| CAS Code Denial Description 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 5 The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 6 The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7 The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 9 The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 10 The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 11 The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 12 The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 13 The date of death precedes the date of service. 14 The date of birth follows the date of service. 15 The authorization number is missing, invalid, or does not apply to the billed services or provider. 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 18 Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) 19 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. 20 This injury/illness is covered by the liability carrier. 21 This injury/illness is the liability of the no-fault carrier. 22 This care may be covered by another payer per coordination of benefits. 23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) 24 Charges are covered under a capitation agreement/managed care plan. 26 Expenses incurred prior to coverage. 27 Expenses incurred after coverage terminated. 29 The time limit for filing has expired. 31 Patient cannot be identified as our insured. 32 Our records indicate that this dependent is not an eligible dependent as defined. 33 Insured has no dependent coverage. 34 Insured has no coverage for newborns. 35 Lifetime benefit maximum has been reached. 39 Services denied at the time authorization/pre-certification was requested. 40 Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 44 Prompt-pay discount. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability) 49 This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 50 These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 51 These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 53 Services by an immediate relative or a member of the same household are not covered. 54 Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 55 Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 56 Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 59 Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. 61 Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 66 Blood Deductible. 69 Day outlier amount. 70 Cost outlier - Adjustment to compensate for additional costs. 74 Indirect Medical Education Adjustment. 75 Direct Medical Education Adjustment. 76 Disproportionate Share Adjustment. 78 Non-Covered days/Room charge adjustment. 85 Patient Interest Adjustment (Use Only Group code PR) 89 Professional fees removed from charges. 90 Ingredient cost adjustment. Note: To be used for pharmaceuticals only. 91 Dispensing fee adjustment. 94 Processed in Excess of charges. 95 Plan procedures not followed. 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 100 Payment made to patient/insured/responsible party/employer. 101 Predetermination: anticipated payment upon completion of services or claim adjudication. 102 Major Medical Adjustment. 103 Provider promotional discount (e.g., Senior citizen discount). 104 Managed care withholding. 105 Tax withholding. 106 Patient payment option/election not in effect. 107 The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 108 Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 109 Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. 110 Billing date predates service date. 111 Not covered unless the provider accepts assignment. 112 Service not furnished directly to the patient and/or not documented. 114 Procedure/product not approved by the Food and Drug Administration. 115 Procedure postponed, canceled, or delayed. 116 The advance indemnification notice signed by the patient did not comply with requirements. 117 Transportation is only covered to the closest facility that can provide the necessary care. 118 ESRD network support adjustment. 119 Benefit maximum for this time period or occurrence has been reached. 121 Indemnification adjustment - compensation for outstanding member responsibility. 122 Psychiatric reduction. 128 Newborn's services are covered in the mother's Allowance. 129 Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 130 Claim submission fee. 131 Claim specific negotiated discount. 132 Prearranged demonstration project adjustment. 133 The disposition of the claim/service is pending further review. (Use only with Group Code OA). This change effective 11/01/2014: The disposition of this service line is pending further review. (Use only with Group Code OA). NOTE: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). 134 Technical fees removed from charges. 135 Interim bills cannot be processed. 136 Failure to follow prior payer's coverage rules. (Use only with Group Code OA) 137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. 138 Appeal procedures not followed or time limits not met. 139 Contracted funding agreement - Subscriber is employed by the provider of services. 140 Patient/Insured health identification number and name do not match. 142 Monthly Medicaid patient liability amount. 143 Portion of payment deferred. 144 Incentive adjustment, e.g. preferred product/service. 146 Diagnosis was invalid for the date(s) of service reported. 147 Provider contracted/negotiated rate expired or not on file. 148 Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 149 Lifetime benefit maximum has been reached for this service/benefit category. 150 Payer deems the information submitted does not support this level of service. 151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. 152 Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 153 Payer deems the information submitted does not support this dosage. 154 Payer deems the information submitted does not support this day's supply. 155 Patient refused the service/procedure. 157 Service/procedure was provided as a result of an act of war. 158 Service/procedure was provided outside of the United States. 159 Service/procedure was provided as a result of terrorism. 160 Injury/illness was the result of an activity that is a benefit exclusion. 161 Provider performance bonus 163 Attachment/other documentation referenced on the claim was not received. 164 Attachment/other documentation referenced on the claim was not received in a timely fashion. 165 Referral absent or exceeded. 166 These services were submitted after this payers responsibility for processing claims under this plan ended. 167 This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 168 Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. 169 Alternate benefit has been provided. 170 Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 171 Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 172 Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 173 Service/equipment was not prescribed by a physician. 174 Service was not prescribed prior to delivery. 175 Prescription is incomplete. 176 Prescription is not current. 177 Patient has not met the required eligibility requirements. 178 Patient has not met the required spend down requirements. 179 Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 180 Patient has not met the required residency requirements. 181 Procedure code was invalid on the date of service. 182 Procedure modifier was invalid on the date of service. 183 The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 185 The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 186 Level of care change adjustment. 187 Failure to follow prior payer's coverage rules. (Use only with Group Code OA) 188 This product/procedure is only covered when used according to FDA recommendations. 189 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. 192 Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. 193 Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. 194 Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. 195 Refund issued to an erroneous priority payer for this claim/service. 197 Precertification/authorization/notification absent. 198 Precertification/authorization exceeded. 199 Revenue code and Procedure code do not match. 200 Expenses incurred during lapse in coverage 201 Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use only with Group Code PR) 202 Non-covered personal comfort or convenience services. 203 Discontinued or reduced service. 204 This service/equipment/drug is not covered under the patient’s current benefit plan 205 Pharmacy discount card processing fee 206 National Provider Identifier - missing. 207 National Provider identifier - Invalid format 208 National Provider Identifier - Not matched. 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA) 210 Payment adjusted because pre-certification/authorization not received in a timely fashion 211 National Drug Codes (NDC) not eligible for rebate, are not covered. 212 Administrative surcharges are not covered 213 Non-compliance with the physician self referral prohibition legislation or payer policy. 215 Based on subrogation of a third party settlement 216 Based on the findings of a review organization 219 Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 223 Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. 224 Patient identification compromised by identity theft. Identity verification required for processing this and future claims. 225 Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) 226 Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 227 Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 228 Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication 229 Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR) 231 Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 232 Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 233 Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. 234 This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 235 Sales Tax 236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. 237 Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 238 Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR) 239 Claim spans eligible and ineligible periods of coverage. Rebill separate claims. 240 The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 241 Low Income Subsidy (LIS) Co-payment Amount 242 Services not provided by network/primary care providers. 243 Services not authorized by network/primary care providers. 245 Provider performance program withhold. 246 This non-payable code is for required reporting only. 247 Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. 248 Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. 249 This claim has been identified as a readmission. (Use only with Group Code CO) 250 The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 251 The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 252 An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 253 Sequestration - reduction in federal payment 254 Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. 256 Service not payable per managed care contract. 257 The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) 258 Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. 259 Additional payment for Dental/Vision service utilization. 260 Processed under Medicaid ACA Enhanced Fee Schedule 261 The procedure or service is inconsistent with the patient's history. A0 Patient refund amount. A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) A5 Medicare Claim PPS Capital Cost Outlier Amount. A6 Prior hospitalization or 30 day transfer requirement not met. A7 Presumptive Payment Adjustment A8 Ungroupable DRG. B1 Non-covered visits. B4 Late filing penalty. B5 Coverage/program guidelines were not met or were exceeded. B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B8 Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B9 Patient is enrolled in a Hospice. B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. B12 Services not documented in patients' medical records. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. B14 Only one visit or consultation per physician per day is covered. B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B16 'New Patient' qualifications were not met. B20 Procedure/service was partially or fully furnished by another provider. B22 This payment is adjusted based on the diagnosis. B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. P1 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only. P2 Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only. P3 Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR) P4 Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only P5 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only. P6 Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. P7 The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only. P8 Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. P9 No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only. P10 Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA) P12 Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. P13 Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. P14 The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. P15 Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only. P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA) P17 Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only. P18 Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only. P19 Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only. P20 Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only. P21 Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. P22 Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. P23 Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. 234 This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 235 Sales Tax 236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. 237 Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 238 Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR) 239 Claim spans eligible and ineligible periods of coverage. Rebill separate claims. 240 The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 241 Low Income Subsidy (LIS) Co-payment Amount 242 Services not provided by network/primary care providers. 243 Services not authorized by network/primary care providers. 245 Provider performance program withhold. 246 This non-payable code is for required reporting only. 247 Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. 248 Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. 249 This claim has been identified as a readmission. (Use only with Group Code CO) 250 The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 251 The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 252 An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 253 Sequestration - reduction in federal payment 254 Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. 256 Service not payable per managed care contract. 257 The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) 258 Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. 259 Additional payment for Dental/Vision service utilization. 260 Processed under Medicaid ACA Enhanced Fee Schedule 261 The procedure or service is inconsistent with the patient's history. A0 Patient refund amount. A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) A5 Medicare Claim PPS Capital Cost Outlier Amount. A6 Prior hospitalization or 30 day transfer requirement not met. A7 Presumptive Payment Adjustment A8 Ungroupable DRG. B1 Non-covered visits. B4 Late filing penalty. B5 Coverage/program guidelines were not met or were exceeded. B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B8 Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B9 Patient is enrolled in a Hospice. B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. B12 Services not documented in patients' medical records. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. B14 Only one visit or consultation per physician per day is covered. B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B16 'New Patient' qualifications were not met. B20 Procedure/service was partially or fully furnished by another provider. B22 This payment is adjusted based on the diagnosis. B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. P1 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only. P2 Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only. P3 Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR) P4 Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only P5 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only. P6 Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. P7 The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only. P8 Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. P9 No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only. P10 Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA) P12 Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. P13 Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. P14 The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. P15 Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only. P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA) P17 Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only. P18 Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only. P19 Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only. P20 Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only. P21 Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. P22 Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. P23 Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. M1 X-ray not taken within the past 12 months or near enough to the start of treatment. M2 Not paid separately when the patient is an inpatient. M3 Equipment is the same or similar to equipment already being used. M4 Alert: This is the last monthly installment payment for this durable medical equipment. M5 Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed. M6 Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment. M7 No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price. M8 We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. M9 Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement. M10 Equipment purchases are limited to the first or the tenth month of medical necessity. M11 DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code. M12 Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim. M13 Only one initial visit is covered per specialty per medical group. M14 No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection. M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. M16 Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision. M17 Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions. M18 Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home. M19 Missing oxygen certification/re-certification. M20 Missing/incomplete/invalid HCPCS. M21 Missing/incomplete/invalid place of residence for this service/item provided in a home. M22 Missing/incomplete/invalid number of miles traveled. M23 Missing invoice. M24 Missing/incomplete/invalid number of doses per vial. M25 The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. M26 The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. M27 Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office. M28 This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. M29 Missing operative note/report. M30 Missing pathology report. M31 Missing radiology report. M32 Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service. M36 This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase. M37 Not covered when the patient is under age 35. M38 The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay. M39 The patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. M40 Claim must be assigned and must be filed by the practitioner's employer. M41 We do not pay for this as the patient has no legal obligation to pay for this. M42 The medical necessity form must be personally signed by the attending physician. M44 Missing/incomplete/invalid condition code. M45 Missing/incomplete/invalid occurrence code(s). M46 Missing/incomplete/invalid occurrence span code(s). M47 Missing/incomplete/invalid internal or document control number. M49 Missing/incomplete/invalid value code(s) or amount(s). M50 Missing/incomplete/invalid revenue code(s). M51 Missing/incomplete/invalid procedure code(s). M52 Missing/incomplete/invalid “from” date(s) of service. M53 Missing/incomplete/invalid days or units of service. M54 Missing/incomplete/invalid total charges. M55 We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug. M56 Missing/incomplete/invalid payer identifier. M59 Missing/incomplete/invalid “to” date(s) of service. M60 Missing Certificate of Medical Necessity. M61 We cannot pay for this as the approval period for the FDA clinical trial has expired. M62 Missing/incomplete/invalid treatment authorization code. M64 Missing/incomplete/invalid other diagnosis. M65 One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician. M66 Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items. M67 Missing/incomplete/invalid other procedure code(s). M69 Paid at the regular rate as you did not submit documentation to justify the modified procedure code. M70 Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item. M71 Total payment reduced due to overlap of tests billed. M73 The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components. M74 This service does not qualify for a HPSA/Physician Scarcity bonus payment. M75 Multiple automated multichannel tests performed on the same day combined for payment. M76 Missing/incomplete/invalid diagnosis or condition. M77 Missing/incomplete/invalid/inappropriate place of service. M79 Missing/incomplete/invalid charge. M80 Not covered when performed during the same session/date as a previously processed service for the patient. M81 You are required to code to the highest level of specificity. M82 Service is not covered when patient is under age 50. M83 Service is not covered unless the patient is classified as at high risk. M84 Medical code sets used must be the codes in effect at the time of service. M85 Subjected to review of physician evaluation and management services. M86 Service denied because payment already made for same/similar procedure within set time frame. M87 Claim/service(s) subjected to CFO-CAP prepayment review. M89 Not covered more than once under age 40. M90 Not covered more than once in a 12 month period. M91 Lab procedures with different CLIA certification numbers must be billed on separate claims. M93 Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment. M94 Information supplied does not support a break in therapy. A new capped rental period will not begin. M95 Services subjected to Home Health Initiative medical review/cost report audit. M96 The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only. M97 Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility. M99 Missing/incomplete/invalid Universal Product Number/Serial Number. M100 We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug. M102 Service not performed on equipment approved by the FDA for this purpose. M103 Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment. M104 Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service. M105 Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin. M107 Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%. M109 We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner. M111 We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken. M112 Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides. M113 Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program. M114 This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor. M115 This item is denied when provided to this patient by a non-contract or non-demonstration supplier. M116 Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program. M117 Not covered unless submitted via electronic claim. M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC). M121 We pay for this service only when performed with a covered cryosurgical ablation. M122 Missing/incomplete/invalid level of subluxation. M123 Missing/incomplete/invalid name, strength, or dosage of the drug furnished. M124 Missing indication of whether the patient owns the equipment that requires the part or supply. M125 Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed. M126 Missing/incomplete/invalid individual lab codes included in the test. M127 Missing patient medical record for this service. M129 Missing/incomplete/invalid indicator of x-ray availability for review. M130 Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used. M131 Missing physician financial relationship form. M132 Missing pacemaker registration form. M133 Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test. M134 Performed by a facility/supplier in which the provider has a financial interest. M135 Missing/incomplete/invalid plan of treatment. M136 Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician. M137 Part B coinsurance under a demonstration project or pilot program. M138 Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants. M139 Denied services exceed the coverage limit for the demonstration. M141 Missing physician certified plan of care. M142 Missing American Diabetes Association Certificate of Recognition. M143 The provider must update license information with the payer. M144 Pre-/post-operative care payment is included in the allowance for the surgery/procedure. MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late. MA02 Alert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice. MA04 Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible. MA07 Alert: The claim information has also been forwarded to Medicaid for review. MA08 Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare. MA09 Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims. MA10 Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient. MA12 You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s). MA13 Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code. MA14 Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services. MA15 Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. MA16 The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703. MA17 We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment. MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. MA19 Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer. MA20 Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence. MA21 SSA records indicate mismatch with name and sex. MA22 Payment of less than $1.00 suppressed. MA23 Demand bill approved as result of medical review. MA24 Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period. MA25 A patient may not elect to change a hospice provider more than once in a benefit period. MA26 Alert: Our records indicate that you were previously informed of this rule. MA27 Missing/incomplete/invalid entitlement number or name shown on the claim. MA28 Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice. MA30 Missing/incomplete/invalid type of bill. MA31 Missing/incomplete/invalid beginning and ending dates of the period billed. MA32 Missing/incomplete/invalid number of covered days during the billing period. MA33 Missing/incomplete/invalid noncovered days during the billing period. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. MA35 Missing/incomplete/invalid number of lifetime reserve days. MA36 Missing/incomplete/invalid patient name. MA37 Missing/incomplete/invalid patient's address. MA39 Missing/incomplete/invalid gender. MA40 Missing/incomplete/invalid admission date. MA41 Missing/incomplete/invalid admission type. MA42 Missing/incomplete/invalid admission source. MA43 Missing/incomplete/invalid patient status. MA44 Alert: No appeal rights. Adjudicative decision based on law. MA45 Alert: As previously advised, a portion or all of your payment is being held in a special account. MA46 The new information was considered but additional payment will not be issued. MA47 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment. MA48 Missing/incomplete/invalid name or address of responsible party or primary payer. MA50 Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number. MA53 Missing/incomplete/invalid Competitive Bidding Demonstration Project identification. MA54 Physician certification or election consent for hospice care not received timely. MA55 Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services. MA56 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount. MA57 Patient submitted written request to revoke his/her election for religious non-medical health care services. MA58 Missing/incomplete/invalid release of information indicator. MA59 Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice. MA60 Missing/incomplete/invalid patient relationship to insured. MA61 Missing/incomplete/invalid social security number or health insurance claim number. MA62 Alert: This is a telephone review decision. MA63 Missing/incomplete/invalid principal diagnosis. MA64 Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers. MA65 Missing/incomplete/invalid admitting diagnosis. MA66 Missing/incomplete/invalid principal procedure code. MA67 Correction to a prior claim. MA68 Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim. MA69 Missing/incomplete/invalid remarks. MA70 Missing/incomplete/invalid provider representative signature. MA71 Missing/incomplete/invalid provider representative signature date. MA72 Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the patient on this notice. MA73 Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care. MA74 This payment replaces an earlier payment for this claim that was either lost, damaged or returned. MA75 Missing/incomplete/invalid patient or authorized representative signature. MA76 Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services. MA77 Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient’s payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice. MA79 Billed in excess of interim rate. MA80 Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project. MA81 Missing/incomplete/invalid provider/supplier signature. MA83 Did not indicate whether we are the primary or secondary payer. MA84 Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy. MA88 Missing/incomplete/invalid insured's address and/or telephone number for the primary payer. MA89 Missing/incomplete/invalid patient's relationship to the insured for the primary payer. MA90 Missing/incomplete/invalid employment status code for the primary insured. MA91 This determination is the result of the appeal you filed. MA92 Missing plan information for other insurance. MA93 Non-PIP (Periodic Interim Payment) claim. MA94 Did not enter the statement “Attending physician not hospice employee” on the claim form to certify that the rendering physician is not an employee of the hospice. MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan. MA97 Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number. MA99 Missing/incomplete/invalid Medigap information. MA100 Missing/incomplete/invalid date of current illness or symptoms. MA103 Hemophilia Add On. MA106 PIP (Periodic Interim Payment) claim. MA107 Paper claim contains more than three separate data items in field 19. MA108 Paper claim contains more than one data item in field 23. MA109 Claim processed in accordance with ambulatory surgical guidelines. MA110 Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim. MA111 Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address. MA112 Missing/incomplete/invalid group practice information. MA113 Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN. MA114 Missing/incomplete/invalid information on where the services were furnished. MA115 Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA). MA116 Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution. MA117 This claim has been assessed a $1.00 user fee. MA118 Coinsurance and/or deductible amounts apply to a claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued. MA120 Missing/incomplete/invalid CLIA certification number. MA121 Missing/incomplete/invalid x-ray date. MA122 Missing/incomplete/invalid initial treatment date. MA123 Your center was not selected to participate in this study, therefore, we cannot pay for these services. MA125 Per legislation governing this program, payment constitutes payment in full. MA126 Pancreas transplant not covered unless kidney transplant performed. MA128 Missing/incomplete/invalid FDA approval number. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. MA131 Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim. MA132 Adjustment to the pre-demonstration rate. MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay. MA134 Missing/incomplete/invalid provider number of the facility where the patient resides. N1 Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes. N2 This allowance has been made in accordance with the most appropriate course of treatment provision of the plan. N3 Missing consent form. N4 Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. N5 EOB received from previous payer. Claim not on file. N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B. N7 Alert: Processing of this claim/service has included consideration under Major Medical provisions. N8 Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication. N9 Adjustment represents the estimated amount a previous payer may pay. N10 Payment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review. N11 Denial reversed because of medical review. N12 Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare. N13 Payment based on professional/technical component modifier(s). N15 Services for a newborn must be billed separately. N16 Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage. N19 Procedure code incidental to primary procedure. N20 Service not payable with other service rendered on the same date. N21 Alert: Your line item has been separated into multiple lines to expedite handling. N22 This procedure code was added/changed because it more accurately describes the services rendered. N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions. N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information. N25 This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan. N26 Missing itemized bill/statement. N27 Missing/incomplete/invalid treatment number. N28 Consent form requirements not fulfilled. N29 Missing documentation/orders/notes/summary/report/chart. N30 Patient ineligible for this service. N31 Missing/incomplete/invalid prescribing provider identifier. N32 Claim must be submitted by the provider who rendered the service. N33 No record of health check prior to initiation of treatment. N34 Incorrect claim form/format for this service. N35 Program integrity/utilization review decision. N36 Claim must meet primary payer’s processing requirements before we can consider payment. N37 Missing/incomplete/invalid tooth number/letter. N39 Procedure code is not compatible with tooth number/letter. N40 Missing radiology film(s)/image(s). N42 No record of mental health assessment. N43 Bed hold or leave days exceeded. N45 Payment based on authorized amount. N46 Missing/incomplete/invalid admission hour. N47 Claim conflicts with another inpatient stay. N48 Claim information does not agree with information received from other insurance carrier. N49 Court ordered coverage information needs validation. N50 Missing/incomplete/invalid discharge information. N51 Electronic interchange agreement not on file for provider/submitter. N52 Patient not enrolled in the billing provider's managed care plan on the date of service. N53 Missing/incomplete/invalid point of pick-up address. N54 Claim information is inconsistent with pre-certified/authorized services. N55 Procedures for billing with group/referring/performing providers were not followed. N56 Procedure code billed is not correct/valid for the services billed or the date of service billed. N57 Missing/incomplete/invalid prescribing date. N58 Missing/incomplete/invalid patient liability amount. N59 Please refer to your provider manual for additional program and provider information. N61 Rebill services on separate claims. N62 Dates of service span multiple rate periods. Resubmit separate claims. N63 Rebill services on separate claim lines. N64 The “from” and “to” dates must be different. N65 Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider. N67 Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient’s admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim. N68 Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days. N69 PPS (Prospective Payment System) code changed by claims processing system. N70 Consolidated billing and payment applies. N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims. N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records. N74 Resubmit with multiple claims, each claim covering services provided in only one calendar month. N75 Missing/incomplete/invalid tooth surface information. N76 Missing/incomplete/invalid number of riders. N77 Missing/incomplete/invalid designated provider number. N78 The necessary components of the child and teen checkup (EPSDT) were not completed. N79 Service billed is not compatible with patient location information. N80 Missing/incomplete/invalid prenatal screening information. N81 Procedure billed is not compatible with tooth surface code. N82 Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement. N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration project. N84 Alert: Further installment payments are forthcoming. N85 Alert: This is the final installment payment. N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered. N87 Home use of biofeedback therapy is not covered. N88 Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care. N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice. N90 Covered only when performed by the attending physician. N91 Services not included in the appeal review. N92 This facility is not certified for digital mammography. N93 A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim. N94 Claim/Service denied because a more specific taxonomy code is required for adjudication. N95 This provider type/provider specialty may not bill this service. N96 Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. N97 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded. N98 Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries. N99 Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated. N100 PPS (Prospect Payment System) code corrected during adjudication. N102 This claim has been denied without reviewing the medical/dental record because the requested records were not received or were not received timely. N103 Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate. N104 This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. N105 This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing. N106 Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service. N107 Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services. N108 Missing/incomplete/invalid upgrade information. N109 This claim/service was chosen for complex review and was denied after reviewing the medical records. N110 This facility is not certified for film mammography. N111 No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated. N112 This claim is excluded from your electronic remittance advice. N113 Only one initial visit is covered per physician, group practice or provider. N114 During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be. N115 This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. N116 This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency’s (HHA’s) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care. N117 This service is paid only once in a patient’s lifetime. N118 This service is not paid if billed more than once every 28 days. N119 This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days. N120 Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode. N121 Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay. N122 Add-on code cannot be billed by itself. N123 This is a split service and represents a portion of the units from the originally submitted service. N124 Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay. N125 Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. N126 Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported. N127 This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them. N128 This amount represents the prior to coverage portion of the allowance. N129 Not eligible due to the patient's age. N130 Consult plan benefit documents/guidelines for information about restrictions for this service. N131 Total payments under multiple contracts cannot exceed the allowance for this service. N132 Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified. N133 Alert: Services for predetermination and services requesting payment are being processed separately. N134 Alert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service. N135 Record fees are the patient's responsibility and limited to the specified co-payment. N136 Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548. N137 Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority. N138 Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review. N139 Alert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter. N140 Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter. N141 The patient was not residing in a long-term care facility during all or part of the service dates billed. N142 The original claim was denied. Resubmit a new claim, not a replacement claim. N143 The patient was not in a hospice program during all or part of the service dates billed. N144 The rate changed during the dates of service billed. N146 Missing screening document. N147 Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request. N148 Missing/incomplete/invalid date of last menstrual period. N149 Rebill all applicable services on a single claim. N150 Missing/incomplete/invalid model number. N151 Telephone contact services will not be paid until the face-to-face contact requirement has been met. N152 Missing/incomplete/invalid replacement claim information. N153 Missing/incomplete/invalid room and board rate. N154 Alert: This payment was delayed for correction of provider's mailing address. N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records. N156 Alert: The patient is responsible for the difference between the approved treatment and the elective treatment. N157 Transportation to/from this destination is not covered. N158 Transportation in a vehicle other than an ambulance is not covered. N159 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. N160 The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service. N161 This drug/service/supply is covered only when the associated service is covered. N162 Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future. N163 Medical record does not support code billed per the code definition. N167 Charges exceed the post-transplant coverage limit. N170 A new/revised/renewed certificate of medical necessity is needed. N171 Payment for repair or replacement is not covered or has exceeded the purchase price. N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item. N173 No qualifying hospital stay dates were provided for this episode of care. N174 This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'. N175 Missing review organization approval. N176 Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service. N177 Alert: We did not send this claim to patient’s other insurer. They have indicated no additional payment can be made. N178 Missing pre-operative images/visual field results. N179 Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information. N180 This item or service does not meet the criteria for the category under which it was billed. N181 Additional information is required from another provider involved in this service. N182 This claim/service must be billed according to the schedule for this plan. N183 Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits. N184 Rebill technical and professional components separately. N185 Alert: Do not resubmit this claim/service. N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance. N187 Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents. N188 The approved level of care does not match the procedure code submitted. N189 Alert: This service has been paid as a one-time exception to the plan's benefit restrictions. N190 Missing contract indicator. N191 The provider must update insurance information directly with payer. N192 Patient is a Medicaid/Qualified Medicare Beneficiary. N193 Specific federal/state/local program may cover this service through another payer. N194 Technical component not paid if provider does not own the equipment used. N195 The technical component must be billed separately. N196 Alert: Patient eligible to apply for other coverage which may be primary. N197 The subscriber must update insurance information directly with payer. N198 Rendering provider must be affiliated with the pay-to provider. N199 Additional payment/recoupment approved based on payer-initiated review/audit. N200 The professional component must be billed separately. N202 Additional information/explanation will be sent separately. N203 Missing/incomplete/invalid anesthesia time/units. N204 Services under review for possible pre-existing condition. Send medical records for prior 12 months N205 Information provided was illegible. N206 The supporting documentation does not match the information sent on the claim. N207 Missing/incomplete/invalid weight. N208 Missing/incomplete/invalid DRG code. N209 Missing/incomplete/invalid taxpayer identification number (TIN). N210 Alert: You may appeal this decision. N211 Alert: You may not appeal this decision. N212 Charges processed under a Point of Service benefit . N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information. N214 Missing/incomplete/invalid history of the related initial surgical procedure(s). N215 Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination. N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package. N217 We pay only one site of service per provider per claim. N218 You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual. N219 Payment based on previous payer's allowed amount. N220 Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute. N221 Missing Admitting History and Physical report. N222 Incomplete/invalid Admitting History and Physical report. N223 Missing documentation of benefit to the patient during initial treatment period. N224 Incomplete/invalid documentation of benefit to the patient during initial treatment period. N225 Incomplete/invalid documentation/orders/notes/summary/report/chart. N226 Incomplete/invalid American Diabetes Association Certificate of Recognition. N227 Incomplete/invalid Certificate of Medical Necessity. N228 Incomplete/invalid consent form. N229 Incomplete/invalid contract indicator. N230 Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply. N231 Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used. N232 Incomplete/invalid itemized bill/statement. N233 Incomplete/invalid operative note/report. N234 Incomplete/invalid oxygen certification/re-certification. N235 Incomplete/invalid pacemaker registration form. N236 Incomplete/invalid pathology report. N237 Incomplete/invalid patient medical record for this service. N238 Incomplete/invalid physician certified plan of care. N239 Incomplete/invalid physician financial relationship form. N240 Incomplete/invalid radiology report. N241 Incomplete/invalid review organization approval. N242 Incomplete/invalid radiology film(s)/image(s). N243 Incomplete/invalid/not approved screening document. N244 Incomplete/Invalid pre-operative images/visual field results. N245 Incomplete/invalid plan information for other insurance . N246 State regulated patient payment limitations apply to this service. N247 Missing/incomplete/invalid assistant surgeon taxonomy. N248 Missing/incomplete/invalid assistant surgeon name. N249 Missing/incomplete/invalid assistant surgeon primary identifier. N250 Missing/incomplete/invalid assistant surgeon secondary identifier. N251 Missing/incomplete/invalid attending provider taxonomy. N252 Missing/incomplete/invalid attending provider name. N253 Missing/incomplete/invalid attending provider primary identifier. N254 Missing/incomplete/invalid attending provider secondary identifier. N255 Missing/incomplete/invalid billing provider taxonomy. N256 Missing/incomplete/invalid billing provider/supplier name. N257 Missing/incomplete/invalid billing provider/supplier primary identifier. N258 Missing/incomplete/invalid billing provider/supplier address. N259 Missing/incomplete/invalid billing provider/supplier secondary identifier. N260 Missing/incomplete/invalid billing provider/supplier contact information. N261 Missing/incomplete/invalid operating provider name. N262 Missing/incomplete/invalid operating provider primary identifier. N263 Missing/incomplete/invalid operating provider secondary identifier. N264 Missing/incomplete/invalid ordering provider name. N265 Missing/incomplete/invalid ordering provider primary identifier. N266 Missing/incomplete/invalid ordering provider address. N267 Missing/incomplete/invalid ordering provider secondary identifier. N268 Missing/incomplete/invalid ordering provider contact information. N269 Missing/incomplete/invalid other provider name. N270 Missing/incomplete/invalid other provider primary identifier. N271 Missing/incomplete/invalid other provider secondary identifier. N272 Missing/incomplete/invalid other payer attending provider identifier. N273 Missing/incomplete/invalid other payer operating provider identifier. N274 Missing/incomplete/invalid other payer other provider identifier. N275 Missing/incomplete/invalid other payer purchased service provider identifier. N276 Missing/incomplete/invalid other payer referring provider identifier. N277 Missing/incomplete/invalid other payer rendering provider identifier. N278 Missing/incomplete/invalid other payer rendering provider identifier. N279 Missing/incomplete/invalid pay-to provider name. N280 Missing/incomplete/invalid pay-to provider primary identifier. N281 Missing/incomplete/invalid pay-to provider address. N282 Missing/incomplete/invalid pay-to provider secondary identifier. N283 Missing/incomplete/invalid purchased service provider identifier. N284 Missing/incomplete/invalid referring provider taxonomy. N285 Missing/incomplete/invalid referring provider name. N286 Missing/incomplete/invalid referring provider primary identifier. N287 Missing/incomplete/invalid referring provider secondary identifier. N288 Missing/incomplete/invalid rendering provider taxonomy. N289 Missing/incomplete/invalid rendering provider name. N290 Missing/incomplete/invalid rendering provider primary identifier. N291 Missing/incomplete/invalid rendering provider secondary identifier. N292 Missing/incomplete/invalid service facility name. N293 Missing/incomplete/invalid service facility primary identifier. N294 Missing/incomplete/invalid service facility primary address. N295 Missing/incomplete/invalid service facility secondary identifier. N296 Missing/incomplete/invalid supervising provider name. N297 Missing/incomplete/invalid supervising provider primary identifier. N298 Missing/incomplete/invalid supervising provider secondary identifier. N299 Missing/incomplete/invalid occurrence date(s). N300 Missing/incomplete/invalid occurrence span date(s). N301 Missing/incomplete/invalid procedure date(s). N302 Missing/incomplete/invalid other procedure date(s). N303 Missing/incomplete/invalid principal procedure date. N304 Missing/incomplete/invalid dispensed date. N305 Missing/incomplete/invalid accident date. N306 Missing/incomplete/invalid acute manifestation date. N307 Missing/incomplete/invalid adjudication or payment date. N308 Missing/incomplete/invalid appliance placement date. N309 Missing/incomplete/invalid assessment date. N310 Missing/incomplete/invalid assumed or relinquished care date. N311 Missing/incomplete/invalid authorized to return to work date. N312 Missing/incomplete/invalid begin therapy date. N313 Missing/incomplete/invalid certification revision date. N314 Missing/incomplete/invalid diagnosis date. N315 Missing/incomplete/invalid disability from date. N316 Missing/incomplete/invalid disability to date. N317 Missing/incomplete/invalid discharge hour. N318 Missing/incomplete/invalid discharge or end of care date. N319 Missing/incomplete/invalid hearing or vision prescription date. N320 Missing/incomplete/invalid Home Health Certification Period. N321 Missing/incomplete/invalid last admission period. N322 Missing/incomplete/invalid last certification date. N323 Missing/incomplete/invalid last contact date. N324 Missing/incomplete/invalid last seen/visit date. N325 Missing/incomplete/invalid last worked date. N326 Missing/incomplete/invalid last x-ray date. N327 Missing/incomplete/invalid other insured birth date. N328 Missing/incomplete/invalid Oxygen Saturation Test date. N329 Missing/incomplete/invalid patient birth date. N330 Missing/incomplete/invalid patient death date. N331 Missing/incomplete/invalid physician order date. N332 Missing/incomplete/invalid prior hospital discharge date. N333 Missing/incomplete/invalid prior placement date. N334 Missing/incomplete/invalid re-evaluation date. N335 Missing/incomplete/invalid referral date. N336 Missing/incomplete/invalid replacement date. N337 Missing/incomplete/invalid secondary diagnosis date. N338 Missing/incomplete/invalid shipped date. N339 Missing/incomplete/invalid similar illness or symptom date. N340 Missing/incomplete/invalid subscriber birth date. N341 Missing/incomplete/invalid surgery date. N342 Missing/incomplete/invalid test performed date. N343 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date. N344 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date. N345 Date range not valid with units submitted. N346 Missing/incomplete/invalid oral cavity designation code. N347 Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer. N348 You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier. N349 The administration method and drug must be reported to adjudicate this service. N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure. N351 Service date outside of the approved treatment plan service dates. N352 Alert: There are no scheduled payments for this service. Submit a claim for each patient visit. N353 Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim. N354 Incomplete/invalid invoice. N355 Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. N356 Not covered when performed with, or subsequent to, a non-covered service. N357 Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met. N358 Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted. N359 Missing/incomplete/invalid height. N360 Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim. N362 The number of Days or Units of Service exceeds our acceptable maximum. N363 Alert: in the near future we are implementing new policies/procedures that would affect this determination. N364 Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts. N366 Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice. N367 Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account. N368 You must appeal the determination of the previously adjudicated claim. N369 Alert: Although this claim has been processed, it is deficient according to state legislation/regulation. N370 Billing exceeds the rental months covered/approved by the payer. N371 Alert: title of this equipment must be transferred to the patient. N372 Only reasonable and necessary maintenance/service charges are covered. N373 It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf. N374 Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required. N375 Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility. N376 Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE. N377 Payment based on a processed replacement claim. N378 Missing/incomplete/invalid prescription quantity. N379 Claim level information does not match line level information. N380 The original claim has been processed, submit a corrected claim. N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges. N382 Missing/incomplete/invalid patient identifier. N383 Not covered when deemed cosmetic. N384 Records indicate that the referenced body part/tooth has been removed in a previous procedure. N385 Notification of admission was not timely according to published plan procedures. N386 This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. N387 Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. N388 Missing/incomplete/invalid prescription number. N389 Duplicate prescription number submitted. N390 This service/report cannot be billed separately. N391 Missing emergency department records. N392 Incomplete/invalid emergency department records. N393 Missing progress notes/report. N394 Incomplete/invalid progress notes/report. N395 Missing laboratory report. N396 Incomplete/invalid laboratory report. N397 Benefits are not available for incomplete service(s)/undelivered item(s). N398 Missing elective consent form. N399 Incomplete/invalid elective consent form. N400 Alert: Electronically enabled providers should submit claims electronically. N401 Missing periodontal charting. N402 Incomplete/invalid periodontal charting. N403 Missing facility certification. N404 Incomplete/invalid facility certification. N405 This service is only covered when the donor's insurer(s) do not provide coverage for the service. N406 This service is only covered when the recipient's insurer(s) do not provide coverage for the service. N407 You are not an approved submitter for this transmission format. N408 This payer does not cover deductibles assessed by a previous payer. N409 This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident. N410 Not covered unless the prescription changes. N418 Misrouted claim. See the payer's claim submission instructions. N419 Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change. N420 Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery. N421 Claim payment was the result of a payer's retroactive adjustment due to a review organization decision. N422 Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program. N423 Claim payment was the result of a payer's retroactive adjustment due to a non standard program. N424 Patient does not reside in the geographic area required for this type of payment. N425 Statutorily excluded service(s). N426 No coverage when self-administered. N427 Payment for eyeglasses or contact lenses can be made only after cataract surgery. N428 Not covered when performed in this place of service. N429 Not covered when considered routine. N430 Procedure code is inconsistent with the units billed. N431 Not covered with this procedure. N432 Adjustment based on a Recovery Audit. N433 Resubmit this claim using only your National Provider Identifier (NPI). N434 Missing/Incomplete/Invalid Present on Admission indicator. N435 Exceeds number/frequency approved /allowed within time period without support documentation. N436 The injury claim has not been accepted and a mandatory medical reimbursement has been made. N437 Alert: If the injury claim is accepted, these charges will be reconsidered. N438 This jurisdiction only accepts paper claims. N439 Missing anesthesia physical status report/indicators. N440 Incomplete/invalid anesthesia physical status report/indicators. N441 This missed/cancelled appointment is not covered. N442 Payment based on an alternate fee schedule. N443 Missing/incomplete/invalid total time or begin/end time. N444 Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation. N445 Missing document for actual cost or paid amount. N446 Incomplete/invalid document for actual cost or paid amount. N447 Payment is based on a generic equivalent as required documentation was not provided. N448 This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement. N449 Payment based on a comparable drug/service/supply. N450 Covered only when performed by the primary treating physician or the designee. N451 Missing Admission Summary Report. N452 Incomplete/invalid Admission Summary Report. N453 Missing Consultation Report. N454 Incomplete/invalid Consultation Report. N455 Missing Physician Order. N456 Incomplete/invalid Physician Order. N457 Missing Diagnostic Report. N458 Incomplete/invalid Diagnostic Report. N459 Missing Discharge Summary. N460 Incomplete/invalid Discharge Summary. N461 Missing Nursing Notes. N462 Incomplete/invalid Nursing Notes. N463 Missing support data for claim. N464 Incomplete/invalid support data for claim. N465 Missing Physical Therapy Notes/Report. N466 Incomplete/invalid Physical Therapy Notes/Report. N467 Missing Tests and Analysis Report. N468 Incomplete/invalid Report of Tests and Analysis Report. N469 Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). N470 This payment will complete the mandatory medical reimbursement limit. N471 Missing/incomplete/invalid HIPPS Rate Code. N472 Payment for this service has been issued to another provider. N473 Missing certification. N474 Incomplete/invalid certification. N475 Missing completed referral form. N476 Incomplete/invalid completed referral form. N477 Missing Dental Models. N478 Incomplete/invalid Dental Models. N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). N480 Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). N481 Missing Models. N482 Incomplete/invalid Models. N483 Missing Periodontal Charts. N484 Incomplete/invalid Periodontal Charts. N485 Missing Physical Therapy Certification. N486 Incomplete/invalid Physical Therapy Certification. N487 Missing Prosthetics or Orthotics Certification. N488 Incomplete/invalid Prosthetics or Orthotics Certification. N489 Missing referral form. N490 Incomplete/invalid referral form. N491 Missing/Incomplete/Invalid Exclusionary Rider Condition. N492 Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge. N493 Missing Doctor First Report of Injury. N494 Incomplete/invalid Doctor First Report of Injury. N495 Missing Supplemental Medical Report. N496 Incomplete/invalid Supplemental Medical Report. N497 Missing Medical Permanent Impairment or Disability Report. N498 Incomplete/invalid Medical Permanent Impairment or Disability Report. N499 Missing Medical Legal Report. N500 Incomplete/invalid Medical Legal Report. N501 Missing Vocational Report. N502 Incomplete/invalid Vocational Report. N503 Missing Work Status Report. N504 Incomplete/invalid Work Status Report. N505 Alert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time. N506 Alert: This is an estimate of the member’s liability based on the information available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment. N507 Plan distance requirements have not been met. N508 Alert: This real time claim adjudication response represents the member responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions. N509 Alert: A current inquiry shows the member’s Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing. N510 Alert: A current inquiry shows the member’s Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing. N511 Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time. N512 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication. N513 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication. N516 Records indicate a mismatch between the submitted NPI and EIN. N517 Resubmit a new claim with the requested information. N518 No separate payment for accessories when furnished for use with oxygen equipment. N519 Invalid combination of HCPCS modifiers. N520 Alert: Payment made from a Consumer Spending Account. N521 Mismatch between the submitted provider information and the provider information stored in our system. N522 Duplicate of a claim processed, or to be processed, as a crossover claim. N523 The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid. N524 Based on policy this payment constitutes payment in full. N525 These services are not covered when performed within the global period of another service. N526 Not qualified for recovery based on employer size. N527 We processed this claim as the primary payer prior to receiving the recovery demand. N528 Patient is entitled to benefits for Institutional Services only. N529 Patient is entitled to benefits for Professional Services only. N530 Not Qualified for Recovery based on enrollment information. N531 Not qualified for recovery based on direct payment of premium. N532 Not qualified for recovery based on disability and working status. N533 Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan. N534 This is an individual policy, the employer does not participate in plan sponsorship. N535 Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service. N536 We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us. N537 We have examined claims history and no records of the services have been found. N538 A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents. N539 Alert: We processed appeals/waiver requests on your behalf and that request has been denied. N540 Payment adjusted based on the interrupted stay policy. N541 Mismatch between the submitted insurance type code and the information stored in our system. N542 Missing income verification. N543 Incomplete/invalid income verification. N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected this will not be paid in the future. N545 Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program. N546 Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program. N547 A refund request (Frequency Type Code 8) was processed previously. N548 Alert: Patient's calendar year deductible has been met. N549 Alert: Patient's calendar year out-of-pocket maximum has been met. N550 Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future. N551 Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program. N552 Payment adjusted to reverse a previous withhold/bonus amount. N554 Missing/Incomplete/Invalid Family Planning Indicator. N555 Missing medication list. N556 Incomplete/invalid medication list. N557 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected. N558 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received. N559 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located. N560 The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received. N561 The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission. N562 The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment. N563 Missing required provider/supplier issuance of advance patient notice of non-coverage. The patient is not liable for payment for this service. N564 Patient did not meet the inclusion criteria for the demonstration project or pilot program. N565 Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed. N566 Alert: This procedure code requires functional reporting. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed. N567 Not covered when considered preventative. N568 Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative. N569 Not covered when performed for the reported diagnosis. N570 Missing/incomplete/invalid credentialing data. N571 Alert: Payment will be issued quarterly by another payer/contractor. N572 This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted. N573 Alert: You have been overpaid and must refund the overpayment. The refund will be requested separately by another payer/contractor. N574 Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider. N575 Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records. N576 Services not related to the specific incident/claim/accident/loss being reported. N577 Personal Injury Protection (PIP) Coverage. N578 Coverages do not apply to this loss. N579 Medical Payments Coverage (MPC). N580 Determination based on the provisions of the insurance policy. N581 Investigation of coverage eligibility is pending. N582 Benefits suspended pending the patient's cooperation. N583 Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person. N584 Not covered based on the insured's noncompliance with policy or statutory conditions. N585 Benefits are no longer available based on a final injury settlement. N586 The injured party does not qualify for benefits. N587 Policy benefits have been exhausted. N588 The patient has instructed that medical claims/bills are not to be paid. N589 Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug. N590 Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered. N591 Payment based on an Independent Medical Examination (IME) or Utilization Review (UR). N592 Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription. N593 Not covered based on failure to attend a scheduled Independent Medical Exam (IME). N594 Records reflect the injured party did not complete an Application for Benefits for this loss. N595 Records reflect the injured party did not complete an Assignment of Benefits for this loss. N596 Records reflect the injured party did not complete a Medical Authorization for this loss. N597 Adjusted based on a medical/dental provider's apportionment of care between related injuries and other unrelated medical/dental conditions/injuries. N598 Health care policy coverage is primary. N599 Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered. N600 Adjusted based on the applicable fee schedule for the region in which the service was rendered. N601 In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii. N602 Adjusted based on the Redbook maximum allowance. N603 This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage. N604 In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR. N605 This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68. N606 The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524. N607 Service provided for non-compensable condition(s). N608 The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6. N609 80% of the provider's billed amount is being recommended for payment according to Act 6. N610 Alert: Payment based on an appropriate level of care. N611 Claim in litigation. Contact insurer for more information. N612 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future. N614 Alert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information). N615 Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period. N616 Alert: This enrollee is in the first month of the advance premium tax credit grace period. N617 This enrollee is in the second or third month of the advance premium tax credit grace period. N618 Alert: This claim will automatically be reprocessed if the enrollee pays their premiums. N619 Coverage terminated for non-payment of premium. N620 Alert: This procedure code is for quality reporting/informational purposes only. N621 Charges for Jurisdiction required forms, reports, or chart notes are not payable. N622 Not covered based on the date of injury/accident. N623 Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate. N624 The associated Workers' Compensation claim has been withdrawn. N625 Missing/Incomplete/Invalid Workers' Compensation Claim Number. N626 New or established patient E/M codes are not payable with chiropractic care codes. N628 Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed. N629 Reviews/documentation/notes/summaries/reports/charts not requested. N630 Referral not authorized by attending physician. N631 Medical Fee Schedule does not list this code. An allowance was made for a comparable service. N633 Additional anesthesia time units are not allowed. N634 The allowance is calculated based on anesthesia time units. N635 The Allowance is calculated based on the anesthesia base units plus time. N636 Adjusted because this is reimbursable only once per injury. N637 Consultations are not allowed once treatment has been rendered by the same provider. N638 Reimbursement has been made according to the home health fee schedule. N639 Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule. N640 Exceeds number/frequency approved/allowed within time period. N641 Reimbursement has been based on the number of body areas rated. N642 Adjusted when billed as individual tests instead of as a panel. N643 The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule. N644 Reimbursement has been made according to the bilateral procedure rule. N645 Mark-up allowance. N646 Reimbursement has been adjusted based on the guidelines for an assistant. N647 Adjusted based on diagnosis-related group (DRG). N648 Adjusted based on Stop Loss. N649 Payment based on invoice. N650 This policy was not in effect for this date of loss. No coverage is available. N651 No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss. N652 The date of service is before the date of loss. N653 The date of injury does not match the reported date of loss. N654 Adjusted based on achievement of maximum medical improvement (MMI). N655 Payment based on provider's geographic region. N656 An interest payment is being made because benefits are being paid outside the statutory requirement. N657 This should be billed with the appropriate code for these services. N658 The billed service(s) are not considered medical expenses. N659 This item is exempt from sales tax. N660 Sales tax has been included in the reimbursement. N661 Documentation does not support that the services rendered were medically necessary. N662 Alert: Consideration of payment will be made upon receipt of a final bill. N663 Adjusted based on an agreed amount. N664 Adjusted based on a legal settlement. N665 Services by an unlicensed provider are not reimbursable. N666 Only one evaluation and management code at this service level is covered during the course of care. N667 Missing prescription. N668 Incomplete/invalid prescription. N669 Adjusted based on the Medicare fee schedule. N670 This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule. N671 Payment based on a jurisdiction cost-charge ratio. N672 Alert: Amount applied to Health Insurance Offset. N673 Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount. N674 Not covered unless a pre-requisite procedure/service has been provided. N675 Additional information is required from the injured party. N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule. N677 Alert: Films/Images will not be returned. N678 Missing post-operative images/visual field results. N679 Incomplete/Invalid post-operative images/visual field results. N680 Missing/Incomplete/Invalid date of previous dental extractions. N681 Missing/Incomplete/Invalid full arch series. N682 Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance. N683 Missing/Incomplete/Invalid prior treatment documentation. N684 Payment denied as this is a specialty claim submitted as a general claim. N685 Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code. N686 Missing/incomplete/Invalid questionnaire needed to complete payment determination. N687 Alert: This reversal is due to a retroactive disenrollment. N688 Alert: This reversal is due to a medical or utilization review decision. N689 Alert: This reversal is due to a retroactive rate change. N690 Alert: This reversal is due to a provider submitted appeal. N691 Alert: This reversal is due to a patient submitted appeal. N692 Alert: This reversal is due to an incorrect rate on the initial adjudication. N693 Alert: This reversal is due to a cancellation of the claim by the provider. N694 Alert: This reversal is due to a resubmission/change to the claim by the provider. N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication. N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment. N697 Alert: This reversal is due to a payer's retroactive contract incentive program adjustment. N698 Alert: This reversal is due to non-payment of the Health Insurance Exchange premiums by the end of the premium payment grace period, resulting in loss of coverage. N699 Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program. N700 Payment adjusted based on the Electronic Health Records (EHR) Incentive Program. N701 Payment adjusted based on the Value-based Payment Modifier. N702 Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services. N703 This service is incompatible with previously adjudicated claims or claims in process. N704 Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted. N705 Incomplete/invalid documentation. N706 Missing documentation. N707 Incomplete/invalid orders. N708 Missing orders. N709 Incomplete/invalid notes. N710 Missing notes. N711 Incomplete/invalid summary. N712 Missing summary. N713 Incomplete/invalid report. N714 Missing report. N715 Incomplete/invalid chart. N716 Missing chart. N717 Incomplete/Invalid documentation of face-to-face examination. N718 Missing documentation of face-to-face examination. N719 Penalty applied based on plan requirements not being met. N720 Alert: The patient overpaid you. You may need to issue the patient a refund for the difference between the patient’s payment and the amount shown as patient responsibility on this notice. N721 This service is only covered when performed as part of a clinical trial. N722 Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item. N723 Patient must use Liability set-aside (LSA) funds to pay for the medical service or item. N724 Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item. N725 A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis. N726 A conditional payment is not allowed. N727 A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis. N728 A workers' compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis. |
CR Corrections and Reversal
Note: This value is not to be used with 005010 and up.
OA Other Adjustment
PI Payer Initiated Reductions
PR Patient Responsibility
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