CHARGE(S).                    M20      MISSING/INCOMPLETE/INVALID HCPCS.        84
      PROCEDURE CODE. PLEASE REBILL
      USING THE CPT, HCPCS, REVENUE,
      OTHER VALID NATIONAL CODE OR
      BUNDLED PROCEDURE CODE THAT
      APPLIES TO THE SERVICE.




707   ONLY ALLOW CERTAIN RSPMI         B7       THIS PROVIDER WAS NOT                     MA120    MISSING/INCOMPLETE/INVALID CLIA          109
      SERVICES TO BE PAYABLE FOR                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS             CERTIFICATION NUMBER.
      NURSING HOME RESIDENTS                    PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
708   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EVALUATION PER MONTH.                     OCCURRENCE HAS BEEN REACHED.

709   EXCEEDS LIMIT OF 832 UNITS PER   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      STATE FISCAL YEAR.                        OCCURRENCE HAS BEEN REACHED.

710   DME PROCEDURE TOS I PREVIOUSLY   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      BILLED AND PAID IN CURRENT                OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR


711   TOS I,6,9,H,OR U PREVIOUSLY      B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                           483
      BILLED AND PAID FOR SAME                  CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
      PROCEDURE CODE WITHIN CURRENT             A PREVIOUS PAYMENT.
      SFY CLAIM IS NOT FOR INITIAL
      CONTRACTPERIOD.


712   DME TOS 1,6,9,H,OR U NOT         B13      PREVIOUSLY PAID. PAYMENT FOR THIS         N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      PAYABLE SAME TIME AS DME TOS I            CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN            RENDERED ON THE SAME DATE.
      FOR SAME PROCEDURE CODE                   A PREVIOUS PAYMENT.


713   EXCEEDS MAXIMUM OF 25 HOME       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      HEALTH VISITS PER SFY                     OCCURRENCE HAS BEEN REACHED.

714   MAXIMUM PAYMENT OF 50 UNITS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      84
      PERSONAL CARE NOT PREVIOUSLY              OCCURRENCE HAS BEEN REACHED.
       BILLED FOR DDS WAIVER
      RECIPIENT
715   MAXIMUM PAYMENT OF 50 UNITS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PER MONTH FOR PERSONAL CARE               OCCURRENCE HAS BEEN REACHED.

716   EXCEEDS LIMIT OF $7500.00 PER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      STATE FISCAL YEAR.                        OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                             277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
717   EXCEEDS LIMIT OF 48 UNITS PER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      STATE FISCAL YEAR.                        OCCURRENCE HAS BEEN REACHED.

718   IN HOME RESPITE CARE SFY         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      BENEFIT LIMIT REACHED.                    OCCURRENCE HAS BEEN REACHED.

719   TCM SERVICES PREVIOUSLY          B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                       84
      SUBMITTED AND PAID TO TCM                 FULLY FURNISHED BY ANOTHER PROVIDER.
      PROVIDER DIFFERENT TCM
      PROVIDERS MAY NOT BILL FOR
      SAME DOS

720   ONE EPSDT DENTAL SCREEN          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      APPROPRIATE PER 150 DAYS                  OCCURRENCE HAS BEEN REACHED.

721   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      DENTAL SCREENS PAYABLE FOR                OCCURRENCE HAS BEEN REACHED.
      NEWBORN(0-12 MONTHS)
722   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      VISION SCREENS PAYABLE FOR 5              OCCURRENCE HAS BEEN REACHED.
      YEARS
723   TWO EPSDT AGE APPROPRIATE        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      VISION SCREENS PAYABLE FROM               OCCURRENCE HAS BEEN REACHED.
      NEW- BORN THRU 4 YEARS


724   PROVIDER CANCELED.   DENY ALL    B7       THIS PROVIDER WAS NOT                                                                    483
      CLAIMS.                                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
                                                PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
725   EXCEEDS LIMIT OF TWO             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      DIAGNOSIS: SPEECH EVALUATION              OCCURRENCE HAS BEEN REACHED.
      PER SFY
726   EXCEEDS LIMIT OF THREE PAIR OF   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      INSERTS PER SHOE PER STATE                OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR, OR SIX TOTAL


727   EXCEEDS LIMIT OF TWO POWER       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      WHEELCHAIR ACCESSORIES,                   OCCURRENCE HAS BEEN REACHED.
      BATTERIES AND/OR CHARGERS, PER
      STATE FISCAL YEAR.


728   TRANSPORTATION SERVICES IN       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      EXCESS OF 300 MILES PER DATE              OCCURRENCE HAS BEEN REACHED.
      OF SERVICE
729   STERILIZATIONS NOT COVERED FOR   96       NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.   109
      PREGNANT WOMEN/UNBORN CHILD
      GROUP
730   UNITS EXCEED 72 PER MONTH FOR    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                   483
      PERSONAL CARE                             OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                  Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
731   EXCEEDED LIMIT OF 48 CRISIS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      MANAGEMENT SERVICE UNITS PER              OCCURRENCE HAS BEEN REACHED.
      SFY
732   EXCEEDED MAXIMUM OF TWO          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      CONSULTATIONS PER STATE FISCAL            OCCURRENCE HAS BEEN REACHED.
      YEAR.
733   CONSULT PREVIOUSLY BILLED FOR    B13      PREVIOUSLY PAID. PAYMENT FOR THIS                                                           483
      THIS RECIPIENT                            CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN
                                                A PREVIOUS PAYMENT.
734   RECIPIENT AID CATEGORY LIMITED                                                      N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      TO OB SERVICES.
735   PROVIDER TO CONTACT PRIVATE      A1       CLAIM DENIED CHARGES.                     N36      CLAIM MUST MEET PRIMARY PAYER’S          85
      TRUST FUND FOR PAYMENT.                                                                      PROCESSING REQUIREMENTS BEFORE WE CAN
                                                                                                   CONSIDER PAYMENT.
736   PERIODIC FAMILY PLANNING VISIT   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      EXCEEDS THE 3 ALLOWABLE PER               OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR.


737   CLAIM CUT BACK TO BENEFIT LIMIT 119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      65
                                                OCCURRENCE HAS BEEN REACHED.

738   ALLOWED DAYS CUTBACK DUE TO                                                         N144     THE RATE CHANGED DURING THE DATES OF     456
      CHANGE IN AUTHORIZED LEVEL OF                                                                SERVICE BILLED.
       CARE DURING BILLING PERIOD.
      REBILL REMAINING DAYS ON NEXT
      TAD AT NEW LEVEL OF CARE.


739   RECIPIENT EXCEEDS 2920 HOUR      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMIT OF APD ATTENDANT CARE               OCCURRENCE HAS BEEN REACHED.
      PER SFY
740   ADJUSTMENT RESULTING FROM A      125      SUBMISSION/BILLING ERROR(S).              MA31     MISSING/INCOMPLETE/INVALID BEGINNING     101
      CHANGE IN THE DATES OF SERVICE                                                               AND ENDING DATES OF THE PERIOD BILLED.

741   ADJUSTMENT RESULTING FROM        125      SUBMISSION/BILLING ERROR(S).              M64      MISSING/INCOMPLETE/INVALID OTHER         101
      CHANGE IN THE DIAGNOSIS CODE                                                                 DIAGNOSIS.

742   ADJUSTMENT RESULTING FROM A      125      SUBMISSION/BILLING ERROR(S).              N251     MISSING/INCOMPLETE/INVALID ATTENDING     101
      CHANGE IN THE PERFORMING                                                                     PROVIDER IDENTIFIER.
      PROVIDER
743   OP HEMODIALYSIS NOT PAYABLE                                                         M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      SAME DOS AS HOME DIALYSIS                                                                    MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
744   COMBINED LAB PROCEDURE CODE      97       THE BENEFIT FOR THIS SERVICE IS                                                             419
                                                INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
745   ADJUSTMENT RESULTING FROM A      15       THE AUTHORIZATION NUMBER IS MISSING,     N54      CLAIM INFORMATION IS INCONSISTENT WITH   101
      CHANGE IN THE PRIOR                       INVALID, OR DOES NOT APPLY TO THE                 PRE-CERTIFIED/AUTHORIZED SERVICES.
      AUTHORIZATION NUMBER                      BILLED SERVICES OR PROVIDER.


746   ADJUSTMENT DUE TO MEDICALLY      175      PRESCRIPTION IS INCOMPLETE.                                                                101
      NECESSARY PRESCRIPTION

747   DENTAL SERVICE LIMITED TO FOUR   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER VISIT                                 OCCURRENCE HAS BEEN REACHED.

748   RECOUPMENT OF PAYMENT PAID BY    23       THE IMPACT OF PRIOR PAYER(S)                                                               101
      PATIENT'S OTHER INSURANCE                 ADJUDICATION INCLUDING PAYMENTS AND/OR
                                                ADJUSTMENTS.
749   HOME PERITONEAL DIALYSIS NOT     B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   84
      PAYABLE SAME DOS OP                       MET OR WERE EXCEEDED.                             MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      HEMODIALYSIS                                                                                SET TIME FRAME.
750   PAID ASSOCIATED PROCEDURE        97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      PREVENTS PAYMENT OF CRITICAL              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      CARE CODE                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


751   PERITONEAL DIALYSIS TRNG NON-    B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   84
      PAYABLE SAME DOS AS DAILY                 MET OR WERE EXCEEDED.                             MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      PHYSICIAN RATE                                                                              SET TIME FRAME.
752   ONLY ONE PROPHY WITH FLUORIDE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ALLOWED PER SIX MONTH PERIOD.             OCCURRENCE HAS BEEN REACHED.

753   RECIPIENT HAS OTHER INSURANCE                                                      MA92     MISSING PLAN INFORMATION FOR OTHER       171
      COVERAGE                                                                                    INSURANCE.

754   DENTAL SERVICE LIMITED TO ONCE   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER FIVE YEAR PERIOD                      OCCURRENCE HAS BEEN REACHED.

755   PROCEDURE NOT PAYABLE IN         97       THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CONJUNCTION, OR WITH PAID                 INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
      CRITICAL CARE CODE                        ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


756   ONLY ONE SERVICE/PROCEDURE IS    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      INDICATED PER 12 MONTHS                   OCCURRENCE HAS BEEN REACHED.

757   BITEWING NOT ALLOWED WITHIN 30   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      DAYS FROM FULL MOUTH X-RAY.               OCCURRENCE HAS BEEN REACHED.

758   EXCEEDS LIMIT OF 12 PHYSICIAN    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      VISITS PER STATE FISCAL YEAR.             OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
759   MENTAL HEALTH-ONLY ONE SERVICE   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS                           OCCURRENCE HAS BEEN REACHED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
760   ONLY ONE OFFICE VISIT ALLOWED    B14      ONLY ONE VISIT OR CONSULTATION PER       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      PER DOS PER ATTENDING PROVIDER            PHYSICIAN PER DAY IS COVERED.                     MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
761   ONLY ONE HOSPITAL VISIT          B14      ONLY ONE VISIT OR CONSULTATION PER       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      SERVICE ALLOWED PER DOS PER               PHYSICIAN PER DAY IS COVERED.                     MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      ATTENDING PROVIDER                                                                          SET TIME FRAME.
762   ONLY ONE CARE FACILITY VISIT     B14      ONLY ONE VISIT OR CONSULTATION PER       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS                           PHYSICIAN PER DAY IS COVERED.                     MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
763   ONLY ONE TYPE OF THIS DME                                                          M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS.                                                                            MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
764   ONLY ONE FAMILY PLANNING VISIT                                                     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS                                                                             MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
765   COMPLETE DENTURE ADJUSTMENTS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      OR REALIGNMENTS ARE NOT                   OCCURRENCE HAS BEEN REACHED.
      COVERED WITHIN SIX MONTHS OF
      APPLIANCE PLACEMENT.


766   PARTIAL DENTURE ADJUSTMENTS OR   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      REALIGNMENTS ARE NOT COVERED              OCCURRENCE HAS BEEN REACHED.
      WITHIN SIX MONTHS OF APPLIANCE
      PLACEMENT.


767   ONLY ONE AMALGAM OR COMPOSITE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      RESTORATION PER SURFACE                   OCCURRENCE HAS BEEN REACHED.
      ALLOWED EVERY 2 YEARS.


768   ONLY ONE EVALUATION PROCEDURE    B14      ONLY ONE VISIT OR CONSULTATION PER       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS PER ATTENDING             PHYSICIAN PER DAY IS COVERED.                     MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      PROVIDER                                                                                    SET TIME FRAME.
769   MULTIPLE AMALGAM RESTORATIONS    97       THE BENEFIT FOR THIS SERVICE IS                                                            12
      FOR SAME TOOTH COMBINED.                  INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


770   MULTIPLE COMPOSITE               97       THE BENEFIT FOR THIS SERVICE IS                                                            12
      RESTORATIONS FOR SAME TOOTH               INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      COMBINED AND PREVIOUSLY PAID              ANOTHER SERVICE/PROCEDURE THAT HAS
      AT MAX ALLOWABLE.                         ALREADY BEEN ADJUDICATED.


771   MORE THAN ONE CROWN OR BRIDGE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      RESTORATION PER TOOTH IS NOT              OCCURRENCE HAS BEEN REACHED.
      COVERED.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
772   FIRST EXTRACTION USE D7111.                                                         N22      THIS PROCEDURE CODE WAS ADDED/CHANGED    15
      EACH ADDITIONAL EXTRACTION ON                                                                BECAUSE IT MORE ACCURATELY DESCRIBES
      SAME DATE OF SERVICE USE CODE                                                                THE SERVICES RENDERED.
      D7140.
773   ONLY ONE HEARING AID EXAM        B14      ONLY ONE VISIT OR CONSULTATION PER        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS PER ATTENDING             PHYSICIAN PER DAY IS COVERED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
         PROVIDER                                                                                  SET TIME FRAME.
774   ONLY ONE ELECTROACOUSTIC                                                            M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      EVALUATION PROCEDURE ALLOWED                                                                 MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      PER   DOS                                                                                    SET TIME FRAME.
775   ONLY ONE PRESCHOOL VISIT         B14      ONLY ONE VISIT OR CONSULTATION PER        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS                           PHYSICIAN PER DAY IS COVERED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
776   DENIED ADJUSTMENT RESULTING      45       CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM                                                        101
      FROM AEVCS REVERSAL OF A PAID             ALLOWABLE OR CONTRACTED/LEGISLTATED FEE
       CLAIM.                                   ARRANGMENT. (USE GROUPE CODES PR OR CO
                                                DEPENDING ON LIABILITY).


777   ONLY A COLLECTION FEE IS         134      TECHNICAL FEES REMOVED FROM CHARGES.                                                        107
      ALLOWED ON TESTS NOT PERFORMED
      IN YOUR LAB
778   EXCEEDS LIMIT OF ONE Z0560       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      DIAGNOSIS PER SFY                         OCCURRENCE HAS BEEN REACHED.

779   RECIPIENT EXCEEDS LIMIT OF       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      $10,000.00 PER LIFETIME FOR               OCCURRENCE HAS BEEN REACHED.
      APD DME
780   RECIPIENT INELIGIBLE FOR                                                            N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      WAIVER SERVICES SAME OR
      OVERLAPPING DOS AS
      INSTITUTIONAL CLAIM.
781   EXCEEDS LIMIT OF ONE             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      INTERPRETATION OF DIAGNOSIS               OCCURRENCE HAS BEEN REACHED.
      PER SFY
782   EXCEEDS LIMIT OF SIX UNITS-      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      GROUP OUTPATIENT THERAPY PER              OCCURRENCE HAS BEEN REACHED.
      WEEK
783   EPSDT SCREEN OR PREVENTATIVE     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      107
      SCREEN/OFFICE VISITS NOT                  OCCURRENCE HAS BEEN REACHED.
      PAYABLE ON SAME DATE OF
      SERVICE.


784   EXCEEDS ONE NORPLANT REMOVAL     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      WITHIN FIVE YEAR PERIOD                   OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
785   PARTIAL EPSDT SCREENS NOT        97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      PAYABLE SAME DOS AS EPSDT FULL            INCLUDED IN THE PAYMENT/ALLOWANCE FOR
         SCREEN                                 ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


786   TREATMENT/ THERAPY CODE NON                                                        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      PAYABLE WITH PAID EMERGENCY                                                                 MADE FOR SIMILAR PROCEDURE WITHIN SET
      PROCEDURE(S). SUBMIT AN                                                                     TIME FRAME.
      ADJUSTMENT IF APPLICABLE.


787   92340 MUST BE BILLED WITH        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      S0620, S0621 OR S0592 FOR SAME            OCCURRENCE HAS BEEN REACHED.                      RENDERED ON THE SAME DATE.
      RECIPIENT AND SAME DATE OF
      SERVICE.
788   HOSPICE ROUTINE CARE NOT         A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      PAYABLE SAME DAY AS PAID CLAIM                                                              RENDERED ON THE SAME DATE.
      FOR INPATIENT RESPITE CARE.


789   HOSPICE ROUTINE CARE NOT         A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      PAYABLE SAME DAY AS PAID CLAIM                                                              RENDERED ON THE SAME DATE.
      FOR CONTINOUS HOME CARE.


790   CONTINUOUS HOME CARE NOT         B9       PATIENT IS ENROLLED IN A HOSPICE.                                                          107
      PAYABLE SAME DAY AS PAID CLAIM
      FOR HOSPICE ROUTINE CARE


791   INPATIENT RESPITE CARE NOT       B9       PATIENT IS ENROLLED IN A HOSPICE.                                                          107
      PAYABLE SAME DAY AS PAID CLAIM
      FOR HOSPICE ROUTINE CARE


792   ROUTINE POST-OP CARE IS                                                            M144     PRE-/POST-OPERATIVE CARE PAYMENT IS      107
      INCLUDED IN THE PAYMENT FOR                                                                 INCLUDED IN THE ALLOWANCE FOR THE
      THE     SURGICAL PROCEDURE.                                                                 SURGERY/PROCEDURE.


793   INPATIENT HOSPICE CARE           A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      NON/PAYABLE SAME DOS AS                                                                     RENDERED ON THE SAME DATE.
      HOSPICE CON- TINUOUS HOME CARE


794   ONLY ONE HEARING AID EXAM        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS.                          OCCURRENCE HAS BEEN REACHED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
795   HOSPICE CONTINUOUS HOME CARE     A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      NONPAYABLE SAME DOS AS IN-                                                                  RENDERED ON THE SAME DATE.
      PATIENT HOSPICE CARE
796   FORM DHS-2606 MUST BE ATTACHED   16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               294
      TO ANY HYSTERECTOMY CLAIM WITH            IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      DATES OF SERVICE ON OR AFTER                                                                T/CHART.
      11-01-93.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
797   INPATIENT HOSPICE CARE           A1       CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      NONPAYABLE SAME DOS AS HOSPICE                                                               RENDERED ON THE SAME DATE.
      ROOM AND BOARD
798   HOSPICE ROOM AND BOARD           A1       CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      NONPAYABLE SAME DOS AS                                                                       RENDERED ON THE SAME DATE.
      INPATIENT HOS-PICE CARE
799   ONLY ONE PURE TONE AUDIOMETRY    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      PROCEDURE ALLOWED PER DOS                 OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
800   DME RENTAL IS LIMITED TO ONCE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PER MONTH                                 OCCURRENCE HAS BEEN REACHED.

801   SINGLE FILM NOT ALLOWED WITH     97       THE BENEFIT FOR THIS SERVICE IS                                                             107
      FULL MOUTH SERIES                         INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


802   HOSPICE SERVICES NONPAYABLE ON   A1       CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SAME DOS AS PAID/PENDING CLAIM                                                               RENDERED ON THE SAME DATE.
      FOR GENERAL INPATIENT HOSPICE.


803   SERVICE NOT PAYABLE IN           A1       CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CONJUNCTION WITH 93503 SAME                                                                  RENDERED ON THE SAME DATE.
      DOS.
804   OFFICE VISIT AND VISUAL          B14      PAYMENT DENIED BECAUSE ONLY ONE VISIT     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      ANALYSIS NOT ALLOWED SAME DATE            OR CONSULTATION PER PHYSICIAN PER DAY              RENDERED ON THE SAME DATE.
      OF SERVICE                                IS COVERED.
805   MULTIPLE SURGERY HAS BEEN        59       PROCESSED BASED ON MULTIPLE OR                                                              65
      SYSTEMATICALLY PRICED.                    CONCURRENT PROCEDURE RULES (FOR EXAMPLE
                                                MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
                                                CONCURRENT ANESTHESIA.)


806   AMOUNT REDUCED BY SPENDDOWN      178      PATIENT HAS NOT MET THE REQUIRED SPEND                                                      68
      AND RECIPIENT HAS OTHER                   DOWN REQUIREMENTS.
      INSURANCE COVERAGE.


807   GROUP OUTPATIENT/ THERAPY        B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                          107
      SERVICES HAVE BEEN SUBMITTED              FULLY FURNISHED BY ANOTHER PROVIDER.
      AND   PAID TO RSPMI FOR SAME
      DATE OF SERVICE.


808   MARITAL/FAMILY THERAPY           B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                          107
      SERVICES HAVE BEEN PAID TO                FULLY FURNISHED BY ANOTHER PROVIDER.
      ANOTHER   MENTAL HEALTH
      PROVIDER FOR THE SAME DATE OF
      SERVICE.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
809   INDIVIDUAL                      A1        CLAIM DENIED CHARGES.                    N347     YOUR CLAIM FOR A REFERRED OR PURCHASED   107
      OUTPATIENT/COLLATERAL SERVICES                                                              SERVICE CANNOT BE PAID BECAUSE PAYMENT
      NOT PAYABLE TO    MULTIPLE                                                                  HAS ALREADY BEEN MADE FOR THIS SAME
      MENTAL HEALTH PROVIDERS FOR                                                                 SERVICE TO ANOTHER PROVIDER BY A
      THE SAME DATE OF       SERVICE.                                                             PAYMENT CONTRACTOR REPRESENTING THE
                                                                                                  PAYER.


810   DATE OF SERVICE ON CLAIM FORM    129      PRIOR PROCESSING INFORMATION APPEARS     MA31     MISSING/INCOMPLETE/INVALID BEGINNING     187
      AND DATE OF SERVICE ON ATTACH-            INCORRECT.                                        AND ENDING DATES OF THE PERIOD BILLED.
      MENTS DO NOT MATCH.


811   SURGEON'S LICENSE NUMBER                                                           N31      MISSING/INCOMPLETE/INVALID PRESCRIBING   142
      OMITTED.                                                                                    PROVIDER IDENTIFIER.
812   LICENSE NUMBER OMITTED                                                             N31      MISSING/INCOMPLETE/INVALID PRESCRIBING   142
                                                                                                  PROVIDER IDENTIFIER.
813   INDIVIDUAL OUTPATIENT/ THERAPY   B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      SESSION HAS BEEN PAID TO                  FULLY FURNISHED BY ANOTHER PROVIDER.
      ANOTHER MENTAL HEALTH PROVIDER
      FOR THE SAME DATE OF SERVICE.



814   CRISIS MANAGEMENT SERVICES       B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      HAVE BEEN SUBMITTED AND PAID              FULLY FURNISHED BY ANOTHER PROVIDER.
      TO RSPMI FOR THIS DATE OF
      SERVICE.


815   BENEFITS EXCEED MAXIMUM OF       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      $500.00 PER STATE FISCAL YEAR.            OCCURRENCE HAS BEEN REACHED.

816   LAST NAME OF RECIPIENT ON        140      PATIENT/INSURED HEALTH IDENTIFICATION                                                      31
      DOCUMENTATION SUBMITTED FOR               NUMBER AND NAME DO NOT MATCH.
      REVIEWDOES NOT MATCH LAST NAME
      ON FILE.
817   INTERPRETATION OF DIAGNOSIS      B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      SERVICE HAS BEEN PAID TO                  FULLY FURNISHED BY ANOTHER PROVIDER.
      ANOTHER MENTAL HEALTH PROVIDER
      FOR THE SAME DATE OF SERVICE.



818   $2.00 WAS ADDED FOR              91       DISPENSING FEE ADJUSTMENT.                                                                 171
      DIFFERENTIAL DISPENSING FEE
      AND RECIPIENT HAS OTHER
      INSURANCE COVERAGE.
819   DIAGNOSIS/ PSYCHOLOGICAL         B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      TESTING BATTERY SERVICE HAS               FULLY FURNISHED BY ANOTHER PROVIDER.
      BEEN PAID TO ANOTHER MENTAL
      HEALTH PROVIDER FOR THE SAME
      DATE OF SERVICE.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
820   ONLY ONE PRE-NATAL LAB COVERED   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      IN NINE MONTH SPAN.                       OCCURRENCE HAS BEEN REACHED.

821   DIAGNOSIS/ PSYCHOLOGICAL TEST    B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      SERVICE NOT PAYABLE TO                    FULLY FURNISHED BY ANOTHER PROVIDER.
      MULTIPLE MENTAL HEALTH
      PROVIDERS FOR THE SAME DATE OF
            SERVICE.

822   DIAGNOSIS SERVICES HAS BEEN      B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      SUBMITTED AND PAID TO ANOTHER             FULLY FURNISHED BY ANOTHER PROVIDER.
       MENTAL HEALTH PROVIDER FOR
      THE SAME DATE OF SERVICE.


823   ATTACHMENT IS NOT DATED          16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               395
                                                IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
824   VENTIPUNCTURE/ANESTHESIOLOGY    97        THE BENEFIT FOR THIS SERVICE IS          N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CODE DISALLOWED SAME DOS 90780.           INCLUDED IN THE PAYMENT/ALLOWANCE FOR             RENDERED ON THE SAME DATE.
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


825   PAPER CLAIMS ARE BEING PAID 30                                                                                                       277
      DAYS FROM RECEIPT PER STATE
      DIRECTIVE. DO NOT RESUBMIT.
      SEE OFFICIAL NOTE OMS-93-W-4
      DATED DEC. 21, 1993.


826   AMOUNT REDUCED BY SPENDDOWN      178      PATIENT HAS NOT MET THE REQUIRED SPEND                                                     68
      AND THE $2.00 DISPENSING FEE              DOWN REQUIREMENTS.
      WAS ADDED. THIS RECIPIENT
      ALSO HAS OTHER INSURANCE
      COVERAGE.

827   FRAGMENTED IMMUNIZATION CODES                                                      N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CANNOT BE BILLED ON SAME DOS                                                                RENDERED ON THE SAME DATE.
      AS COMBINED CODE.
828   OP TREATMENT/ THERAPY CODES     97        THE BENEFIT FOR THIS SERVICE IS                                                            107
      INCLUDE ALL RELATED PROCEDURES.           INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


829   PROCEDURE NOT ALLOWED ON         96       NON-COVERED CHARGE(S).                   N56      PROCEDURE CODE BILLED IS NOT             107
      NEWBORNS WITH COMPLICATIONS                                                                 CORRECT/VALID FOR THE SERVICES BILLED
                                                                                                  OR THE DATE OF SERVICE BILLED.


830   DENTAL SERVICE LIMITED TO ONE    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER 6 MONTH PERIOD                        OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
831   GENERAL INPATIENT HOSPICE        B9       PATIENT IS ENROLLED IN A HOSPICE.        N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      NONPAYABLE IN CONJUNCTION WITH                                                              RENDERED ON THE SAME DATE.
      OTHER HOSPICE SERVICES


832   PAYMENT FOR PHYSICAL MEDICINE    97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      INCLUDES FEE FOR OFFICE VISIT.            INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


833   FULL/PANO X-RAY NOT ALLOWED      96       NON-COVERED CHARGE(S).                   N242     INCOMPLETE/INVALID X-RAY                 107
      WITHIN 30 DAYS OF PAYMENT FOR
       BITEWINGS.
834   OFFICE, ER, NURSING HOME,        60       CHARGES FOR OUTPATIENT SERVICES WITH                                                       107
      PSYCHOLOGY VISIT, OR HOSPITAL             THIS PROXIMITY TO INPATIENT SERVICES
      DIS-CHARGE DAY MANAGEMENT IS              ARE NOT COVERED.
      NOT ALLOWED THE SAME DOS AS
          HOSPITAL ADMISSION.


835   LEVEL IV ACS CASE MANAGEMENT     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M90      NOT COVERED MORE THAN ONCE IN A 12       483
      LIMITED TO 1 PER 12 MONTH                 OCCURRENCE HAS BEEN REACHED.                      MONTH PERIOD.
      PERIOD FOR DDS CLIENT.


836   NITROUS OXIDE NOT PAYABLE WITH                                                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      EXAMINATIONS, PROPHYS,                                                                      RENDERED ON THE SAME DATE.
      FLUORIDES AND DENTAL SEALANTS
      FOR SAME DOS.


837   COMPONENT TESTS ARE INCLUDED     97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      IN COMPLETE BLOOD COUNT.                  INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


838   GROUP OUTPATIENT/THERAPY         A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SERVICE NOT PAYABLE TO                                                                      RENDERED ON THE SAME DATE.
      MULTIPLE    MENTAL HEALTH
      PROVIDERS ON THE SAME DATE OF
      SERVICE.

839   DIAGNOSIS SERVICES NOT PAYABLE   A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      TO RSPMI WHEN PAID TO                                                                       RENDERED ON THE SAME DATE.
      PSYCHOLOGIST ON SAME DATE OF
      SERVICE.


840   DIAGNOSIS/ PSYCHOLOGICAL TEST    A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SERVICE NOT PAYABLE TO RSPMI                                                                RENDERED ON THE SAME DATE.
      WHEN PAID TO PSYCHOLOGIST ON
      SAME DOS.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
841   DIAGNOSIS/ PSYCHOLOGICAL         A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      TESTING BATTERY SERVICE NOT                                                                 RENDERED ON THE SAME DATE.
      PAYABLE TO RSPMI WHEN PAID TO
      PSYCHOLOGIST ON SAME DATE OF
      SERVICE.

842   INTERPRETATION OF DIAGNOSIS      A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SERVICE NOT PAYABLE TO RSPMI                                                                RENDERED ON THE SAME DATE.
       WHEN PAID TO PSYCHOLOGIST ON
      SAME DOS.


843   MARITAL/FAMILY THERAPY           A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SERVICES NOT PAYABLE TO RSPMI                                                               RENDERED ON THE SAME DATE.
      WHEN   PAID TO PSYCHOLOGIST ON
      SAME DATE OF SERVICE.


844   INDIVIDUAL OUTPATIENT/THERAPY    A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      SESSION NOT PAYABLE TO RSPMI                                                                RENDERED ON THE SAME DATE.
      WHEN PAID TO PSYCHOLOGIST ON
      SAME DATE OF SERVICE



845   INDIVIDUAL/COLLATERAL SERVICES   B20      PROCEDURE/SERVICE WAS PARTIALLY OR                                                         107
      HAVE BEEN SUBMITTED AND PAID              FULLY FURNISHED BY ANOTHER PROVIDER.
      TO ANOTHER MENTAL HEALTH
      PROVIDER FOR THE SAME DATE OF
      SERVICE.


846   CRISIS MANAGEMENT SERVICES       A1       CLAIM DENIED CHARGES.                    N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      HAVE BEEN SUBMITTED AND PAID                                                                RENDERED ON THE SAME DATE.
      TO ANOTHER MENTAL HEALTH
      PROVIDER FOR THE SAME DATE OF
      SERVICE.


847   URINALYSIS INCLUDED IN          97        THE BENEFIT FOR THIS SERVICE IS                                                            107
      OBSTETRICAL CARE WITH DELIVERY.           INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


848   SERVICE NON-PAYABLE FOR PACE     96       NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      RECIPIENT/PROVIDER.
849   ARKIDS B ANNUAL COST-SHARING     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      CAP HAS BEEN MET FOR THE                  OCCURRENCE HAS BEEN REACHED.
      CURRENT STATE FISCAL YEAR.


850   STANDARD WHEELCHAIR NONPAYABLE   96       NON-COVERED CHARGE(S).                   N351     SERVICE DATE OUTSIDE OF THE APPROVED     107
      WITHIN 2 YEARS OF                                                                           TREATMENT PLAN SERVICE DATES.
      SPECIALIZEDWHEELCHAIR.




                                                                                                                                                    Effective 10/22/10
                                                                                 EOB TO 277 & 835



                                        835                                               835                                                277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT     835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK    DESCRIPTION                              STATUS
851   OUTPATIENT HOSPITAL DRUGS,        96       NON-COVERED CHARGE(S).                   N20       SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      INJECTIONS, AND SUPPLIES                                                                      RENDERED ON THE SAME DATE.
        NON-PAYABLE IN NON-EMERGENCY
      ROOM.


852   E0608 LIMITED TO ONE UNIT PER     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86       SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      DATE OF SERVICE                            OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
853   SERVICES NOT PAID IN              97       THE BENEFIT FOR THIS SERVICE IS          N20       SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      CONJUNCTION WITH OTHER PAID                INCLUDED IN THE PAYMENT/ALLOWANCE FOR              RENDERED ON THE SAME DATE.
      ELDERCHOICESERVICES. CONTACT               ANOTHER SERVICE/PROCEDURE THAT HAS
      DHS REGISTERED NURSE FOR                   ALREADY BEEN ADJUDICATED.
      RECIPIENT.

854   SERVICE NOT PAYABLE ON SAME                                                         N20       SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      DOS AS LONG TERM FACILITY RESP-                                                               RENDERED ON THE SAME DATE.
       ITE CARE
855   ARKIDS B COST-SHARING HAS BEEN    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      REDUCED DUE TO THE STATE                   OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR CAP.
856   INDIVIDUAL INTEGRATED SUPPORTS    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      LIMITED TO $160.00 PER DATE OF             OCCURRENCE HAS BEEN REACHED.
      SERVICE.


857   PROCEDURE NOT ALLOWED ON SAME                                                       N20       SERVICE NOT PAYABLE WITH OTHER SERVICE   107
      DOS AS PC/RCF.                                                                                RENDERED ON THE SAME DATE.

858   MEDICARE PAYMENT MANUALLY         133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                       46
      REVIEWED.                                  IS PENDING FURTHER REVIEW.

859   ONLY ONE ADC OR ADHC SERVICE      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86       SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      ALLOWED PER DOS.                           OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                    SET TIME FRAME.
860   ARKIDS B ANNUAL COST SHARING      91       DISPENSING FEE ADJUSTMENT.                                                                  483
      HAS BEEN MET AND A $2.00
      DIFFERENTIAL DISPENSING FEE
      HAS BEEN ADDED.


861   PLACE OF SERVICE INVALID WITH     58       TREATMENT WAS DEEMED BY THE PAYER TO     M77       MISSING/INCOMPLETE/INVALID PLACE OF      249
      RESPITE CARE AND PERS ON SAME              HAVE BEEN RENDERED IN AN INAPPROPRIATE             SERVICE.
      DOS.                                       OR INVALID PLACE OF SERVICE.


862   NO APNEA MONITOR BILLED PRIOR     95       PLAN PROCEDURES NOT FOLLOWED.                                                               107
      TO 30 DAYS OF INITIAL SET UP
      OF APNEA MONITOR.




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
863   PROCEDURE CODE IS OUTSIDE OF     B7       THIS PROVIDER WAS NOT                    MA120    MISSING/INCOMPLETE/INVALID CLIA          454
      AGREED UPON CONTRACT. PLEASE              CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            CERTIFICATION NUMBER.
      CONTACT PERSON WITH WHOM YOU              PROCEDURE/SERVICE ON THIS DATE OF
      ESTABLISHED YOUR PRESENT CON-             SERVICE.
      TRACT. REQUEST MMIS BE
      CONTACTED OF ANY CHANGE IN
      CONTRACT.


864   ADC OR ADHC NOT PAYABLE SAME                                                       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DOS AS PAID HOMEMAKER OR CHORE                                                              MADE FOR SIMILAR PROCEDURE WITHIN SET
      SEVICES.                                                                                    TIME FRAME.


865   HOMEMAKER OR CHORE SERVICE NOT                                                     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      PAYABLE SAME DOS AS ADC OR                                                                  MADE FOR SIMILAR PROCEDURE WITHIN SET
      ADHC.                                                                                       TIME FRAME.
866   ADULT DAY HEALTH CARE            18       DUPLICATE CLAIM/SERVICE.                                                                   107
      RECOUPED. SERVICE REPETITIOUS
      TO PHYSICAL THERAPY HOME
      HEALTH SERVICE BILLED ON SAME
      DATE OF SERVICE.


867   ADULT DAY HEALTH CARE SERVICES                                                     M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      REVIEWED AND DEEMED NOT                                                                     MADE FOR SIMILAR PROCEDURE WITHIN SET
      PAYABLE ON SAME DOS AS                                                                      TIME FRAME.
      PHYSICAL THERAPY HOME HEALTH
      SERVICE.


868   TARGETED CASE MANAGEMENT NOT                                                       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      PAYABLE SAME DOS AS RSPMI                                                                   MADE FOR SIMILAR PROCEDURE WITHIN SET
      INTERVENTION                                                                                TIME FRAME.
869   CLAIM EXCEEDS 50 UNITS ALLOWED   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER DOS FOR PRIVATE CARE                  OCCURRENCE HAS BEEN REACHED.
      PERSONAL CARE TRANSPORTATION.


870   TCM SERVICE NOT PAYABLE FOR                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.     107
      RECIPIENT AGE 21 THRU 59 YEARS
       OF AGE
871   PAID AS CO-SURGEON.              172      PAYMENT IS ADJUSTED WHEN                                                                   65
                                                PERFORMED/BILLED BY A PROVIDER OF THIS
                                                SPECIALTY.
872   ACS SPECIALIZED MEDICAL          119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      SUPPLIES EXCEEDS LIMIT OF                 OCCURRENCE HAS BEEN REACHED.
      $300.00 PER CALENDAR MONTH.


873   ACS SUPPORTED EMPLOYMENT         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EXCEEDS LIMIT OF 32 UNITS PER             OCCURRENCE HAS BEEN REACHED.
      DATE OF SERVICE.




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
874   OFFICE VISIT INCLUDED WITH       97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      CAST REMOVAL OR REPAIR                    INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


875   CAST INCLUDED IN FEE FOR         97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      SURGICAL PROCEDURE.                       INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


876   INCLUDED IN FLAT FEE FOR MAJOR   97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      PROCEDURE.                                INCLUDED IN THE PAYMENT/ALLOWANCE FOR
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


877   FQHC ANCILLARY CHARGES FOR       B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     N45      PAYMENT BASED ON AUTHORIZED AMOUNT.      107
      COST SETTLEMENT ONLY.                     MET OR WERE EXCEEDED.
878   PROCEDURE INCLUDES OFFICE VISIT 97        THE BENEFIT FOR THIS SERVICE IS          N19      PROCEDURE CODE INCIDENTAL TO PRIMARY     107
                                                INCLUDED IN THE PAYMENT/ALLOWANCE FOR             PROCEDURE.
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


879   ARKIDS B ANNUAL COST SHARING     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     171
      HAS BEEN MET AND RECIPIENT HAS            OCCURRENCE HAS BEEN REACHED.
      OTHER INSURANCE COVERAGE.


880   PAYMENT FOR THIS CLAIM WAS       97       THE BENEFIT FOR THIS SERVICE IS          M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DENIED.   PROCEDURE IS                    INCLUDED IN THE PAYMENT/ALLOWANCE FOR             MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      INCLUDED IN THE PAYMENT FOR A             ANOTHER SERVICE/PROCEDURE THAT HAS                SET TIME FRAME.
      COMPREHENSIVE SERVICE.                    ALREADY BEEN ADJUDICATED.


881   INDICATE IF ANY OR ALL DRUGS     96       NON-COVERED CHARGE(S).                   N29      MISSING/INCOMPLETE/INVALID               216
      BILLED WERE TAKEN HOME.                                                                     DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                  T/CHART.
882   NO PAYMENT ALLOWED FOR TAKE      96       NON-COVERED CHARGE(S).                   M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 216
      HOME DRUGS.                                                                                 ITHDRAWN NATIONAL DRUG CODE (NDC).

883   PROCEDURE BILLED INCLUDED IN     97       THE BENEFIT FOR THIS SERVICE IS          N19      PROCEDURE CODE INCIDENTAL TO PRIMARY     107
      PAYMENT FOR GLOBAL OB CARE.               INCLUDED IN THE PAYMENT/ALLOWANCE FOR             PROCEDURE.
                                                ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


884   ACS CASE MANAGEMENT LIMITED TO   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M139     DENIED SERVICES EXCEED THE COVERAGE      483
      ONCE PER CALENDAR MONTH                   OCCURRENCE HAS BEEN REACHED.                      LIMIT FOR THE DEMONSTRATION.

885   E0570 EXCEEDS TOTAL              119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M139     DENIED SERVICES EXCEED THE COVERAGE      483
      REIMBURSEMENT OF $140.00 FOR              OCCURRENCE HAS BEEN REACHED.                      LIMIT FOR THE DEMONSTRATION.
      TOS U




                                                                                                                                                    Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                            277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                           STATUS
886   E0570 EXCEEDS TOTAL              119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M139     DENIED SERVICES EXCEED THE COVERAGE   483
      REIMBURSEMENT OF $175.00                  OCCURRENCE HAS BEEN REACHED.                      LIMIT FOR THE DEMONSTRATION.

887   EXCEED MAXIMUM 30 UNITS PER      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  483
      DATE OF SERVICE PER RECIPIENT.            OCCURRENCE HAS BEEN REACHED.

888   THIS PROCEDURE ALLOWED ONLY      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N23      ALERT: PATIENT LIABILITY MAY BE       483
      TWICE IN A LIFETIME                       OCCURRENCE HAS BEEN REACHED.                      AFFECTED DUE TO COORDINATION OF
                                                                                                  BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                                  MAXIMUM BENEFIT PROVISIONS.


889   ARKIDS B ANNUAL COST SHARING     91       DISPENSING FEE ADJUSTMENT.                                                              171
      HAS BEEN MET AND A $2.00
      DIFFERENTIAL DISPENSING FEE
      HAS BEEN ADDED AND RECIPIENT
      HAS OTHER INSURANCE COVERAGE.


890   ARKIDS B COST-SHARING HAS BEEN   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  483
      REDUCED DUE TO THE STATE                  OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR CAP AND A $2.00
      DIFFERENTIAL DISPENSING FEE
      HAS BEEN ADDED.


891   ARKIDS B COST-SHARING HAS BEEN   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  171
      REDUCED DUE TO THE STATE                  OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR CAP AND RECIPIENT
      HAS OTHER INSURANCE COVERAGE.


892   ONLY ONE EYE EXAM PER 12         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N23      ALERT: PATIENT LIABILITY MAY BE       483
      MONTHS, EXCLUDING REPAIRS OR              OCCURRENCE HAS BEEN REACHED.                      AFFECTED DUE TO COORDINATION OF
          REPLACEMENT OF BROKEN OR                                                                BENEFITS WITH OTHER CARRIERS AND/OR
      LOST GLASSES FOR RECIPIENTS                                                                 MAXIMUM BENEFIT PROVISIONS.
      UNDER 21.

893   ONLY ONE PAIR OF GLASSES PER     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N23      ALERT: PATIENT LIABILITY MAY BE       483
      12 MONTHS EXCLUDING REPAIRS OR            OCCURRENCE HAS BEEN REACHED.                      AFFECTED DUE TO COORDINATION OF
      REPLACEMENT OF BROKEN OR LOST                                                               BENEFITS WITH OTHER CARRIERS AND/OR
      GLASSES FOR RECIPIENTS UNDER                                                                MAXIMUM BENEFIT PROVISIONS.
      21 YEARS OF AGE


894   ARKIDS B COST-SHARING HAS BEEN   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                  171
      REDUCED DUE TO THE STATE                  OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR CAP AND A $2.00
      DIFFERENTIAL DISPENSING FEE
      AND RECIPIENT HAS OTHER
      INSURANCE COVERAGE.




                                                                                                                                                 Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
895   ONLY ONE ANNUAL FAMILY           119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   N23      ALERT: PATIENT LIABILITY MAY BE          483
      PLANNING VISIT ALLOWED PER                OCCURRENCE HAS BEEN REACHED.                      AFFECTED DUE TO COORDINATION OF
      STATE FISCAL YEAR.                                                                          BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                                  MAXIMUM BENEFIT PROVISIONS.


896   OUTPATIENT SURGICAL PROCEDURE    97       PAYMENT IS INCLUDED IN THE ALLOWANCE     N23      ALERT: PATIENT LIABILITY MAY BE          107
      INCLUDES ALL RELATED                      FOR ANOTHER SERVICE/PROCEDURE.                    AFFECTED DUE TO COORDINATION OF
      PROCEDURES.                                                                                 BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                                  MAXIMUM BENEFIT PROVISIONS.


897   DENIED IN CLAIMCHECK AUDITING    97       THE BENEFIT FOR THIS SERVICE IS          M144     PRE-/POST-OPERATIVE CARE PAYMENT IS      107
      DUE TO RELATED PROCEDURE PAID             INCLUDED IN THE PAYMENT/ALLOWANCE FOR             INCLUDED IN THE ALLOWANCE FOR THE
      IN HISTORY. SUBMIT ADJUSTMENT             ANOTHER SERVICE/PROCEDURE THAT HAS                SURGERY/PROCEDURE.
      IF APPLICABLE.                            ALREADY BEEN ADJUDICATED.


898   EXCEEDS 2 PR EYE GLASSES PER     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      12 MO. WITH CATARACT DX                   OCCURRENCE HAS BEEN REACHED.

899   MULTIPLE COMPOSITE                                                                 N149     REBILL ALL APPLICABLE SERVICES ON A      107
      RESTORATIONS FOR THE SAME                                                                   SINGLE CLAIM.
      TOOTH WERE BILLED ON SEPARATE
      CLAIMS. PLEASE COMBINE
      RESTORATIONS AND RESUBMIT FOR
      PAYMENT.

900   PRICING OF THIS PROCEDURE        97       THE BENEFIT FOR THIS SERVICE IS          M144     PRE-/POST-OPERATIVE CARE PAYMENT IS      107
      INCLUDES RELATED SERVICES . A             INCLUDED IN THE PAYMENT/ALLOWANCE FOR             INCLUDED IN THE ALLOWANCE FOR THE
      RE- LATED SERVICE HAS BEEN                ANOTHER SERVICE/PROCEDURE THAT HAS                SURGERY/PROCEDURE.
      PAID PREVENTING PAYMENT OF                ALREADY BEEN ADJUDICATED.
      THIS CODE SUBMIT ADJUSTMENT IF
      APPLICABLE.


901   COMPOUND DRUG STRENGTH/UNITS     16       CLAIM/SERVICE LACKS INFORMATION WHICH    N29      MISSING/INCOMPLETE/INVALID               216
      INCOMPLETE FOR PRICING                    IS NEEDED FOR ADJUDICATION.                       DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      DETERMINATION.                                                                              T/CHART.


902   DAYS SUPPLY NOT NUMERIC OR IS    154      PAYER DEEMS THE INFORMATION SUBMITTED    M53      MISSING/INCOMPLETE/INVALID DAYS OR       221
      ZERO, OR EXCEEDS 31 DAYS                  DOES NOT SUPPORT THIS DAY'S SUPPLY.               UNITS OF SERVICE.

903   PAYMENT REDUCED                  B5       COVERAGE/PROGRAM GUIDELINES WERE NOT     M139     DENIED SERVICES EXCEED THE COVERAGE      107
      PROPORTIONATELY TO COMPLY WITH            MET OR WERE EXCEEDED.                             LIMIT FOR THE DEMONSTRATION.
      MEDICAL      POLICY QUANTITY
      LIMITATION.
904   THE DRUG QUANTITY ENTERED IN     16       CLAIM/SERVICE LACKS INFORMATION WHICH    M125     MISSING/INCOMPLETE/INVALID INFORMATION   476
      THE QUANTITY FIELD ON THE                 IS NEEDED FOR ADJUDICATION.                       ON THE PERIOD OF TIME FOR WHICH THE
      CLAIM FORM WAS EITHER MISSING                                                               SERVICE/SUPPLY/EQUIPMENT WILL BE NEEDED.
      OR INVALID




                                                                                                                                                    Effective 10/22/10
                                                                                   EOB TO 277 & 835



                                        835                                                835                                                 277
                                        ADJ      835 ADJUSTMENT REASON CODE                REMIT      835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                               REMARK     DESCRIPTION                              STATUS
905   DRUG NOT COVERED, CHECK NDC,      96       NON-COVERED CHARGE(S).                    M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      MAY BE OBSOLETE                                                                                 ITHDRAWN NATIONAL DRUG CODE (NDC).

906   DRUG CLASSIFICATION ON REVIEW     133      THE DISPOSITION OF THIS CLAIM/SERVICE     MA07       THE CLAIM INFORMATION HAS ALSO BEEN      46
      FOR BILLING PROVIDER.                      IS PENDING FURTHER REVIEW.                           FORWARDED TO MEDICAID FOR REVIEW.

907   PRESCRIBING PHYSICIAN NUMBER                                                         N31        MISSING/INCOMPLETE/INVALID PRESCRIBING   153
      INVALID/MISSING.                                                                                PROVIDER IDENTIFIER.
908   2 PR EYEGLASSES PER 12 MONTHS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                        483
      UNDER AGE 21.                              OCCURRENCE HAS BEEN REACHED.

909   COMPOUND DRUG NOT COVERED         96       NON-COVERED CHARGE(S).                    M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 216
                                                                                                      ITHDRAWN NATIONAL DRUG CODE (NDC).

910   NDC MISSING OR INVALID                                                               M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
                                                                                                      ITHDRAWN NATIONAL DRUG CODE (NDC).

911   REFILL INDICATOR MISSING OR       16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29        MISSING/INCOMPLETE/INVALID               216
      INVALID.                                   IS NEEDED FOR ADJUDICATION.                          DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                      T/CHART.
912   TAKE HOME DRUGS DENIED            96       NON-COVERED CHARGE(S).                    M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 216
                                                                                                      ITHDRAWN NATIONAL DRUG CODE (NDC).

913   PRESCRIPTION NUMBER INVALID OR    16       CLAIM/SERVICE LACKS INFORMATION WHICH     N29        MISSING/INCOMPLETE/INVALID               219
      MISSING.                                   IS NEEDED FOR ADJUDICATION.                          DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                      T/CHART.
914   NDC NOT LISTED IN REDBOOK OR                                                         M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      BLUEBOOK. CHECK NDC AND                                                                         ITHDRAWN NATIONAL DRUG CODE (NDC).
      RESUBMIT ALONG WITH THE
      MANUFACTURERS NAME.


915   DESI DRUG NOT PAYABLE BY          96       NON-COVERED CHARGE(S).                    M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      MEDICAID                                                                                        ITHDRAWN NATIONAL DRUG CODE (NDC).

916   NDC NUMBER OBSOLETE.     REBILL                                                      M119       MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      USING CURRENT NDC.                                                                              ITHDRAWN NATIONAL DRUG CODE (NDC).

917   PRESCRIBING PHYSICIAN             173      SERVICE WAS NOT PRESCRIBED BY A           N29        MISSING/INCOMPLETE/INVALID               91
      INVALID/MISSING. EFFECTIVE FOR             PHYSICIAN.                                           DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      CLAIMS WITH DATES OF SERVICE                                                                    T/CHART.
      ON OR AFTER 6/1/89 CLAIMS WILL
      DENY.


918   BENEFITS FOR AID CATEGORY = 99                                                       N30        PATIENT INELIGIBLE FOR THIS SERVICE.     88
      RECIPIENTS ARE LIMITED TO
      PRESCRIPTION DRUGS ONLY.




                                                                                                                                                        Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                                835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
919   OVER THE COUNTER PRESCRIPTION     96       NON-COVERED CHARGE(S).                    N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      NOT PAYABLE TO LONG TERM CARE
      RECIPIENTS.


920   EXCEEDS ONE REPAIR PER 12         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      MONTHS AGE 21 AND OLDER                    OCCURRENCE HAS BEEN REACHED.

921   COVERAGE RESTRICTED DRUG          B5       COVERAGE/PROGRAM GUIDELINES WERE NOT      M139     DENIED SERVICES EXCEED THE COVERAGE      216
      BILLED WITHOUT COVERAGE                    MET OR WERE EXCEEDED.                              LIMIT FOR THE DEMONSTRATION.
      RESTRICTED INDICATOR
922   CLAIM MUST BE BILLED THRU AEVCS                                                      M117     NOT COVERED UNLESS SUBMITTED VIA         481
                                                                                                    ELECTRONIC CLAIM.
923   EXCEEDS LIMIT OF 2 REPAIRS PER    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      12 MONTHS UNDER AGE 21                     OCCURRENCE HAS BEEN REACHED.

924   PROCEDURE CODE REQUIRES NDC(S)    16       CLAIM/SERVICE LACKS INFORMATION WHICH     M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      FOR ADMINISTERED DRUG                      IS NEEDED FOR ADJUDICATION.                        ITHDRAWN NATIONAL DRUG CODE (NDC).

925   PROCEDURE CODE AND NDC DO NOT     16       CLAIM/SERVICE LACKS INFORMATION WHICH     M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      MATCH                                      IS NEEDED FOR ADJUDICATION.                        ITHDRAWN NATIONAL DRUG CODE (NDC).

926   NDC &/OR LABELER NOT QUALIFIED    B5       COVERAGE/PROGRAM GUIDELINES WERE NOT      M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      FOR REBATE OR IS OUTSIDE                   MET OR WERE EXCEEDED.                              ITHDRAWN NATIONAL DRUG CODE (NDC).
      REBATE DATES
927   INCORRECT PROCEDURE CODE FOR      16       CLAIM/SERVICE LACKS INFORMATION WHICH     M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      NDC BILLED.                                IS NEEDED FOR ADJUDICATION.                        ITHDRAWN NATIONAL DRUG CODE (NDC).

928   NON LEGEND ITEM NOT INCLUDED      96       NON-COVERED CHARGE(S).                    N59      ATTN: PLEASE REFER TO YOUR PROVIDER      84
      IN PROGRAM.                                                                                   MANUAL FOR ADDITIONAL PROGRAM AND
                                                                                                    PROVIDER INFORMATION.
929   PROCEDURE CODE-64763 ALLOWED      35       LIFETIME BENEFIT MAXIMUM HAS BEEN                                                           483
      ONLY TWICE IN A LIFETIME                   REACHED.

930   DRUG NOT PAYABLE UNDER TITLE      96       NON-COVERED CHARGE(S).                    M119     MISSING/INCOMPLETE/INVALID/DEACTIVATED/W 218
      XIX                                                                                           ITHDRAWN NATIONAL DRUG CODE (NDC).

931   NAME BRAND DRUG BILLED WITHOUT    50       THESE ARE NON-COVERED SERVICES BECAUSE    N170     A NEW/REVISED/RENEWED CERTIFICATE OF     287
      MEDICAL NECESSITY                          THIS IS NOT DEEMED A 'MEDICAL                      MEDICAL NECESSITY IS NEEDED.
                                                 NECESSITY' BY THE PAYER.
932   PAYMENT REDUCED TO MAXIMUM     B10         ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE                                                     65
      ALLOWED MINUS AMOUNT                       A COMPONENT OF THE BASIC PROCEDURE/TEST
      PREVIOUSLY PAID FOR BITEWINGS.             WAS PAID. THE BENEFICIARY IS NOT
                                                 LIABLE FOR MORE THAN THE CHARGE LIMIT
                                                 FOR THE BASIC PROCEDURE/TEST.


933   ONE PAIR EYE GLASSES EVERY 12     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M90      NOT COVERED MORE THAN ONCE IN A 12       483
      MONTHS FOR RECIPIENTS AGE 21               OCCURRENCE HAS BEEN REACHED.                       MONTH PERIOD.
      AND OLDER




                                                                                                                                                      Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
934   ALS NON-PAYABLE SAME DOS AS BLS A1        CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
                                                                                                   RENDERED ON THE SAME DATE.

935   PAYMENT EXCEEDS MAXIMUM OF       119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      $200.00 PER CALENDAR MONTH                OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
936   NO JUSTIFICATION FOR BILLING     4        THE PROCEDURE CODE IS INCONSISTENT WITH                                                     453
      "9" MODIFIER                              THE MODIFIER USED OR A REQUIRED
                                                MODIFIER IS MISSING.


937   INTEGRATED GROUP SUPPORT         119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      LIMITED TO $102.00 PER DATE OF            OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      SERVICE.                                                                                     SET TIME FRAME.
938   EXCEEDS LIMIT OF TWO PODIATRY    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      VISITS PER SFY.                           OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
939   BLS NON-PAYABLE SAME DOS AS ALS A1        CLAIM DENIED CHARGES.                     N20      SERVICE NOT PAYABLE WITH OTHER SERVICE   107
                                                                                                   RENDERED ON THE SAME DATE.

940   RECIPIENT AGE 65 OR OLDER NOT    96       NON-COVERED CHARGE(S).                    N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      ENTITLED TO INPATIENT
      PSYCHIATRIC SERVICES
941   RECIPIENT COST SHARE AMOUNT      177      PATIENT HAS NOT MET THE REQUIRED                                                            483
      CUT BACK MONTHLY COST SHARE               ELIGIBILITY REQUIREMENTS.
      LIMIT REACHED
942   INJECTION REQUIRES SPECIFIC      11       THE DIAGNOSIS IS INCONSISTENT WITH THE    MA63     MISSING/INCOMPLETE/INVALID PRINCIPAL     255
      DIAGNOSIS CODE                            PROCEDURE.                                         DIAGNOSIS.
943   W1 RECIPIENT NOT ELIGIBLE FOR    96       NON-COVERED CHARGE(S).                    N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      TCM SERVICE
944   CLAIM CAN NOT BE PROCESSED                                                          M53      MISSING/INCOMPLETE/INVALID DAYS OR       476
      WITHOUT UNITS ENTERED ON CLAIM                                                               UNITS OF SERVICE.
        FORM.
945   A VALID CLIA NUMBER IS                                                              MA51     MISSING/INCOMPLETE/INVALID CLIA          142
      REQUIRED FOR THIS PROCEDURE                                                                  CERTIFICATION NUMBER FOR LABORATORY
                                                                                                   SERVICES BILLED BY PHYSICIAN OFFICE
                                                                                                   LABORATORY.
946   ELIGIBLE FOR MEDICARE ONLY.      129      PRIOR PROCESSING INFORMATION APPEARS      N30      PATIENT INELIGIBLE FOR THIS SERVICE.     109
      NO MEDICAID OR QMB BENEFITS.              INCORRECT.

947   VISUAL OFFICE MEDICAL SERV LTD   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      TO TWO PER SFY                            OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
948   PERSONAL CARE LIMITED TO 40      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      UNITS PER MONTH WITHOUT PA.               OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
949   PULPOTOMY/PUPAL DEBRIDEMENT      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      NOT PAYABLE WITH IN TWO YEARS             OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      OF ROOT CANAL (SAME TOOTH).                                                                  SET TIME FRAME.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                              STATUS
950   ARKIDS FIRST-B PARTICIPANT      119       BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      CUMULATIVE ALLOWED EXCEEDS                OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      $2500 FOR SFY '99 FOR                                                                        SET TIME FRAME.
      OUTPATIENT MENTAL AND
      BEHAVIORAL HEALTH     SERVICES.


951   CLAIM CANNOT SPAN TWO MONTHS.                                                       N74      RESUBMIT WITH MULTIPLE CLAIMS, EACH      187
      PLEASE REBILL AS MULTIPLE                                                                    CLAIM COVERING SERVICES PROVIDED IN
      CLAIMS.                                                                                      ONLY ONE CALENDAR MONTH.


952   SERVICE REQUIRES PRIMARY CARE                                                       M68      MISSING/INCOMPLETE/INVALID ATTENDING,    94
      PHYSICIAN REFERRAL.                                                                          ORDERING, RENDERING, SUPERVISING OR
                                                                                                   REFERRING PHYSICIAN IDENTIFICATION.


953   ONLY ONE CHIROPRACTIC X-RAY      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M90      NOT COVERED MORE THAN ONCE IN A 12       483
      PER STATE FISCAL YEAR.                    OCCURRENCE HAS BEEN REACHED.                       MONTH PERIOD.

954   ROOT CANAL NOT PAYABLE WITH IN   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR    M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      TWO YEARS OF PULPOTAMY/PUPAL              OCCURRENCE HAS BEEN REACHED.                       MADE FOR SAME/SIMILAR PROCEDURE WITHIN
      DEBRIDEMENT (SAME TOOTH).                                                                    SET TIME FRAME.


955   A PAID PANEL CODE PREVENTS     97         THE BENEFIT FOR THIS SERVICE IS           M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL    419
      PAYMENT OF THIS INDIVIDUAL                INCLUDED IN THE PAYMENT/ALLOWANCE FOR              LAB CODES INCLUDED IN THE TEST.
      TEST FOR SAME DATE OF SERVICE.            ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


956   ABSENCE OF ANESTHESIA            107      THE RELATED OR QUALIFYING CLAIM/SERVICE   M20      MISSING/INCOMPLETE/INVALID HCPCS.        42
      PROCEDURE CODE PREVENTS                   WAS NOT IDENTIFIED ON THIS CLAIM.
      PAYMENT OF    CLAIM.
957   PANEL TEST NONPAYABLE IN         97       THE BENEFIT FOR THIS SERVICE IS                                                             419
      ADDITION TO INDIVIDUAL OR                 INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      PANEL    TEST ON THE SAME DOS.            ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


958   CLAIM EXCEEDS LIMIT OF $250.00   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PER CALENDAR MONTH FOR                    OCCURRENCE HAS BEEN REACHED.
      MEDICAL SUPPLIES.


959   CLAIM EXCEEDS LIMIT OF $80.00    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                      483
      PER CALENDAR MONTH FOR                    OCCURRENCE HAS BEEN REACHED.
      MEDICAL SUPPLIES.


960   ONLY LTC PROVIDERS MAY BILL      B7       THIS PROVIDER WAS NOT                                                                       88
      FOR NON-HOSPICE PATIENT LTC               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
       SERVICES.                                PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
961   HOSPICE RECIPIENT IS NOT                                                            N30      PATIENT INELIGIBLE FOR THIS SERVICE.     88
      MEDICAID AND MEDICARE PART A
          ELIGIBLE.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                               835                                               277
                                       ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
962   PAID PANEL CODE 77419 PREVENTS   97       THE BENEFIT FOR THIS SERVICE IS                                                            419
      PAYMENT OF THIS RELATED                   INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      PROCEDURE CODE FOR SAME DOS.              ANOTHER SERVICE/PROCEDURE THAT HAS
                                                ALREADY BEEN ADJUDICATED.


963   77419 NONPAYABLE ON SAME DOS                                                       M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      AS PAID CODES 77420-77431.                                                                  MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
964   EFFECTIVE 2/8/97, DRUG CLAIMS                                                      M117     NOT COVERED UNLESS SUBMITTED VIA         481
      MUST BE BILLED THROUGH AEVCS.                                                               ELECTRONIC CLAIM.
      PAPER CLAIMS MAY BE SUBMITTED
      WHEN NECESSARY.


965   ONLY HOSPICE PROVIDERS MAY       B7       THIS PROVIDER WAS NOT                                                                      88
      BILL FOR LTC HOSPICE PATIENT              CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
        SERVICES.                               PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
966   EXCEEDS BENEFIT LIMIT OF THREE   119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER LIFETIME                              OCCURRENCE HAS BEEN REACHED.

967   01996-PAIN MANAGEMENT LIMITED    119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR   M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   483
      TO ONCE PER DOS.                          OCCURRENCE HAS BEEN REACHED.                      MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                  SET TIME FRAME.
968   NOT ENROLLED AS EPSDT            B7       THIS PROVIDER WAS NOT                    N34      INCORRECT CLAIM FORM/FORMAT FOR THIS     481
      PROVIDER. RESUBMIT CLAIM ON               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            SERVICE.
      DIFFERENT CLAIM FORM.                     PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
969   ROOM AND BOARD REVENUE CODE(S)                                                     M50      MISSING/INCOMPLETE/INVALID REVENUE       455
      NOT ALLOWED WITH REVENUE CODE                                                               CODE(S).
      128, 129 OR 249.


970   BILLING PERIOD CANNOT SPAN TWO                                                     N61      REBILL SERVICES ON SEPARATE CLAIMS.      187
      LOC. PLEASE RESUBMIT WITH
      EACH LOC AS A SEPARATE DETAIL
      OR CLAIM.


971   ANESTHESIOLOGIST MAY NOT         97       THE BENEFIT FOR THIS SERVICE IS                                                            107
      RECEIVE PAYMENT FOR HOSPITAL              INCLUDED IN THE PAYMENT/ALLOWANCE FOR
      VISITSIN ADDITION TO PAIN                 ANOTHER SERVICE/PROCEDURE THAT HAS
      MANAGEMENT.                               ALREADY BEEN ADJUDICATED.


972   EXCEEDS LIMIT OF THREE UNITS     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER DOS FOR INDIVIDUAL SPEECH             OCCURRENCE HAS BEEN REACHED.
      SESSIONS.


973   EXCEEDS LIMIT OF 4 SPEECH        119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EVALUATIONS PER STATE FISCAL              OCCURRENCE HAS BEEN REACHED.
      YEAR.




                                                                                                                                                    Effective 10/22/10
                                                                                EOB TO 277 & 835



                                        835                                               835                                               277
                                        ADJ      835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   EDS DESCRIPTION                   REASON   DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
974   EXCEEDS LIMIT OF ONE PHYSICAL     119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      THERAPY EVALUATION PER SFY.                OCCURRENCE HAS BEEN REACHED.

975   EXCEEDS LIMIT OF ONE            119        BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      OCCUPATIONAL THERAPY EVALUATION            OCCURRENCE HAS BEEN REACHED.

976   EXCEEDS LIMIT OF THREE UNITS      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER DOS FOR INDIVIDUAL                     OCCURRENCE HAS BEEN REACHED.
      OCCUPATIONAL THERAPY.


977   EXCEEDS LIMIT OF O.T.             119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      EVALUATION PER SFY                         OCCURRENCE HAS BEEN REACHED.

978   IN RELATION   TO EFFECTIVE DATE   B7       THIS PROVIDER WAS NOT                    N95      THIS PROVIDER TYPE/PROVIDER SPECIALTY    145
      OF PROVIDER   SPECIALTY,                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            MAY NOT BILL THIS SERVICE.
      PROVIDER IS   INELIGIBLE TO                PROCEDURE/SERVICE ON THIS DATE OF
      RENDER THIS   SERVICE.                     SERVICE.


979   FORM EMS-2698 MUST BE             17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      COMPLETED AND ATTACHED TO THE              OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      CLAIM.                                                                                       T/CHART.
980   FORM EMS-2698 MUST INCLUDE THE    17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      NAME AND ADDRESS OF THE                    OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      PATIENT.                                                                                     T/CHART.


981   FORM EMS-2698 MUST BE             17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      COMPLETED PRIOR TO THE                     OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
      PROCEDURE.                                                                                   T/CHART.
982   SECTION I OF FORM EMS-2698 IS     17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      INCOMPLETE.                                OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.
983   SECTION II OF FORM EMS-2698 IS    17       REQUESTED INFORMATION WAS NOT PROVIDED   N29      MISSING/INCOMPLETE/INVALID               294
      INCOMPLETE.                                OR WAS INSUFFICIENT/INCOMPLETE.                   DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPOR
                                                                                                   T/CHART.
984   00857/00955 NOT PAYABLE SAME                                                        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DOS AS 62278/62279.                                                                          MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
985   62278/62279 NOT PAYABLE SAME                                                        M86      SERVICE DENIED BECAUSE PAYMENT ALREADY   107
      DOS AS 00857/00955.                                                                          MADE FOR SAME/SIMILAR PROCEDURE WITHIN
                                                                                                   SET TIME FRAME.
986   FQHC CLAIMS WITH DOS SPANNING                                                       N61      REBILL SERVICES ON SEPARATE CLAIMS.      187
      11/01/94 MUST BE SPLIT AND
      REBILLED.
987   EXCEEDS BENEFIT LIMIT OF ONE      119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      PER THREE YEARS                            OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                     Effective 10/22/10
                                                                               EOB TO 277 & 835



                                       835                                                835                                              277
                                       ADJ      835 ADJUSTMENT REASON CODE                REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   EDS DESCRIPTION                  REASON   DESCRIPTION                               REMARK   DESCRIPTION                             STATUS
988   OB/ROUTINE NEWBORN CARE          177      PATIENT HAS NOT MET THE REQUIRED                                                           84
      SERVICES IN WAIVER COUNTY                 ELIGIBILITY REQUIREMENTS.
      REQUIRES WAIVER COUNTY
      CONTRACT HOSPITAL.
989   PATIENT REQUIRES WAIVER COUNTY   177      PATIENT HAS NOT MET THE REQUIRED                                                           84
      CONTRACT HOSPITAL FOR OB/                 ELIGIBILITY REQUIREMENTS.
      ROUTINE NEWBORN CARE SERVICES.


990   INVALID REVENUE CODE FOR         8        THE PROCEDURE CODE IS INCONSISTENT WITH   M50      MISSING/INCOMPLETE/INVALID REVENUE      455
      PROVIDER SPECIALTY. CHECK FOR             THE PROVIDER TYPE/SPECIALTY (TAXONOMY).            CODE(S).
          CORRECT BILLING PROVIDER
      NUMBER.
991   INVALID TYPE OF ADMISSION CODE. 16        CLAIM/SERVICE LACKS INFORMATION WHICH     MA41     MISSING/INCOMPLETE/INVALID ADMISSION    231
                                                IS NEEDED FOR ADJUDICATION.                        TYPE.
992   RECIPIENT MUST BE UNDER AGE 21   8        THE PROCEDURE CODE IS INCONSISTENT WITH   N95      THIS PROVIDER TYPE/PROVIDER SPECIALTY   88
      TO BILL USING PROVIDER                    THE PROVIDER TYPE/SPECIALTY (TAXONOMY).            MAY NOT BILL THIS SERVICE.
      SPECIALTY RC.


993   PROVIDER SPECIALTIES RC OR RH    B7       THIS PROVIDER WAS NOT                                                                      455
      CAN ONLY BILL WITH REVENUE                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      CODE 249. CHECK FOR CORRECT               PROCEDURE/SERVICE ON THIS DATE OF
      BILLING PROVIDER NUMBER.                  SERVICE.


994   CLAIM PAID AT MAXIMUM            150      PAYER DEEMS THE INFORMATION SUBMITTED                                                      65
      ALLOWABLE PAS OR PSRO DAYS FOR            DOES NOT SUPPORT THIS LEVEL OF SERVICE.
      PERCENTAGE ON FILE.


995   CLAIM PAYMENT REDUCED DUE TO     178      PATIENT HAS NOT MET THE REQUIRED SPEND                                                     68
      RECIPIENT'S SPENDDOWN AMOUNT.             DOWN REQUIREMENTS.

996   CLAIMS REIMBURSED ACCORDING TO   B5       COVERAGE/PROGRAM GUIDELINES WERE NOT                                                       65
      ADEMS GUIDELINES.                         MET OR WERE EXCEEDED.

997   RECIPIENT 21 OR OVER ON DOS      N30      PATIENT INELIGIBLE FOR THIS SERVICE.                                                       109
      NOT ELIGIBLE FOR EPSDT
      SERVICES.
998   CLAIM PAID AT MAXIMUM            119      BENEFIT MAXIMUM FOR THE TIME PERIOD OR                                                     483
      ALLOWABLE DAYS.                           OCCURRENCE HAS BEEN REACHED.

999   CLAIM HAS BEEN SUSPENDED         133      THE DISPOSITION OF THIS CLAIM/SERVICE                                                      20
      TEMPORARILY AND WILL RELEASE              IS PENDING FURTHER REVIEW.
      NEXT CYCLE.




                                                                                                                                                    Effective 10/22/10
                                                                           EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
STATEMENT FROM-THROUGH DATES.

FACILITY ADMISSION DATE.



STATEMENT FROM-THROUGH DATES.

DATE(S) OF SERVICE.




DATE(S) OF SERVICE.



FACILITY DISCHARGE DATE.



STATEMENT FROM-THROUGH DATES.



NO PAYMENT WILL BE MADE FOR THIS CLAIM.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.



MAXIMUM LEAVE DAYS EXHAUSTED.

MISSING OR INVALID INFORMATION.           554      DATE CLAIM PAID

NUBC CONDITION CODE(S).




LINE INFORMATION.




ACCEPTED FOR PROCESSING.




MISSING OR INVALID INFORMATION.           677      ENTITY NOT AFFILIATED




                                                                                              Effective 10/22/10
                                                                            EOB TO 277 & 835



                                       277
277 CLAIM STATUS CODE                  CLAIM
DESCRIPTION                            STATUS   277 CLAIM STATUS CODE DESCRIPTION
NUBC CONDITION CODE(S).




DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.




MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.



LINE INFORMATION.

OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).



COVERED DAY(S).



COVERED DAY(S).




CLAIM IS OUT OF BALANCE.

PATIENT DISCHARGE STATUS.

TYPE OF SERVICE.



SUPPORTING DOCUMENTATION.



AUTHORIZATION/CERTIFICATION NUMBER.




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




                                                                                               Effective 10/22/10
                                                                      EOB TO 277 & 835



                                       277
277 CLAIM STATUS CODE                  CLAIM
DESCRIPTION                            STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.




NUBC CONDITION CODE(S).




CLAIM/LINE HAS BEEN PAID.




ENTITY NOT ELIGIBLE.

MISSING OR INVALID UNITS OF SERVICE.



MISSING OR INVALID UNITS OF SERVICE.

SERVICE NOT AUTHORIZED.




STATEMENT FROM-THROUGH DATES.



CLAIM/SUBMISSION FORMAT IS INVALID.

TYPE OF SERVICE.




TYPE OF SERVICE.




INTERNAL REVIEW/AUDIT.



AUTHORIZATION/CERTIFICATION NUMBER.

OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




                                                                                         Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM SUBMISSION FORMAT IS INVALID.




SERVICE NOT AUTHORIZED.




THIS AMOUNT IS NOT ENTITY'S
RESPONSIBILITY.

PARTIAL PAYMENT MADE FOR THIS CLAIM.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCEDURE CODE NOT VALID FOR PATIENT
AGE.
ENTITY'S MEDICAID PROVIDER ID.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

CLAIM HAS BEEN ADJUDICATED AND IS
AWAITING PAYMENT CYCLE.
INTERNAL REVIEW/AUDIT.



DATE(S) OF SERVICE.




PAYMENT MADE IN FULL.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DATE(S) OF SERVICE.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



COVERED DAY(S).



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.
NO PAYMENT WILL BE MADE FOR THIS CLAIM.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MISSING OR INVALID INFORMATION.           677      ENTITY NOT AFFILIATED




NO PAYMENT WILL BE MADE FOR THIS CLAIM.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.




CLAIM/LINE HAS BEEN PAID.



DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

AWAITING RELATED CHARGES.




NON-COVERED DAY(S).




                                                                                              Effective 10/22/10
                                                                              EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




OPERATIVE REPORT.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

FACILITY DISCHARGE DATE.

MISSING OR INVALID INFORMATION.           475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.



MISSING OR INVALID INFORMATION.           145      ENTITY'S SPECIALTY/TAXONOMY CODE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




CLAIM/SUBMISSION FORMAT IS INVALID.

CLAIM SUBMITTED TO INCORRECT PAYER.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                                 Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
DATE(S) OF SERVICE.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.



SUPPORTING DOCUMENTATION.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

AUTHORIZATION/CERTIFICATION NUMBER.




DATES OF SERVICE




TOTAL ANESTHESIA MINUTES.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS CLAIM.




CLAIM/LINE HAS BEEN PAID.




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




CLAIM/LINE HAS BEEN PAID.




ACCEPTED FOR PROCESSING.



DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

SERVICE NOT AUTHORIZED.



CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

ENTITY'S SPECIALTY/TAXONOMY CODE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
NUBC CONDITION CODE(S).




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




TOOTH NUMBER OR LETTER.

TOOTH SURFACE(S) INVOLVED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



TOOTH NUMBER OR LETTER.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.




                                                                                            Effective 10/22/10
                                                                               EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID INFORMATION.           294      SUPPORTING DOCUMENTATION.




ADDITIONAL INFORMATION REQUESTED FROM
ENTITY.

SERVICE NOT AUTHORIZED.



PLACE OF SERVICE.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
PROCEDURE CODE FOR SERVICES RENDERED.




PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
ENTITY NOT ELIGIBLE.




PROCEDURE CODE FOR SERVICES RENDERED.




                                                                                                  Effective 10/22/10
                                                                               EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PLACE OF SERVICE.



PROCEDURE CODE NOT VALID FOR PATIENT
AGE.

PROCEDURE CODE AND PATIENT GENDER
MISMATCH.

PROCEDURE CODE FOR SERVICES RENDERED.



PROCEDURE CODE FOR SERVICES RENDERED.

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
AMBULANCE CERTIFICATION/DOCUMENTATION.



MISSING OR INVALID INFORMATION.           294      SUPPORTING DOCUMENTATION.




MISSING OR INVALID INFORMATION.           476      MISSING OR INVALID UNITS OF SERVICE.



DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

TOOTH SURFACE(S) INVOLVED.



PROCEDURE CODE FOR SERVICES RENDERED.




DAYS/UNITS FOR PROCEDURE/REVENUE CODE.




PROCEDURE CODE FOR SERVICES RENDERED.




                                                                                                  Effective 10/22/10
                                                                       EOB TO 277 & 835



                                        277
277 CLAIM STATUS CODE                   CLAIM
DESCRIPTION                             STATUS   277 CLAIM STATUS CODE DESCRIPTION
TYPE OF SERVICE.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




PROCEDURE CODE FOR SERVICES RENDERED.



ENTITIES ORIGINAL SIGNATURE.

PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.



PROCEDURE CODE FOR SERVICES RENDERED.



PROCEDURE CODE FOR SERVICES RENDERED.



DATE(S) OF SERVICE.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DATE(S) OF SERVICE.



DATE(S) OF SERVICE.



OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




FACILITY ADMISSION DATE.




                                                                                          Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES RENDERED.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




NUBC CONDITION CODE(S).




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

DAYS/UNITS FOR PROCEDURE/REVENUE CODE.




ITEMIZED CLAIM.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

ENTITY NOT ELIGIBLE.



DIAGNOSIS CODE.




DIAGNOSIS CODE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PRIMARY DIAGNOSIS CODE.

DIAGNOSIS CODE.

ALL CURRENT DIAGNOSES.



DIAGNOSIS CODE.



DIAGNOSIS AND PATIENT GENDER MISMATCH.

DIAGNOSIS AND PATIENT GENDER MISMATCH.

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE.



CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

DIAGNOSIS CODE.

ADMITTING DIAGNOSIS.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY'S SPECIALTY/TAXONOMY CODE.


MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DIAGNOSIS AND PATIENT GENDER MISMATCH.

DIAGNOSIS CODE.

ENTITY NOT ELIGIBLE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



DIAGNOSIS CODE.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ITEMIZED CLAIM.



DATE(S) OF SERVICE.

NON-COVERED DAY(S).

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.



ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




SERVICE NOT AUTHORIZED.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

AUTHORIZATION/CERTIFICATION NUMBER.



MISSING OR INVALID INFORMATION.

ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




REVENUE CODE FOR SERVICES RENDERED.




ENTITY'S LICENSE/CERTIFICATION NUMBER.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SERVICE NOT AUTHORIZED.

MEDICAL NECESSITY FOR SERVICE.




                                                                                            Effective 10/22/10
                                                                      EOB TO 277 & 835



                                       277
277 CLAIM STATUS CODE                  CLAIM
DESCRIPTION                            STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




SERVICE NOT AUTHORIZED.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




AWAITING ELIGIBILITY DETERMINATION.




ENTITY'S ID NUMBER.




SERVICE NOT AUTHORIZED.



CLAIM/SUBMISSION FORMAT IS INVALID.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



CLAIM/SUBMISSION FORMAT IS INVALID.

CLAIM/SUBMISSION FORMAT IS INVALID.




                                                                                         Effective 10/22/10
                                                                               EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY'S NAME, ADDRESS, PHONE AND ID
NUMBER.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.
ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.

MISSING OR INVALID INFORMATION.           294      SUPPORTING DOCUMENTATION.




                                                                                                  Effective 10/22/10
                                                                      EOB TO 277 & 835



                                       277
277 CLAIM STATUS CODE                  CLAIM
DESCRIPTION                            STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




ENTITY NOT ELIGIBLE.

AWAITING ELIGIBILITY DETERMINATION.



ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
DATE(S) OF SERVICE.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.

NON-COVERED DAY(S).




ENTITY'S ID NUMBER.

OTHER PAYER'S EXPLANATION OF
BENEFITS/PAYMENT INFORMATION.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




INTERNAL REVIEW/AUDIT.




                                                                                         Effective 10/22/10
                                                                            EOB TO 277 & 835



                                       277
277 CLAIM STATUS CODE                  CLAIM
DESCRIPTION                            STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY SIGNATURE DATE.



ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.



SERVICE NOT AUTHORIZED.



CLAIM/SUBMISSION FORMAT IS INVALID.



ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.

ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.



CLAIM/LINE HAS BEEN PAID.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.



SERVICE NOT AUTHORIZED.



CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).

MISSING OR INVALID INFORMATION.        4        THIS IS A SUBSEQUENT REQUEST FOR
                                                INFORMATION FROM THE ORIGINAL REQUEST.




                                                                                               Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM SUBMITTED TO INCORRECT PAYER.




SERVICE NOT AUTHORIZED.

CLAIM SUBMITTED TO INCORRECT PAYER.



LENGTH OF TIME FOR SERVICES RENDERED.



DIAGNOSIS CODE.




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

CLAIM SUBMITTED TO INCORRECT PAYER.




MISSING OR INVALID INFORMATION.           187      DATE(S) OF SERVICE.




ENTITY NOT ELIGIBLE.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.

PROCEDURE CODE NOT VALID FOR PATIENT
AGE.
ENTITY NOT APPROVED AS AN ELECTRONIC
SUBMITTER.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS CLAIM.



SERVICE NOT AUTHORIZED.




DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.

LINE INFORMATION.



SERVICE NOT AUTHORIZED.



CLAIM/LINE HAS BEEN PAID.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.



CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.



OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCEDURE CODE FOR SERVICES RENDERED.




CLAIM IS OUT OF BALANCE.



ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




COVERED DAY(S).



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

X-RAYS.




CLAIM IS OUT OF BALANCE.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN MODIFIED.




PAYMENT REFLECTS USUAL AND CUSTOMARY
CHARGES.



ENTITY'S ID NUMBER.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES RENDERED.

PROCEDURE CODE FOR SERVICES RENDERED.




PROCEDURE CODE FOR SERVICES RENDERED.




PROCEDURE CODE FOR SERVICES RENDERED.

PROCEDURE CODE FOR SERVICES RENDERED.




FACILITY DISCHARGE DATE.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.
CLAIM/LINE HAS BEEN PAID.




CLAIM/LINE HAS BEEN PAID.




CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

CLAIM/LINE HAS BEEN PAID.




CLAIM/LINE HAS BEEN PAID.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SUPPORTING DOCUMENTATION.



CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

COVERED DAY(S).



COVERED DAY(S).




SUPPORTING DOCUMENTATION.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.
PAYMENT MADE IN FULL.
DATE(S) OF SERVICE.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




SERVICE NOT AUTHORIZED.

HOSPITAL'S SEMI-PRIVATE ROOM RATE.




                                                                                            Effective 10/22/10
                                                                              EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID INFORMATION.           56       AWAITING ELIGIBILITY DETERMINATION.




NDC NUMBER.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



DRUG DISPENSING UNITS AND AVERAGE
WHOLESALE PRICE (AWP).

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
REVENUE CODE FOR SERVICES RENDERED.




NO PAYMENT WILL BE MADE FOR THIS 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.




ALLOWABLE/PAID FROM PRIMARY COVERAGE.



DATE(S) OF SERVICE.




                                                                                                 Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/LINE HAS BEEN PAID.




ALLOWABLE/PAID FROM PRIMARY COVERAGE.




ALLOWABLE/PAID FROM PRIMARY COVERAGE.



CLAIM/LINE HAS BEEN PAID.




ALLOWABLE/PAID FROM PRIMARY COVERAGE.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SERVICE NOT AUTHORIZED.



LINE INFORMATION.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ALLOWABLE/PAID FROM PRIMARY COVERAGE.

ALLOWABLE/PAID FROM PRIMARY COVERAGE.



CHARGES FOR PREGNANCY DEFERRED UNTIL
DELIVERY.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.




CLAIM COMBINED WITH OTHER CLAIM(S).



CLAIM COMBINED WITH OTHER CLAIM(S).




ALLOWABLE/PAID FROM PRIMARY COVERAGE.




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.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
AUTHORIZATION/CERTIFICATION NUMBER.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



AUTHORIZATION/CERTIFICATION NUMBER.



AUTHORIZATION/CERTIFICATION NUMBER.




SERVICE LINE NUMBER GREATER THAN
MAXIMUM ALLOWABLE FOR PAYER.



AUTHORIZATION/CERTIFICATION NUMBER.




AUTHORIZATION/CERTIFICATION NUMBER.



AUTHORIZATION/CERTIFICATION NUMBER.




SERVICE NOT AUTHORIZED.

AUTHORIZATION/CERTIFICATION NUMBER.



AUTHORIZATION/CERTIFICATION NUMBER.



AUTHORIZATION/CERTIFICATION NUMBER.



AUTHORIZATION/CERTIFICATION NUMBER.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




NO PAYMENT WILL BE MADE FOR THIS CLAIM.




CLAIM/LINE HAS BEEN PAID.




DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.

ENTITY'S LICENSE/CERTIFICATION NUMBER.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

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.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MISSING OR INVALID UNITS OF SERVICE.




SERVICE NOT AUTHORIZED.




                                                                                            Effective 10/22/10
                                                                               EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
RETURNED TO ENTITY.




MISSING OR INVALID INFORMATION.           294      SUPPORTING DOCUMENTATION.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



AWAITING RELATED CHARGES.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




LINE INFORMATION.




MISSING OR INVALID UNITS OF SERVICE.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DIAGNOSIS CODE.



SUPPORTING DOCUMENTATION.




                                                                                                  Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES RENDERED.



PROCEDURE CODE FOR SERVICES RENDERED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SERVICE NOT AUTHORIZED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



FACILITY ADMISSION DATE.

MISSING OR INVALID UNITS OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




SERVICE NOT AUTHORIZED.




DUPLICATE OF AN EXISTING CLAIM/LINE,
AWAITING PROCESSING.
DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
DUPLICATE OF AN EXISTING CLAIM/LINE,
AWAITING PROCESSING.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PAPER CLAIM.




SERVICE NOT AUTHORIZED.



FACILITY ADMISSION DATE.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



CLAIM/SUBMISSION FORMAT IS INVALID.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




CLAIM/SUBMISSION FORMAT IS INVALID.




SUPPORTING DOCUMENTATION.



LENGTH OF TIME FOR SERVICES RENDERED.




INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.

MISSING OR INVALID LAB INDICATOR.

HISTORY AND PHYSICAL.



DETAILED DESCRIPTION OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PATHOLOGY NOTES/REPORTS.

OPERATIVE REPORT.

TYPE OF SURGERY/SERVICE FOR WHICH
ANESTHESIA WAS ADMINISTERED.

DISCHARGE SUMMARY.

NEED FOR MORE THAN ONE PHYSICIAN TO
TREAT PATIENT.
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS CLAIM.




PROCEDURE CODE FOR SERVICES RENDERED.

PROCEDURE CODE FOR SERVICES RENDERED.




DETAILED DESCRIPTION OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




SUPPORTING DOCUMENTATION.



DRUG NAME, STRENGTH AND DOSAGE FORM.



SUPPORTING DOCUMENTATION.




                                                                                            Effective 10/22/10
                                                                      EOB TO 277 & 835



                                  277
277 CLAIM STATUS CODE             CLAIM
DESCRIPTION                       STATUS   277 CLAIM STATUS CODE DESCRIPTION
PATHOLOGY NOTES/REPORTS.




SUPPORTING DOCUMENTATION.




SUPPORTING DOCUMENTATION.




MISSING OR INVALID INFORMATION.   481      CLAIM/SUBMISSION FORMAT IS INVALID.



ENTITIES ORIGINAL SIGNATURE.



ENTITY SIGNATURE DATE.



MISSING OR INVALID INFORMATION.   481      CLAIM/SUBMISSION FORMAT IS INVALID.




ENTITY SIGNATURE DATE.



ENTITIES ORIGINAL SIGNATURE.



ENTITY SIGNATURE DATE.




ENTITY'S DATE OF BIRTH.



SERVICE NOT AUTHORIZED.




                                                                                         Effective 10/22/10
                                                                              EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY SIGNATURE DATE.




ENTITY SIGNATURE DATE.




DIAGNOSIS CODE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCEDURE CODE FOR SERVICES RENDERED.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN COMBINED.

ENTITY NOT APPROVED.




MISSING OR INVALID INFORMATION.           481      CLAIM/SUBMISSION FORMAT IS INVALID.




                                                                                                 Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




ENTITY NOT ELIGIBLE.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN MODIFIED.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.




OTHER PROCEDURE CODE FOR SERVICE(S)
RENDERED.

HOSPITAL INFORMATION.

CLAIM/LINE IS CAPITATED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

AUTHORIZATION/CERTIFICATION NUMBER.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY'S SPECIALTY/TAXONOMY CODE.




ENTITY'S SPECIALTY/TAXONOMY CODE.



SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SERVICE NOT AUTHORIZED.




CLAIM/SUBMISSION FORMAT IS INVALID.




ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DUPLICATE OF A PREVIOUSLY PROCESSED
CLAIM/LINE.
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN COMBINED.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN MODIFIED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY'S SPECIALTY/TAXONOMY CODE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MEDICAL NECESSITY FOR SERVICE.




PROCEDURE CODE FOR SERVICES RENDERED.



SERVICE NOT AUTHORIZED.

AUTHORIZATION/CERTIFICATION NUMBER.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE NOT VALID FOR PATIENT
AGE.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE AND PATIENT GENDER
MISMATCH.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
AUTHORIZATION/CERTIFICATION NUMBER.



SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

TOOTH NUMBER OR LETTER.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MEDICAL NECESSITY FOR SERVICE.



SERVICE NOT AUTHORIZED.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

LENGTH OF TIME FOR SERVICES RENDERED.




TYPE OF SURGERY/SERVICE FOR WHICH
ANESTHESIA WAS ADMINISTERED.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.



OTHER PROCEDURE CODE FOR SERVICE(S)
RENDERED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




PROCEDURE CODE FOR SERVICES RENDERED.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



SUPPORTING DOCUMENTATION.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN MODIFIED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.



TYPE OF BILL FOR UB CLAIM.




CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SUPPORTING DOCUMENTATION.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

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.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCEDURE CODE FOR SERVICES RENDERED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




ENTITY NOT ELIGIBLE.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.

ENTITY NOT PRIMARY.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



CLAIM/LINE HAS BEEN PAID.



COVERED DAY(S).




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

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.

INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
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.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.

SERVICE NOT AUTHORIZED.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




SERVICE NOT AUTHORIZED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN COMBINED.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN COMBINED.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN MODIFIED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

CLAIM WAS PROCESSED AS ADJUSTMENT TO
PREVIOUS CLAIM.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

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.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

SUPPORTING DOCUMENTATION.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

CLAIM/LINE HAS BEEN PAID.




PARTIAL PAYMENT MADE FOR THIS CLAIM.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DATE(S) OF SERVICE.




ENTITY'S LICENSE/CERTIFICATION NUMBER.

ENTITY'S LICENSE/CERTIFICATION NUMBER.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

SUBSCRIBER AND POLICYHOLDER NAME
MISMATCHED.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DATE ENTITY SIGNED
CERTIFICATION/RECERTIFICATION

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PAPER CLAIM.




PARTIAL PAYMENT MADE FOR THIS CLAIM.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

INTERNAL REVIEW/AUDIT.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




PLACE OF SERVICE.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCEDURE CODE FOR SERVICES RENDERED.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

CLAIM/LINE HAS BEEN PAID.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DRUG INFORMATION.



DRUG INFORMATION.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE INFORMATION
(HEALTH, LIABILITY, AUTO, ETC).




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




DRUG INFORMATION.




DRUG DAYS SUPPLY AND DOSAGE.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



MISSING OR INVALID UNITS OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
NDC NUMBER.



INTERNAL REVIEW/AUDIT.



ENTITY'S ID NUMBER.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DRUG INFORMATION.



NDC NUMBER.



DRUG INFORMATION.



DRUG INFORMATION.



PRESCRIPTION NUMBER.



NDC NUMBER.




NDC NUMBER.



NDC NUMBER.



ENTITY NOT ELIGIBLE/NOT APPROVED FOR
DATES OF SERVICE.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DRUG INFORMATION.



CLAIM/SUBMISSION FORMAT IS INVALID.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

NDC NUMBER.



NDC NUMBER.



NDC NUMBER.



NDC NUMBER.



SERVICE NOT AUTHORIZED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

NDC NUMBER.



MEDICAL NECESSITY FOR SERVICE.



CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

DIAGNOSIS CODE.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
MISSING OR INVALID UNITS OF SERVICE.



ENTITY'S LICENSE/CERTIFICATION NUMBER.




ENTITY NOT ELIGIBLE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




DATE(S) OF SERVICE.




ENTITY NOT REFERRED BY SELECTED PRIMARY
CARE PROVIDER.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.



INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




AWAITING RELATED CHARGES.



INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.



ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
INDIVIDUAL TEST(S) COMPRISING THE PANEL
AND THE CHARGES FOR EACH TEST.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

CLAIM/SUBMISSION FORMAT IS INVALID.




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.

CLAIM/SUBMISSION FORMAT IS INVALID.




REVENUE CODE FOR SERVICES RENDERED.




DATE(S) OF SERVICE.




PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ENTITY'S SPECIALTY/TAXONOMY CODE.




SUPPORTING DOCUMENTATION.



SUPPORTING DOCUMENTATION.




SUPPORTING DOCUMENTATION.



SUPPORTING DOCUMENTATION.



SUPPORTING DOCUMENTATION.



PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

PROCESSED ACCORDING TO CONTRACT/PLAN
PROVISIONS.

DATE(S) OF SERVICE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                          277
277 CLAIM STATUS CODE                     CLAIM
DESCRIPTION                               STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.




SERVICE NOT AUTHORIZED.




REVENUE CODE FOR SERVICES RENDERED.




HOSPITAL ADMISSION TYPE.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.



REVENUE CODE FOR SERVICES RENDERED.




CLAIM/LINE HAS BEEN PAID.




PARTIAL PAYMENT MADE FOR THIS CLAIM.



CLAIM/LINE HAS BEEN PAID.



ENTITY NOT ELIGIBLE.



MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
FOR BENEFIT PERIOD.

ACCEPTED FOR PROCESSING.




                                                                                            Effective 10/22/10
                                                                 ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A00            ZZZ    Z1704-RESPITE CARE PROVIDED MORE THAN 14 CONSECUTIVE DAYS      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A03            ZZZ    DRUG PAYMENT EXCEEDS 3 PERSCRIPTIONS PER MONTH                 483      FOR BENEFIT PERIOD.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     A04            ZZZ    WAIVER SERVICES ON OVERLAPPING DOS AS INSTITUTIONAL CLAIM      88       SUBMITTED DATES OF SERVICE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A05            ZZZ    OUTPATIENT/PODIATRY LAB AND X-RAY LTD TO $500 PER SFY          483      FOR BENEFIT PERIOD.

     A06            ZZZ    OUTPATIENT FAMILY PLANNING SVC NON PAY SAME DOS OTHER FEE      104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OUTPATIENT NORPLANT INSERTION PAYABLE TWICE PER FIVE YEAR               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A07            ZZZ    PERIOD                                                         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A08            ZZZ    OUTPATIENT NORPLANT REMOVAL PAYABLE ONCE PER FIVE YEAR PERIOD 483       FOR BENEFIT PERIOD.

     A09            ZZZ    OUTPATIENT FACILITY FEE NON PAY SAME DOS AS OUTP FAM PLAN      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     A10            ZZZ    LAB PROCEDURE NOT PERFORMED WITHIN 7 DAYS OF SCREENING         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A11            ZZZ    REMOVAL OF CERVIX TISSUE ALLOWED ONCE IN A LIFETIME            483      FOR BENEFIT PERIOD.
                           NEUROBEHAVIOR STATUS EXAM LIMITED TO ONE HOUR PER STATE                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A13            DDS    FISCAL YEAR                                                    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A13            ZZZ    NEUROBEHAVIOR STATUS EXAM LIMITED TO ONE HOUR PER SFY          483      FOR BENEFIT PERIOD.

     A14            ZZZ    FAIL IF RELATED PROC BILLED SAME DOS/ATTENDING PROVIDER        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     A15            ZZZ    FAIL IF RELATED PROC BILLED SAME DOS/ATTENDING PROVIDER        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           NEW BIRTH STANDBY NON-PAYABLE SAME DOS AS PHYSICIAN STANDBY
     A16            ZZZ    SERV                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           PHYSICIAN STANDBY SERV NON-PAYABLE SAME DOS AS NEW BIRTH
     A17            ZZZ    STANDBY                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A20            DDS    Z0473 LIMITED TO TWO UNITS PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A21            DDS    Z2267 LIMITED TO ONE UNIT PER MONTH                            483      FOR BENEFIT PERIOD.
                           RENTAL WHEELCHAIR NON-PAYABLE W/IN 5 YRS OF PURCHASED                   PROCESSED ACCORDING TO CONTRACT/PLAN
     A22            ZZZ    WHEELCHAIR                                                     107      PROVISIONS.
                           PURCHASED WHEELCHAIR NON-PAYABLE W/IN 5 YRS OF RENTAL                   PROCESSED ACCORDING TO CONTRACT/PLAN
     A23            ZZZ    WHEELCHAIR                                                     107      PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     A24            ZZZ    12 OUTPATIENT HOSPITAL VISITS EXCEEDED FOR STATE FISCAL YEAR   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C00            DDS    Z1582 LIMITED TO 832 UNITS PER SFY FOR AGES 21 AND OVER        483      FOR BENEFIT PERIOD.




6/16/2011                                                         Page 225
                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C01            DDS    Z1919 LIMITED TO $7500.00 PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C02            DDS    Z2336 LIMITED TO 48 UNITS PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C03            ZZZ    LIGATION OR TRANSECTION OF FALLOPIAN TUBES ONCE IN LIFETIME   483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C05            ZZZ    TWO ULTRASOUNDS PER PREGNANCY                                 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C06            ZZZ    FIVE FETAL NON-STRESS TESTS PER PREGNANCY                     483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C07            ZZZ    PELVIC EXENTERATION ALLOWED ONCE IN A LIFETIME                483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C08            ZZZ    VAGINECTOMY ALLOWED TWICE IN A LIFETIME                       483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     C09            ZZZ    SMALL INTESTINE REMOVAL ALLOWED ONCE IN A LIFETIME            483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E02            ZZZ    EXCEEDS LIMIT OF 12 OUTPATIENT VISITS PER STATE FISCAL YEAR   483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E05            ZZZ    PURCHASE OF THIS DME LIMITED TO ONE PER YEAR                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E06            ZZZ    PURCHASE OF THIS DME LIMITED TO ONCE EVERY TWO YEARS          483      FOR BENEFIT PERIOD.
                           PURCHASE OF THIS DURABLE MED EQUIP LIMITED TO ONCE IN A                MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E07            ZZZ    LIFETIME                                                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E08            ZZZ    PURCHASE OF THIS DME LIMITED TO ONCE EVERY 6 MONTHS           483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E09            ZZZ    EXCEEDS LIMIT OF 455 UNITS FOR THE PURCHASE OF THIS DME       483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E10            ZZZ    DME TOS I PROCEDURE CODE PAYABLE ONCE PER SFY                 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E11            ZZZ    TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR AGE 5      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E12            ZZZ    TWO EPSDT AGE APPROPRIATE HEARING SCREENS 16 THRU 17 YEARS    483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E13            ZZZ    TWO EPSDT HEARING SCREENS APPROPRIATE AGES 18 THRU 20 YEARS   483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E14            ZZZ    TWO EPSDT HEARING SCREENS APPROPRIATE AGES 12 THRU 15 YEARS   483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E15            ZZZ    TWO EPSDT VISION SCREENS APPROPRIATE FROM 6 THRU 9 YEARS      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E16            ZZZ    TWO EPSDT VISION SCREENS APPROPRIATE FROM 10 THRU 11 YEARS    483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E17            ZZZ    TWO EPSDT AGE APPROPRIATE VISION SCREEN 12 THRU 15 YEARS      483      FOR BENEFIT PERIOD.




6/16/2011                                                        Page 226
                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E18            ZZZ    TWO EPSDT AGE APPROPRIATE VISION SCREEN 16 THRU 17 YEARS       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E19            ZZZ    TWO EPSDT AGE APPROPRIATE VISION SCREEN 18 THRU 20 YEARS       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E21            AR1    ONE PREVENTATIVE DENTAL SCREEN FROM NEWBORN TO 12 MONTHS       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E22            ZZZ    TWO EPSDT AGE APPROPRIATE VISION SCREENS FOR 5 YEARS OF AGE    483      FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREENS FOR NEWBORN THRU 4             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E23            ZZZ    YRS                                                            483      FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS FOR NEWBORN THRU 4            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E24            ZZZ    YRS                                                            483      FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS FOR AGE 8 THRU 11             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E25            ZZZ    YRS                                                            483      FOR BENEFIT PERIOD.

     E26            ZZZ    VENIPUNCTURE NON-PAYABLE SAME DOS AS LAB TEST, SAME PROVIDER   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     E27            ZZZ    LAB TEST NON-PAYABLE SAME DOS AS VENIPUNCTURE, SAME PROVIDER   104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E28            ZZZ    Z0560 EXCEEDS LIMIT OF ONE PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E31            ZZZ    Z0564 EXCEEDS LIMIT OF ONE PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E32            ZZZ    Z0574 EXCEEDS LIMIT OF SIX UNITS PER WEEK                      483      FOR BENEFIT PERIOD.
                           ONE PAIR EYE GLASSES EVERY 12 MONTHS FOR RECIPIENTS AGE                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E33            ZZZ    21/OLDER                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E34            ZZZ    DIAPERS AND UNDERPADS EXCEEDS $130.00 PER CALENDAR MONTH       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E37            ZZZ    EYE EXAMINE EXCEEDS ONE PER 12 MONTH PERIOD                    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E38            ZZZ    NORPLANT SYSTEM PAYABLE TWICE PER 5 YEAR PERIOD                483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E39            ZZZ    NORPLANT INSERTION PAYABLE TWICE PER FIVE YEAR PERIOD          483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E44            ZZZ    TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR AGE 6       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E45            ZZZ    TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR AGE 7       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E66            ZZZ    TCM SERVICES EXCEED LIMIT OF 832 UNITS PER SFY                 483      FOR BENEFIT PERIOD.

     E67            ZZZ    TCM SERVICES NOT ALLOWED ON SAME DOS BY DIFFERENT PROVIDERS    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     E68            ZZZ    Z1885 EXCEEDS LIMIT OF 600 UNITS PER SFY                       483      FOR BENEFIT PERIOD.




6/16/2011                                                        Page 227
                                                                      ESC TO 277



                                                                                               277
                         PLAN                                                                  CLAIM
      EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E69            ZZZ    12 NURSE PRACTITIONER/CERT NURSE MIDWIFE VISTS PER SFY        483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E74            ZZZ    Z1888/WHEELCHAIR VAN/PAYABLE ONLY ONCE PER DOS                483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E75            ZZZ    Z1889 EXCEEDS LIMIT OF 15 MILES PER DOS                       483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
E76                       ZZZ    Z1890 EXCEEDS LIMIT OF 30 MILES PER DOS                       483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E77            ZZZ    TRANSPORTATION SERV LIMITED TO 50 MILES PER DATE OF SERVICE   483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E78            ZZZ    Z1904/PAYABLE ONLY ONCE PER DATE OF SERVICE                   483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E79            ZZZ    Z1905/PAYABLE ONLY ONCE PER DATE OF SERVICE                   483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E84            ZZZ    TRANSPORTATION SERVICES IN EXCESS OF 300 MILES PER DOS        483      FOR BENEFIT PERIOD.

           E85            ZZZ    TRANSPORTATION CODE NOT PAYABLE AS BILLED                     104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E87            ZZZ    P CARE TRANSPORTATION LIMIT 30 UNITS PER DOS/RECIP            483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E88            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                     483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E89            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                     483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E90            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                     483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E95            ZZZ    MEDICAL EVALUATION LIMITED TO FOUR UNITS PER SFY              483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E96            ZZZ    PHYSICAL EVALUATION LIMITED TO FOUR UNITS PER SFY             483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E97            ZZZ    OCCUPATIONAL EVALUATION LIMITED TO FOUR UNITS PER SFY         483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           E98            ZZZ    PELVIC LYMPHADENECTOMY ALLOWED TWICE IN A LIFETIME            483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           F00            ZZZ    INGUINOFEMORAL LYMPHADENECTOMY ALLOWED TWICE IN A LIFETIME    483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           F02            ZZZ    ORCHIECTOMY ALLOWED TWICE IN A LIFETIME                       483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           F04            ZZZ    VESICULECTOMY ALLOWED TWICE IN A LIFETIME                     483      FOR BENEFIT PERIOD.
                                 TRANSECTION/AVULSION OBTURATOR, EXTRAPELVIC TWICE IN A                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           F06            ZZZ    LIFETIME                                                      483      FOR BENEFIT PERIOD.
                                                                                                        MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
           F07            ZZZ    TRANSECTION/AVULSION PUDENDAL NERVE TWICE IN A LIFETIME       483      FOR BENEFIT PERIOD.




      6/16/2011                                                        Page 228
                                                                 ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F11            ZZZ    NEPHRECTOMY & RENAL HOMOTRANSPLANT ALLOWED ONCE IN A LIFETIME 483       FOR BENEFIT PERIOD.
                           TRANSECTION/AVULSION OBTURATOR, INTRAPELVIC TWICE IN A                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F12            ZZZ    LIFETIME                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F17            ZZZ    ANESTHESIOLOGY PROCEDURE CODE 01996 ALLOWED ONCE PER SAME DOS 483       FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F19            ZZZ    EXCEEDS 2 TELEMEDICINE CONSULTATION PER SFY                    483      FOR BENEFIT PERIOD.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     F21            ZZZ    DETAIL DENIED.   DUPLICATE SERVICES                            54       CLAIM/LINE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F26            AR1    PA REQUIRED FOR ARKIDS EXCEEDING $500 LMT PER SFY MENTAL HLTH 483       FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F27            AR1    ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH SERVICES   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F28            ZZZ    CHMS IND PSYCHOTHERAPY 20-30 MIN LIMITED TO TWO PER SFY        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F29            ZZZ    CHMS IND PSYCHOTHERAPY 45-50 MIN LIMITED TO TWO PER SFY        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F30            ZZZ    LIMIT OF 3 UNITS PER DAY WITHOUT A BENEFIT EXTENSION           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F31            ZZZ    TWO EPSDT DENTAL SCREENS ALLOWED PER 150 DAYS                  483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F32            ZZZ    CHMS SCREENING TEST LIMITED TO TWO PER SFY                     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F33            ZZZ    CHMS PURE TONE AUDIOMETRY; AIR LIMITED TO TWO PER SFY          483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F34            ZZZ    CHMS PURE TONE AUDIOMETRY; AIR/BONE LIMITED TO TWO PER SFY     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F35            ZZZ    CHMS SPEECH AUDIOMETRY THRESHOLD LIMITED TO TWO PER SFY        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F36            ZZZ    CHMS COMPREHENSIVE AUDIOMETRY LIMITED TO TWO PER SFY           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F37            ZZZ    CHMS TYMPANOMETRY LIMITED TO TWO PER SFY                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F38            ZZZ    CHMS CONDITIONING PLAY AUDIOMETRY LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                           CHMS AUDITORY EVOKED POTENTIAL/RESPONSE LIMITED TO TWO PER              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     F39            ZZZ    SFY                                                            483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H00            ZZZ    VISUAL OFFICE MEDICAL SERVICES LTD TO 2 PER SFY                483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H14            ZZZ    CHMS EVOKED OTOACOUSTIC EMISSIONS LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                           CHMS EVOKED OTOACOUSTIC EMISSIONS;COMPREHENSIVE LTD TWO PER             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H15            ZZZ    SFY                                                            483      FOR BENEFIT PERIOD.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H16            ZZZ    CHMS OTORHINOLAYRNGOLOGICAL PROCEDURE LIMITED TO TWO PER SFY   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H17            ZZZ    WHEELCHAIR PURCHASE LIMITED TO ONE PER TWO YEAR PERIOD         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H18            ZZZ    CHMS ASSESSMENT OF APHASIA LIMITED TO TWO PER SFY              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H19            ZZZ    CHMS DEVELOPMENTAL TESTING LIMITED TO TWO PER SFY              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H20            ZZZ    MATERNAL MMR INJECTION LIMITED TO TWO PER LIFETIME             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H21            ZZZ    CHMS NEUROPSYCHOLOGICAL TESTING LIMITED TO EIGHT PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H22            ZZZ    CHMS OFFICE VISIT FOR EVAL 10 MIN LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H23            ZZZ    CHMS OFFICE VISIT FOR EVAL 20 MIN LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H24            ZZZ    CHMS OFFICE VISIT FOR EVAL 30 MIN LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H25            ZZZ    CHMS OFFICE VISIT FOR EVAL 45 MIN LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H26            ZZZ    CHMS OFFICE VISIT FOR EVAL 60 MIN LIMITED TO TWO PER SFY       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H27            ZZZ    CHMS DIAGNOSTIC EVAL/REVIEW RECORDS LIMITED TO SIX PER SFY     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H28            ZZZ    CHMS PSYCHOLOGICAL TESTING BATTERY LIMITED TO EIGHT PER SFY    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H29            ZZZ    CHMS INTERPRETATION OF DIAGNOSIS LIMITED TO SIX PER SFY        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H30                   PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES OVER TEN 483       FOR BENEFIT PERIOD.
                           PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES OVER               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H31                   FIVE                                                           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H32            ZZZ    CHMS NUTRITION SCREENING LIMITED TO TWO PER SFY                483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H33            ZZZ    CHMS NUTRITION ASSESSMENT LIMITED TO TWO PER SFY               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H34            ZZZ    CHMS COMPREHENSIVE NUTRITION ASSESSMENT LTD TO FOUR PER SFY    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H35            ZZZ    BRIEF CONSULTATION VISIT LIMITED TO FOUR PER SFY               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H36            ZZZ    COLLATERAL SERVICES LIMITED TO FOUR PER SFY                    483      FOR BENEFIT PERIOD.
                           PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES OVER               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H37                   FOUR                                                           483      FOR BENEFIT PERIOD.




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                                                                                     277
                   PLAN                                                              CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     H38            ZZZ    LIMIT TWO ULTRASOUNDS PER NINE MONTH PERIOD               483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I00            ZZZ    PERSONAL CARE TRANSPORTATION   LIMIT 50 MILES PER DOS     483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I01            AR1    EXCEEDS HOME HEALTH VISITS PER SFY                        483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I01            ZZZ    EXCEEDS HOME HEALTH VISITS PER SFY                        483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I03            ZZZ    Z1918 LIMITED TO 32 UNITS PER DOS                         483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I04            DDS    92506 EXCEEDS LIMIT OF FOUR UNITS PER SFY                 483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     IO4            ZZZ    92506 DDTCS SPEECH THERAPY EVAL EXCEED 4 UNITS SFY        483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I05            ZZZ    Z1919 LIMITED TO $7500.00 PER LIFETIME                    483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I06            DDS    Z1920 LIMITED TO $300.00 PER CALENDAR MONTH               483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I06            ZZZ    T1920 LIMITED TO $300.00 PER CALENDAR MONTH               483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I07            DDS    Z1921 LIMITED TO ONCE PER CALENDER MONTH                  483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I07            ZZZ    Z1921 LIMITED TO ONCE PER CALENDER MONTH                  483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I08            ZZZ    Z1917 LIMITED TO $102.00 PER DOS                          483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I09            ZZZ    Z0481 LIMITED TO 40 UNITS PER MONTH                       483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I12            ZZZ    HOME -DELIVERED MEALS LIMITED TO 31 PER MONTH             483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I13            ZZZ    Z2282 EXCEEDS LIMIT OF FOUR MEALS PER SFY                 483      FOR BENEFIT PERIOD.
                           Z2283-PERS ONE INSTALLATION PER LIFETIME OR PERIOD OF              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I14            ZZZ    ELIGIBILITY                                               483      FOR BENEFIT PERIOD.
                           DDS LEVEL IV CASE MANAGEMENT LIMITED TO ONCE PER 12 MO.            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I15            ZZZ    PERIOD                                                    483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I16            ZZZ    ONLY ONE DDS CASE MANAGEMENT SERVICE PER MONTH            483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I17            ZZZ    ONLY ONE DDS CASE MANAGEMENT SERVICE PER MONTH            483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I18            ZZZ    CHMS IND PSYCHOTHERAPY 75-80 MIN LIMITED TO TWO PER SFY   483      FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I19            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 10       483      FOR BENEFIT PERIOD.




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                                                                                    277
                   PLAN                                                             CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I19            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 10                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I20            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 11      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I20            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 11                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I21            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 12      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I21            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 12                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I22            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 13      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I22            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 13                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I23            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 14      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I23            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 14                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I24            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 15      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I24            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 15                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I25            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 16      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I25            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 16                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I26            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 17      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I26            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 17                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I27            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 18      483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I27            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 18                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I28            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 19                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     I29            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 20                 483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J00            ZZZ    E0570 EXCEEDS TOTAL REIMBURSEMENT OF $140.00 FOR TOS U   483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J01            ZZZ    E0570 EXCEEDS TOTAL REIMBURSEMENT OF $175.00             483      FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J03            ZZZ    TWO PODIATRY VISITS ALLOWED PER STATE FISCAL YEAR        483      FOR BENEFIT PERIOD.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J05            ZZZ    MEDICAL SUPPLIES EXCEED $250.00 PER CALENDAR MONTH             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J06            ZZZ    MEDICAL SUPPLIES EXCEED $80.00 PER CALENDAR MONTH              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J08            ZZZ    92506 EXCEEDS LIMIT TO FOUR UNITS PER SFY                      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J10            ZZZ    95882 EXCEEDS LIMIT OF ONE PER SFY                             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J13            ZZZ    EXCEEDS LIMIT OF 30 RSPD (PT=26, PS=RH) DAYS PER CURRENT SFY   483      FOR BENEFIT PERIOD.
                           AUGMENTATIVE COMMUNICATIVE DEVICES EXCEED $7500 LIFETIME                MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J14            ZZZ    BENEFIT                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J15            ZZZ    EXCEEDS 12 FQHC VISITS PER SFY                                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J16            ZZZ    EXCEEDS LIMIT OF 30 RSPD (PT=26, PS=RH) DAYS PER PRIOR SFY     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J17            ZZZ    OCCUPATIONAL THERAPY CODE Z1929 LIMITED TO 4 UNITS PER DOS     483      FOR BENEFIT PERIOD.
                           PUBLIC TRANSPORTATION Z1989 LTD TO 30 UNITS PER DATE OF                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J60            ZZZ    SERVICE                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J61            ZZZ    FETAL ULTRASOUND LTD TO TWO PER NINE MO PERIOD COMPLETE/PROF   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J62            ZZZ    FETAL ULTRASOUND LTD TO TWO PER NINE MO PERIOD COMPLETE/TECH   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J63            ZZZ    PROSTHETICS DEVICES LIMITED TO $20,000 PER STATE FISCAL YEAR   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J64            ZZZ    PROSTHETICS DEVICES LIMITED TO ONE IN FIVE YEARS               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J65            ZZZ    ORTHOTIC APPLIANCE LIMITED TO $3,000 PER STATE FISCAL YEAR     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J66            ZZZ    ORTHOTIC APPLIANCE REPLACEMENT LIMITED TO ONE PER 12 MONTHS    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J67            ZZZ    POST STERILIZATION VISIT LIMITED TO ONE PER STATE FISCAL YEAR 483       FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J68            ZZZ    PROSTHETICS DEVICES LIMITED TO ONE IN FIVE YEARS (BILATERAL)   483      FOR BENEFIT PERIOD.
                           ORTHOTIC APPL REPLACEMENT LIMITED TO ONE PER 12 MO                      MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J69            ZZZ    (BILATERAL)                                                    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J70            DDS    OCCUPATIONAL THERAPY EVAL LIMITED TO 4 PER SFY                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J71            DDS    FAMILY SUPPORT SERVICES LIMITED TO $5,000 PER STATE FISCAL YR 483       FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J72            AR1    PA REQUIRED FOR ARKIDS EXCEEDING $500 LMT PER SFY MENTAL HLTH 483       FOR BENEFIT PERIOD.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J73            AR1    ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH SERVICES   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     J74            ZZZ    TWO FETAL NON-STRESS TESTS ALLOWED PER NINE-MONTH PERIOD       483      FOR BENEFIT PERIOD.

     J75            ZZZ    FORMULAS NOT PAYABLE WITH SAME TOS IN SAME MONTH               9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     J76            ZZZ    FORMULAS NOT PAYABLE WITH SAME TOS IN SAME MONTH               9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     N00            ZZZ    DME TOS I PCODE NOT PAYABLE SAME DOS AS DME PCODE TOS 169HUI   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N01            ZZZ    DME TOS 169H OR U PCODE NOT PAY SAME OR O/LAP DOS AS PCODE I   104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     N02            DDS    PHYSICAL THERAPY EVAL LIMITED TO 4 PER SFY                     483      FOR BENEFIT PERIOD.
                           FULL AND INTERPERIODIC MEDICAL SCREENS NOT PAYABLE ON SAME
     N03            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           INTERPERIODIC AND FULL MEDICAL SCREENS NOT PAYABLE ON SAME
     N04            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N05            ZZZ    PARTIAL EPSDT SCREEN NOPAY SAME DOS AS FULL EPSDT SCREEN       104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           RECOUPE OR DENY PART/SCREENS WHEN BILLED SAME DOS AS FULL
     N06            ZZZ    SCREEN                                                         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           INPATIENT HOSPICE CARE NONPAYABLE SAME DOS AS HOSPICE
     N07            ZZZ    ROOM/BOARD                                                     104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           HOSPICE ROOM /BOARD NONPAYABLE SAME DOS AS INPATIENT HOSPICE
     N08            ZZZ    CARE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N09            ZZZ    ROUTINE HOME CARE NO/PAY SAME DOS AS CONT/HOMECARE/RESP/CARE   104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           CONT/HOME CARE OR RESP/CARE NO/PAY SAME DOS AS ROUTINE
     N10            ZZZ    HOMECARE                                                       104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N11            ZZZ    Z1714 NONPAYABLE IN CONJUNCTION WITH OTHER HOSPICE SERVICES    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           HOSPICE SERV/NONPAYABLE ON SAME DOS AS PAID/PENDING
     N12            ZZZ    CLAIM/Z1714                                                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N13            ZZZ    INPATIENT HOSPICE CARE NOPAY/SAME DOS AS HOSPICE HOME CARE     104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N14            ZZZ    HOSPICE HOME CARE NOPAY/SAME DOS AS INPATIENT HOSPICE CARE     104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     N17            ZZZ    NORPLANT REMOVAL ALLOWED ONCE PER FIVE YEAR PERIOD             483      FOR BENEFIT PERIOD.

     N18            ZZZ    Z0561 NOT PAYABLE SAME DOS AS Z0562                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ABSENCE OF ANESTHESIA PROCEDURE CODE PREVENTS PAYMENT OF
     N19            ZZZ    CLAIM                                                          454      PROCEDURE CODE FOR SERVICES RENDERED.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                           93541 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIOLOGICAL
     N50            ZZZ    CODE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N51            ZZZ    PROCEDURE IS INCLUDED IN 93541 FOR SAME DOS                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93542 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIOLOGICAL
     N52            ZZZ    CODE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N53            ZZZ    PROCEDURE IS INCLUDED IN 93542 FOR SAME DOS                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N54            ZZZ    93543/93546 NOT ALLOW SAME DOS AS COMPANION RADIOLOGICAL CODE 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     N55            ZZZ    PROCEDURE IS INCLUDED IN 93543/93546 FOR SAME DOS              104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93544 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIOLOGICAL
     N56            ZZZ    CODE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N57            ZZZ    PROCEDURE INCLUDED IN CODE 93544 FOR SAME DOS                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93545 NOT ALLOWED SAME DOS AS CERTAIN COMPANION RADIOLOGICAL
     N58            ZZZ    CODE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N59            ZZZ    PROCEDURE INCLUDED IN CODE 93545 FOR SAME DOS                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93501-93529 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIO
     N64            ZZZ    CODES                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N65            ZZZ    PROCEDURE INCLUDED IN CODES 93501-93529 FOR SAME DOS           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93551 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIOLOGICAL
     N68            ZZZ    CODES                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N69            ZZZ    PROCEDURE INCLUDED IN CODE 93551 FOR SAME DOS                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           93552-93553 NOT ALLOW SAME DOS AS CERTAIN COMPANION RADIO
     N70            ZZZ    CODES                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N71            ZZZ    PROCEDURE INCLUDED IN CODES 93552-93553 FOR SAME DOS           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N72            ZZZ    SERVICE INCLUDED IN CRITICAL OR SUBSEQUENT HOSPITAL CARE CODE 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     N73            ZZZ    CRITICAL OR SUB HOSPITAL CARE NO PAY SAME DOS AS RELATED PROC 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     N74            ZZZ    93503 NOT PAYABLE IN CONJUNCTION WITH RELATED PROCEDURE        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N75            ZZZ    SERVICE NOT PAYABLE SAME DOS AS 93503                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N76            ZZZ    90704/90705/90706/90707 NOT ALLOWED ON SAME DOS                104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N78            ZZZ    90704/90706/90709 NOT ALLOWED ON SAME DOS                      104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE

     N79            ZZZ    90705/90706/90708 NOT ALLOWED ON SAME DOS                      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N80            ZZZ    VENIPUNCTURE/ANESTHESIOLOGY CODE DISALLOWED SAME DOS 90780     104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     N81            ZZZ    90780 DISALLOWED IN CONJUNCTION WITH PAID VENIPUNC/ANESTHESIA 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     P00            ZZZ    NEONATAL INTENSIVE CARE NOT PAID IN ADDITION TO RELATED PROC   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P01            ZZZ    PROCEDURE INCLUDED IN CODES 99295-99297 FOR SAME DOS           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           NEONATAL INTENSIVE CARE NOT PAID IN ADDITION TO RELATED
     P02            ZZZ    SERVICE                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P03            ZZZ    PROCEDURE INCLUDED IN CODES 99295-99297 FOR SAME DOS           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P14            ZZZ    PAID PANEL 77419 PREENTS PAY OF RELATED PROCEDURE SAME DOS     104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P15            ZZZ    RADIOLOGY PROCEDURE 77419 NOT ALLOWED SAME DOS AS 77420-77431 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     P16            ZZZ    ANESTHESIA NO PAY FOR HOSP VISIT W/01996 FOR SAME DOS          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P17            ZZZ    ANESTHESIA NO PAY FOR 01996 SAME DOS AS PAID HOSP VISIT        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P18            ZZZ    00857 OR 00955 NOT SAME DOS 62278 OR 62279                     104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P19            ZZZ    62278 OR 62279 NOT SAME DOS AS 00857 OR 00955                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P20            ZZZ    GMIS/INCIDENTAL PROCEDURE, SHOULD NOT BE REIMBURSED            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P21            ZZZ    GMIS/PROCEDURE REBUNDLED TO A GLOBAL COM CODE                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P22            ZZZ    GMIS/MED VISITS ARE CONTENT OF SRV ON SAME DOS                 104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P23            ZZZ    GMIS/GMIS/MUTUALLY EXCLUS CODE NOT CO-EXIST SAME DOS           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P24            ZZZ    OUTPATIENT ER AND NON-ER SERVICES INCLUDE ASSESSMENT           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P25            ZZZ    OUTPATIENT ER AND NON-ER SERVICES INCLUDE ASSESSMENT           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     P26            ZZZ    GMIS/PAID RELATED PROC PREVENTS PAYMENT OF THIS CODE           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P27            ZZZ    FLU VACCINE LIMITED TO ONE PER STATE FISCAL YEAR               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P29            ZZZ    LIMIT Z2734/Z2735 RO $1000 PER DATE OF SERVICE                 483      FOR BENEFIT PERIOD.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P30            ZZZ    APD ENVIRONMENT ADAPTATION LIMITED TO $7500 PER LIFETIME       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P31            ZZZ    PNEUMONIA VACCINE LIMITED TO ONE EVERY TEN YEARS               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P36            AR1    ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH SERVICE    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P37            ZZZ    ONE AEROCHAMBER DEVICE PER 365 DAYS FOR RECIPIENTS UNDER 21    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P38            ZZZ    ONE THIN PAP SMEAR ALLOWED PER SFY                             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     P39            ZZZ    INSERTS LIMITED TO THREE PAIR PER SHOE PER SFY (6 INSERTS)     483      FOR BENEFIT PERIOD.
     Q00            ZZZ    HOSPICE INPATIENT RESPITE CARE 5 CONSECUTIVE DAYS              456      COVERED DAY(S).
     Q01            ZZZ    HOSPICE CONT'D HOME CARE NO PAY FOR UNITS <8 DOS               456      COVERED DAY(S).
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO MULT
     Q12            DDS    PROV SAME DOS                                                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO MULT
     Q12            ZZZ    PROV SAME DOS                                                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO MULT
     Q13            DDS    PROV SAME DOS                                                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO MULT
     Q13            ZZZ    PROV SAME DOS                                                  104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS ON SAME
     Q14            DDS    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS ON SAME
     Q14            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS ON SAME
     Q15            DDS    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS ON SAME
     Q15            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q17            ZZZ    ONE PAIR EYE GLASSES EVERY 24 MONTHS FOR REC 21 AND OLDER      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q18            ZZZ    ONE EYE EXAM EVERY 24 MONTHS FOR RECIPIENTS 21 AND OLDER       483      FOR BENEFIT PERIOD.
                           POWER WHEELCHAIR ACCESSORIES, BATTERY/CHARGER, LIMITED TO               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q19            ZZZ    TWO PER SFY                                                    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q20            ZZZ    PERSONAL CARE SERV LTD TO 256 UNITS W/O EXT OF BENEFITS PA     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q24            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q25            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                      483      FOR BENEFIT PERIOD.




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                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q26            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                     483      FOR BENEFIT PERIOD.

     Q27            ZZZ    SERVICES NOT PAYABLE TO POST-STERILIZED RECIPIENT             104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     Q28            ZZZ    SERVICES NOT PAYABLE TO POST-STERILIZED RECIPIENT             104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OFFICE/OP VISITS W/TOS R PT26 NON-PAYABLE W/PSYCHOTHERAPY
     Q29            ZZZ    CODES                                                         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           PSYCHOTHERAPY CODE NONPAYABLE WITH OFFICE/OUTPAT/HOSPITAL
     Q30            ZZZ    VISITS                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q31            ZZZ    ONLY ONE PSYCHOTHERAPY VISIT ALLOWED PER DAY                  483      FOR BENEFIT PERIOD.
     Q32            ZZZ    ONE DISP FEE PER MONTH PER LTC RECIPIENT                      216      DRUG INFORMATION.
                           31 UNITS ASSISTED LIVING PHARMACIST CONSULTANT SERVICES                MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q35            ZZZ    ALLOWED PER MO                                                483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q36            ZZZ    ONLY ONE CONSULT/OFFICE VISIT PER DOS PER PERFORMING PROVIDER 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     Q37            ZZZ    31 UNITS ASSISTED LIVING WAIVER SERVICES ALLOWED PER MONTH    483      FOR BENEFIT PERIOD.
                           X-RAYS LIMITED TO $52.00 PER 5 YEARS WITHOUT PRIOR                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R05            ZZZ    AUTHORIZATION                                                 483      FOR BENEFIT PERIOD.
                           FILLING NOT ALLOWED ON TOOTH NUMBERS WITH CROWNS WITHIN ONE
     R06            ZZZ    YEAR                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R08            ZZZ    PERIODIC FAMILY PLANNING VISITS LIMITED TO 3 PER SFY          483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R09            ZZZ    PERIODIC FAMILY PLANNING VISITS LIMITED TO 3 PER SFY          483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R10            ZZZ    ONLY ONE FAMILY PLANNING VISIT/SERVICE ALLOWED PER DOS        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R11            ZZZ    ONLY ONE FAMILY PLANNING VISIT/SERVICE ALLOWED PER DOS        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R12            ZZZ    ONE ANNUAL FAMILY PLANNING VISIT PER SFY                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R13            ZZZ    ONE ANNUAL FAMILY PLANNING VISIT PER SFY                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R14            ZZZ    NORPLANT REMOVAL PAYABLE ONCE PER 5 YEAR PERIOD               483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R15            ZZZ    NORPLANT REMOVAL PAYABLE ONCE PER 5 YEAR PERIOD               483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R18            ZZZ    NORPLANT INSERTION PAYABLE TWICE PER 5 YEAR PERIOD            483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R19            ZZZ    NORPLANT INSERTION PAYABLE TWICE PER 5 YEAR PERIOD            483      FOR BENEFIT PERIOD.




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                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                           OFFICE/OP VISIT NOT PAYABLE SAME DOS AS COCHLEAR IMPLANT
     R20            ZZZ    ANL/RPR                                                       104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           COCHLEAR IMPLANT ANAL/REPROG NOT PAYABLE SAME DOS/PROV AS
     R21            ZZZ    OFF/OP                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
     R23            ZZZ    PRODUR EARLY REFILL                                           216      DRUG INFORMATION.
                                                                                                  CANNOT PROVIDE FURTHUR STATUS
     R24            ZZZ    MULTIPLE PARTIALS ON SAME PRESCRIPTION NUMBER NOT ALLOWED     0        ELECTRONICALLY.
                           COMPLETION REQUEST SHOULD HAVE ONLY ONE RELATED PARTIAL IN             CANNOT PROVIDE FURTHUR STATUS
     R25            ZZZ    HISTORY                                                       0        ELECTRONICALLY.
                           COMPLETION DOS SHOULD BE DIFFERENT FROM THE RELATED PARTIAL            CANNOT PROVIDE FURTHUR STATUS
     R26            ZZZ    IN HISTORY                                                    0        ELECTRONICALLY.
                           INCOMING DOS ON COMPLETION MUST BE LESS THAN 31 DAYS AFTER             CANNOT PROVIDE FURTHUR STATUS
     R27            ZZZ    THE PARTIAL DATE OF SERVICE                                   0        ELECTRONICALLY.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R28            ZZZ    HOMEMAKER SERVICES LIMITED TO 172 UNITS PER MONTH             483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R29            ZZZ    ADULT DAY CARE LIMITED TO 736 UNITS PER MONTH                 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R30            ZZZ    ADULT DAY CARE LIMITED TO 736 UNITS PER MONTH                 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     R31            ZZZ    IN HOME RESPITE CARE LIMITED TO 2400 UNITS PER SFY            483      FOR BENEFIT PERIOD.

     S00            ZZZ    IN-HOME RESPITE NOT ALLOWED WITH PAID ELDERCHOICES            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     S01            ZZZ    ELDERCHOICE DISALLOWED WITH IN-HOME RESPITE CARE              104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     S02            ZZZ    PERS INSTALL NOT REQUIRED FOR CONNECTED PERS UNIT             104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     T02            ZZZ    BITEWING NOT ALLOWED WITHIN 30 DAYS FULL/PANO X-RAY           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     T03            ZZZ    FULL/PANO X-RAY NOT ALLOWED WITHIN 30 DAYS PAY OF BITEWING    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     U00            ZZZ    STANDARD WHEELCHAIR NO-PAY SAME DOS AS SPECIALIZED WHEELCHAIR 104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     U01            ZZZ    SPECIALIZED WHEELCHAIR NO-PAY SAME DOS AS STANDARD WHEELCHAIR 104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     U02            ZZZ    STANDARD WHEELCHAIR NOPAY N 2 YRS OF SPECIALIZED WHEELCHAIR   104      PROCESSED ACCORDING TO PLAN PROVISIONS.
     400            ZZZ    SERVICE NOT PAYABLE TO STERILIZED RECIPIENT                   109      ENTITY NOT ELIGIBLE.
                           INTER/PERIODIC SCREEN NON-PAY 7 DAYS BEF/AFT FULL MEDICAL
     402            ZZZ    SCREEN                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     403            ZZZ    DUP EPSDT SCREENS NON-PAY 7 DAYS BEFORE/AFTER DATE OF SERVICE 104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                  ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     404            ZZZ    PERSONAL CARE AIDE IN PUBLIC SCHOOL LTD TO 3 HOURS PER DAY     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     405            ZZZ    ATTENDANT CARE SERVICES LIMITED TO 2 HOURS PER DAY             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     406            ZZZ    PERSONAL CARE SERVICES LIMITED TO 64 HOURS PER MONTH           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     407            AR1    ARKIDS 1ST PARTICIPANT EXCEEDS $500 LIMIT FOR DME              483      FOR BENEFIT PERIOD.
                           MED SUPPLY LTD TO $125/CALENDAR MONTH FOR ARKIDS 1ST                    MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     408            AR1    PARTICIPANT                                                    483      FOR BENEFIT PERIOD.
                           PRIOR APPROVAL REQUIRED FOR ARKIDS 1ST PARTICIPANT EXCEED               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     409            AR1    $500                                                           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     409            ZZZ    REHAB HOSP SVCS REQ PA IF NET BENE LIMIT OVER $                483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     428            ZZZ    PERSONAL CARE SERVICES WITH NET UNITS OVER 64 REQUIRE PA       483      FOR BENEFIT PERIOD.
                           ONLY ONE HEALTH SCREEN ALLOWED FOR AGES 18 YRS 1 DAY TO 19              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     429            AR1    YRS                                                            483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     433            ZZZ    ADULT WHEELCHAIR LIMITED TO ONE PER FIVE YEARS                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     436            ZZZ    DME SERVICES LIMITED TO $1000.00 PER SFY WITHOUT PA            483      FOR BENEFIT PERIOD.
     441            ZZZ    ANTI-ULCER ACUTE DOSAGE REQUIRES PA                            252      AUTHORIZATION/CERTIFICATION NUMBER.
     447            ZZZ    CLAIM DOS OVERLAPS SPENDDOWN BEGIN DATE                        187      DATE(S) OF SERVICE.

     449            ZZZ    DAIGNOSIS NO TON INSTITUTIONAL CRITERIA FILE FOR PAS DAYS      255      DIAGNOSIS CODE.
     450            ZZZ    PAS DAYS ON INST CRIT FILE ARE ZERO                            456      COVERED DAY(S).
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     451            ZZZ    MAX PAID INPATIENT HOSP DAYS PER PRIOR SFY FOR AGES 21-99      483      FOR BENEFIT PERIOD.
     452            ZZZ    EXCESS OF 14 CONSECUTIVE HOME LEAVE DAYS                       457      NON-COVERED DAY(S).
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     453            ZZZ    MAX PAID INPAT HOSP DAYS 21-99 /SFY WHICH PRECEDES PRIOR SFY   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     457            ZZZ    DRUG PAYMENT EXCEEDS 4 PRESCRIPTIONS PER MONTH                 483      FOR BENEFIT PERIOD.
                           MAX TRANSPLANT REIMBURSE AMT EXCEED - TAKE WORKSHEET TO                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     459            ZZZ    SYSTEMS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     460            ZZZ    MAX PAID INPATIENT HOSP DAYS PER CURRENT SFY FOR AGES 21-99    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     462            ZZZ    SEALANT ONCE IN A LIFETIME FOR TOOTH                           483      FOR BENEFIT PERIOD.
     463            ZZZ    TANDEM/PRESCRIPTION IS ALL USED UP, NEW REQUIRED               219      PRESCRIPTION NUMBER.

     464            ZZZ    PAS ALLOWED DAYS USED, 96 HOURS READMISSION EXCEEDED           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.




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                                                                 ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     466            ZZZ    INGUINOFERMORAL LYMPHADENECTOMY ALLOWED TWICE IN A LIFETIME    483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     467            ZZZ    DEDUCTIBLE LIMITED T OONCE PER 60 DAY BENEFIT PERIOD           483      FOR BENEFIT PERIOD.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     468            ZZZ    DUPE ICN OF CLAIM ON HISTORY/PROF AND INSTITUTION              54       CLAIM/LINE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     469            ZZZ    TWO CHIROPREACTIC X-RAYS PER STATE FISCAL YEAR                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     470            ZZZ    DENTAL ORAL EXAM LIMITED TO ONE PER STATE FISCAL YEAR          483      FOR BENEFIT PERIOD.
                           PREVENTATIVE DENTAL SCREEN LIMITED TO ONE PER STATE FISCAL              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     472            AR1    YEAR                                                           483      FOR BENEFIT PERIOD.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     473            ZZZ    SUSPECT DUPE * OVERLAPPING DOS, RID                            54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     474            ZZZ    DUPE NUTRITIONAL FORMULA PROC NOT ALLED ON SAME/OVERLAP DOS    54       CLAIM/LINE.
                                                                                                   CANNOT PROVIDE FURTHUR STATUS
     477            ZZZ    NO LONGER IN USE                                               0        ELECTRONICALLY.
                           SUSPECT DUPE, DENTAL * PROCEDURE CODE, TOS, DOS, TOOTH                  DUPLICATE OF A PREVIOUSLY PROCESSED
     478            ZZZ    SURFACE                                                        54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     479            ZZZ    SUSPECT DUPE, PROFESSIONAL * PROCEDURE CODE, TOS, OVERLAP DOS 54        CLAIM/LINE.
                           LESS SEVERE DUPE, PHYSICIAN * PROVIDER, PROC, TOS, OVERLAP              DUPLICATE OF A PREVIOUSLY PROCESSED
     480            ZZZ    DOS                                                            54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     481            ZZZ    LESS SEVERE DUPE, PHARMACY * PROVIDER, NDC, DOS, RID           54       CLAIM/LINE.
                           LESS SEVERE DUPE, INSTITUTIONAL * PROVIDER, OVERLAPPING DOS,            DUPLICATE OF A PREVIOUSLY PROCESSED
     482            ZZZ    RID                                                            54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     483            ZZZ    LESS SEVERE DUPE, INSTITUTIONAL * PROVIDER, EXACT DOS, RID     54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     484            ZZZ    LESS SEVERE DUPE * PROCEDURE, OVERLAPPING DOS, TOS, RID        54       CLAIM/LINE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     485            ZZZ    NO MORE THAN 1 INPATIENT HOSPITAL VISIT PER DAY PER PROVIDER   483      FOR BENEFIT PERIOD.
                                                                                                   CANNOT PROVIDE FURTHUR STATUS
     486            ZZZ    NO LONGER IN USE                                               0        ELECTRONICALLY.
                           LESS SEVERE DUPE, PHYSICIAN * PROV, 1ST 3 DGT OF PROC, TOS,             DUPLICATE OF A PREVIOUSLY PROCESSED
     487            ZZZ    O/DOS                                                          54       CLAIM/LINE.
                           LESS SEVERE DUPE, DENTAL * PROV, PROC, TOS, O/DOS, TOOTH                DUPLICATE OF A PREVIOUSLY PROCESSED
     488            ZZZ    SURFACE                                                        54       CLAIM/LINE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     490            ZZZ    MAX 35 INPATIENT REHAB HOSPITAL DAYS PER STATE FISCAL YEAR     483      FOR BENEFIT PERIOD.
                           EXACT DUPE OF DRUG CLAIM * NDC, BILLED AMT, DOS, PROV, TOS,             DUPLICATE OF A PREVIOUSLY PROCESSED
     491            ZZZ    RID                                                            54       CLAIM/LINE.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                           EXACT DUPE, INSTITUTIONAL * PROV, BILLED AMT, DOS, PROC,                DUPLICATE OF A PREVIOUSLY PROCESSED
     492            ZZZ    TOS, RID                                                       54       CLAIM/LINE.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     493            ZZZ    TANDEM/DUPLICATE RX CODE FOR SAME DATE OF SERVICE              54       CLAIM/LINE.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     495            ZZZ    BITEWINGS LIMITED TO ONE PER STATE FISCAL YEAR                 483      FOR BENEFIT PERIOD.
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     496            ZZZ    EXACT DUPE, CROSSOVER * RID, PROV, DOS, BILLED AMOUNT          54       CLAIM/LINE.
                           EXACT DUPE, PHYSICIAN * PROV, 1ST 3 DGT PROC,TOS, O/DOS,                DUPLICATE OF A PREVIOUSLY PROCESSED
     497            ZZZ    BILL AMT                                                       54       CLAIM/LINE.
                           EXACT DUPE, DENTAL * PROV, PROC, TOS, DOS, BILL AMT, TTH # &            DUPLICATE OF A PREVIOUSLY PROCESSED
     498            ZZZ    SURF                                                           54       CLAIM/LINE.
                           EXACT DUPE, PROFESSIONAL * PROV, PROC, TOS, DOS, BILLED                 DUPLICATE OF A PREVIOUSLY PROCESSED
     499            ZZZ    AMOUNT                                                         54       CLAIM/LINE.
     500            ZZZ    EXCESS OF 5 CONSECUTIVE HOSPITAL LEAVE DAYS                    457      NON-COVERED DAY(S).
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     506            ZZZ    LIMIT FACILITY RESPITE CARE TO 600 UNITS PER SFY               483      FOR BENEFIT PERIOD.

     507            ZZZ    Z1700/MEALS NP RECIP RCVG 5 MORE HRS ADLT DAY CARE SAME DOS    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           Z1700/MEALS NP RECIP RCVG 5 MORE HRS ADLT DAY HLTH CARE SAME
     508            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     510            ZZZ    Z1709-CHORE SERVICES LIMITED TO 20 UNITS PER MONTH             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     512            ZZZ    Z1689-HOMEMAKER SERVICES LIMITED TO 43 UNITS PER MONTH         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     513            ZZZ    ADULT DAYCARE LIMITED TO 184 UNITS PER MONTH                   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     514            ZZZ    Z1710-PERS INSTALLATION LIMITED TO 1 PER SFY                   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     515            ZZZ    LIMIT Z1701-PERS TO 31 UNITS PER MONTH                         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     516            ZZZ    LIMIT Z1688-ADULT FOSTER CARE TO 31 UNITS PER MONTH            483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     517            ZZZ    ONLY 12 NURSE PRACTITIONER VISITS PER SFY                      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     518            ZZZ    CRISIS MANAGEMENT VISIT LIMITED TO 48 1/4 HR UNITS/SFY         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     519            ZZZ    FAMILY THERAPY/MARITAL LIMITED TO SIX UNITS/WEEK               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     520            ZZZ    INDIVIDUAL OUTPT-COLLATERAL SVCS LIMITED TO 12 UNITS/90 DAYS   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     522            ZZZ    PRE-SCHOOL SERVICES LIMITED TO 155 UNITS PER MONTH             483      FOR BENEFIT PERIOD.




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                                                                   ESC TO 277



                                                                                            277
                   PLAN                                                                     CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                           STATUS   CLAIM STATUS CODE
                           EARLY INTERVENTION AND PRE-SCHOOLI SERVICES LIMITED TO 1                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     531            ZZZ    UNIT/DOS                                                         483      FOR BENEFIT PERIOD.
                           ADD. THERAPEUTIC DAY TREATMENT LIMITED TO 32 UNTS/DOS/ATT                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     537            ZZZ    PROV                                                             483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     541            ZZZ    CRISIS MANAGEMENT LIMITED TO 4 UNITS PER DOS PER ATT     PROV    483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     547            ZZZ    OCCUPATIONAL INDIVIDUAL THERAPY LIMITED TO 3 UNITS/DOS           483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     548            ZZZ    INDIVIDUAL OUTPT-MED. ADMIN. LIMITED TO 2 UNITS/DOS/ATT     PROV 483      FOR BENEFIT PERIOD.
                           DIAGNOSIS AND EVALUATION SERVICES LIMITED TO 1 PER 12 MONTH               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     553            ZZZ    PER                                                              483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     554            ZZZ    INDIVIDUAL OUTPT - THERAPY SESSION LIMITED TO 4 UNITS/WEEK       483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     555            ZZZ    PROCEDURE CODE Z1555 LIMITED TO 720 UNITS/12 MONTH PERIOD        483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     563            ZZZ    ANY COMBINATION OF WAIVER SERVICES LIMITED TO 720 UNITS/MONTH 483         FOR BENEFIT PERIOD.

     576            ZZZ    MEALS DISALLOWED SAME DOS AS ADC OR ADHC                         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     583            ZZZ    ONE PSYCHOTHERAPY PROCEDURE/DOS/RECIP                            483      FOR BENEFIT PERIOD.

                                                                                                     MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     584            ZZZ    MANUAL REV OF MULT SURGERIES DONE SAME DAY - EX SUBSEQ SURG      421      SERVICE(S).

                                                                                                     MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     585            ZZZ    MANUAL REV OF MULT SURGERIES DONE SAME DAY - EX SUBSEQ SURG      421      SERVICE(S).
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     586            ZZZ    ADULT SERVICES EXCEED 155 UNITS PER MONTH                        483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     587            ZZZ    THERAPEUTIC DAY TREATMENT, 224-1/4 HOUR UNIT/WEEK                483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     588            ZZZ    Z1685-APNEA MONITOR WITH SET-UP LIMITED TO ONCE IN A LIFETIME 483         FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     590            ZZZ    E0608-APNEA MONITOR-1 UNIT PER DATE OF SERVICE                   483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     592            ZZZ    CS. MGMT. SERVICE PLANNING LIMITED TO 6 UNITS/SFY                483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     593            ZZZ    CS. MGMT. SERVICE COORDINATION LIMITIED TO 60 UNITS/SFY          483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     594            ZZZ    CS. MGMT. ASSESSMENT SERVICE LIMITED TO 8 UNITS/SFY              483      FOR BENEFIT PERIOD.
                                                                                                     MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     595            ZZZ    CS. MGMT. SERVICE MONITORING LIMITED TO 60 UNITS/SFY             483      FOR BENEFIT PERIOD.




6/16/2011                                                           Page 243
                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     596            ZZZ    CS. MGMT. SERVICE PLAN UPDATING LIMITED TO 16 UNITS/SFY        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     598            ZZZ    ADULT DAY HEALTH CARE LIMITED TO 184 UNITS PER MONTH           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     599            AR1    NEWBORN CARE ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     599            ZZZ    NEWBORN CARE ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     600            ZZZ    EXTRACTIONS MAY BE PERFORMED ONCE IN A LIFETIME                483      FOR BENEFIT PERIOD.
                           ONLY 6 PREVENTATIVE HEALTH SCREENS AGES BIRTH THROUGH 12                MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     601            AR1    MONTHS                                                         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     601            ZZZ    ONLY 6 EPSDT MED SCREENS FROM BIRTH TO 12 MONTHS               483      FOR BENEFIT PERIOD.
                           ONLY 3 PREV HEALTH SCREENS FOR PARTICIPANTS 12 MO 1 DAY TO 2            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     602            AR1    YEARS                                                          483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     602            ZZZ    ONLY 3 EPSDT MEDIC SCRNS FOR AGES 12 MOS 1 DAY-2YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 2 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     603            AR1    3 YEARS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     603            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 2 YRS 1 DAY-3 YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 3 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     604            AR1    4 YEARS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     604            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 3 YRS 1 DAY-4 YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 4 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     606            AR1    5 YEARS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     606            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 4 YRS 1 DAY-5 YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 5 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     607            AR1    6 YEARS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     607            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 5 YRS 1 DAY-6 YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 6 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     608            AR1    8 YEARS                                                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     608            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 6 YRS 1 DAY-8 YR             483      FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 8 YEARS 1 DAY TO            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     609            AR1    10 YEARS                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     609            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 8 YRS 1 DAY-10 YR            483      FOR BENEFIT PERIOD.
                           MAXIMUM OF 12 CHIROPRACTIC VISITS ALLOWED PER STATE FISCAL              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     610            ZZZ    YEAR                                                           483      FOR BENEFIT PERIOD.




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                                                                   ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                           1ST EXTRACTION 07110 EA ADD EXTRACTION 07120, 3 XTRACTIONS             ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE
     630            ZZZ    USE PA                                                        15       CODES HAVE BEEN MODIFIED.
                           HEARING AID - ONLY TWO APPLIANCES ALLOWED PER SIX MONTH                MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     643            ZZZ    PERIOD                                                        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     646            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER     483      FOR BENEFIT PERIOD.

                                                                                                  MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     649            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES                           421      SERVICE(S).

                                                                                                  MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     650            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES                           421      SERVICE(S).
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     653            ZZZ    DME * ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS            483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     654            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS                            483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     655            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS                            483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     658            ZZZ    ONE NEW PATIENT VISIT PER 3 YEARS SAME ATTENDING PROVIDER     483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     659            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                         483      FOR BENEFIT PERIOD.
                           FAIL IF 2 ADMITS BILLED ON SAME DAY (SAME OR DIFF ATTENDING
     660            ZZZ    PROV)                                                         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     662            ZZZ    ONLY ONE DELIVERY IN A NINE MONTH PERIOD                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     663            ZZZ    ONLY ONE DELIVERY IN A NINE MONTH PERIOD                      483      FOR BENEFIT PERIOD.

                                                                                                  MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     664            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES DONE SAME DAY             421      SERVICE(S).

                                                                                                  MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     665            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES DONE SAME DAY             421      SERVICE(S).
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     667            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                         483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     668            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                         483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     671            ZZZ    LAPAROSCOPY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     674            ZZZ    VASECTOMY ALLOWED ONCE IN A LIFETIME                          483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     675            ZZZ    HYSTERECTOMY/BLADDER REPAIR ALLOWED ONCE IN A LIFETIME        483      FOR BENEFIT PERIOD.




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                                                                  ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     676            ZZZ    OOPHORECTOMY ALLOWED TWICE IN A LIFETIME                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     677            ZZZ    REMOVAL OF EAR ALLOWED TWICE IN A LIFETIME                    483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     678            ZZZ    EXCISION SUBMAXILLARY GLAND ALLOWED ONCE IN A LIFETIME        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     679            ZZZ    EXCISION SUBLINGUAL GLAND ALLOWED ONCE IN A LIFETIME          483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     680            ZZZ    PROCEDURE MAY BE PERFORMED ONCE IN A LIFETIME                 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     681            ZZZ    REMOVAL OF TEAR GLAND ALLOWED TWICE IN A LIFETIME             483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     683            ZZZ    VAGINECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     684            ZZZ    ESOPHAGECTOMY ALLOWED ONCE IN A LIFETIME                      483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     685            ZZZ    RESECTION OF PHARYNGEAL WALL ALLOWED ONCE IN A LIFETIME       483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     686            ZZZ    COCCYGECTOMY; PRIMARY SUTURE ALLOWED ONCE IN A LIFETIME       483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     688            ZZZ    REMOVAL OF NOSE ALLOWED ONCE IN A LIFETIME                    483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     689            ZZZ    REMOVAL OF LARYNX ALLOWED ONCE IN A LIFETIME                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     691            ZZZ    REMOVAL OF EPIGLOTTIS ALLOWED ONCE IN A LIFETIME              483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     692            ZZZ    REMOVAL OF SPLEEN ALLOWED ONCE IN A LIFETIME                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     693            ZZZ    REMOVAL OF SUPRAHYOID LYMPH NODES ALLOWED TWICE IN A LIFETIME 483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     694            ZZZ    REMOVAL OF CERVICAL LYMPH NODES ALLOWED TWICE IN A LIFETIME   483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     697            ZZZ    EXCISE LIP OR CHEEK FOLD ALLOWED ONCE IN A LIFETIME           483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     698            ZZZ    GLOSSECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     699            ZZZ    EXCISION OF UVULA ALLOWED ONCE IN A LIFETIME                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     701            ZZZ    REMOVAL OF TONSILS/ADENOIDS ALLOWED ONCE IN A LIFETIME        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     702            ZZZ    GASTRECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     703            ZZZ    COLECTOMY ALLOWED ONCE IN A LIFETIME                          483      FOR BENEFIT PERIOD.




6/16/2011                                                           Page 246
                                                                   ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     704            ZZZ    APPENDECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     705            ZZZ    PROCTECTOMY ALLOWED ONCE IN A LIFETIME                         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     707            ZZZ    CHOLECYSTECTOMY ALLOWED ONCE IN A LIFETIME                     483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     708            ZZZ    PANCREATECTOMY ALLOWED ONCE IN A LIFETIME                      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     709            ZZZ    UMBILLECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     712            ZZZ    REMOVAL OF PELVIC STRUCTURES ALLOWED ONCE IN A LIFETIME        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     713            ZZZ    URETHRECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     714            ZZZ    AMPUTATION OF PENIS ALLOWED ONCE IN A LIFETIME                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     719            ZZZ    PROSTATECTOMY ALLOWED ONCE IN A LIFETIME                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     720            ZZZ    VULVECTOMY ALLOWED ONCE IN A LIFETIME                          483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     722            ZZZ    TRACHELECTOMY ALLOWED ONCE IN A LIFETIME                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     723            ZZZ    HYSTERECTOMY ALLOWED ONCE IN A LIFETIME                        483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     726            ZZZ    THYROIDECTOMY ALLOWED ONCE IN A LIFETIME                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     727            ZZZ    THYMECTOMY ALLOWED ONCE IN A LIFETIME                          483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     731            ZZZ    CRISIS MANAGEMENT SERVICE LIMITED TO 48-1/4 HOUR UNIT PER SFY 483       FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     732            ZZZ    MAXIMUM OF TWO CONSULTATIONS PER STATE FISCAL YEAR             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     733            ZZZ    ONLY ONE CONSULTATION PER STATE FISCAL YEAR SAME PROVIDER      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     736            ZZZ    PERODIC FAMILY PLANNING VISIT - 3 PER STATE FISCAL YEAR        483      FOR BENEFIT PERIOD.
                           DENTURE ADJ/REALIGN NOT COVERED WITHIN 6 MTH OF APPLIANCE
     740            ZZZ    PLACEMT                                                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           FAIL IF OVER 1 OCCURANCE IN 2 YRS SAME ATTENDING PROV TOOTH
     741            ZZZ    NUM                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     742            ZZZ    FAIL IF SUBJECT PROC BILLED SAME DAY-TOOTH-ATTENDING PROVIDER 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     743            ZZZ    FAIL IF SUBJECT PROCEDURE BILLED SAME DAY-ATTENDING PROVIDER   104      PROCESSED ACCORDING TO PLAN PROVISIONS.




6/16/2011                                                           Page 247
                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE

     744            ZZZ    FAIL IF SUBJECT PROC BILLED ANY DOS-SAME-TOOTH-PROV-RECIPIENT 104       PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     746            ZZZ    ONLY ONE PRE-NATAL LAB COVERED IN NINE MONTH SPAN              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     748            AR1    ONLY ONE EYE EXAM PER 12 MONTHS UNDER 18 YEARS OLD             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     748            ZZZ    ONLY ONE EXAM PER 12 MONTHS UNDER 21 YEARS OLD                 483      FOR BENEFIT PERIOD.
                           ONLY ONE PAIR OF GLASSES PER 12 MO FOR PARTICIPANTS UNDER 18            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     749            AR1    YR OLD                                                         483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     749            ZZZ    ONE PAIR OF GLASSES PER 12 MONTHS/UNDER 21 YEARS               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     750            ZZZ    ONLY ONE ANNUAL FAMILY PLANNING VISIT PER STATE FISCAL YEAR    483      FOR BENEFIT PERIOD.

     751            ZZZ    COMPONENT TESTS INCLUDED IN COMPLETE BLOOD COUNT               104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     752            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     753            ZZZ    MENTAL HEALTH - ONLY ONE SERVICE ALLOWED PER DOS               483      FOR BENEFIT PERIOD.

     754            ZZZ    OP NON-ER ROOM CHARGE NOT ALLOWED W/TREATMENT/THERAPY CODES    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     756            ZZZ    CHROME CROWN WITH BASE INCLUDES PULPOTOMY/PULP CAP             104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     759            ZZZ    MENTAL HEALTH * ONLY ONE SERVICE ALLOWED PER DOS               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     760            ZZZ    ONLY 1 OFFICE VISIT ALLOWED PER DOS/ATTEND PROV                483      FOR BENEFIT PERIOD.
                           ONLY 1 HOSPITAL SERVICE VISIT ALLOWED PER DOS ATTENDING                 MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     761            ZZZ    PROVIDER                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     762            ZZZ    1 CARE FACILITY VISIT ALLOWED PER DOS/ATTEND PROV              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     763            ZZZ    DME * ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     764            ZZZ    ONLY ONE FAMILY PLANNING VISIT ALLOWED PER DOS                 483      FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE CODE ALLOWED PER DOS PER ATTENDING                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     765            ZZZ    PROVIDER                                                       483      FOR BENEFIT PERIOD.

     766            ZZZ    FAIL IF ADJ/REALIGN BILLED WITHIN SIX MONTHS OF PLACEMENT      104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ONLY ONE PROCEDURE CODE ALLOWED PER DOS PER ATTENDING                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     767            ZZZ    PROVIDER                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     768            ZZZ    ONLY ONE EVALUATION PROCEDURE ALLOWED PER DOS PER ATTEND PROV 483       FOR BENEFIT PERIOD.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     769            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.
                           ONLY ONE PURE TONE AUDIOMETRY PROC ALLOWED/DOS PER ATTEND               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     770            ZZZ    PROV                                                           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     771            ZZZ    ONE HEARING TEST ALLOWED PER DOS PER ATTEND PROV               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     772            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.
                           ONLY ONE HEARING AID EXAM PROCEDURE ALLOWED/DOS PER ATTEND              MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     773            ZZZ    PROV                                                           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     774            ZZZ    ONLY 1 ELECTROACOUSTIC EVAL PROC ALLOWED/DOS PER ATTEND PROV   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     775            ZZZ    DDTCS-ONE PRESCHOOL VISIT/DOS PER ATTEND PROVIDER              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     777            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     778            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.

     779            ZZZ    IV INSERTION INCLUDED IN CHEMOTHERAPY ADMINISTRATION           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     780            ZZZ    IV INSERTION INCLUDED IN CHEMOTHERAPY ADMINISTRATION           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     781            ZZZ    ONLY ONE OFFICE VISIT ALLOWED PER DOS PER ATTENDING PROVIDER   483      FOR BENEFIT PERIOD.
                           ONLY ONE HOSPITAL VISIT ALLOWED PER DOS PER ATTENDING                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     782            ZZZ    PROVIDER                                                       483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     785            ZZZ    MENTAL HEALTH - ONLY ONE SERVICE ALLOWED PER DOS               483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     786            ZZZ    1 CARE FACILITY VISIT ALLOWED PER DOS/ATTEND PROV              483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     787            ZZZ    DME - ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS             483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     788            ZZZ    ONLY ONE FAMILY PLANNING VISIT SERVICE ALLOWED PER DOS         483      FOR BENEFIT PERIOD.

     789            ZZZ    FAIL IF ADJ/REALIGN BILLED WITHIN 6 MONTHS OF PLACEMENT        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     790            ZZZ    ONLY ONE EVALUATION PROCEDURE ALLOWED PER DOS PER ATTEND PROV 483       FOR BENEFIT PERIOD.

     791            ZZZ    OP NON-ER ROOM CHARGE NOT ALLOWED W/TREATMENT/THERAPY CODES    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     792            ZZZ    10 DAYS POST-OP CARE INCLUDE IN PAY FOR SURGICAL PROCEDURE     104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     793            ZZZ    10 DAYS POST-OP CARE INCLUDE IN PAY FOR SURGICAL PROCEDURE     104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     794            ZZZ    ONLY 1 HEARING TEST ALLOWED/DOS PER ATTEND PROV                483      FOR BENEFIT PERIOD.
                           ONLY ONE HEARING AID EXAM PROCEDURE ALLOWED PER DOS PER ATT             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     795            ZZZ    PROV                                                           483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     796            ZZZ    ONLY 1 ELECTROACOUSTIC EVAL PROC ALLOWED/DOS PER ATTEND PROV   483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     797            ZZZ    DDTCS - ONE PRESCHOOL VISIT/DOS PER ATTEND PROVIDER            483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     798            ZZZ    DDTCS-1 ADULT DEVELOPMENT VISIT ALLOWED/DOS PER ATTEND PROV    483      FOR BENEFIT PERIOD.
                           ONLY 1 PURE TONE AUDIOMETRY PROCEDURE ALLOWED/DOS PER ATT               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     799            ZZZ    PROV                                                           483      FOR BENEFIT PERIOD.

     800            ZZZ    SINGLE FILM NOT ALLOWED WITH FULL MOUTH SERIES                 104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     801            ZZZ    SINGLE FILM NOT ALLOWED WITH FULL MOUTH SERIES                 104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OP NON-PHYSICIAN SVCS NOT ALLOWED WITH TREATMENT/THERAPY
     802            ZZZ    CODES                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OP NON-PHYSICIAN SVCS NOT ALLOWED WITH TREATMENT/THERAPY
     803            ZZZ    CODES                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OFFICE VST AND VISUAL ANALYSIS NOT ALLWD SAME DOS SAME ATT
     804            ZZZ    PROV                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OFFICE VST AND VISUAL ANALYSIS NOT ALLWD SAME DOS SAME ATT
     805            ZZZ    PROV                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           GROUP OUTP/THERAPY SVCS N-PAY TO MENTAL HEALTH PROV ON SAME
     806            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     808            ZZZ    INDIV/COLLATERAL SVCS N-PAY TO MULTIPLE MH PROV ON SAME DOS    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     809            ZZZ    INDIV/COLLATERAL SVCS N-PAY TO MULTIPLE MH PROV ON SAME DOS    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           MARITAL/FAMILY THERAPY SVCS N-PAY TO MULTIPLE MH PROV SAME
     810            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     812            ZZZ    INDIV OUTP/THERAPY SESSION N-PAY TO MULT MH PROV ON SAME DOS   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     814            ZZZ    CRISIS MGMT SERV N-PAY TO MULTIPLE MH PROV ON SAME DOS         104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     816            ZZZ    INTERPRETATION OF DIAG SVC N-PAY TO MULTIPLE MH PROV SAME DOS 104       PROCESSED ACCORDING TO PLAN PROVISIONS.
                           DIAG/PSYCH TEST BATTERY SVC N-PAY PSYCH WHEN PAID RSPMI SAME
     818            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           DIAGN/PSYCH TEST SVC N-PAY TO PSYCH WHEN PAID TO RSPMI SAME
     820            ZZZ    DOS                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     822            ZZZ    DIAGNOSIS SVC N-PAY TO MULTIPLE MH PROVIDERS ON SAME DOS       104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     825            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     826            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING PROVIDER      483      FOR BENEFIT PERIOD.

     829            ZZZ    ROUTINE NEWBORN CARE INCLUDES ROUTINE HOSPITAL CARE            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     830            ZZZ    ROUTINE NEWBORN CARE INCLUDES ROUTINE HOSPITAL CARE            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     832            ZZZ    PAYMENT FOR PHYSICAL MEDICINE INCLUDES FEE FOR OFFICE VISIT    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     833            ZZZ    PAYMENT FOR PHYSICAL MEDICINE INCLUDES FEE FOR OFFICE VISIT    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           HOSP ADM NOT ALLOWED SAME DAY OFFICE,ER,NH,PSYCH,HOSP
     836            ZZZ    DISCHARGE                                                      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     837            ZZZ    COMPONENT TEST INCLUDED IN COMPLETE BLOOD COUNT                104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           OFFICE,ER,NH,PSYCH,HOSP DISCHARGE NOT ALLOWED SAME DAY HOSP
     838            ZZZ    ADM                                                            104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     839            ZZZ    PROC CODE Z1555 NOT ALLOWED SAME DOS AS PROC CODE Z1556        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     840            ZZZ    PROC CODE Z1556 NOT ALLOWED SAME DOS AS PROC CODE Z1555        104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     841            ZZZ    PROC CODE Z0481 NOT ALLOWED SAME DOS PROC CODE Z1564           104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     847            ZZZ    URINALYSIS INCLUDED IN PROCEDURE CODE-Z1635                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     848            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS                 483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     849            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS                 483      FOR BENEFIT PERIOD.

     851            ZZZ    OUTPA HOSPITAL DRUGS, INJEC AND SUPPLIES N-PAY IN N-EMER ROOM 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     852            ZZZ    OUTPA HOSPITAL DRUGS, INJEC AND SUPPLIES N-PAY IN N-EMER ROOM 104       PROCESSED ACCORDING TO PLAN PROVISIONS.
                           Z1688-ADULT FOSTER CARE INCLUSIVE OF ALL ELDER CHOICES WVER
     853            ZZZ    SVSC                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ELDER CHOICE SERVICE NOPAY SAME DOS AS Z1704 LT FACILITY RES
     854            ZZZ    CARE                                                           104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           RESPITE CARE SERVICE Z1704 NOT PAYABLE SAME DOS AS PD
     855            ZZZ    ELDERCHOICE                                                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ELDER CHOICE WAIVER SERVICE NOT PAYABLE IN CONJUNCTION WITH
     856            ZZZ    Z1688                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ELDER CHOICE WAIVER SERVICES NOT PAYABLE SAME DOS AS Z1687-
     857            ZZZ    PC/RCF                                                         104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     859            ZZZ    ONLY ONE ADC OR ADHC SERVICE ALLOWED PER DOS                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     860            ZZZ    ONLY ONE ADC OR ADHC SERVICE ALLOWED PER DOS                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     861            ZZZ    SCALING LIMITED TO ONE PER STATE FISCAL YEAR                  483      FOR BENEFIT PERIOD.

     862            ZZZ    E0608 BILLED PRIOR TO 30 DAYS OF Z1685                        104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     863            ZZZ    PROPHYS/FLOURIDE TREATMENT LIMITED TO ONE PER SFY             483      FOR BENEFIT PERIOD.

     864            ZZZ    ADC OR ADHC NOT PAYABLE SAME DOS AS PAID HOMEMAKER OR CHORE   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     865            ZZZ    HOMEMAKER OR CHORE NOT PAYABLE SAME DOS AS PAID ADC OR ADHC   104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           REVIEW PD CLM Z1703-ADHC WHEN OCCURRING ON SAME DOS AS Z0005-
     866            ZZZ    HHPT                                                          104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     867            ZZZ    SUSPEND Z1703-ADHC WHEN BILLED SAME DOS AS Z0005-HHPT         104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     869            ZZZ    PERIAPRICAL X-RAYS LIMITED TO FOUR PER VISIT                  483      FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     871            ZZZ    TANDEM/THERAPEUTIC CLASS DOSAGE MAX EXCEEDED FOR MONTH        483      FOR BENEFIT PERIOD.

     872            ZZZ    INCLUDED IN FLAT FEE FOR MAJOR PROCEDURE                      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     875            ZZZ    CAST INCLUDED IN FEE FOR SURGICAL PROCEDURE                   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     876            ZZZ    INCLUDED IN FLAT FEE FOR MAJOR PROCEDURE                      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     877            ZZZ    CAST INCLUDED IN FEE FOR SURGICAL PROCEDURE                   104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     878            ZZZ    PROCEDURE INCLUDED IN OFFICE VISIT IF BILLED ON SAME DOS      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     879            ZZZ    PROCEDURE INCLUDED IN OFFICE VISIT IF BILLED ON SAME DOS      104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     880            ZZZ    PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE SERVICE       104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     881            ZZZ    PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE SERVICE       104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     882            ZZZ    PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE SERVICE       104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     883            ZZZ    PROCEDURE INCLUDED IN GLOBAL OB CARE BY SAME PROVIDER         104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     884            ZZZ    PROCEDURE INCLUDED IN GLOBAL OB CARE BY SAME PROVIDER         104      PROCESSED ACCORDING TO PLAN PROVISIONS.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE

     885            ZZZ    PROCEDURE INCLUDED IN COMPREHENSIVE SERVICE                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     886            ZZZ    PROCEDURE INCLUDED IN COMPREHENSIVE SERVICE                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     887            ZZZ    PROCEDURE INCLUDED IN COMPREHENSIVE SERVICE                    104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     888            ZZZ    OFFICE VISIT INCLUDED WITH CAST REMOVAL OR REPAIR              104      PROCESSED ACCORDING TO PLAN PROVISIONS.

     889            ZZZ    OFFICE VISIT INCLUDED WITH CAST REMOVAL OR REPAIR              104      PROCESSED ACCORDING TO PLAN PROVISIONS.
                           ELDER CHOICE WAIVER SVC NOT PAYABLE SAME DOS AS Z1709-CHORE             MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     890            ZZZ    SVCS                                                           483      FOR BENEFIT PERIOD.
                           Z1709-CHORE SVCS NOT PAY SAME DOS AS OTHER ELDER CHOICE WVER            MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     891            ZZZ    SCS                                                            483      FOR BENEFIT PERIOD.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     892            ZZZ    12 PHYSICIAN VISITS PER STATE FISCAL YEAR                      483      FOR BENEFIT PERIOD.
                           PANORAMIC X-RAYS/INTRAORAL COMPLETE SERIES LTD TO ONE PER               MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     893            ZZZ    FIVE YR                                                        483      FOR BENEFIT PERIOD.

     896            ZZZ    OUTPATIENT SURGICAL PROCEDURE INCLUDES ALL RELATED PROCEDURES 104       PROCESSED ACCORDING TO PLAN PROVISIONS.

     897            ZZZ    OUTPATIENT SURGICAL PROCEDURE INCLUDES ALL RELATED PROCEDURES 104       PROCESSED ACCORDING TO PLAN PROVISIONS.
                                                                                                   CANNOT PROVIDE FURTHUR STATUS
     000     ZZ     ZZZ    DENY CODE PRESENT -- ESC MISSING                               0        ELECTRONICALLY.
     001     ZZ     ZZZ    SERVICE DATE - FROM INVALID                                    187      DATE(S) OF SERVICE.
     002     IP     ZZZ    ADMISSION DATE MISSING OR INVALID                              189      HOSPITAL ADMISSION DATE.
     002     IX     ZZZ    ADMISSION DATE MISSING OR INVALID                              189      HOSPITAL ADMISSION DATE.
     002     LT     ZZZ    ADMISSION DATE MISSING OR INVALID                              189      HOSPITAL ADMISSION DATE.
     003     ZZ     ZZZ    SERVICE DATE - TO INVALID                                      187      DATE(S) OF SERVICE.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     004     ZZ     ZZZ    INVALID MEDICARE PAID DATE                                     122      PROCESSING CLAIM.
     005     IP     ZZZ    DELIVERY/SURGERY DATE INVALID                                  187      DATE(S) OF SERVICE.

     006     IP     ZZZ    DISCHARGE DATE TO PATIENT STATUS OR INVALID DISCHARGE DATE     190      HOSPITAL DISCHARGE DATE.

     006     LT     ZZZ    DISCHARGE DATE TO PATIENT STATUS OR INVALID DISCHARGE DATE     190      HOSPITAL DISCHARGE DATE.
     007     IP     ZZZ    TOTAL DAYS STAY                                                456      COVERED DAY(S).
     007     LT     ZZZ    TOTAL DAYS STAY                                                456      COVERED DAY(S).

     008     IP     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     008     IX     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.




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                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE

     008     LT     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     008     NX     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     008     OX     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     008     PX     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     009     ZZ     ZZZ    MEDICAID PAID AMOUNT IN ERROR (NOTIFY SYSTEMS)                46       INTERNAL REVIEW/AUDIT.
                                                                                                  PRINCIPAL PROCEDURE CODE FOR SERVICE(S)
     010     OP     ZZZ    EMERGENCY SUPPLIES BILLED WITHOUT EMERGENCY ROOM BILLED       465      RENDERED.
     011     LT     ZZZ    NURSING HOME DAYS EDIT                                        456      COVERED DAY(S).
     012     ZZ     ZZZ    PATIENT LIABILITY FORMAT                                      21       MISSING OR INVALID INFORMATION.

     013     IP     ZZZ    INSUFFICIENT OR INVALID DATA FOR THE CONDITION CODE 'AB'      460      NUBC CONDITION CODE(S).
     014     LT     ZZZ    LOA CODE INVALID                                              21       MISSING OR INVALID INFORMATION.
                                                                                                  DIAGNOSIS CODE(S) FOR THE SERVICES
     015     OP     ZZZ    DIAGNOSIS INVALID FOR REVENUE CODE                            488      RENDERED.

     016     ZZ     ZZZ    MANUAL DENY.                                                  9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     017     IP     ZZZ    INVALID PATIENT STATUS - 30.                                  234      PATIENT DISCHARGE STATUS.
     018     ZZ     ZZZ    MEDICAID PAID AMOUNT EXCEEDS THRESHOLD AMOUNT                 46       INTERNAL REVIEW/AUDIT.
                                                                                                  DIAGNOSIS CODE(S) FOR THE SERVICES
     019     HC     FAM    DIAGNOSIS REQUIRES FAMILY PLANNING PROCEDURE CODE             488      RENDERED.
                                                                                                  DIAGNOSIS CODE(S) FOR THE SERVICES
     019     HC     ZZZ    DIAGNOSIS REQUIRES FAMILY PLANNING PROCEDURE CODE             488      RENDERED.
                                                                                                  DIAGNOSIS CODE(S) FOR THE SERVICES
     020     OP     FAM    DIAGNOSIS REQUIRES FAMILY PLANNING PROCEDURE CODE             488      RENDERED.
                                                                                                  DIAGNOSIS CODE(S) FOR THE SERVICES
     020     OP     ZZZ    DIAGNOSIS REQUIRES FAMILY PLANNING PROCEDURE CODE             488      RENDERED.

     021     DE     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     EP     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     HC     FAM    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     HC     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     IP     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     OP     FAM    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.




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                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE

     021     OP     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.

     021     VI     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING SERVICES 109      ENTITY NOT ELIGIBLE.
     022     EP     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     022     HC     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     022     IP     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     022     IX     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     022     LT     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     022     OP     ZZZ    COVERED DAYS FORMAT                                           456      COVERED DAY(S).
     023     ZZ     ZZZ    NON-COVERED DAYS FORMAT                                       457      NON-COVERED DAY(S).
     024     ZZ     ZZZ    DETAIL BILLED/AMOUNT FORMAT                                   247      LINE INFORMATION.
     025     ZZ     ZZZ    MANUAL PRICE GREATER THAN DETAIL BILLED.                      110      CLAIM REQUIRES PRICING INFORMATION.
     026     ZZ     ZZZ    AUDIT OVERRIDE CODE FORMAT                                    247      LINE INFORMATION.
                                                                                                  PROCEDURE CODE MODIFIER(S) FOR SERVICE(S)
     027     ZZ     ZZZ    MODIFIER INVALID FOR TYPE OF SERVICE                          453      RENDERED.
     028     DE     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
     028     EP     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
     028     HC     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
     028     OP     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
     028     PH     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
     028     VI     ZZZ    INVALID PRICING ACTION CODE                                   21       MISSING OR INVALID INFORMATION.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     029     IP     ZZZ    INVALID TYPE OF BILL                                          122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     029     OP     ZZZ    INVALID TYPE OF BILL                                          122      PROCESSING CLAIM.
     030     DE     ZZZ    MULTIPLE SERVICE/UNITS FORMAT                                 476      MISSING OR INVALID UNITS OF SERVICE.
     030     EP     ZZZ    MULTIPLE SERVICE/UNITS FORMAT                                 476      MISSING OR INVALID UNITS OF SERVICE.
     030     HC     ZZZ    MULTIPLE SERVICE/UNITS FORMAT                                 476      MISSING OR INVALID UNITS OF SERVICE.
     030     OP     ZZZ    MULTIPLE SERVICE/UNITS FORMAT                                 476      MISSING OR INVALID UNITS OF SERVICE.
     030     VI     ZZZ    MULTIPLE SERVICE/UNITS FORMAT                                 476      MISSING OR INVALID UNITS OF SERVICE.
                                                                                                  NO RATE ON FILE WITH THE PAYER FOR THIS
     031     ZZ     ZZZ    REIMBURSEMENT RATE MISSING OR INVALID                         499      SERVICE FOR THIS ENTITY.
     032     IP     ZZZ    INPATIENT CLAIM MISSING A REQUIRED CONDITION CODE             460      NUBC CONDITION CODE(S).
     033     ZZ     ZZZ    INVALID DASH CODE                                             21       MISSING OR INVALID INFORMATION.
     034     ZZ     ZZZ    SERVICES NOT COVERED                                          425      ITEMIZE NON-COVERED SERVICES.
     035     IP     ZZZ    INVALID DATA FOR THE CONDITION CODE 'AN'                      460      NUBC CONDITION CODE(S).
     036     IP     ZZZ    INVALID DATA FOR THE CONDITION CODE 'AX'                      460      NUBC CONDITION CODE(S).
     037     HC     ZZZ    PROCEDURE CODE PAYABLE TO AID CATEGORY 69 ONLY                109      ENTITY NOT ELIGIBLE.




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                                                                ESC TO 277



                                                                                      277
                   PLAN                                                               CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               SERVICE LINE NUMBER GREATER THAN MAXIMUM
     038     PH     ZZZ    OVER 27 DETAILS                                            121      ALLOWABLE FOR PAYER.
                                                                                               SERVICE LINE NUMBER GREATER THAN MAXIMUM
     038     ZZ     ZZZ    OVER 27 DETAILS                                            121      ALLOWABLE FOR PAYER.

     039     ZZ     ZZZ    PATIENT LIABILITY APPLIED TO MEDICARE/MEDICAID ALLOWABLE   182      ALLOWABLE/PAID FROM PRIMARY COVERAGE.
     040     DE     ZZZ    TYPE OF SERVICE INVALID OR MISSING                         250      TYPE OF SERVICE.
     040     EP     ZZZ    TYPE OF SERVICE INVALID OR MISSING                         250      TYPE OF SERVICE.
     040     HC     ZZZ    TYPE OF SERVICE INVALID OR MISSING                         250      TYPE OF SERVICE.
     040     OP     ZZZ    TYPE OF SERVICE INVALID OR MISSING                         250      TYPE OF SERVICE.
     040     VI     ZZZ    TYPE OF SERVICE INVALID OR MISSING                         250      TYPE OF SERVICE.
     041     ZZ     ZZZ    TOS INVALID FOR PHYSICIAN EXTENDER                         250      TYPE OF SERVICE.
     043     ZZ     ZZZ    TOTAL BILLED INVALID                                       400      CLAIM IS OUT OF BALANCE.
                                                                                               OTHER PAYER'S EXPLANATION OF
     044     ZZ     ZZZ    OTHER INSURANCE INVALID                                    286      BENEFITS/PAYMENT INFORMATION.
                                                                                               OTHER PAYER'S EXPLANATION OF
     045     IX     ZZZ    MEDICARE ALLOWED AMOUNT MUST BE NUMERIC                    286      BENEFITS/PAYMENT INFORMATION.
                                                                                               OTHER PAYER'S EXPLANATION OF
     045     NX     ZZZ    MEDICARE ALLOWED AMOUNT MUST BE NUMERIC                    286      BENEFITS/PAYMENT INFORMATION.
                                                                                               OTHER PAYER'S EXPLANATION OF
     045     OX     ZZZ    MEDICARE ALLOWED AMOUNT MUST BE NUMERIC                    286      BENEFITS/PAYMENT INFORMATION.
                                                                                               OTHER PAYER'S EXPLANATION OF
     045     PX     ZZZ    MEDICARE ALLOWED AMOUNT MUST BE NUMERIC                    286      BENEFITS/PAYMENT INFORMATION.

     046     ZZ     ZZZ    FILING DEADLINE FOR ADJUSTMENT REQUEST                     9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     DE     AR1    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     HC     AR1    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     IP     AR1    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     OP     AR1    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     VI     AR1    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     048     ZZ     ZZZ    ARKIDS 1ST PARTICIPANT HAS FULL COVERAGE INSURANCE         171      (HEALTH, LIABILITY, AUTO, ETC).




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                                                                ESC TO 277



                                                                                     277
                   PLAN                                                              CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE

     049     NX     ZZZ    MEDICARE ALLOWED CHARGE                                   182      ALLOWABLE/PAID FROM PRIMARY COVERAGE.

     049     OX     ZZZ    MEDICARE ALLOWED CHARGE                                   182      ALLOWABLE/PAID FROM PRIMARY COVERAGE.

     049     PX     ZZZ    MEDICARE ALLOWED CHARGE                                   182      ALLOWABLE/PAID FROM PRIMARY COVERAGE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     050     HC     ZZZ    PARTICIPANT INVALID FOR ARKIDS 1ST RSPMI SPECIALTY        91       OF SERVICE.
     051     IP     ZZZ    INVALID PATIENT STATUS CODE                               234      PATIENT DISCHARGE STATUS.
     051     LT     ZZZ    INVALID PATIENT STATUS CODE                               234      PATIENT DISCHARGE STATUS.
     052     NX     ZZZ    MEDICARE PAID AMOUNT INVALID                              21       MISSING OR INVALID INFORMATION.
     052     OX     ZZZ    MEDICARE PAID AMOUNT INVALID                              21       MISSING OR INVALID INFORMATION.
     052     PX     ZZZ    MEDICARE PAID AMOUNT INVALID                              21       MISSING OR INVALID INFORMATION.
     053     IP     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     053     IX     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     053     NX     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     053     OX     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     053     PX     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     053     ZZ     ZZZ    NET BILLED OUT OF BALANCE                                 400      CLAIM IS OUT OF BALANCE.
     054     ZZ     ZZZ    PATIENT LIABILITY AMOUNT                                  21       MISSING OR INVALID INFORMATION.
     055     IP     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
     055     IX     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
     055     NX     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
     055     OX     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
     055     PX     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
     055     ZZ     ZZZ    TOTAL BILLED NOT EQUAL TO SUM OF DETAILS                  400      CLAIM IS OUT OF BALANCE.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     056     ZZ     ZZZ    CLAIM OVER DOLLAR LIMIT/TOTAL BILLED AMOUNT INVALID       122      PROCESSING CLAIM.

     057     ZZ     ZZZ    EOB INVALID                                               285      VOUCHERS/EXPLANATION OF BENEFITS (EOB).

     058     ZZ     ZZZ    EOB CONFIRMATION CODE DISAGREES WITH EOB STATUS           285      VOUCHERS/EXPLANATION OF BENEFITS (EOB).

     059     PH     ZZZ    ARKIDS 1ST PARTICIPANT NOT ELIGIBLE FOR BILLED SERVICES   109      ENTITY NOT ELIGIBLE.

     059     ZZ     AR1    ARKIDS 1ST PARTICIPANT NOT ELIGIBLE FOR BILLED SERVICES   109      ENTITY NOT ELIGIBLE.
     060     ZZ     ZZZ    ATTEMPTED TRANSFER IS INVALID                             21       MISSING OR INVALID INFORMATION.
     061     DE     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                109      ENTITY NOT ELIGIBLE.
     061     HC     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                109      ENTITY NOT ELIGIBLE.
     061     IP     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                109      ENTITY NOT ELIGIBLE.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
     061     OP     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                     109      ENTITY NOT ELIGIBLE.
     061     PH     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                     109      ENTITY NOT ELIGIBLE.
     061     VI     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                     109      ENTITY NOT ELIGIBLE.
     061     12     AR1    ARKIDS 1ST PARTICIPANT OVER AGE 18 FOR DOS                     109      ENTITY NOT ELIGIBLE.

     062     ZZ     ZZZ    DISALLOW EOB                                                   285      VOUCHERS/EXPLANATION OF BENEFITS (EOB).
                                                                                                   DUPLICATE OF A PREVIOUSLY PROCESSED
     063     ZZ     ZZZ    DUPLICATE ICN                                                  54       CLAIM/LINE.

     064     PH     ZZZ    RECIPIENT AID CATEGORY 69 LIMITED TO FAMILY PLANNING DRUGS     104      PROCESSED ACCORDING TO PLAN PROVISIONS.
     065     PH     CMS    CLAIM MUST BE BILLED THRU AEVCS                                481      CLAIM/SUBMISSION FORMAT IS INVALID.
     065     ZZ     CMS    CLAIM MUST BE BILLED THRU AEVCS                                481      CLAIM/SUBMISSION FORMAT IS INVALID.
     065     ZZ     DDS    CLAIM MUST BE BILLED THRU AEVCS                                481      CLAIM/SUBMISSION FORMAT IS INVALID.
     066     IP     ZZZ    INVALID TYPE OF ADMISSION CODE                                 231      HOSPITAL ADMISSION TYPE.
                           OB/RNC SVCS IN WAIVER COUNTY REQUIRES WAIVER COUNTY CONTRACT            PROCESSED ACCORDING TO CONTRACT/PLAN
     067     IP     ZZZ    HOSP                                                           107      PROVISIONS.
                           PATIENT REQUIRES WAIVER COUNTY CONTRACT HOSP FOR OB/RNC                 PROCESSED ACCORDING TO CONTRACT/PLAN
     068     IP     ZZZ    SERVICES                                                       107      PROVISIONS.

     069     ZZ     ZZZ    CLAIM SUSPENDED TO ALLOW FOR LOGIC CHANGE--NOTIFY SYSTEMS      20       ACCEPTED FOR PROCESSING.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     070     IP     ZZZ    RECIPIENT EXCEEDS AGE FOR RESIDENTIAL REHAB CENTERS            88       SUBMITTED DATES OF SERVICE.
     071     ZZ     ZZZ    HEADER EDITS FULL                                              20       ACCEPTED FOR PROCESSING.
     072     IP     ZZZ    RSPD REVENUE CODE NOT VALID FOR PROVIDER SPECIALTY             455      REVENUE CODE FOR SERVICES RENDERED.

     073     IP     ZZZ    REV CODE 249 (RSPD) REQUIRED WITH PROVIDER SPEC OF RC OR RH    455      REVENUE CODE FOR SERVICES RENDERED.

     074     ZZ     ZZZ    DATES OF SERVICE FOR RSPD CLAIM CANNOT BE PRIOR TO 2-15-95     187      DATE(S) OF SERVICE.

     075     HC     ZZZ    RECIPIENTS AID CATEGORY INELIGIBLE FOR PERSONAL CARE SERVICES 109       ENTITY NOT ELIGIBLE.

     076     PH     CMS    RECIPIENTS NOT ELIGIBLE FOR BILLED SERVICES UNDER CMS PROGRAM 109       ENTITY NOT ELIGIBLE.

     076     ZZ     CMS    RECIPIENTS NOT ELIGIBLE FOR BILLED SERVICES UNDER CMS PROGRAM 109       ENTITY NOT ELIGIBLE.

     077     DE     ZZZ    EMERGENCY PROCDURE CODE INVALID IN A NON-EMERGENCY SETTING     454      PROCEDURE CODE FOR SERVICES RENDERED.

     077     EP     ZZZ    EMERGENCY PROCDURE CODE INVALID IN A NON-EMERGENCY SETTING     454      PROCEDURE CODE FOR SERVICES RENDERED.

     077     HC     ZZZ    EMERGENCY PROCDURE CODE INVALID IN A NON-EMERGENCY SETTING     454      PROCEDURE CODE FOR SERVICES RENDERED.

     077     OP     ZZZ    EMERGENCY PROCDURE CODE INVALID IN A NON-EMERGENCY SETTING     454      PROCEDURE CODE FOR SERVICES RENDERED.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE

     077     VI     ZZZ    EMERGENCY PROCDURE CODE INVALID IN A NON-EMERGENCY SETTING     454      PROCEDURE CODE FOR SERVICES RENDERED.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     DE     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     HC     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     IP     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     OP     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     PH     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     VI     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     ZZ     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     078     12     CMS    CMS NON-MEDICAID RECIP OVER AGE RESTRICTION                    88       SUBMITTED DATES OF SERVICE.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     079     PH     CMS    NON-MEDICAID DRUGS REQUIRE PRIOR AUTHORIZATION FROM CMS        107      PROVISIONS.
     080     ZZ     CMS    PROVIDER CANNOT BILL FOR CMS NON-MEDICAID SERVICES             109      ENTITY NOT ELIGIBLE.

     081     ZZ     ZZZ    RECIPIENT/PROVIDER INELIGIBILE FOR DDS NON-MEDICAID SERVICES   109      ENTITY NOT ELIGIBLE.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     082     ZZ     DDS    DDS NON-MEDICAID FUND CODE INVALID/NOT ON PROV OR REC PROFILE 122       PROCESSING CLAIM.
     083     ZZ     DDS    DDS NON-MEDICAID SERVICE IS INVALID FOR FUND CODE              21       MISSING OR INVALID INFORMATION.
                                                                                                   ENTITY NOT APPROVED AS AN ELECTRONIC
     084     ZZ     CMS    NON-MEDICAID CLAIM SUSPENDED DUE TO NON-EFT PROVIDER           24       SUBMITTER.
                                                                                                   ENTITY NOT APPROVED AS AN ELECTRONIC
     084     ZZ     DDS    NON-MEDICAID CLAIM SUSPENDED DUE TO NON-EFT PROVIDER           24       SUBMITTER.
                                                                                                   MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     085     ZZ     DDS    QUARTERLY AMOUNT EXCEEDED FOR DDS NON-MEDICAID FUND CODE       483      FOR BENEFIT PERIOD.
     086     HC     ZZZ    PROV/RECIP INELIGIBLE FOR MANAGED CARE NET SERVICES            109      ENTITY NOT ELIGIBLE.
                                                                                                   SERVICE LINE NUMBER GREATER THAN MAXIMUM
     087     DE     AR1    ARKIDS PAPER CLAIMS EXCEEDED 28 DETAILS                        121      ALLOWABLE FOR PAYER.
                                                                                                   SERVICE LINE NUMBER GREATER THAN MAXIMUM
     087     HC     AR1    ARKIDS PAPER CLAIMS EXCEEDED 28 DETAILS                        121      ALLOWABLE FOR PAYER.
                                                                                                   SERVICE LINE NUMBER GREATER THAN MAXIMUM
     087     OP     AR1    ARKIDS PAPER CLAIMS EXCEEDED 28 DETAILS                        121      ALLOWABLE FOR PAYER.
                                                                                                   SERVICE LINE NUMBER GREATER THAN MAXIMUM
     087     VI     AR1    ARKIDS PAPER CLAIMS EXCEEDED 28 DETAILS                        121      ALLOWABLE FOR PAYER.
                                                                                                   AUTHORIZATION/CERTIFICATION (INCLUDE
     088     EP     ZZZ    CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE                  332      PERIOD COVERED).




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                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  AUTHORIZATION/CERTIFICATION (INCLUDE
     088     HC     CMS    CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE                 332      PERIOD COVERED).
                                                                                                  AUTHORIZATION/CERTIFICATION (INCLUDE
     088     HC     ZZZ    CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE                 332      PERIOD COVERED).
                                                                                                  AUTHORIZATION/CERTIFICATION (INCLUDE
     088     OP     CMS    CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE                 332      PERIOD COVERED).
                                                                                                  AUTHORIZATION/CERTIFICATION (INCLUDE
     088     OP     ZZZ    CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE                 332      PERIOD COVERED).

     090     ZZ     ZZZ    PROVIDER LIMITED TO CAPITATION CLAIMS ONLY (REGION 22)        105      CLAIM/LINE IS CAPITATED.

     091     ZZ     ZZZ    PROVIDER LIMITED TO MENTAL HEALTH MANAGED CARE CLAIMS (MCP)   109      ENTITY NOT ELIGIBLE.
                           DCFS REC (AID CAT 02,05) ELIGIBLE FOR BENEFIT ARKANSAS SERV
     092     ZZ     ZZZ    ONLY                                                          109      ENTITY NOT ELIGIBLE.
     093     ZZ     ZZZ    CLAIM SPANS MORE THAN ONE MANAGED CARE PLAN                   187      DATE(S) OF SERVICE.

     094     ZZ     ZZZ    CLAIM/RECIPIENT NOT COVERED BY MENTAL HEALTH MANAGED CARE     109      ENTITY NOT ELIGIBLE.

                                                                                                  OTHER INSURANCE COVERAGE INFORMATION
     095     DE     CMS    CMS COPAY CODE PAYABLE ONLY IF RECIPIENT HAS TPL ON FILE      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                                  OTHER INSURANCE COVERAGE INFORMATION
     095     HC     CMS    CMS COPAY CODE PAYABLE ONLY IF RECIPIENT HAS TPL ON FILE      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                                  OTHER INSURANCE COVERAGE INFORMATION
     095     OP     CMS    CMS COPAY CODE PAYABLE ONLY IF RECIPIENT HAS TPL ON FILE      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                                  OTHER INSURANCE COVERAGE INFORMATION
     095     VI     CMS    CMS COPAY CODE PAYABLE ONLY IF RECIPIENT HAS TPL ON FILE      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                                  OTHER INSURANCE COVERAGE INFORMATION
     095     ZZ     CMS    CMS COPAY CODE PAYABLE ONLY IF RECIPIENT HAS TPL ON FILE      171      (HEALTH, LIABILITY, AUTO, ETC).
                           ANCILLARY SERV ARE NOT ALLOWED WITH EMERG DEPT ASSESSMENT              PROCESSED ACCORDING TO CONTRACT/PLAN
     096     OP     ZZZ    FEE CHG                                                       107      PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     097     OP     ZZZ    OUTPATIENT SERVICE BILLING LIMITED TO ONE ENCOUNTER PER ICN   483      FOR BENEFIT PERIOD.
     098     DE     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.
     098     EP     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.
     098     HC     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.
     098     IP     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.
     098     OP     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.
     098     VI     ZZZ    NON-COVERED SERVICE                                           425      ITEMIZE NON-COVERED SERVICES.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE

     099     HC     ZZZ    SERVICE IS NON-PAYABLE FOR THIS INDEPENDENT CHOICES CLIENT     425      ITEMIZE NON-COVERED SERVICES.
     100     ZZ     ZZZ    HEADER/DETAIL FROM DATES OF SERVICE MISSING/INVALID            187      DATE(S) OF SERVICE.
     101     ZZ     ZZZ    HEADER/DETAIL TO DATE OF SERVICE MISSING/INVALID               187      DATE(S) OF SERVICE.

     102     ZZ     ZZZ    SUBMISSION DATE DOES NOT MEET TIMELY FILING REQUIREMENTS       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     103     PH     ZZZ    ECS DRUG CLAIM MUST BE BILLED THRU AEVCS                       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     104     EP     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     104     HC     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     104     OP     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.

     105     IP     ZZZ    SEXUAL OFFENDER REVENUE CODE(128) INVALID FOR PROVIDER SPEC.   455      REVENUE CODE FOR SERVICES RENDERED.

     106     IP     ZZZ    PROVIDER SPECIALITY WC MUST ONLY BILL REVENUE CODE 128.        455      REVENUE CODE FOR SERVICES RENDERED.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     107     EP     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     107     HC     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     107     IP     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.
                                                                                                   ENTITY IS NOT SELECTED PRIMARY CARE
     107     OP     ZZZ    PRIMARY CARE PHYSICIAN DOES NOT MATCH PERF OR REFF PHYSICIAN. 93        PROVIDER.

     109     HC     ZZZ    INVALID USE OF HOSPITAL PCP ENROLLMENT PCODE Z2278             454      PROCEDURE CODE FOR SERVICES RENDERED.

     109     OP     ZZZ    INVALID USE OF HOSPITAL PCP ENROLLMENT PCODE Z2278             454      PROCEDURE CODE FOR SERVICES RENDERED.
     110     ZZ     ZZZ    OBSOLET PROCEDURE; REQUIRES MANUAL REVIEW                      46       INTERNAL REVIEW/AUDIT.
     111     ZZ     ZZZ    UNLISTED PROCEDURE; REQUIRES MANUAL REVIEW                     46       INTERNAL REVIEW/AUDIT.
     112     ZZ     ZZZ    COSMETIC SURGERY; NON PAYABLE WITHOUT PA                       84       SERVICE NOT AUTHORIZED.
     113     ZZ     ZZZ    ASSISTANT SURGEON DENIED; SHOULD NOT BE REIMBURSED             252      AUTHORIZATION/CERTIFICATION NUMBER.

     114     ZZ     ZZZ    REPLACEMENT DUE TO ALTERNATE AGE REPLACEMENT                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     115     ZZ     ZZZ    REPLACEMENT DUE TO ALTERNATE SEX REPLACEMENT                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     116     ZZ     ZZZ    DELETED PROCEDURES ARE NON COVERED                             454      PROCEDURE CODE FOR SERVICES RENDERED.
                                                                                                   ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     117     ZZ     ZZZ    PROVIDER CANCELED-DENY ALL CLAIMS                              91       OF SERVICE.




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                                                                 ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  OTHER PAYER'S EXPLANATION OF
     118     IX     ZZZ    MEDICARE DENIED                                               286      BENEFITS/PAYMENT INFORMATION.
                                                                                                  OTHER PAYER'S EXPLANATION OF
     118     NX     ZZZ    MEDICARE DENIED                                               286      BENEFITS/PAYMENT INFORMATION.
                                                                                                  OTHER PAYER'S EXPLANATION OF
     118     OX     ZZZ    MEDICARE DENIED                                               286      BENEFITS/PAYMENT INFORMATION.
                                                                                                  OTHER PAYER'S EXPLANATION OF
     118     PX     ZZZ    MEDICARE DENIED                                               286      BENEFITS/PAYMENT INFORMATION.
                                                                                                  OTHER PAYER'S EXPLANATION OF
     119     PX     ZZZ    MEDICARE PAID GREATER THAN MEDICAID ALLOWED                   286      BENEFITS/PAYMENT INFORMATION.
                           EXCEEDS MAXIMUM OF 40 DETAILS IN GMIS. SPLIT CLAIM AND                 SERVICE LINE NUMBER GREATER THAN MAXIMUM
     120     ZZ     ZZZ    RECYCLE                                                       121      ALLOWABLE FOR PAYER.

     121     ZZ     ZZZ    RECYCLE CLAIM TO PRICE NEW DETAIL(S) CREATED BY GMIS          64       RE-PRICING INFORMATION.
                                                                                                  SERVICE LINE NUMBER GREATER THAN MAXIMUM
     122     ZZ     ZZZ    EXCEEDS MAXIMUM OF 28 DETAILS                                 121      ALLOWABLE FOR PAYER.

     123     ZZ     ZZZ    SWING BED/RECUPERATIVE BEDS NOT COVERED BY MEDICAID           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     124     HC     ZZZ    PREVENT PROVIDER TYPE 89 FROM BILLING AS A PAY-TO PROVIDER    132      ENTITY'S MEDICAID PROVIDER ID.
     125     DE     ZZZ    INVALID TOOTH NUMBER                                          244      TOOTH NUMBER OR LETTER.
     126     DE     ZZZ    INVALID TOOTH SURFACE                                         240      TOOTH SURFACE(S) INVOLVED.
                           PROC CODE REQUIRES PA WHEN TPL IS LESS THAN 50% OF ALLOWED
     127     ZZ     ZZZ    AMT                                                           252      AUTHORIZATION/CERTIFICATION NUMBER.
     128     DE     ZZZ    PROCEDURE VS TOOTH NUMBER MISMATCH                            244      TOOTH NUMBER OR LETTER.
     129     ZZ     ZZZ    DETAIL EDITS FULL                                             20       ACCEPTED FOR PROCESSING.
                           PREGNANT WOMEN AID CATEGORY 61 ELIGIBLE FOR OB/GYN SERVICES
     130     ZZ     ZZZ    ONLY.                                                         109      ENTITY NOT ELIGIBLE.
                                                                                                  PROCESSED ACCORDING TO CONTRACT/PLAN
     131     ZZ     ZZZ    RAPE/INCEST ABORTION CODE EDIT: CLAIM TO ALWAYS DENY.         107      PROVISIONS.
                           RECIPIENT HAS MEDICARE HMO. BENEFITS LTD TO COPAYMENT AMT              PROCESSED ACCORDING TO CONTRACT/PLAN
     132     ZZ     ZZZ    ONLY.                                                         107      PROVISIONS.
                                                                                                  PROCEDURE CODE MODIFIER(S) FOR SERVICE(S)
     133     ZZ     ZZZ    MODIFIER IS INVALID                                           453      RENDERED.
     135     ZZ     ZZZ    CLAIM RECORD POS DOES NOT MATCH PA RECORD POS                 249      PLACE OF SERVICE.
     136     DE     ZZZ    PLACE OF SERVICE MISSING OR INVALID                           249      PLACE OF SERVICE.
     136     EP     ZZZ    PLACE OF SERVICE MISSING OR INVALID                           249      PLACE OF SERVICE.
     136     HC     ZZZ    PLACE OF SERVICE MISSING OR INVALID                           249      PLACE OF SERVICE.
     136     VI     ZZZ    PLACE OF SERVICE MISSING OR INVALID                           249      PLACE OF SERVICE.

     137     ZZ     ZZZ    PROCEDURE TO EPSDT INDICATOR                                  454      PROCEDURE CODE FOR SERVICES RENDERED.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                           NON-COVERED TRANSPORTATION SERV BASED ON RECIPIENT COUNTY OF
     138     HC     ZZZ    RES                                                            425      ITEMIZE NON-COVERED SERVICES.
     139     EP     ZZZ    INVALID EPSDT REFERRAL REASON                                  21       MISSING OR INVALID INFORMATION.

     140     DE     ZZZ    NON-COVERED SERVICE MUST BE RESULT OF EPSDT REFERRAL           425      ITEMIZE NON-COVERED SERVICES.

     140     HC     ZZZ    NON-COVERED SERVICE MUST BE RESULT OF EPSDT REFERRAL           425      ITEMIZE NON-COVERED SERVICES.

     140     OP     ZZZ    NON-COVERED SERVICE MUST BE RESULT OF EPSDT REFERRAL           425      ITEMIZE NON-COVERED SERVICES.

     140     VI     ZZZ    NON-COVERED SERVICE MUST BE RESULT OF EPSDT REFERRAL           425      ITEMIZE NON-COVERED SERVICES.
     141     EP     ZZZ    EPSDT INDICATOR TO HEADER DIAGNOSIS                            254      PRIMARY DIAGNOSIS CODE.
     142     ZZ     ZZZ    EPSDT DIAGNOSIS                                                255      DIAGNOSIS CODE.

     143     EP     ZZZ    EPSDT REFERRAL/PROCEDURE CODE MISMATCH                         454      PROCEDURE CODE FOR SERVICES RENDERED.
     144     EP     ZZZ    EPSDT INITIAL/PERIODIC INVALID                                 21       MISSING OR INVALID INFORMATION.
                                                                                                   PROCEDURE CODE MODIFIER(S) FOR SERVICE(S)
     145     HC     ZZZ    MODIFIER INVALID                                               453      RENDERED.

     146     DE     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     146     EP     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     146     HC     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     146     IP     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     146     OP     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     146     VI     ZZZ    PROCEDURE CODE INVALID TO PROVIDER TYPE                        454      PROCEDURE CODE FOR SERVICES RENDERED.

     148     DE     ZZZ    PROCEDURE CODE TO PLACE OF SERVICE VALIDITY CHECK              454      PROCEDURE CODE FOR SERVICES RENDERED.

     148     EP     ZZZ    PROCEDURE CODE TO PLACE OF SERVICE VALIDITY CHECK              454      PROCEDURE CODE FOR SERVICES RENDERED.

     148     HC     ZZZ    PROCEDURE CODE TO PLACE OF SERVICE VALIDITY CHECK              454      PROCEDURE CODE FOR SERVICES RENDERED.

     148     OP     ZZZ    PROCEDURE CODE TO PLACE OF SERVICE VALIDITY CHECK              454      PROCEDURE CODE FOR SERVICES RENDERED.

     148     VI     ZZZ    PROCEDURE CODE TO PLACE OF SERVICE VALIDITY CHECK              454      PROCEDURE CODE FOR SERVICES RENDERED.

     149     DE     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                           475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.




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                                                                  ESC TO 277



                                                                               277
                   PLAN                                                        CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                              STATUS   CLAIM STATUS CODE

     149     EP     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     149     HC     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     149     IP     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     149     OP     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     149     PH     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     149     VI     ZZZ    PROCEDURE CODE TO AGE VALIDITY CHECK                475      PROCEDURE CODE NOT VALID FOR PATIENT AGE.

     150     EP     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.

     150     HC     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.

     150     IP     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.

     150     OP     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.

     150     PH     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.

     150     PX     ZZZ    PROCEDURE CODE TO SEX VALIDITY CHECK                474      PROCEDURE CODE AND PATIENT GENDER MISMATCH.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     DE     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     EP     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     HC     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     IP     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     OP     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     PH     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     PX     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     VI     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     151     ZZ     ZZZ    PROCEDURE/NDC CODE INVALID FOR DATE(S) OF SERVICE   122      PROCESSING CLAIM.

     152     DE     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                  454      PROCEDURE CODE FOR SERVICES RENDERED.




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                                                                  ESC TO 277



                                                                                 277
                   PLAN                                                          CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                STATUS   CLAIM STATUS CODE

     152     EP     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     IP     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     IX     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     LT     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     NX     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     OP     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     OX     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     PH     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     PX     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     VI     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.

     152     ZZ     ZZZ    NDC/PROCEDURE/REVENUE/ NOT OF FILE                    454      PROCEDURE CODE FOR SERVICES RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     DE     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     EP     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     HC     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     IP     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     OP     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.
                                                                                          DIAGNOSIS CODE(S) FOR THE SERVICES
     153     VI     ZZZ    INVALID DIAGNOSIS FOR PROCEDURE CODE                  488      RENDERED.

     154     HC     ZZZ    PROCEDURE CODE TO PROVIDER SPECIALTY VALIDITY CHECK   454      PROCEDURE CODE FOR SERVICES RENDERED.
                                                                                          MISSING/INVALID DATA PREVENTS PAYER FROM
     155     DE     ZZZ    PROCEDURE CODE TO CLAIM TYPE VALIDITY CHECK           122      PROCESSING CLAIM.
                                                                                          MISSING/INVALID DATA PREVENTS PAYER FROM
     155     EP     ZZZ    PROCEDURE CODE TO CLAIM TYPE VALIDITY CHECK           122      PROCESSING CLAIM.
                                                                                          MISSING/INVALID DATA PREVENTS PAYER FROM
     155     HC     ZZZ    PROCEDURE CODE TO CLAIM TYPE VALIDITY CHECK           122      PROCESSING CLAIM.
                                                                                          MISSING/INVALID DATA PREVENTS PAYER FROM
     155     OP     ZZZ    PROCEDURE CODE TO CLAIM TYPE VALIDITY CHECK           122      PROCESSING CLAIM.




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                                                                             277
                   PLAN                                                      CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                            STATUS   CLAIM STATUS CODE
                                                                                      MISSING/INVALID DATA PREVENTS PAYER FROM
     155     VI     ZZZ    PROCEDURE CODE TO CLAIM TYPE VALIDITY CHECK       122      PROCESSING CLAIM.
     156     DE     ZZZ    PROCEDURE CODE ON REVIEW FOR THIS PROVIDER        46       INTERNAL REVIEW/AUDIT.
     156     EP     ZZZ    PROCEDURE CODE ON REVIEW FOR THIS PROVIDER        46       INTERNAL REVIEW/AUDIT.
     156     HC     ZZZ    PROCEDURE CODE ON REVIEW FOR THIS PROVIDER        46       INTERNAL REVIEW/AUDIT.
     156     PX     ZZZ    PROCEDURE CODE ON REVIEW FOR THIS PROVIDER        46       INTERNAL REVIEW/AUDIT.
     156     VI     ZZZ    PROCEDURE CODE ON REVIEW FOR THIS PROVIDER        46       INTERNAL REVIEW/AUDIT.
     157     ZZ     ZZZ    AMBULANCE ATTACHMENT REQUIRED                     294      SUPPORTING DOCUMENTATION.
     158     HC     ZZZ    OUTSIDE CITY LIMITS                               21       MISSING OR INVALID INFORMATION.

     159     ZZ     ZZZ    CODE NOT ON LEVEL I FILE                          454      PROCEDURE CODE FOR SERVICES RENDERED.
     160     DE     ZZZ    PROCEDURE TO TOOTH SURFACE                        240      TOOTH SURFACE(S) INVOLVED.
     161     IX     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
     161     LT     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
     161     NX     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
     161     OX     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
     161     PX     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
     161     ZZ     ZZZ    TOS INVALID TO PROCEDURE CODE                     250      TYPE OF SERVICE.
                                                                                      MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     162     IP     ZZZ    UNITS BILLED EXCEED MAX ALLOWED PER DAY           483      FOR BENEFIT PERIOD.
                                                                                      MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     162     OP     ZZZ    UNITS BILLED EXCEED MAX ALLOWED PER DAY           483      FOR BENEFIT PERIOD.
                                                                                      MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     162     ZZ     ZZZ    UNITS BILLED EXCEED MAX ALLOWED PER DAY           483      FOR BENEFIT PERIOD.

     163     IX     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     163     LT     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     163     NX     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     163     OX     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     163     PX     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.

     163     ZZ     ZZZ    LAB NOT CERTIFIED FOR PROCEDURE                   454      PROCEDURE CODE FOR SERVICES RENDERED.
     164     IP     ZZZ    ACCOMODATION UNITS DO NOT EQUAL COVERED DAYS      416      MISSING OR INVALID UNITS OF SERVICE.
     165     DE     ZZZ    SERVICE NOT COVERED UNDER AID CATEGORY 62         109      ENTITY NOT ELIGIBLE.
     165     EP     ZZZ    SERVICE NOT COVERED UNDER AID CATEGORY 62         109      ENTITY NOT ELIGIBLE.
     165     HC     ZZZ    SERVICE NOT COVERED UNDER AID CATEGORY 62         109      ENTITY NOT ELIGIBLE.
     165     IP     ZZZ    SERVICE NOT COVERED UNDER AID CATEGORY 62         109      ENTITY NOT ELIGIBLE.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
     165     VI     ZZZ    SERVICE NOT COVERED UNDER AID CATEGORY 62                      109      ENTITY NOT ELIGIBLE.

     166     PX     ZZZ    MEDICARE PROCEDURE NOT ON MCARE/MCAID PROCEDURE XREF FILE      454      PROCEDURE CODE FOR SERVICES RENDERED.

     167     PX     ZZZ    MEDICARE PROCEDURE HAS NO MEDICAID EQUIVALENT                  454      PROCEDURE CODE FOR SERVICES RENDERED.

     168     PX     ZZZ    MEDICARE PROCEDURE HAS NOT BEEN MAPPED                         454      PROCEDURE CODE FOR SERVICES RENDERED.

     169     PX     ZZZ    CLINICAL LAB PROCEDURE CODE                                    454      PROCEDURE CODE FOR SERVICES RENDERED.

                                                                                                   MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     170     IP     ZZZ    PROCEDURE/SURGERY CODE ON REVIEW                               421      SERVICE(S).

                                                                                                   MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     171     PX     ZZZ    PROCEDURE CODE ON REVIEW                                       421      SERVICE(S).

                                                                                                   MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     171     ZZ     ZZZ    PROCEDURE CODE ON REVIEW                                       421      SERVICE(S).

     172     IP     ZZZ    CONDITION CODE 38 OR 39 OMITTED FOR PRIVATE ROOM ACCOMODATION 460       NUBC CONDITION CODE(S).

     173     PX     ZZZ    PROCEDURE CODE HAS MEDICARE FEE AMOUNT OF ZERO                 454      PROCEDURE CODE FOR SERVICES RENDERED.
                           MEDICARE DID NOT PRICE THE CLAIM AT 80 PERCENT OF THE
     174     PX     ZZZ    ALLOWED AMT                                                    110      CLAIM REQUIRES PRICING INFORMATION.
                           SUM OF MCARE DTL ALLOWED AMTS NOT EQUAL HEADER MCARE ALLOWED
     175     PX     ZZZ    AMTT                                                           247      LINE INFORMATION.
                                                                                                   PROCEDURE/REVENUE CODE FOR SERVICES(S)
     176     ZZ     ZZZ    ADMISSION PROCEDURE CODE MISSING/INVALID                       253      RENDERED.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     177     DE     ZZZ    FQHC CAPTURE FOR COST SETTLEMENT                               107      PROVISIONS.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     177     EP     ZZZ    FQHC CAPTURE FOR COST SETTLEMENT                               107      PROVISIONS.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     177     HC     ZZZ    FQHC CAPTURE FOR COST SETTLEMENT                               107      PROVISIONS.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     177     OP     ZZZ    FQHC CAPTURE FOR COST SETTLEMENT                               107      PROVISIONS.
                                                                                                   PROCESSED ACCORDING TO CONTRACT/PLAN
     177     VI     ZZZ    FQHC CAPTURE FOR COST SETTLEMENT                               107      PROVISIONS.

     178     OP     ZZZ    ONE OTHER NON-ER SERVICES PROC CODE (Z0647) ALLOWED PER CLAIM 454       PROCEDURE CODE FOR SERVICES RENDERED.
     179     IX     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.
     179     LT     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.
     179     NX     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
     179     OX     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.
     179     PX     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.
     179     ZZ     ZZZ    PROCEDURE MUST BE BILLED ON PAPER CLAIM                        481      CLAIM/SUBMISSION FORMAT IS INVALID.

     180     HC     ZZZ    THERAPY SVCS IND. AND/OR SCHL DIST. LEA CODE MISSING/INVALID   21       MISSING OR INVALID INFORMATION.

     181     HC     ZZZ    THERAPY SERVICES INDICATOR INVALID FOR PROVIDER TYPE           21       MISSING OR INVALID INFORMATION.

     182     HC     ZZZ    THERAPY SERVICES INDICATOR INVALID FOR RECIPIENT'S AGE         21       MISSING OR INVALID INFORMATION.
                                                                                                   ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     183     ZZ     ZZZ    CLAIM FDOS PRIOR TO RECIPIENT DOB                              91       OF SERVICE.

     185     IP     ZZZ    ROOM/BOARD REV CODE NOT ALLOWED W/REV CODE 128,129, OR 249.    455      REVENUE CODE FOR SERVICES RENDERED.
     188     PH     CMS    PRIOR AUTH VALID FOR CMS NON-MEDICAID SERVICES ONLY            252      AUTHORIZATION/CERTIFICATION NUMBER.
     188     ZZ     CMS    PRIOR AUTH VALID FOR CMS NON-MEDICAID SERVICES ONLY            252      AUTHORIZATION/CERTIFICATION NUMBER.
     188     ZZ     ZZZ    PRIOR AUTH VALID FOR CMS NON-MEDICAID SERVICES ONLY            252      AUTHORIZATION/CERTIFICATION NUMBER.

     189     ZZ     ZZZ    RECIPIENT PARTIALLY/TOTALLY INELIGIBLE FOR DOS BILLED          252      AUTHORIZATION/CERTIFICATION NUMBER.
     190     DE     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     HC     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     IX     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     NX     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     OX     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     PH     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     PX     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     190     ZZ     ZZZ    PRIMARY HEADER DIAGNOSIS NOT VALID INPUT                       254      PRIMARY DIAGNOSIS CODE.
     191     HC     ZZZ    SECONDARY HEADER DIAGNOSIS INVALID                             255      DIAGNOSIS CODE.
     191     IP     ZZZ    SECONDARY HEADER DIAGNOSIS INVALID                             255      DIAGNOSIS CODE.
     191     LT     ZZZ    SECONDARY HEADER DIAGNOSIS INVALID                             255      DIAGNOSIS CODE.
     191     OP     ZZZ    SECONDARY HEADER DIAGNOSIS INVALID                             255      DIAGNOSIS CODE.
     191     VI     ZZZ    SECONDARY HEADER DIAGNOSIS INVALID                             255      DIAGNOSIS CODE.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     192     HC     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE                488      RENDERED.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     192     LT     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE                488      RENDERED.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     192     VI     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE                488      RENDERED.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     192     ZZ     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE                488      RENDERED.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     193     HC     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE              488      RENDERED.




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                                                                                      277
                   PLAN                                                               CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               DIAGNOSIS CODE(S) FOR THE SERVICES
     193     IP     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE          488      RENDERED.
                                                                                               DIAGNOSIS CODE(S) FOR THE SERVICES
     193     LT     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE          488      RENDERED.
                                                                                               DIAGNOSIS CODE(S) FOR THE SERVICES
     193     OP     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE          488      RENDERED.
                                                                                               DIAGNOSIS CODE(S) FOR THE SERVICES
     193     VI     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S AGE          488      RENDERED.

     194     DE     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     194     HC     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     194     PH     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     194     PX     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     194     VI     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     194     ZZ     ZZZ    PRIMARY DIAGNOSIS ILLOGICAL FOR RECIPIENT'S SEX            86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     195     HC     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL TO RECIPIENT'S SEX           86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     195     IP     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL TO RECIPIENT'S SEX           86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     195     LT     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL TO RECIPIENT'S SEX           86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     195     OP     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL TO RECIPIENT'S SEX           86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     195     VI     ZZZ    SECONDARY DIAGNOSIS ILLOGICAL TO RECIPIENT'S SEX           86       DIAGNOSIS AND PATIENT GENDER MISMATCH.
     196     DE     ZZZ    HEADER DIAGNOSIS SUSPEND                                   255      DIAGNOSIS CODE.
     196     HC     ZZZ    HEADER DIAGNOSIS SUSPEND                                   255      DIAGNOSIS CODE.
     196     PH     ZZZ    HEADER DIAGNOSIS SUSPEND                                   255      DIAGNOSIS CODE.
     196     ZZ     ZZZ    HEADER DIAGNOSIS SUSPEND                                   255      DIAGNOSIS CODE.
                                                                                               ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     197     ZZ     ZZZ    DATES OF SERVICE CANNOT SPAN FEDERAL FISCAL YEAR           88       SUBMITTED DATES OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     198     HC     ZZZ    PROV TO RECIPIENT MISMATCH FOR SCHOOL DIST OUTREACH SERV   91       OF SERVICE.
     200     IX     ZZZ    DIAGNOSIS ON REVIEW FOR PROVIDER SUSPEND                   255      DIAGNOSIS CODE.
     200     NX     ZZZ    DIAGNOSIS ON REVIEW FOR PROVIDER SUSPEND                   255      DIAGNOSIS CODE.
     200     OX     ZZZ    DIAGNOSIS ON REVIEW FOR PROVIDER SUSPEND                   255      DIAGNOSIS CODE.
     200     PH     ZZZ    DIAGNOSIS ON REVIEW FOR PROVIDER SUSPEND                   255      DIAGNOSIS CODE.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
     200     ZZ     ZZZ    DIAGNOSIS ON REVIEW FOR PROVIDER SUSPEND                       255      DIAGNOSIS CODE.
     201     HC     ZZZ    DETAIL DIAGNOSIS SUSPEND                                       255      DIAGNOSIS CODE.
     201     VI     ZZZ    DETAIL DIAGNOSIS SUSPEND                                       255      DIAGNOSIS CODE.
     203     ZZ     ZZZ    CLAIM SPAN 11/01/01 TOBACCO FUNDING EFFECTIVE DATE             187      DATE(S) OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     204     PH     ZZZ    THIS SERVICE NOT COVERED FOR RECIPIENTS 21 AND UNDER           91       OF SERVICE.
     205     HC     ZZZ    DETAIL DIAGNOSIS FORMAT                                        255      DIAGNOSIS CODE.
     205     VI     ZZZ    DETAIL DIAGNOSIS FORMAT                                        255      DIAGNOSIS CODE.

     206     HC     ZZZ    DETAIL DIAGNOSIS TO SEX                                        86       DIAGNOSIS AND PATIENT GENDER MISMATCH.

     206     VI     ZZZ    DETAIL DIAGNOSIS TO SEX                                        86       DIAGNOSIS AND PATIENT GENDER MISMATCH.
                                                                                                   DIAGNOSIS CODE(S) FOR THE SERVICES
     207     HC     ZZZ    DETAIL DIAGNOSIS TO AGE                                        488      RENDERED.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     208     HC     ZZZ    RECIPIENT LIMITED TO TB RELATED SERVICE ONLY                   88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     208     OP     ZZZ    RECIPIENT LIMITED TO TB RELATED SERVICE ONLY                   88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     208     PH     ZZZ    RECIPIENT LIMITED TO TB RELATED SERVICE ONLY                   88       SUBMITTED DATES OF SERVICE.
                                                                                                   ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     208     ZZ     ZZZ    RECIPIENT LIMITED TO TB RELATED SERVICE ONLY                   88       SUBMITTED DATES OF SERVICE.

                                                                                                   OTHER INSURANCE COVERAGE INFORMATION
     209     HC     ZZZ    TPL INJURY SUSPECT                                             171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                                   OTHER INSURANCE COVERAGE INFORMATION
     209     VI     ZZZ    TPL INJURY SUSPECT                                             171      (HEALTH, LIABILITY, AUTO, ETC).
     210     HC     ZZZ    WELL CHILD/WELL BABY DIAG INVALID TO CLAIM TYPE J              481      CLAIM/SUBMISSION FORMAT IS INVALID.

                           SURG PROC CODES 10000-69999 NOT PAY WITH TOS 2 AND MOD 80 OR            MEDICAL REVIEW ATTACHMENT/INFORMATION FOR
     212     HC     ZZZ    82.                                                            421      SERVICE(S).
                                                                                                   ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     214     ZZ     ZZZ    SERVICES COVERED ONLY FOR ASSISTED LIVING WAIVER CLIENTS       91       OF SERVICE.
     216     IP     ZZZ    HEADER DATES OF SERVICE SPAN PROV FISCAL YEAR.                 187      DATE(S) OF SERVICE.
     217     IX     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     217     NX     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     217     OX     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     217     PX     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     217     VI     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     217     ZZ     ZZZ    OUT OF STATE PROVIDER                                          48       REFERRAL/AUTHORIZATION.
     218     ZZ     ZZZ    LICENSE NUMBER NOT ON FILE                                     21       MISSING OR INVALID INFORMATION.



6/16/2011                                                        Page 270
                                                                   ESC TO 277



                                                                                   277
                   PLAN                                                            CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE

     219     ZZ     ZZZ    MULTIPLE PROVIDERS FOR LICENSE NUMBER                   142      ENTITY'S LICENSE/CERTIFICATION NUMBER.
                                                                                            ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     220     ZZ     ZZZ    BILLING PROVIDER - FIRST VARIABLE                       88       SUBMITTED DATES OF SERVICE.

     221     ZZ     ZZZ    PROVIDER DECEASED                                       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     222     ZZ     ZZZ    PROVIDER CANCELLED                                      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     223     ZZ     ZZZ    PROVIDER SUSPENDED                                      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     224     IP     ZZZ    INPATIENT PSYCH PROV SPECIALTY TO AGE                   145      ENTITY'S SPECIALTY CODE.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     EP     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     HC     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     IP     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     IX     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     LT     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     OP     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
                                                                                            NO RATE ON FILE WITH THE PAYER FOR THIS
     225     ZZ     ZZZ    PROVIDER RATE NOT ON FILE                               499      SERVICE FOR THIS ENTITY.
     226     ZZ     ZZZ    PROVIDER TYPE/SPECIALTY INVALID FOR CLAIM TYPE          145      ENTITY'S SPECIALTY CODE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     IP     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     IX     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     NX     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     OX     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     PX     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
                                                                                            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     228     ZZ     ZZZ    PROVIDER INELIGIBLE FOR DATE OF SERVICE                 91       OF SERVICE.
     229     ZZ     ZZZ    PROVIDER NUMBER INVALID/NOT ON FILE                     26       ENTITY NOT FOUND.

     230     IP     ZZZ    ATTENDING/PERFORMING PHYSICIAN LICENSE NUMBER OMITTED   26       ENTITY NOT FOUND.

     230     LT     ZZZ    ATTENDING/PERFORMING PHYSICIAN LICENSE NUMBER OMITTED   26       ENTITY NOT FOUND.




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                                                                 ESC TO 277



                                                                                   277
                   PLAN                                                            CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE

     230     OP     ZZZ    ATTENDING/PERFORMING PHYSICIAN LICENSE NUMBER OMITTED   26       ENTITY NOT FOUND.

     231     ZZ     ZZZ    PROVIDER NAME TO NUMBER MISMATCH                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     232     ZZ     ZZZ    PROVIDER ON REVIEW                                      46       INTERNAL REVIEW/AUDIT.

     233     DE     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     EP     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     HC     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     IP     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     LT     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     OP     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     233     VI     ZZZ    REFERRING/ADMITTING PHYSICIAN                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     234     IP     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     IX     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     LT     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     NX     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     OX     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     PH     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     PX     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     VI     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     234     ZZ     ZZZ    TYPE OF SERVICE ON REVIEW                               250      TYPE OF SERVICE.
     235     IP     ZZZ    PROVIDER ON REVIEW FOR REVENUE CODE                     455      REVENUE CODE FOR SERVICES RENDERED.

     236     DE     ZZZ    PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     236     EP     ZZZ    PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     236     HC     ZZZ    PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     236     VI     ZZZ    PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     236     ZZ     ZZZ    PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP       9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     237     DE     ZZZ    PERFORMING PROVIDER MISSING, INVALID, OR CANCELLED      21       MISSING OR INVALID INFORMATION.
     237     EP     ZZZ    PERFORMING PROVIDER MISSING, INVALID, OR CANCELLED      21       MISSING OR INVALID INFORMATION.
     237     HC     ZZZ    PERFORMING PROVIDER MISSING, INVALID, OR CANCELLED      21       MISSING OR INVALID INFORMATION.




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                                                                   ESC TO 277



                                                                                           277
                   PLAN                                                                    CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                          STATUS   CLAIM STATUS CODE
     237     VI     ZZZ    PERFORMING PROVIDER MISSING, INVALID, OR CANCELLED              21       MISSING OR INVALID INFORMATION.
                           PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP FOR DOS                ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     238     DE     ZZZ    BILLED                                                          91       OF SERVICE.
                           PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP FOR DOS                ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     238     EP     ZZZ    BILLED                                                          91       OF SERVICE.
                           PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP FOR DOS                ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     238     HC     ZZZ    BILLED                                                          91       OF SERVICE.
                           PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP FOR DOS                ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     238     VI     ZZZ    BILLED                                                          91       OF SERVICE.
                           PERFORMING PROVIDER NOT ASSOCIATED WITH THE GROUP FOR DOS                ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     238     ZZ     ZZZ    BILLED                                                          91       OF SERVICE.
     239     IX     ZZZ    CLAIM TYPE MUST BE CROSSOVER FOR PROVIDER                       481      CLAIM/SUBMISSION FORMAT IS INVALID.
     239     NX     ZZZ    CLAIM TYPE MUST BE CROSSOVER FOR PROVIDER                       481      CLAIM/SUBMISSION FORMAT IS INVALID.
     239     OX     ZZZ    CLAIM TYPE MUST BE CROSSOVER FOR PROVIDER                       481      CLAIM/SUBMISSION FORMAT IS INVALID.
     239     PX     ZZZ    CLAIM TYPE MUST BE CROSSOVER FOR PROVIDER                       481      CLAIM/SUBMISSION FORMAT IS INVALID.
     239     ZZ     ZZZ    CLAIM TYPE MUST BE CROSSOVER FOR PROVIDER                       481      CLAIM/SUBMISSION FORMAT IS INVALID.
                                                                                                    MISSING/INVALID DATA PREVENTS PAYER FROM
     240     ZZ     ZZZ    PROVIDER CATEGORY OF SERVICE                                    122      PROCESSING CLAIM.
                                                                                                    MISSING/INVALID DATA PREVENTS PAYER FROM
     241     ZZ     ZZZ    TRANSPLANT SUSPECT     LOCKIN RECORD HAS PROVIDER 444444444     122      PROCESSING CLAIM.
                           TRANSPLANT CLAIM     LOCKIN RECORD DOES NOT HAVE PROVIDER                MISSING/INVALID DATA PREVENTS PAYER FROM
     242     ZZ     ZZZ    444444444                                                       122      PROCESSING CLAIM.
                           TRANSPLANT PRICING PERCENTAGE INVALID     GREATER THAN 80 PCT            MISSING/INVALID DATA PREVENTS PAYER FROM
     243     ZZ     ZZZ    OR 0                                                            122      PROCESSING CLAIM.
     245     ZZ     ZZZ    RECIPIENT HAS NO ELIGIBILITY SEGMENTS                           109      ENTITY NOT ELIGIBLE.

     246     LT     ZZZ    NH PROVIDER BILLING SERVICES FOR A HOSPICE RECIPIENT            109      ENTITY NOT ELIGIBLE.

     247     LT     ZZZ    HOSPICE PROVIDER BILLING SERVICES FOR A NH RECIPIENT            109      ENTITY NOT ELIGIBLE.

     248     ZZ     ZZZ    ELIGIBLE FOR MEDICARE ONLY.     NO MEDICAID OR QMB BENEFITS     109      ENTITY NOT ELIGIBLE.

     249     IX     ZZZ    INVALID CLAIM TYPE FOR RECIPIENT AID CATEGORY 18,38,48 (QMB)    481      CLAIM/SUBMISSION FORMAT IS INVALID.

     249     NX     ZZZ    INVALID CLAIM TYPE FOR RECIPIENT AID CATEGORY 18,38,48 (QMB)    481      CLAIM/SUBMISSION FORMAT IS INVALID.

     249     OX     ZZZ    INVALID CLAIM TYPE FOR RECIPIENT AID CATEGORY 18,38,48 (QMB)    481      CLAIM/SUBMISSION FORMAT IS INVALID.

     249     PX     ZZZ    INVALID CLAIM TYPE FOR RECIPIENT AID CATEGORY 18,38,48 (QMB)    481      CLAIM/SUBMISSION FORMAT IS INVALID.

     249     ZZ     ZZZ    INVALID CLAIM TYPE FOR RECIPIENT AID CATEGORY 18,38,48 (QMB)    481      CLAIM/SUBMISSION FORMAT IS INVALID.
                                                                                                    MISSING/INVALID DATA PREVENTS PAYER FROM
     250     ZZ     ZZZ    RECIPIENT NOT ON FILE                                           122      PROCESSING CLAIM.




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                                                                 ESC TO 277



                                                                                 277
                   PLAN                                                          CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                STATUS   CLAIM STATUS CODE
     251     ZZ     ZZZ    UNUSABLE ELIGIBILITY RECORD                           109      ENTITY NOT ELIGIBLE.

     252     ZZ     ZZZ    RECIPIENT LAST NAME/NUMBER MISMATCH                   30       SUBSCRIBER AND SUBSCRIBER ID MISMATCHED.
                                                                                          ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     253     ZZ     ZZZ    RECIPIENT DECEASED BEFORE HEADER TO DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     IP     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     IX     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     LT     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     NX     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     OX     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     PX     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     254     12     ZZZ    TOTALLY INELIGIBLE FOR HEADER DATES OF SERVICE        91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     255     IP     ZZZ    PARTIALLY INELIGIBLE FOR HEADER DATES OF SERVICE      91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     255     IX     ZZZ    PARTIALLY INELIGIBLE FOR HEADER DATES OF SERVICE      91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     255     NX     ZZZ    PARTIALLY INELIGIBLE FOR HEADER DATES OF SERVICE      91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     255     OX     ZZZ    PARTIALLY INELIGIBLE FOR HEADER DATES OF SERVICE      91       OF SERVICE.
                                                                                          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     255     PX     ZZZ    PARTIALLY INELIGIBLE FOR HEADER DATES OF SERVICE      91       OF SERVICE.

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     256     HC     ZZZ    MEDICARE SUSPECT                                      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     256     IP     ZZZ    MEDICARE SUSPECT                                      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     256     OP     ZZZ    MEDICARE SUSPECT                                      171      (HEALTH, LIABILITY, AUTO, ETC).
     257     IX     ZZZ    EPSDT INDICATOR TO AGE                                21       MISSING OR INVALID INFORMATION.
     257     NX     ZZZ    EPSDT INDICATOR TO AGE                                21       MISSING OR INVALID INFORMATION.
     257     OX     ZZZ    EPSDT INDICATOR TO AGE                                21       MISSING OR INVALID INFORMATION.
     257     PX     ZZZ    EPSDT INDICATOR TO AGE                                21       MISSING OR INVALID INFORMATION.
     257     ZZ     ZZZ    EPSDT INDICATOR TO AGE                                21       MISSING OR INVALID INFORMATION.




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                                                                  ESC TO 277



                                                                                     277
                   PLAN                                                              CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     IX     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     LT     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     NX     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     OX     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     PX     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     258     ZZ     ZZZ    LOCK-IN PATIENT                                           88       SUBMITTED DATES OF SERVICE.

     259     ZZ     ZZZ    RECIPIENT FIRST NAME/NUMBER MISMATCH                      30       SUBSCRIBER AND SUBSCRIBER ID MISMATCHED.
     260     ZZ     ZZZ    V202 DIAGNOSIS INVALID TO CLAIM TYPE J                    255      DIAGNOSIS CODE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     IP     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     IX     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     NX     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     OX     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     PX     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     261     ZZ     ZZZ    RECIPIENT DECEASED BEFORE DETAIL ENDING DATE OF SERVICE   88       SUBMITTED DATES OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     IP     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     IX     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     NX     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     OX     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     PX     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     262     ZZ     ZZZ    TOTALLY INELIGIBLE FOR DETAIL DATE OF SERVICE             91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     IP     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE         91       OF SERVICE.
                                                                                              ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     IX     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE         91       OF SERVICE.




6/16/2011                                                           Page 275
                                                                ESC TO 277



                                                                                      277
                   PLAN                                                               CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     NX     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE          91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     OX     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE          91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     PX     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE          91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     263     ZZ     ZZZ    PARTIALLY INELIGIBILE FOR DETAIL DATES OF SERVICE          91       OF SERVICE.

     264     IP     ZZZ    AGED PSYCHIATRIC PATIENT INELIGIBLE FOR SERVICE            9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     265     ZZ     ZZZ    RECIPIENT NUMBER MISSING/INVALID                           33       SUBSCRIBER AND SUBSCRIBER ID NOT FOUND.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     266     ZZ     ZZZ    Z                                                          91       OF SERVICE.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     267     LT     ZZZ    CENSUS DATA MISSING FOR MONTH PRIOR TO DATES OF SERVICE    122      PROCESSING CLAIM.
     268     IX     ZZZ    REVIEW PATIENT                                             46       INTERNAL REVIEW/AUDIT.
     268     NX     ZZZ    REVIEW PATIENT                                             46       INTERNAL REVIEW/AUDIT.
     268     OX     ZZZ    REVIEW PATIENT                                             46       INTERNAL REVIEW/AUDIT.
     268     PX     ZZZ    REVIEW PATIENT                                             46       INTERNAL REVIEW/AUDIT.
     268     ZZ     ZZZ    REVIEW PATIENT                                             46       INTERNAL REVIEW/AUDIT.
                           HOSPICE RECIPIENT IS NOT DUALLY ELIGIBLE FOR MEDICARE &
     269     LT     ZZZ    MEDICAID                                                   9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     270     LT     ZZZ    NURSING HOME CARE NOT AUTHORIZED                           91       OF SERVICE.

     271     LT     ZZZ    INVALID LOA FOR FACILITY CLASS                             9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                           RECIPIENT AUTHORIZED LEVEL OF CARE MISSING FOR DATES OF             MISSING/INVALID DATA PREVENTS PAYER FROM
     272     LT     ZZZ    SERVICE                                                    122      PROCESSING CLAIM.
                           RECIPIENT AUTHORIZED LEVEL OF CARE INVALID FOR DATES OF             MISSING/INVALID DATA PREVENTS PAYER FROM
     273     LT     ZZZ    SERVICE                                                    122      PROCESSING CLAIM.

     274     LT     ZZZ    RECIPIENT LEVEL OF CARE CHANGED DURING BILLED PERIOD       21       MISSING OR INVALID INFORMATION.

     274     PH     ZZZ    RECIPIENT LEVEL OF CARE CHANGED DURING BILLED PERIOD       21       MISSING OR INVALID INFORMATION.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     275     LT     ZZZ    RECIPIENT PATIENT LIABILITY MISSING FOR DATES OF SERVICE   122      PROCESSING CLAIM.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     276     HC     ZZZ    RECIPIENT INELIGIBLE FOR WAIVER SERVICES W4                91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     276     ZZ     ZZZ    RECIPIENT INELIGIBLE FOR WAIVER SERVICES W4                91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     277     HC     ZZZ    RECIPIENT INELIGIBLE FOR WAIVER SERVICES W1                91       OF SERVICE.




6/16/2011                                                        Page 276
                                                                   ESC TO 277



                                                                                      277
                   PLAN                                                               CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     277     ZZ     ZZZ    RECIPIENT INELIGIBLE FOR WAIVER SERVICES W1                91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     278     ZZ     ZZZ    RECIPIENT INELIGIBLE FOR WAIVER SERVICES W2                91       OF SERVICE.
                                                                                               ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     279     ZZ     ZZZ    W1 RECIPIENT NOT ELIGIBLE FOR TCM SERVICE                  91       OF SERVICE.

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     280     ZZ     ZZZ    THIRD PARTY LIABILITY SUSPECT                              171      (HEALTH, LIABILITY, AUTO, ETC).
     282     HC     ZZZ    MEDICARE SUSPECT                                           116      CLAIM SUBMITTED TO INCORRECT PAYER.
     282     IP     ZZZ    MEDICARE SUSPECT                                           116      CLAIM SUBMITTED TO INCORRECT PAYER.
     282     OP     ZZZ    MEDICARE SUSPECT                                           116      CLAIM SUBMITTED TO INCORRECT PAYER.
     282     VI     ZZZ    MEDICARE SUSPECT                                           116      CLAIM SUBMITTED TO INCORRECT PAYER.
     285     ZZ     ZZZ    CLIENT CAN NOT BE BILLED ON THIS CLAIM TYPE                481      CLAIM/SUBMISSION FORMAT IS INVALID.

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     286     ZZ     ZZZ    TPL INJURY SUSPECT                                         171      (HEALTH, LIABILITY, AUTO, ETC).
     287     ZZ     ZZZ    PROVIDER CAN NOT BILL THIS CLAIM TYPE                      481      CLAIM/SUBMISSION FORMAT IS INVALID.
     288     ZZ     ZZZ    PERFORMING PROVIDER INELIGIBLE FOR CLAIM TYPE              109      ENTITY NOT ELIGIBLE.
     300     IP     ZZZ    DOS BEFORE 10/1/85   --   PAS DAYS CHECK                   456      COVERED DAY(S).

     301     IP     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     IX     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     LT     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     NX     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     OX     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     PX     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     301     ZZ     ZZZ    PROCEDURE/NDC CODE MISSING OR INVALID                      454      PROCEDURE CODE FOR SERVICES RENDERED.

     302     OP     ZZZ    NON EMERGENCY PROCEDURE BILLED TO AN EMERGENCY IND CLAIM   454      PROCEDURE CODE FOR SERVICES RENDERED.

     303     OP     ZZZ    EMERGENCY PROCEDURE BILLED WITHOUT EMERG APPR IND          454      PROCEDURE CODE FOR SERVICES RENDERED.
     304     IP     ZZZ    SURGEON'S NAME, NONPART, OR MEDICAID NUMBER NOT IND        153      ENTITY'S ID NUMBER.
     304     OP     ZZZ    SURGEON'S NAME, NONPART, OR MEDICAID NUMBER NOT IND        153      ENTITY'S ID NUMBER.




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                                                                               277
                   PLAN                                                        CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                              STATUS   CLAIM STATUS CODE

                                                                                        OTHER INSURANCE COVERAGE INFORMATION
     306     IX     ZZZ    TPL AMOUNT PRESENT/TPL1 CODE MISSING                171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                        OTHER INSURANCE COVERAGE INFORMATION
     306     NX     ZZZ    TPL AMOUNT PRESENT/TPL1 CODE MISSING                171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                        OTHER INSURANCE COVERAGE INFORMATION
     306     OX     ZZZ    TPL AMOUNT PRESENT/TPL1 CODE MISSING                171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                        OTHER INSURANCE COVERAGE INFORMATION
     306     PX     ZZZ    TPL AMOUNT PRESENT/TPL1 CODE MISSING                171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                        OTHER INSURANCE COVERAGE INFORMATION
     306     ZZ     ZZZ    TPL AMOUNT PRESENT/TPL1 CODE MISSING                171      (HEALTH, LIABILITY, AUTO, ETC).
     307     IP     ZZZ    HEADER DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     307     LT     ZZZ    HEADER DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     307     OP     ZZZ    HEADER DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     DE     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     EP     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     HC     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     OP     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     PH     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     308     VI     ZZZ    DETAIL DATES OF SERVICE SPAN STATE FISCAL YEARS     187      DATE(S) OF SERVICE.
     309     ZZ     ZZZ    DIAGNOSIS NOT ON DIAGNOSIS 'PAS' LENGTH OF STAY     255      DIAGNOSIS CODE.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     IP     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     IX     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     NX     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     OX     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     PX     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.
                                                                                        MISSING/INVALID DATA PREVENTS PAYER FROM
     310     ZZ     ZZZ    SUBMITTED LINE ITEM CHARGE NON-NUMERIC              122      PROCESSING CLAIM.

     311     IP     ZZZ    CLAIM HEADER TO DOS OVER TWO YEARS OLD              9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     311     IX     ZZZ    CLAIM HEADER TO DOS OVER TWO YEARS OLD              9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.




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                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE

     311     NX     ZZZ    CLAIM HEADER TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     311     OX     ZZZ    CLAIM HEADER TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     311     PX     ZZZ    CLAIM HEADER TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     IP     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     IX     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     NX     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     OX     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     PX     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     312     ZZ     ZZZ    CLAIM DETAIL TO DOS OVER TWO YEARS OLD                        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     313     IP     ZZZ    ADMIT DIAGNOSIS MISSING, INVALID, OR NOT ON FILE              232      ADMITTING DIAGNOSIS.
     314     HC     ZZZ    BEGIN/END DATES NOT SAME MONTH                                187      DATE(S) OF SERVICE.
     314     OP     ZZZ    BEGIN/END DATES NOT SAME MONTH                                187      DATE(S) OF SERVICE.
                           TOS L DEPENDENT UPON ELIGIBILITY FOR W5 WAIVER SERVICES FOR            ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     315     HC     ZZZ    DOS                                                           91       OF SERVICE.
     316     ZZ     ZZZ    NON-COVERED MEDICAID SERVICE                                  84       SERVICE NOT AUTHORIZED.
     317     ZZ     ZZZ    LEVEL OF CARE INVALID                                         21       MISSING OR INVALID INFORMATION.
     319     IP     ZZZ    DATES OF SERVICE TO PSRO DATES                                187      DATE(S) OF SERVICE.
     320     IP     ZZZ    PSRO DATES MISSING/INVALID                                    188      STATEMENT FROM-THROUGH DATES.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     EP     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     HC     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     IP     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     IX     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     LT     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     321     OP     ZZZ    RATE NOT ON FILE FOR DATES OF SERVICE                         122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     322     IP     ZZZ    SURGERY INFORMATION INCOMPLETE                                122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     323     IX     ZZZ    TPL-1 CODE INVALID                                            122      PROCESSING CLAIM.




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                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     323     NX     ZZZ    TPL-1 CODE INVALID                                            122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     323     OX     ZZZ    TPL-1 CODE INVALID                                            122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     323     PX     ZZZ    TPL-1 CODE INVALID                                            122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     323     ZZ     ZZZ    TPL-1 CODE INVALID                                            122      PROCESSING CLAIM.

     324     OP     ZZZ    OCCURRENCE CODE 05 AND DATE REQ FOR BURN DRESSING CHANGE      461      NUBC OCCURRENCE CODE(S) AND DATES(S)

     325     HC     ZZZ    GLOBAL OB PROCEDURE REQ MINIMUM 4 MONTHS CARE                 263      LENGTH OF TIME FOR SERVICES RENDERED.

     326     HC     ZZZ    GLOBAL OB PROC REQ MINIMUM 2 MONTHS CARE                      263      LENGTH OF TIME FOR SERVICES RENDERED.

     327     IP     ZZZ    SURGICAL REVENUE CODE REQUIRES A SURGICAL PROCEDURE CODE      454      PROCEDURE CODE FOR SERVICES RENDERED.
     332     ZZ     ZZZ    MANUAL PRICE GREATER THAN DETAIL BILLED                       110      CLAIM REQUIRES PRICING INFORMATION.
                                                                                                  ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES
     343     ZZ     ZZZ    PERSONAL CARE NOT ALLOWED TO ASSISTED LIVING WAIVER CLIENTS   91       OF SERVICE.
     345     OP     ZZZ    PROVIDER SPECIALTY IH/IS LIMITED TO PC T1015                  145      ENTITY'S SPECIALTY CODE.
     351     ZZ     ZZZ    LINE ITEM TOTAL BILLED CROSSFOOT                              247      LINE INFORMATION.
     352     ZZ     ZZZ    ACCOMMODATION RATE ERROR                                      21       MISSING OR INVALID INFORMATION.
     353     ZZ     ZZZ    REIMBURSEMENT RATE ERROR                                      21       MISSING OR INVALID INFORMATION.
     354     IP     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     IX     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     LT     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     NX     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     OX     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     PX     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     354     ZZ     ZZZ    MANUAL PRICE INVALID/NOT ACCOMPANIED BY EOB                   110      CLAIM REQUIRES PRICING INFORMATION.
     355     DE     ZZZ    MANUAL PRICE REQUIRED                                         110      CLAIM REQUIRES PRICING INFORMATION.
     355     EP     ZZZ    MANUAL PRICE REQUIRED                                         110      CLAIM REQUIRES PRICING INFORMATION.
     355     HC     ZZZ    MANUAL PRICE REQUIRED                                         110      CLAIM REQUIRES PRICING INFORMATION.
     355     OP     ZZZ    MANUAL PRICE REQUIRED                                         110      CLAIM REQUIRES PRICING INFORMATION.
     355     VI     ZZZ    MANUAL PRICE REQUIRED                                         110      CLAIM REQUIRES PRICING INFORMATION.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED
     356     ZZ     ZZZ    MAXIMUM AMOUNT EXCEEDED                                       483      FOR BENEFIT PERIOD.
     357     IX     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
     357     LT     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
     357     NX     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
     357     OP     ZZZ    VARIANCE                                                      247      LINE INFORMATION.




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                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE
     357     OX     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
     357     PX     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
     357     ZZ     ZZZ    VARIANCE                                                      247      LINE INFORMATION.
                           ONLY ALLOW CERTAIN RSPMI SERVICES TO BE PAYABLE FOR NURSING
     359     ZZ     ZZZ    HOME RESIDENTS                                                109      ENTITY NOT ELIGIBLE.

     361     ZZ     ZZZ    ACCOMMODATION RATE ADJUSTED TO RATE ON MEDICAID FILE          65       CLAIM/LINE HAS BEEN PAID.
     362     ZZ     ZZZ    PATIENT LIABILITY APPLIED TO BILLED AMOUNT                    65       CLAIM/LINE HAS BEEN PAID.
     366     ZZ     ZZZ    PAID IN PART BY MEDICARE                                      68       PARTIAL PAYMENT MADE FOR THIS CLAIM.
     370     ZZ     ZZZ    VISION MANUAL REVIEW                                          46       INTERNAL REVIEW/AUDIT.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     385     ZZ     ZZZ    WAIVER ELIGIBILITY MISSING/INVALID                            122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     386     ZZ     ZZZ    WAIVER LIABILITY MISSING/INVALID                              122      PROCESSING CLAIM.
     389     ZZ     ZZZ    PA NUMBER NOT ON PA MASTER                                    252      AUTHORIZATION/CERTIFICATION NUMBER.
     390     ZZ     ZZZ    CLAIM PROVIDER NUM NOT MATCH P.A. PROVIDER NUM                252      AUTHORIZATION/CERTIFICATION NUMBER.
     391     ZZ     ZZZ    ANESTHESIA PROCEDURE NOT PRIOR AUTHORIZED                     252      AUTHORIZATION/CERTIFICATION NUMBER.
     392     ZZ     ZZZ    AUTHORIZED P.A. UNITS EXHAUSTED                               252      AUTHORIZATION/CERTIFICATION NUMBER.
     393     IP     ZZZ    CLAIM RID NOT MATCH P.A. RID                                  252      AUTHORIZATION/CERTIFICATION NUMBER.
     393     PH     ZZZ    CLAIM RID NOT MATCH P.A. RID                                  252      AUTHORIZATION/CERTIFICATION NUMBER.
     393     ZZ     ZZZ    CLAIM RID NOT MATCH P.A. RID                                  252      AUTHORIZATION/CERTIFICATION NUMBER.
     394     ZZ     ZZZ    TOOTH NUMBER NOT PRIOR AUTHORIZED                             244      TOOTH NUMBER OR LETTER.
     395     ZZ     ZZZ    CLAIM RECORD POS DOES NOT MATCH PA RECORD POS                 249      PLACE OF SERVICE.
     396     ZZ     ZZZ    CLAIM RECORD TOS DOES NOT MATCH PA RECORD TOS                 250      TYPE OF SERVICE.
     397     DE     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     HC     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     IP     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     OP     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     PH     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     VI     ZZZ    P.A. NUMBER MISSING/INVALID                                   252      AUTHORIZATION/CERTIFICATION NUMBER.
     397     ZZ     CMS    PA NUMBER MISSING/INVALID                                     252      AUTHORIZATION/CERTIFICATION NUMBER.
     398     IP     ZZZ    INVALID PRIOR AUTHORIZATION INDICATOR                         252      AUTHORIZATION/CERTIFICATION NUMBER.
     398     ZZ     ZZZ    INVALID PRIOR AUTHORIZATION INDICATOR                         252      AUTHORIZATION/CERTIFICATION NUMBER.
     399     IP     ZZZ    PRIOR AUTHORIZATION REQUIRED                                  252      AUTHORIZATION/CERTIFICATION NUMBER.
     399     ZZ     ZZZ    PRIOR AUTHORIZATION REQUIRED                                  252      AUTHORIZATION/CERTIFICATION NUMBER.
     900     PH     ZZZ    PRESCRIPTION NUMBER                                           219      PRESCRIPTION NUMBER.
     901     PH     ZZZ    DRUG QUANTITY MUST BE NUMERIC                                 216      DRUG INFORMATION.
     902     ZZ     ZZZ    MAXIMUM/MINIMUM QUANTITY                                      216      DRUG INFORMATION.
     903     PH     ZZZ    DAYS SUPPLY NOT NUMERIC OR EXCEEDS 31 DAYS                    221      DRUG DAYS SUPPLY AND DOSAGE.




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                                                                                        277
                   PLAN                                                                 CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                       STATUS   CLAIM STATUS CODE
     904     PH     ZZZ    COMPOUND DRUG                                                216      DRUG INFORMATION.
     905     PH     ZZZ    DISCONTINUED DRUG                                            216      DRUG INFORMATION.
     907     PH     ZZZ    PRESCRIBING PHYSICIAN INVALID/NOF                            21       MISSING OR INVALID INFORMATION.
     910     ZZ     ZZZ    INVALID DISPENSING FEE                                       216      DRUG INFORMATION.
     911     PH     ZZZ    INVALID REFILL INDICATOR                                     216      DRUG INFORMATION.
     913     ZZ     ZZZ    PRESCRIPTION NUMBER INPUT                                    219      PRESCRIPTION NUMBER.

     915     PH     ZZZ    DESI DRUG DISCONTINUED PRIOR TO FROM DATE OF SERVICE         216      DRUG INFORMATION.
                                                                                                 ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     918     PH     ZZZ    INVALID CT FOR RECIPIENT AID CATEGORY 99                     88       SUBMITTED DATES OF SERVICE.
                                                                                                 ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     918     ZZ     ZZZ    INVALID CT FOR RECIPIENT AID CATEGORY 99                     88       SUBMITTED DATES OF SERVICE.

     919     PH     ZZZ    OTC DRUGS NOT PAYABLE TO LONG TERM CARE RECIPIENTS           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                           COVERAGE RESTRICTED DRUG BILLED W/O COVERAGE RESTRICTED
     920     PH     ZZZ    INDICATOR                                                    216      DRUG INFORMATION.
     922     PH     ZZZ    CLAIM MUST BE BILLED THRU AEVCS (REGION 05)                  481      CLAIM/SUBMISSION FORMAT IS INVALID.

     928     PH     ZZZ    DRUG PAC S SUSPEND                                           9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
     929     IX     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.
     929     LT     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.
     929     NX     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.
     929     OX     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.
     929     PX     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.
     929     ZZ     ZZZ    A VALID CLIA NUMBER IS REQUIRED FOR THIS PROCEDURE           21       MISSING OR INVALID INFORMATION.

     930     PH     ZZZ    NAME BRAND DRUG BILLED WITHOUT MEDICAL NECESSITY INDICATOR   287      MEDICAL NECESSITY FOR SERVICE.
     931     HC     ZZZ    INJECTION REQUIRES SPECIFIC DIAGNOSIS CODE                   255      DIAGNOSIS CODE.
     931     OP     ZZZ    INJECTION REQUIRES SPECIFIC DIAGNOSIS CODE                   255      DIAGNOSIS CODE.

     940     PH     ZZZ    MEDICALLY NECESSARY CLAIMS REQUIRE PRIOR AUTHORIZATION       252      AUTHORIZATION/CERTIFICATION NUMBER.

     940     ZZ     ZZZ    MEDICALLY NECESSARY CLAIMS REQUIRE PRIOR AUTHORIZATION       252      AUTHORIZATION/CERTIFICATION NUMBER.
     950     PH     ZZZ    VERIFY DUR CODE VALUES                                       216      DRUG INFORMATION.
                                                                                                 CLAIM NOT FOUND, CLAIM SHOULD HAVE BEEN
     951     PH     ZZZ    PREVIOUSLY DUR ALERTED CLAIM CANNOT BE FOUND                 487      SUBMITTED TO/THROUGH 'ENTITY'.
     952     PH     ZZZ    PREVIOUSLY DUR ALERTED CLAIM CANNOT BE OVERRIDDEN            216      DRUG INFORMATION.

     999                   TEMPORARY SUSPENSION - WILL RELEASE NEXT CYCLE               55       CLAIM ASSIGNED TO AN APPROVER/ANALYST.
     Y01     ZZ     ZZZ    VERIFY DOSAGE FORM DESCRIPTION CODE                          216      DRUG INFORMATION.
     Y02     ZZ     ZZZ    VERIFY COMPOUND DISPENSING UNIT FORM INDICATOR               216      DRUG INFORMATION.




6/16/2011                                                         Page 282
                                                                  ESC TO 277



                                                                                    277
                   PLAN                                                             CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
     Y03     ZZ     ZZZ    VERIFY COMPOUND ROUTE OF ADMINISTRATION                  216      DRUG INFORMATION.
     Y04     ZZ     ZZZ    VERIFY COMPOUND INGREDIENT COMPONENT COUNT               216      DRUG INFORMATION.
     Y05     ZZ     ZZZ    VERIFY COMPOUND PRODUCT ID QUALIFIER                     216      DRUG INFORMATION.
     Y06     ZZ     ZZZ    VERIFY COMPOUND INGREDIENT QUANTITY                      216      DRUG INFORMATION.
     Y07     ZZ     ZZZ    VERIFY COMPOUND INGREDIENT DRUG COST                     216      DRUG INFORMATION.
     Y08     ZZ     ZZZ    VERIFY CLINICAL SEGMENT                                  216      DRUG INFORMATION.
     Y09     ZZ     ZZZ    VERIFY DIAGNOSIS CODE COUNT                              426      ALL CURRENT DIAGNOSES.
     Y10     ZZ     ZZZ    VERIFY DIAGNOSIS CODE QUALIFIER                          426      ALL CURRENT DIAGNOSES.
     Y11     ZZ     ZZZ    VERIFY DIAGNOSIS CODE                                    255      DIAGNOSIS CODE.
     Y12     ZZ     ZZZ    VERIFY CLINICAL INFORMATION COUNTER                      216      DRUG INFORMATION.
     Y13     ZZ     ZZZ    MEASUREMENT DATE                                         216      DRUG INFORMATION.
     Y14     ZZ     ZZZ    MEASUREMENT TIME                                         216      DRUG INFORMATION.
     Y15     ZZ     ZZZ    MEASUREMENT DIMENSION                                    216      DRUG INFORMATION.
     Y16     ZZ     ZZZ    MEASUREMENT UNIT                                         216      DRUG INFORMATION.
     Y17     ZZ     ZZZ    VERIFY COMPOUND SEGMENT                                  216      DRUG INFORMATION.
     Y18     ZZ     ZZZ    VERIFY VALUE CODE IS A VALID VALUE                       463      NUBC VALUE CODE(S) AND/OR AMOUNT(S).
     Y19     ZZ     ZZZ    VERIFY VALUE AMOUNT IS A VALID VALUE                     463      NUBC VALUE CODE(S) AND/OR AMOUNT(S).

     Y20     ZZ     ZZZ    OCCURRENCE SPAN CODE IS INVALID                          462      NUBC OCCURRENCE SPAN CODE(S) AND DATE(S).
     Y21     ZZ     ZZZ    EMERGENCY DIAGNOSIS CODE IS INVALID                      255      DIAGNOSIS CODE.
                                                                                             MISSING/INVALID DATA PREVENTS PAYER FROM
     Y22     ZZ     ZZZ    PAYER ID                                                 122      PROCESSING CLAIM.
                                                                                             MISSING/INVALID DATA PREVENTS PAYER FROM
     Y23     ZZ     ZZZ    EPSDT INDICATOR                                          122      PROCESSING CLAIM.
                           PROCEDURE CODE CANNOT BE ENTERED WITH THE REVENUE CODE
     Y24     ZZ     ZZZ    ENTERED                                                  454      PROCEDURE CODE FOR SERVICES RENDERED.
                                                                                             MISSING/INVALID DATA PREVENTS PAYER FROM
     Y25     ZZ     ZZZ    FACILITY ADDRESS INFORMATION                             122      PROCESSING CLAIM.
                                                                                             MISSING/INVALID DATA PREVENTS PAYER FROM
     Y26     ZZ     ZZZ    CLAIM FILING INDICATOR                                   122      PROCESSING CLAIM.
                                                                                             DIAGNOSIS CODE POINTER IS MISSING OR
     Y27     ZZ     ZZZ    DIAGNOSIS POINTER                                        477      INVALID.
                                                                                             MISSING/INVALID DATA PREVENTS PAYER FROM
     Y28     ZZ     ZZZ    LINE ITEM CONTROL NUMBER                                 122      PROCESSING CLAIM.
     Y29     ZZ     ZZZ    UNIVERSAL PRODUCT NUMBER (UPN)                           220      DRUG PRODUCTION ID NUMBER.
     Y30     ZZ     ZZZ    DRUG NDC                                                 218      NDC NUMBER.
                                                                                             DRUG DISPENSING UNITS AND AVERAGE
     Y31     ZZ     ZZZ    DRUG UNIT PRC                                            222      WHOLESALE PRICE (AWP).
     Y32     ZZ     ZZZ    DRUG QUANTITY                                            221      DRUG DAYS SUPPLY AND DOSAGE.
     Y33     ZZ     ZZZ    DRUG QUANTITY QUALIFIER                                  221      DRUG DAYS SUPPLY AND DOSAGE.




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                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
     Y34     ZZ     ZZZ    MEDICARE PAID AMOUNT MUST BE NUMERIC                           402      AMOUNT MUST BE GREATER THAN ZERO.
     Y35     ZZ     ZZZ    MEDICARE ALLOWED AMOUNT MUST BE NUMERIC AND >0                 402      AMOUNT MUST BE GREATER THAN ZERO.
     Y36     ZZ     ZZZ    MEDICARE TOTAL BILLED MUST BE NUMERIC                          402      AMOUNT MUST BE GREATER THAN ZERO.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Y37     ZZ     ZZZ    MEDICARE COINSURANCE                                           122      PROCESSING CLAIM.
                           SUM OF DETAIL MEDICARE ALLOWED AMOUNTS MUST = HEADER
     Y38     ZZ     ZZZ    MEDICARE ALLOWED AMOUNT                                        400      CLAIM IS OUT OF BALANCE.
                           SUM OF DETAIL MEDICARE BILLED AMOUNTS MUST = HEADER MEDICARE
     Y39     ZZ     ZZZ    BILLED AMOUNT                                                  400      CLAIM IS OUT OF BALANCE.
     Y40     ZZ     ZZZ    MEDICARE DEDUCTIBLE MUST BE NUMERIC                            402      AMOUNT MUST BE GREATER THAN ZERO.
     Y41     ZZ     ZZZ    NON-COVERED CHARGE MUST BE NUMERIC                             402      AMOUNT MUST BE GREATER THAN ZERO.

     Y42     ZZ     ZZZ    SETS IF NON-COVERED CHARGE >0 AND IS >0 = TO CHARGE AMOUNT     402      AMOUNT MUST BE GREATER THAN ZERO.
     Y43     ZZ     ZZZ    TO COVER (ZXG26) MED NEC                                       287      MEDICAL NECESSITY FOR SERVICE.
                           TO COVER THE COMBINATIONS OF NDC NUMBERS AND COMPOUND CODE
     Y44     ZZ     ZZZ    CONDITIONS                                                     216      DRUG INFORMATION.

     Y49     ZZ     ZZZ    TYPE OF SERVICE DEFAULT-PLUGGING DEFAULT TYPE OF SERVICE X     250      TYPE OF SERVICE.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Y50     ZZ     ZZZ    FAMILY PLAN INDICATOR                                          122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Y51     ZZ     ZZZ    INVALID JULIAN DATE                                            122      PROCESSING CLAIM.
     Y52     ZZ     ZZZ    FUTURE FROM DATE OF SERVICE                                    187      DATE(S) OF SERVICE.
     Y53     ZZ     ZZZ    FUTURE TO DATE OF SERVICE                                      187      DATE(S) OF SERVICE.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Y54     ZZ     ZZZ    13 DIGIT ICN REQUIRED                                          122      PROCESSING CLAIM.
     Y55     ZZ     ZZZ    CLAIM FILING INDICATOR NOT VALID (CROSSOVER CLAIM)             481      CLAIM/SUBMISSION FORMAT IS INVALID.

     Y56     DE     ZZZ    VERIFY IF DENTAL DETAIL UNITS IS DIVISIBLE BY TOOTH COUNT      476      MISSING OR INVALID UNITS OF SERVICE.
                           ONE OR MORE OF THE MODIFIER EXPLANATION INDICATORS ARE                  MISSING/INVALID DATA PREVENTS PAYER FROM
     Z00     HC     ZZZ    INVALID                                                        122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z01     12     ZZZ    EPSDT SCREENING TYPE IS INVALID                                122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z01     EV     ZZZ    EPSDT SCREENING TYPE IS INVALID                                122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z01     ZZ     ZZZ    EPSDT SCREENING TYPE IS INVALID                                122      PROCESSING CLAIM.
     Z02     HC     ZZZ    ANESTHESIA UNITS, HOURS, OR MINUTES ARE INVALID                251      TOTAL ANESTHESIA MINUTES.
     Z02     ZZ     ZZZ    ANESTHESIA UNITS, HOURS, OR MINUTES ARE INVALID                251      TOTAL ANESTHESIA MINUTES.
                                                                                                   ACCIDENT DATE, STATE, DESCRIPTION AND
     Z03     DE     ZZZ    EMPLOYMENT RELATED INDICATOR IS INVALID                        248      CAUSE.




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                                                                   ESC TO 277



                                                                                     277
                   PLAN                                                              CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z03     EP     ZZZ    EMPLOYMENT RELATED INDICATOR IS INVALID                   248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z03     HC     ZZZ    EMPLOYMENT RELATED INDICATOR IS INVALID                   248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z03     VI     ZZZ    EMPLOYMENT RELATED INDICATOR IS INVALID                   248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z03     ZZ     ZZZ    EMPLOYMENT RELATED INDICATOR IS INVALID                   248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z04     DE     ZZZ    ACCIDENT RELATED INDICATOR IS INVALID                     248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z04     EP     ZZZ    ACCIDENT RELATED INDICATOR IS INVALID                     248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z04     HC     ZZZ    ACCIDENT RELATED INDICATOR IS INVALID                     248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z04     VI     ZZZ    ACCIDENT RELATED INDICATOR IS INVALID                     248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z04     ZZ     ZZZ    ACCIDENT RELATED INDICATOR IS INVALID                     248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z05     DE     ZZZ    OTHER ACCIDENT RELATED INDICATOR IS INVALID               248      CAUSE.
                                                                                              ACCIDENT DATE, STATE, DESCRIPTION AND
     Z05     ZZ     ZZZ    OTHER ACCIDENT RELATED INDICATOR IS INVALID               248      CAUSE.
     Z06     PH     ZZZ    PHARMACY COUPON INDICATOR IS INVALID                      216      DRUG INFORMATION.
     Z06     ZZ     ZZZ    PHARMACY COUPON INDICATOR IS INVALID                      216      DRUG INFORMATION.
                           ONE OR MORE OF THE EPSDT CLAIM SCREENING INDICATORS ARE            MISSING/INVALID DATA PREVENTS PAYER FROM
     Z07     EP     ZZZ    INVALID                                                   122      PROCESSING CLAIM.
                           ONE OR MORE OF THE EPSDT CLAIM SCREENING INDICATORS ARE            MISSING/INVALID DATA PREVENTS PAYER FROM
     Z07     ZZ     ZZZ    INVALID                                                   122      PROCESSING CLAIM.
                           ONE OR MORE OF THE EPSDT CLAIM SCREENING INDICATORS ARE            MISSING/INVALID DATA PREVENTS PAYER FROM
     Z08     EP     ZZZ    INVALID                                                   122      PROCESSING CLAIM.
                           ONE OR MORE OF THE EPSDT CLAIM SCREENING INDICATORS ARE            MISSING/INVALID DATA PREVENTS PAYER FROM
     Z08     ZZ     ZZZ    INVALID                                                   122      PROCESSING CLAIM.
     Z09     ZZ     ZZZ    NET BILLED IS INVALID                                     400      CLAIM IS OUT OF BALANCE.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     Z10     DE     ZZZ    EPSDT INDICATOR IS INVALID                                122      PROCESSING CLAIM.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     Z10     HC     ZZZ    EPSDT INDICATOR IS INVALID                                122      PROCESSING CLAIM.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     Z10     PH     ZZZ    EPSDT INDICATOR IS INVALID                                122      PROCESSING CLAIM.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     Z10     VI     ZZZ    EPSDT INDICATOR IS INVALID                                122      PROCESSING CLAIM.
                                                                                              MISSING/INVALID DATA PREVENTS PAYER FROM
     Z10     ZZ     ZZZ    EPSDT INDICATOR IS INVALID                                122      PROCESSING CLAIM.




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                                                                ESC TO 277



                                                                                         277
                   PLAN                                                                  CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                        STATUS   CLAIM STATUS CODE

     Z11     OP     ZZZ    DETAIL DATES OF SERVICE NOT WITHIN HEADER DATES OF SERVICE    187      DATE(S) OF SERVICE.

     Z11     ZZ     ZZZ    DETAIL DATES OF SERVICE NOT WITHIN HEADER DATES OF SERVICE    187      DATE(S) OF SERVICE.
     Z12     IP     ZZZ    ADMIT SOURCE IS INVALID                                       229      HOSPITAL ADMISSION SOURCE.
     Z12     ZZ     ZZZ    ADMIT SOURCE IS INVALID                                       229      HOSPITAL ADMISSION SOURCE.
     Z14     IP     ZZZ    ADMIT HOUR IS INVALID                                         230      HOSPITAL ADMISSION HOUR.
     Z14     OP     ZZZ    ADMIT HOUR IS INVALID                                         230      HOSPITAL ADMISSION HOUR.
     Z14     ZZ     ZZZ    ADMIT HOUR IS INVALID                                         230      HOSPITAL ADMISSION HOUR.
     Z16     IP     ZZZ    DISCHARGE HOUR IS INVALID                                     233      HOSPITAL DISCHARGE HOUR.
     Z16     OP     ZZZ    DISCHARGE HOUR IS INVALID                                     233      HOSPITAL DISCHARGE HOUR.
     Z16     ZZ     ZZZ    DISCHARGE HOUR IS INVALID                                     233      HOSPITAL DISCHARGE HOUR.
     Z17     IP     ZZZ    NON-COVERED DAYS ARE INVALID                                  457      NON-COVERED DAY(S).
     Z17     ZZ     ZZZ    NON-COVERED DAYS ARE INVALID                                  457      NON-COVERED DAY(S).
     Z18     IP     ZZZ    ONE OR MORE OF THE OCCURRENCE CODES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z18     OP     ZZZ    ONE OR MORE OF THE OCCURRENCE CODES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z18     ZZ     ZZZ    ONE OR MORE OF THE OCCURRENCE CODES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z19     IP     ZZZ    ONE OR MORE OF THE OCCURRENCE DATES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z19     OP     ZZZ    ONE OR MORE OF THE OCCURRENCE DATES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z19     ZZ     ZZZ    ONE OR MORE OF THE OCCURRENCE DATES ARE INVALID               461      NUBC OCCURRENCE CODE(S) AND DATES(S)
                           ONE OR MORE OF THE OCCURRENCE DATES ARE NOT BETWEEN HDR
     Z20     IP     ZZZ    DATES OF SERVICE                                              461      NUBC OCCURRENCE CODE(S) AND DATES(S)
                           ONE OR MORE OF THE OCCURRENCE DATES ARE NOT BETWEEN HDR
     Z20     OP     ZZZ    DATES OF SERVICE                                              461      NUBC OCCURRENCE CODE(S) AND DATES(S)
                           ONE OR MORE OF THE OCCURRENCE DATES ARE NOT BETWEEN HDR
     Z20     ZZ     ZZZ    DATES OF SERVICE                                              461      NUBC OCCURRENCE CODE(S) AND DATES(S)
     Z21     IP     ZZZ    ONE OR MORE OF THE CONDITION CODES ARE INVALID                460      NUBC CONDITION CODE(S).
     Z21     OP     ZZZ    ONE OR MORE OF THE CONDITION CODES ARE INVALID                460      NUBC CONDITION CODE(S).
     Z21     ZZ     ZZZ    ONE OR MORE OF THE CONDITION CODES ARE INVALID                460      NUBC CONDITION CODE(S).

                                                                                                  TPO REJECTED CLAIM/LINE BECAUSE CLAIM DOES
     Z22     ZZ     ZZZ    TPL AMOUNT IS MISSING OR INVALID                              120      NOT CONTAIN ENOUGH INFORMATION.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     Z23     IP     ZZZ    SURGERY, OCCURRENCE, OR CONDITION COUNT IS MISSING OR INVALID 122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     Z23     OP     ZZZ    SURGERY, OCCURRENCE, OR CONDITION COUNT IS MISSING OR INVALID 122      PROCESSING CLAIM.
                                                                                                  MISSING/INVALID DATA PREVENTS PAYER FROM
     Z23     ZZ     ZZZ    SURGERY, OCCURRENCE, OR CONDITION COUNT IS MISSING OR INVALID 122      PROCESSING CLAIM.
                           TOTAL LICENSED BEDS ON CENSUS MUST BE EQUAL OR LESS THAN ON            MISSING/INVALID DATA PREVENTS PAYER FROM
     Z24     CN     ZZZ    FILE                                                          122      PROCESSING CLAIM.




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                                                                ESC TO 277



                                                                                          277
                   PLAN                                                                   CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                         STATUS   CLAIM STATUS CODE
                           TOTAL LICENSED BEDS ON CENSUS MUST BE EQUAL OR LESS THAN ON             MISSING/INVALID DATA PREVENTS PAYER FROM
     Z24     ZZ     ZZZ    FILE                                                           122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z25     CN     ZZZ    ONE OR MORE OF THE COUNTS ON THE CENSUS ARE NOT NUMERIC        122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z25     ZZ     ZZZ    ONE OR MORE OF THE COUNTS ON THE CENSUS ARE NOT NUMERIC        122      PROCESSING CLAIM.
                                                                                                   TPO REJECTED CLAIM/LINE BECAUSE PAYER NAME
     Z26     ZZ     ZZZ    TPL COMPANY CODE AND/OR NAME IS MISSING OR INVALID             118      IS MISSING.
                                                                                                   TPO REJECTED CLAIM/LINE BECAUSE PAYER NAME
     Z27     HC     ZZZ    SECONDARY TPL COMPANY CODE AND/OR NAME IS MISSING OR INVALID   118      IS MISSING.
                                                                                                   TPO REJECTED CLAIM/LINE BECAUSE PAYER NAME
     Z27     ZZ     ZZZ    SECONDARY TPL COMPANY CODE AND/OR NAME IS MISSING OR INVALID   118      IS MISSING.
                           HEADER DOS COVERED BY MULTIPLE ID CARD NUMBERS, CALL EDS &
     Z28     ZZ     ZZZ    REBILL                                                         197      EFFECTIVE COVERAGE DATE(S).
     Z29     CN     ZZZ    HEADER DATE OF SERVICE IS OVER ONE YEAR OLD                    187      DATE(S) OF SERVICE.
     Z29     IP     ZZZ    HEADER DATE OF SERVICE IS OVER ONE YEAR OLD                    187      DATE(S) OF SERVICE.
     Z29     LT     ZZZ    HEADER DATE OF SERVICE IS OVER ONE YEAR OLD                    187      DATE(S) OF SERVICE.
     Z29     ZZ     ZZZ    HEADER DATE OF SERVICE IS OVER ONE YEAR OLD                    187      DATE(S) OF SERVICE.
     Z30     ZZ     ZZZ    DETAIL DATE OF SERVICE IS OVER ONE YEAR OLD                    187      DATE(S) OF SERVICE.
     Z31     12     ZZZ    SOCIAL SECURITY NUMBER NOT FOUND                               148      ENTITY'S SOCIAL SECURITY NUMBER.
     Z31     EV     ZZZ    SOCIAL SECURITY NUMBER NOT FOUND                               148      ENTITY'S SOCIAL SECURITY NUMBER.
     Z31     ZZ     ZZZ    SOCIAL SECURITY NUMBER NOT FOUND                               148      ENTITY'S SOCIAL SECURITY NUMBER.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z32     LT     ZZZ    LEAVE OF ABSENCE COUNT IS MISSING OR INVALID                   122      PROCESSING CLAIM.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z32     ZZ     ZZZ    LEAVE OF ABSENCE COUNT IS MISSING OR INVALID                   122      PROCESSING CLAIM.
                                                                                                   OTHER CARRIER CLAIM FILING INDICATOR IS
     Z33     HC     ZZZ    SECONDARY TPL INDICATOR IS INVALID                             480      MISSING OR INVALID.
                                                                                                   OTHER CARRIER CLAIM FILING INDICATOR IS
     Z33     ZZ     ZZZ    SECONDARY TPL INDICATOR IS INVALID                             480      MISSING OR INVALID.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z34     ZZ     ZZZ    VERIFY SUBMITTER INFORMATION                                   122      PROCESSING CLAIM.
                                                                                                   CLAIM SUBMITTER'S IDENTIFIER (PATIENT
     Z35     ZZ     ZZZ    VERIFY SUBMITTER ID                                            478      ACCOUNT NUMBER) IS MISSING.

     Z36     ZZ     ZZZ    VERIFY SUBSCRIBER INFORMATION                                  33       SUBSCRIBER AND SUBSCRIBER ID NOT FOUND.
                                                                                                   CLAIM SUBMITTER'S IDENTIFIER (PATIENT
     Z37     ZZ     ZZZ    VERIFY PATIENT ACCOUNT NUMBER                                  478      ACCOUNT NUMBER) IS MISSING.
     Z38     ZZ     ZZZ    VERIFY CLAIM FREQUENCY CODE                                    259      FREQUENCY OF SERVICE.
                                                                                                   MISSING/INVALID DATA PREVENTS PAYER FROM
     Z39     ZZ     ZZZ    VERIFY REPORT TYPE CODE                                        122      PROCESSING CLAIM.




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                                                                 ESC TO 277



                                                                                      277
                   PLAN                                                               CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z40     ZZ     ZZZ    VERIFY REPORT TRANSMISSION CODE                            122      PROCESSING CLAIM.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z41     ZZ     ZZZ    VERIFY RELATED CAUSE CODE                                  122      PROCESSING CLAIM.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z42     ZZ     ZZZ    VERIFY SPECIAL PROGRAM CODE                                122      PROCESSING CLAIM.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z43     ZZ     ZZZ    VERIFIES REFERENCE ID                                      122      PROCESSING CLAIM.
     Z44     ZZ     ZZZ    VERIFY ATTACHMENT CONTROL NUMBER                           489      ATTACHMENT CONTROL NUMBER.

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     Z45     ZZ     ZZZ    VERIFY OTHER INSURED INFORMATION                           171      (HEALTH, LIABILITY, AUTO, ETC).
                                                                                               CANNOT PROVIDE FURTHUR STATUS
     Z46     ZZ     ZZZ    PROVIDER TYPE 07 (PHARMACY PROVIDER EDIT)                  0        ELECTRONICALLY.
                                                                                               TOOTH NUMBERS, SURFACES, AND/OR QUADRANTS
     Z47     ZZ     ZZZ    VERIFY ORAL CAVITY CODE                                    242      INVOLVED.
     Z48     ZZ     ZZZ    PROTHESIS CODE                                             239      DENTAL INFORMATION.
     Z49     ZZ     ZZZ    ORTHODONTIC BANDING DATE                                   353      ORTHODONTICS TREATMENT PLAN.
                                                                                               ACCIDENT DATE, STATE, DESCRIPTION AND
     Z50     ZZ     ZZZ    VERIFY ACCIDENT DATE                                       248      CAUSE.
     Z51     ZZ     ZZZ    VERIFY ORTHODONTIC TOTAL MONTHS TREATMENT/REMAINING        353      ORTHODONTICS TREATMENT PLAN.
     Z53     ZZ     ZZZ    ADJUSTMENT/REPLACEMENT FREQUENCY CODE NOT VALID            259      FREQUENCY OF SERVICE.
     Z55     ZZ     ZZZ    ICN NOT FOUND                                              35       CLAIM/ENCOUNTER NOT FOUND.
     Z57     ZZ     ZZZ    REVENUE CODE INVALID FOR LONG TERM CARE                    455      REVENUE CODE FOR SERVICES RENDERED.

                                                                                               OTHER INSURANCE COVERAGE INFORMATION
     Z59     ZZ     ZZZ    VERIFIES INSURANCE SEGMENT SENT                            171      (HEALTH, LIABILITY, AUTO, ETC).
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z60     ZZ     ZZZ    VERIFIES SERVICE PROVIDER ID QUALIFIER                     122      PROCESSING CLAIM.
     Z61     ZZ     ZZZ    VERIFIES DATE OF BIRTH                                     158      ENTITY'S DATE OF BIRTH.
     Z62     ZZ     ZZZ    VERIFIES DATE OF BIRTH AGAIN                               158      ENTITY'S DATE OF BIRTH.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z63     ZZ     ZZZ    VERIFY PATIENT LOCATION                                    122      PROCESSING CLAIM.
                                                                                               MISSING/INVALID DATA PREVENTS PAYER FROM
     Z64     ZZ     ZZZ    VERIFY CLAIM SEGMENT                                       122      PROCESSING CLAIM.

     Z65     ZZ     ZZZ    VERIFY PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER     219      PRESCRIPTION NUMBER.
     Z66     ZZ     ZZZ    VERIFY PRESCRIPTION/SERVICE REFERENCE NUMBER               219      PRESCRIPTION NUMBER.
     Z67     ZZ     ZZZ    VERIFY PRODUCT/SERVICE ID QUALIFIER                        219      PRESCRIPTION NUMBER.

     Z68     ZZ     ZZZ    VERIFY ASSOCIATED PRESCRIPTION/SERVICE REFERENCE SERVICE   219      PRESCRIPTION NUMBER.
     Z69     ZZ     ZZZ    VERIFY ASSOCIATED PRESCRIPTION/SERVICE DATE                187      DATE(S) OF SERVICE.




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                                                                  ESC TO 277



                                                                                 277
                   PLAN                                                          CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                                STATUS   CLAIM STATUS CODE
     Z70     ZZ     ZZZ    VERIFY NEW REFILL CODE/FILL NUMBER                    216      DRUG INFORMATION.
     Z71     ZZ     ZZZ    VERIFY DAYS SUPPLY                                    221      DRUG DAYS SUPPLY AND DOSAGE.
     Z72     ZZ     ZZZ    VERIFY COMPOUND CODE                                  216      DRUG INFORMATION.
     Z73     ZZ     ZZZ    VERIFY SUBMISSION CLARIFICATION CODE                  216      DRUG INFORMATION.
     Z74     ZZ     ZZZ    VERIFY PRESCRIBER SEGMENT                             216      DRUG INFORMATION.
     Z75     ZZ     ZZZ    VERIFY PRESCRIBER ID QUALIFIER                        216      DRUG INFORMATION.

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     Z76     ZZ     ZZZ    VERIFY COB/OTHER PAYMENTS SEGMENT                     171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     Z77     ZZ     ZZZ    VERIFY COB/OTHER PAYMENTS COUNT                       171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     Z78     ZZ     ZZZ    VERIFY OTHER PAYER COVERAGE TYPE                      171      (HEALTH, LIABILITY, AUTO, ETC).

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     Z79     ZZ     ZZZ    VERIFY OTHER PAYER AMOUNT PAID COUNT                  171      (HEALTH, LIABILITY, AUTO, ETC).
     Z80     AR     ZZZ    PHARMACY CLAIM CANNOT BE REVERSED                     481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z80     ZZ     ZZZ    PHARMACY CLAIM CANNOT BE REVERSED                     481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z81     CR     ZZZ    CLAIM CANNOT BE REVERSED                              481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z81     RC     ZZZ    CLAIM CANNOT BE REVERSED                              481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z81     ZZ     ZZZ    CLAIM CANNOT BE REVERSED                              481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z82     CR     ZZZ    RECIPIENTS ID ON REVERSAL REQUEST IS INVALID          153      ENTITY'S ID NUMBER.
     Z82     ZZ     ZZZ    RECIPIENTS ID ON REVERSAL REQUEST IS INVALID          153      ENTITY'S ID NUMBER.
     Z83     CR     ZZZ    PROVIDERS ID ON REVERSAL REQUEST IS INVALID           153      ENTITY'S ID NUMBER.
     Z83     IC     ZZZ    PROVIDERS ID ON REVERSAL REQUEST IS INVALID           153      ENTITY'S ID NUMBER.
     Z83     ZZ     ZZZ    PROVIDERS ID ON REVERSAL REQUEST IS INVALID           153      ENTITY'S ID NUMBER.
     Z84     AR     ZZZ    CLAIM CAN ONLY BE REVERSED ON SAME DAY AS SUBMITTED   481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z84     CR     ZZZ    CLAIM CAN ONLY BE REVERSED ON SAME DAY AS SUBMITTED   481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z84     RC     ZZZ    CLAIM CAN ONLY BE REVERSED ON SAME DAY AS SUBMITTED   481      CLAIM/SUBMISSION FORMAT IS INVALID.
     Z84     ZZ     ZZZ    CLAIM CAN ONLY BE REVERSED ON SAME DAY AS SUBMITTED   481      CLAIM/SUBMISSION FORMAT IS INVALID.

                                                                                          OTHER INSURANCE COVERAGE INFORMATION
     Z85     ZZ     ZZZ    VERIFY OTHER PAYER AMOUNT PAID QUALIFIER              171      (HEALTH, LIABILITY, AUTO, ETC).
     Z86     ZZ     ZZZ    VERIFY DUR/PPS SEGMENT                                216      DRUG INFORMATION.
     Z87     ZZ     ZZZ    VERIFY DUR/PPS CODE COUNTER                           216      DRUG INFORMATION.
     Z88     ZZ     ZZZ    VERIFY DUR CONFLICT CODE                              216      DRUG INFORMATION.
     Z89     ZZ     ZZZ    VERIFY DUR INTERVENTION CODE                          216      DRUG INFORMATION.
     Z90     ZZ     ZZZ    VERIFY DUR OUTCOME CODE                               216      DRUG INFORMATION.




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                                                                ESC TO 277



                                                                             277
                   PLAN                                                      CLAIM
EDIT/AUDIT   TXN    CODE   EDIT/AUDIT DESCRIPTION                            STATUS   CLAIM STATUS CODE
     Z91     ZZ     ZZZ    VERIFY PRICING SEGMENT                            216      DRUG INFORMATION.
     Z92     ZZ     ZZZ    VERIFY INGREDIENT COST SUBMITTED                  216      DRUG INFORMATION.
     Z93     ZZ     ZZZ    VERIFY INCENTIVE AMOUNT SUBMITTED                 216      DRUG INFORMATION.
     Z94     ZZ     ZZZ    VERIFY USUAL AND CUSTOMARY CHARGE                 216      DRUG INFORMATION.
     Z95     ZZ     ZZZ    VERIFY COUPON SEGMENT                             216      DRUG INFORMATION.
     Z96     ZZ     ZZZ    VERIFY COUPON TYPE                                216      DRUG INFORMATION.
     Z97     ZZ     ZZZ    VERIFY COUPON NUMBER                              216      DRUG INFORMATION.
     Z98     ZZ     ZZZ    VERIFY COUPON VALUE AMOUNT                        216      DRUG INFORMATION.
                                                                                      MISSING/INVALID DATA PREVENTS PAYER FROM
     Z99     ZZ     ZZZ    INTERNAL ERROR - DETAIL COUNT IS INVALID          122      PROCESSING CLAIM.




6/16/2011                                                        Page 290

				
DOCUMENT INFO
Description: Hospital Discharge Bill Format document sample