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

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

                                  Deductible amount                                                        Deductible amount

            DD           1                                                                      1                                                              PR        Deductible


                                  Coinsurance Amount.                                                      Coinsurance Amount.


            MI           2                                                                      2                                                              PR       Coinsurance



                                  Copayment amount.                                                        Copayment amount.


            WW           3                                                                      3                                                              PR          Copay



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


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


            XM           4                                                                      4                                                              OA      Non - Covered




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



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


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


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


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


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




8/16/2011                                                                                b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                       1
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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


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


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

            DL       13                                                                       13                                                            OA       Non-Covered


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

            DQ       14                                                                       14                                                            OA       Non-Covered


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


            XD       18                                                                       18                                                            OA      Non - Covered


8/16/2011                                                                              b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                      2
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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


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



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


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


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

            CV       26                                                                       26                                                                PR            Non-Covered


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

            CX       27                                                                       27                                                                PR            Non-Covered


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


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

            TF       29                                                                       29                                                                PR            Non - Covered


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

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


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

            FF       31                                                                       31                                                                PR            Non- Covered


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


                              Insured has no dependent coverage                                          Insured has no dependent coverage

            CZ       33                                                                       33                                                                PR            Non - Covered


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

            C2       34                                                                       34                                                                PR            Non - Covered




8/16/2011                                                                              b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                               3
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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

            BM       35                                                                  35                                                             PR                   Non-Covered


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



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

            NZ       39                                                                  39                                                             PR                   Non - Covered



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


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



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



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



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



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



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




8/16/2011                                                                         b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                                            4
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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



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



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



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

            DP       51                                                                  51                                                           PR             Non- Covered



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

            N1       53                                                                  53                                                           PR            Non - Covered



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

            X4       54                                                                  54                                                           OA            Non - Covered



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

            EV       55                                                                  55                                                           PR             Non-Covered



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



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



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


            PN       78                                                                  78                                                           PR             Non-covered




8/16/2011                                                                         b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                                    5
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

                              Transfer Amount                                                          Transfer Amount


            C1       87                                                                     87                                                            PR                Copay



                              Plan procedures not followed.                                            Plan procedures not followed.

            XP       95                                                                     95                                                            PR            Non - Covered


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


            P5      95E                                                                     95                                                            PR            Non - Covered



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



                              Noncovered charges. Noncovered per policy                                Noncovered charges


            NC       96                                                                     96                                                            PR            Non - Covered



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


            C5      96J                                                                     96                                                            PR             Non-covered



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


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



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



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



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


            RT      108                                                                    108                                                            PR             Non -covered




8/16/2011                                                                            b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                                     6
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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



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



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



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



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


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


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

            AA      111                                                                  111                                                          OA       Non-Covered



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


            C6      115                                                                  115                                                          PR       Non-Covered



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


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

            EG      119                                                                  119                                                          PR       Non- Covered




8/16/2011                                                                          b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                    7
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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



            BN      119                                                                  119                                                            PR            Non - Covered




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



            MX      119                                                                  119                                                            PR            Non - Covered




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

            OC      129                                                                  129                                                            OA            Non - Covered



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



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


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


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


                              Claim specific negotiated discount. HFNID                              Claim specific negotiated discount

                                                                                                                                                               Difference between charged and
            R4      131                                                                  131                                                            CO
                                                                                                                                                                       allowed amount



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

8/16/2011                                                                          b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                                     8
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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


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


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



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



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

                                                                                                                                                 Difference between charged and
            RA      131                                                                 131                                               CO
                                                                                                                                                         allowed amount



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


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


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



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


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


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


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


8/16/2011                                                                         b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                        9
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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

                                                                                                                                                   Difference between charged and
            RL      131                                                                   131                                               CO
                                                                                                                                                           allowed amount




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



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



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


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


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


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

                                                                                                                                                   Difference between charged and
            RX      131                                                                   131                                               CO
                                                                                                                                                           allowed amount



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


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


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


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




8/16/2011                                                                           b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                        10
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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

            YA      133                                                                 133                                                            OA      Non - Covered



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

            XO      133                                                                 133                                                            OA      Non - Covered



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

            ZY      133                                                                 133                                                            OA      Non - Covered



                              Interim bills cannot be processed                                     Interim bills cannot be processed


            I2      135                                                                 135                                                            CO       Non-Covered



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


            GG      136                                                                 136                                                            OA       Non-Covered



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

            TL      138                                                                 138                                                            CO       Non-Covered



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



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

            N4      141                                                                 141                                                            PR       Non-Covered



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


            N5      142                                                                 142                                                            PR       Non-Covered



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

            N7      146                                                                 146                                                            OA       Non-Covered




8/16/2011                                                                         b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                     11
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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



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

            N9      147                                                                   147                                                            CO       Non-Covered



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

            FA      148                                                                   148                                                            PR       Non-Covered



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

            M5      149                                                                   149                                                            PR       Non-Covered



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

            M7      150                                                                   150                                                            OA       Non-Covered



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

            XC      150                                                                   150                                                            OA      Non - Covered



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



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


            DX      167                                                                   167                                                            PR       Non-Covered



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

            ZK      171                                                                   171                                                            CO       Non - Covered



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

            P4      172                                                                   172                                                            OA       Non-Covered




8/16/2011                                                                           b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                      12
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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

            XN      181                                                                     181                                                            OA          Non-Covered



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

            M9      182                                                                     182                                                            OA          Non-Covered



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

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



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



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

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



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

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



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

            NP      202                                                                     202                                                            PR          Non-covered



                              Information requested from the                                            Information requested from the
                              patient/insured/responsible party was not provided                        patient/insured/responsible party was not
                              or was insufficient/incomplete                                            provided or was insufficient/incomplete. At
            FN      227                                                                     227         least one Remark Code must be provided             PR          Non- Covered
                                                                                                        (may be comprised of either the Remittance
                                                                                                        Advice Remark Code or NCPDP Reject
                                                                                                        Reason Code).
                              Information requested from the                                            Information requested from the
                              patient/insured/responsible party was not provided                        patient/insured/responsible party was not
                              or was insufficient/incomplete. Medical Records                           provided or was insufficient/incomplete. At
            MR      227       Requested.                                                    227         least one Remark Code must be provided             PR          Non-Covered
                                                                                                        (may be comprised of either the Remittance
                                                                                                        Advice Remark Code or NCPDP Reject
                                                                                                        Reason Code).
                              Information requested from the                                            Information requested from the
                              patient/insured/responsible party was not provided                        patient/insured/responsible party was not
                              or was insufficient/incomplete                                            provided or was insufficient/incomplete. At
            WN      227                                                                     227         least one Remark Code must be provided             PR         Non - Covered
                                                                                                        (may be comprised of either the Remittance
                                                                                                        Advice Remark Code or NCPDP Reject
                                                                                                        Reason Code).
8/16/2011                                                                             b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                        13
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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

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




                              Ungroupable DRG                                                          Ungroupable DRG


            UG       A8                                                                     A8                                                                OA          Non - Covered



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


            NV       B1                                                                     B1                                                                PR          Non - Covered



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

            HB       B5                                                                     B5                                                                PR          Non- Covered



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

            AS       B8                                                                     B8                                                                PR          Non -covered



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



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

            ZU      B12                                                                    B12                                                                OA          Non - Covered



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



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

            ZV      B14                                                                    B14                                                                OA          Non - Covered




8/16/2011                                                                            b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                             14
                    DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

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

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


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


            XK      B16                                                                  B16                                                              OA             Non - Covered



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

            M2      02G                                                                No Set up     Used for paper only



                              Correction to a prior claim

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



                              Correction to a prior claim


            RV      63C                                                                No Set up                  Used for paper only



                              Interest amount. Interest payment.

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


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

                    93A                                                                No Set up                  Used for paper only


            LE




8/16/2011                                                                          b31df64d-ae7c-49a5-b4bf-7268956e0fdb.xls                                                                     15

				
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Description: Contractor Interim Payment Claim document sample