About Martin’s Point Health Care Electronic Remittance .../media/...Aug 08, 2005 · Electronic remittance advices (ERAs/835s)save time and money, allow for faster payment postings

About Martin’s Point Health Care Electronic Remittance Advices (ERAs/835s)

Electronic remittance advices (ERAs/835s) save time and money, allow for faster payment postings and provide more detailed information regarding claim adjudications and adjustments. Once you sign up for Martin’s Point ERAs through your claims clearing house, we will phase out your paper copies over a four week period. You’ll know that your four week transition has begun when you see the following message on your paper remittance advice: Paper remittance advices will end in four weeks. After that, you will see similar messages each week until your final paper remittance advice indicates: Final paper remittance advice.

From that point forward, your Martin’s Point Generations Advantage and/or US Family Health Plan remittance advices will be sent electronically only, through your claims clearing house. Electronic claims submission and remittance will soon be required for all payers and providers. Thank you for taking the lead on this front. The following resources are available if you have questions about one of our ERAs:

• Provider Portal: Use this tool to review detailed claim adjudication and adjustment information. Paper remittance advices are limited toone claim adjustment reason code (CARC) but the portal will show additional CARCs, if applicable. To use this tool, visitwww.providerview.martinspoint.org or call 1‐888‐732‐7364 to create a username and password. Then access the tool atwww.martinspoint.org/For‐Providers/Claims.

• Provider Inquiry: If you still have questions after consulting the provider portal, please call our Provider Inquiry Team at 1‐888‐732‐7364.

• Electronic Remittance Advice (ERA/835) Provider Guide: Below is a searchable list of industry‐standard claim adjustment reason codes(CARCs) and the corresponding Martin’s Point claims editing rules and remarks.

http://www.providerview.martinspoint.org/

http://www.martinspoint.org/For

http://www.martinspoint.org/For

Electronic Remittance Advice (ERA/835) Provider Guide Version: December 12, 2016

This document maps industry‐standard claim and remittance advice codes to the corresponding claims editing descriptions that appear on Martin’s Point 835 files. To search for a specific code, press your “CTRL” and “F” keys at the same time and type the code it into the “Find” box.

Definitions: • Claim Adjustment Reason Code (CARC): CARCs communicate an adjustment―the reason why a claim or service line was paid differently

than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. Not all CARCS have a corresponding RARC. In these situations, the CARC supplies sufficient information about the claim adjustment we have made.

• Remit Advice Reason Code (RARC): RARCs provide additional explanation for an adjustment already described by a CARC and may conveyinformation about remittance processing. There are two types of RARCs, supplemental and informational. The majority of the RARCs aresupplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation foran adjustment already described by a CARC. The second type of RARC is informational; these RARCs are all prefaced with Alert: and areoften referred to as Alerts. Alerts are used to convey information about remittance processing and are never related to a specificadjustment or CARC.

• Martin’s Point Rule Description: This column provides further information that corresponds to specific CARCS and pertains to our paymentpolicies and rules. Our claims editing processes are closely aligned with correct coding and billing criteria established by the Centers forMedicare and Medicaid Services (CMS). There are some exceptions, usually based on our health plan benefit design. For example, ourmembers have access to important preventive services such as annual physicals and eye exams at $0 copay. But overall, we adhere closelyto Medicare claim editing practices. We also apply Medicare Local Coverage Determination (LCD) rules to claims for services rendered toGenerations Advantage members in Maine and New Hampshire. (LCD rules do not apply to USFHP claims.) LCD rules can be found on thelocal carrier’s website or by contacting them directly. Following are the local carriers for Maine and New Hampshire:

o Medicare Parts A & B: National Government Services, Inc. www.ngsmedicare.com/ngs/portal/ngsmedicare/welcomeo Durable Medical Equipment (DME): NHIC, Corp. www.medicarenhic.com/dme/mrlcdcurrent.aspx

If you receive a claim denial and, upon research and review of the documentation, you feel a corrected claim is in order, you may submit a corrected claim with the appropriate additional information. Before doing so, please review our electronic corrected claim guidelines at www.martinspoint.org/for‐providers/claims. Electronic submission will speed processing time. Please be sure to include the claim number and the patient control number from the original claim to help ensure efficient reprocessing. For more information about Medicare coding and billing criteria, please visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.

Questions? Please visit www.martinspoint.org/for‐providers/claims or call 1‐888‐732‐7364.

http://www.ngsmedicare.com/ngs/portal/ngsmedicare/welcome

http://www.medicarenhic.com/dme/mrlcdcurrent.aspx

http://www.martinspoint.org/for

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd

http://www.martinspoint.org/for

CARC CARC Description Martin's Point Rule Description RARC RARC Description 1 Deductible Amount 915 ‐ REMIT deductibles 10 The diagnosis is inconsistent with the patient's gender.

Changed as of 2/00 915 ‐ Sex conflict; patient's sex and diagnosis are inconsistent

10 The diagnosis is inconsistent with the patient's gender. Changed as of 2/00

915 ‐ Sex conflict; patient's sex and diagnosis are inconsistent






9140 ‐ (DASC2) Patient gender inconsistent with diagnosis

MA39 Missing/incomplete/invalid gender.

100 Payment made to patient/insured/responsible party. 915 ‐ Member received payment from Third Party Insurance, seek reimbursement from member.

107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. Changed as of 6/03

9240 ‐ (mAP) Medicare Deny Add‐On Procedure

N122 Add‐on code cannot be billed by itself.


9247 ‐ Add‐on procedure without primary procedure



6210 ‐ FQHC claim lacks required qualifying visit code

N324 Missing/incomplete/invalid last seen/visit date.


918 ‐ Connect requires claim review

109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

915 ‐ No COB entered with a secondary enrollment

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.


915 ‐ TPA has changed, Bill to Patient Advocates LLC, PO Box 1959, Gray, ME 04039

N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.


915 ‐ Pays Under Pharmacy Benefit


11 The diagnosis is inconsistent with the procedure. 816 ‐ Claim Check: Diag to Procedure Audit

11 The diagnosis is inconsistent with the procedure. 9232 ‐ (LBI/LCI) Missing or Invalid LCD Diagnosis

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.

11 The diagnosis is inconsistent with the procedure. 815 ‐ Claim Check: Intensity of Service Audit

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.

11 The diagnosis is inconsistent with the procedure. 330 ‐ Invalid diagnosis code for benefit

M64 Missing/incomplete/invalid other diagnosis.

11 The diagnosis is inconsistent with the procedure. 9232 ‐ (LBI/LCI) Missing or Invalid LCD Diagnosis


110 Billing date predates service date. 9007 ‐ iCES Future Date of Service Error

110 Billing date predates service date. 824 ‐ Claim Check: Future Date of Service Error

110 Billing date predates service date. 915 ‐ Cannot bill for future date of service

111 Not covered unless the provider accepts assignment. 915 ‐ We received a claim for health care services to a GA/USFHP member during a time our records indicate you opted out of participation in

http://www.cms.gov/mcd

Medicare/Tricare. Federal law prohibits us from paying your claim and you may not bill our member for payment.

114 Procedure/product not approved by the Food and Drug Administration.

6191 ‐ CLIENT CUSTOM EDIT

119 Benefit maximum for this time period or occurrence has been reached. Changed as of 2/04

9243 ‐ Maximum frequency exceeded


9222 ‐ (BFR/LCFR) LCD Frequency Exceeded


9520 ‐ (mDFh) Maximum Frequency in History


116 ‐ Annual Benefit Amount Exceeded


200 ‐ Benefit Day Limit Exceeded


206 ‐ Benefit Visit Limit Exceeded


207 ‐ Benefit Dollar Limit Exceeded


915 ‐ Only one family planning visit allowed per date of service.

M86 Service denied because payment already made for same/similar procedure within set time frame.


915 ‐ Limited service exceeded. M86 Service denied because payment already made for same/similar procedure within set time frame.


915 ‐ Services exceed Psych benefit.


915 ‐ Benefit Visit Limit Exceeded


915 ‐ Benefit Dollar Limit Exceeded


915 ‐ If prenatal care and OB procedure is on paid history within 270 days, same provider, related or unrelated diag, claim is rejected.



915 ‐ If postnatal and an OB proc. are on same claim or paid history, and postnatal care is within 45 days of post ob proc., same prov, related or unrelated diag, claim is denied.



915 ‐ A payment cannot be made for more than three physical therapy procedures.


129 Payment denied ‐ Prior processing information appears incorrect. Changed as of 2/01

132 ‐ Sum of Individual Coinsured Charges Exceeds Maximum

M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

13 The date of death precedes the date of service. 915 ‐ Services billed after date of death.

13 The date of death precedes the date of service. 915 ‐ SERVICE RESPONSIBILITY OF LAB CORP ONLY

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.

131 Claim specific negotiated discount. New as of 2/97 915 ‐ Negotiated Rate Payment

133 The disposition of this claim/service is pending further review. Changed as of 10/99

915 ‐ NMD Exceptions


915 ‐ If major surgery is performed same day as major/minor surgery, same POS, already paid on history and prov are same or different. Claim is pended


915 ‐ If assistant surgery is performed on the same day as another asst surgery, on the same claim or paid history, same POS and the prov are different. Pend claim.


915 ‐ If anesthesia is performed on the same day, same POS as anesthesia no the same claim and the prov are the same or different, pay 100% of time and base unit allowance for greater procedure and 100% of time for each lesser procedure. Pend claim.


915 ‐ Preexisting Condition May Exist


915 ‐ Claim requires manual processing


915 ‐ Manually Pended Claim


915 ‐ Provider has Alert/Memos


915 ‐ Provider Watch flag has been set for review


915 ‐ Benefit Requires Manual Review


915 ‐ Contract Term Requires Manual Review


915 ‐ Provider on Pay Hold


915 ‐ HSS Service Invocation failed


915 ‐ Failed during preparation of HSS Service Request message.


915 ‐ Failed while handling HSS Service Response.


915 ‐ Failed during insertion of Claim Edit based on HSS Service Response.


915 ‐ Failed duing update of claim line manual contract amount.


915 ‐ New Member Letter


915 ‐ Requires manual processing.


915 ‐ REMIT retro termed Pre‐X


915 ‐ Authorization Line Manually Pended


915 ‐ Authorization Status Manually Set


915 ‐ REMIT Qualifying claim not finalized – reversed determining claim


915 ‐ REMIT finalized qualifying claim – reversed determining claim


915 ‐ Code requires manual pricing


915 ‐ No available APC/fee schedule rate


915 ‐ Invalid payment status from Grouper


915 ‐ Missing or invalid fee schedule type


915 ‐ HSS Service Call Failure


915 ‐ Error accessing PAYER file


915 ‐ Error accessing rate calculator file


915 ‐ Missing rate calculator record


915 ‐ Error accessing Grouper program


915 ‐ Error accessing Pricer program


915 ‐ 00027 Only incidental services reported (claim rejection)


915 ‐ Error accessing rate or weight file


915 ‐ Error opening Grouper or Pricer in batch mode


915 ‐ Error opening ACE report file


915 ‐ Error loading Editor program


915 ‐ Benefit Restriction Message


915 ‐ Plan Restriction Message


915 ‐ Initialization error


915 ‐ error allocating memory


915 ‐ Parameter passing error


915 ‐ Unable to load Optimizer


915 ‐ Initialization error


915 ‐ Error opening DRG table


915 ‐ Error reading CC exclusion table


915 ‐ Error closing CC exclusion table


915 ‐ Error opening CC exclusion table


915 ‐ I/O error on table


915 ‐ HAC editor not found


915 ‐ Service submitted for FI/MAC review (condition code 20)


915 ‐ Questionable covered service


915 ‐ Member has an active restriction on enrollment


210 ‐ Member NOT enrolled on DOS

N30 Patient ineligible for this service.


340 ‐ HHPPS Multiple HIPPS codes detected on episode claim


613 ‐ Claim Requires Manual Processing


9174 ‐ (011SFR) Claim submitted for review (Cond Code 20)


111 ‐ Provider Watch


105 ‐ Provider on Pay hold

135 Claim denied. Interim bills cannot be processed. New as of 10/98

915 ‐ Cannot Accept Interim Billing


135 Claim denied. Interim bills cannot be processed. New as of 10/98

915 ‐ Intermim Claim with no Initial Claim

140 Patient/Insured health identification number and name do not match. New as of 6/99

915 ‐ Incorrect Plan ID code. 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.

140 Patient/Insured health identification number and name do not match. New as of 6/99

915 ‐ Incorrect AHCCCS ID code. 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.

141 Claim adjustment because the claim spans eligible and ineligible periods of coverage. Changed as of 6/00

218 ‐ Member Lost Eligibility During Date Span

146 Payment denied because the diagnosis was invalid for the date(s) of service reported. New as of 6/02.

523 ‐ Diagnosis code does not exist


525 ‐ Diagnosis code is not valid on DOS


6035 ‐ Code invalid; not found on table of valid ICD‐9‐CM codes

M76 Missing/incomplete/invalid diagnosis or condition.


6036 ‐ Invalid code, unnecessary 4th digit



6037 ‐ Invalid code, missing 4th digit



6025 ‐ Invalid code for dates, missing 4th/5th digit



6031 ‐ Unacceptable principal diagnosis

MA63 Missing/incomplete/invalid principal diagnosis.


915 ‐ Primary ICD9 Diagnostic Code Required


147 Provider contracted/negotiated rate expired or not on file. New as of 6/02

915 ‐ Provider is Not Credentialed


915 ‐ W/O contractual agreement.


346 ‐ Unable to locate fee schedule


101 ‐ No active provider contract


102 ‐ Provider not active for Plan on DOS


9177 ‐ (024DOR) Date out of OCE range

148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. New as of 6/02

915 ‐ Electronic Claim has COB N4 Missing/incomplete/invalid prior insurance carrier EOB.

148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. New as of 6/02

915 ‐ Reprocessed due to updated OHI, please bill other insurance as appropriate

N4 Missing/incomplete/invalid prior insurance carrier EOB.

149 Lifetime benefit maximum has been reached for this service/benefit category. New as of 10/02

117 ‐ Lifetime Benefit Max Exceeded

149 Lifetime benefit maximum has been reached for this service/benefit category. New as of 10/02

123 ‐ Individual Lifetime Visits Exceeded

15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01

608 ‐ UM is not for same Provider


606 ‐ UM Not found M62 Missing/incomplete/invalid treatment authorization code.


618 ‐ Provider's group does not match authorized group

N54 Claim information is inconsistent with pre‐ certified/authorized services.


622 ‐ Place of Service does not Match Authorized



617 ‐ Provider's specialty does not match authorized specialty

N95 This provider type/provider specialty may not bill this service.


915 ‐ Prior authorization not for same member



915 ‐ Prior authorization not for same member.



915 ‐ Prior authorization is not for same provider.


151 Payment adjusted because the payer deems the information submitted does not support this many services. New as of 10/02

9246 ‐ (mMUE/MUEf/sMUE) Medically Unlikely‐ Exceeds Allowed Units

N431 Service is not covered with this procedure.

152 Payment adjusted because the payer deems the information submitted does not support this length of service. New as of 10/02

915 ‐ Invalid length of stay 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.

16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Changed as of 2/02

915 ‐ Record does not meet criteria for any DRG in MDC



915 ‐ Record does not meet criteria for any DRG in MDC

N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information


915 ‐ Invalid age in years on admission or age in days



915 ‐ Invalid age in years on admission or age in days

MA41 Missing/incomplete/invalid admission type.


915 ‐ Inappropriate specification of bilateral procedure

M51 Missing/incomplete/invalid procedure code(s).


915 ‐ invalid admission source MA42 Missing/incomplete/invalid admission source.


915 ‐ Invalid nursery level 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.


915 ‐ Invalid discharge status MA43 Missing/incomplete/invalid patient status.


915 ‐ Illogical principal diagnosis (PDX)



915 ‐ Invalid principal diagnosis (PDX)



915 ‐ Invalid date or fromdate > thrudate

M52 Missing/incomplete/invalid "from" date(s) of service.


915 ‐ Invalid date or fromdate > thrudate



915 ‐ Invalid operation code M51 Missing/incomplete/invalid procedure code(s).


915 ‐ Invalid operation code 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.


915 ‐ Invalid patient type 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.


915 ‐ Outpatient claim contains unacceptable errors



915 ‐ Outpatient claim contains unacceptable errors

N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule.


915 ‐ From date greater than thru date

M52 Missing/incomplete/invalid "from" date(s) of service.


915 ‐ Invalid Outpatient Classification



915 ‐ Invalid Outpatient Classification



915 ‐ Condition code 21 M44 Missing/incomplete/invalid condition code.


915 ‐ Condition code 21 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.


915 ‐ Invalid from‐thru dates MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.


915 ‐ Date out of OCE range 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.


915 ‐ Date out of OCE range N345 Date range not valid with units submitted.


915 ‐ Invalid procedure code M51 Missing/incomplete/invalid procedure code(s).


915 ‐ This is a clinical trial claim and it is missing the required diagnosis code.



915 ‐ Late charge/ corrected claim received. Denied to allow corrections.

MA67 Correction to a prior claim.


915 ‐ Late charge/ corrected claim received. Denied to allow corrections.

N693 Alert: This reversal is due to a cancellation of the claim by the provider.


915 ‐ No Charges Submitted on Claim Line

M54 Missing/incomplete/invalid total charges.





915 ‐ Invalid code, unnecessary 4th/5th digit



915 ‐ Invalid code missing 4th/5th digit



915 ‐ Code invalid M76 Missing/incomplete/invalid diagnosis or condition.


915 ‐ Invalid code for dates, unnecessary 4th/5th digit



915 ‐ Invalid code for dates, missing 4th/5th digit



915 ‐ Invalid age in days at discharge



915 ‐ Invalid age in days at discharge

N50 Missing/incomplete/invalid discharge information.


915 ‐ Sex invalid; not 1 or 2, M or F



915 ‐ Code is duplicate of principal diagnosis



915 ‐ Code is duplicate of another secondary diagnosis



915 ‐ Diagnosis cannot be used as principal



915 ‐ “E” Code as principal MA63 Missing/incomplete/invalid principal diagnosis.


915 ‐ Manifestation code as principal



915 ‐ Non‐Specific code as principal



915 ‐ Questionable admission 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.


915 ‐ Questionable admission MA41 Missing/incomplete/invalid admission type.


915 ‐ Unacceptable principal diagnosis



915 ‐ Unacceptable principal diagnosis; requires secondary dX



915 ‐ Present On Admission indicator required but not submitted

N434 Missing/Incomplete/Invalid Present on Admission indicator.


915 ‐ Present On Admission indicator required but is not valid



915 ‐ A Present on Admission Indicator (POA) has been applied to a Diagnosis Code that does not require one per Medicare/Tricare OPPS guidelines






915 ‐ Invalid code, unnecessary 4th digit



915 ‐ Invalid code, missing 4th digit



915 ‐ Same Provider As Surgeon/Asst Surgeon Invalid

M80 Not covered when performed during the same session/date as a previously processed service for the patient.


915 ‐ Same Provider As Surgeon/Asst Surgeon Invalid



915 ‐ Adjusted due to processing error



915 ‐ Adjusted due to processing error

N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication.


915 ‐ Adjusted due to processing error‐QNXT



915 ‐ Adjusted due to processing error‐QNXT

N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication.


915 ‐ Appeal MA67 Correction to a prior claim.


915 ‐ Appeal N691 Alert: This reversal is due to a patient submitted appeal.


915 ‐ Reconsideration MA67 Correction to a prior claim.


915 ‐ Reconsideration N690 Alert: This reversal is due to a provider submitted appeal.


915 ‐ Unable to determine which history claim to adjust based off the claim number provided and/or information provided.

N380 The original claim has been processed, submit a corrected claim.


915 ‐ Claims Recovery Project N432 Adjustment based on a Recovery Audit.


915 ‐ Insufficient services on day of partial hospitalization.



915 ‐ Insufficient services on day of partial hospitalization.

MA32 Missing/incomplete/invalid number of covered days during the billing period.


915 ‐ The member has not exhausted their Part A benefits. Martin’s Point does not adhere to this limitation. Please submit a corrected inpatient claim with your room and board charges.



915 ‐ Corrected Claim MA67 Correction to a prior claim.


915 ‐ Corrected Claim N694 Alert: This reversal is due to a resubmission/change to the claim by the provider.


915 ‐ No Assessment Date Submitted on Claim

N309 Missing/incomplete/invalid assessment date.


915 ‐ Invalid value for OPCODE1 M45 Missing/incomplete/invalid occurrence code(s).


915 ‐ Invalid value for OPCODE1 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.


915 ‐ Invalid value for PATTYPE 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.


915 ‐ Invalid value for PATTYPE MA43 Missing/incomplete/invalid patient status.


915 ‐ Claim billed with two different individual NPI’s

MA102 Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider.


915 ‐ This is a clinical trial claim and it is missing the required clinical trial number

MA50 Missing/incomplete/invalid Investigational Device Exemption number for FDA‐approved clinical trial services.


915 ‐ This is a clinical trial claim and it is missing the required Condition code.

M44 Missing/incomplete/invalid condition code.


915 ‐ Invalid Insured/Patient information submitted (Name, DOB, Gender, Member ID)


915 ‐ Rebill with a valid HIPPS code


915 ‐ The procedure code billed is not recognized by Tricare. An alternate code is available.



915 ‐ The procedure code billed is not recognized by Medicare. An alternate code is available.



915 ‐ Denied‐ Please provide a description of service

N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.


915 ‐ Description of Service & a Prior Authorization is Required

N225 Incomplete/invalid documentation/orders/notes/summary/report/ chart.


915 ‐ Invalid Insured/Member ID N382 Missing/incomplete/invalid patient identifier.


915 ‐ Invalid Gender MA39 Missing/incomplete/invalid gender.


915 ‐ Invalid DOB MA52 Missing/incomplete/invalid date.


915 ‐ File with FFS Medicare First 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.


915 ‐ File with FFS Medicare First N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.


915 ‐ Patient Name not matching name on file.

MA36 Missing/incomplete/invalid patient name.


915 ‐ Provider termed from affiliation for DOS billed

N198 Rendering provider must be affiliated with the pay‐to provider.


915 ‐ Provider credentials required for reimbursement.

M143 The provider must update license information with the payer.


915 ‐ HCPC/CPT Code not Valid on a UB Claim

M20 Missing/incomplete/invalid HCPCS.


915 ‐ EOB needed from Primary Insurance



915 ‐ Accept Assignment Box 27 on claim needs to be completed.


915 ‐ EOB does not match claim N4 Missing/incomplete/invalid prior insurance carrier EOB.


915 ‐ Invalid units for modifier M53 Missing/incomplete/invalid days or units of service.


915 ‐ Payment included in composite rate



915 ‐ Invalid HCPCS code M20 Missing/incomplete/invalid HCPCS.


915 ‐ Invalid modifier for pricing M78 Missing/incomplete/invalid HCPCS modifier.


915 ‐ Invalid Admit Diagnosis MA65 Missing/incomplete/invalid admitting diagnosis.


915 ‐ Claim returned to provider for correction (RTP)



915 ‐ Invalid units for this modifier

M53 Missing/incomplete/invalid days or units of service.


915 ‐ ZIP code missing or inv (for Ambulance)

MA29 Missing/incomplete/invalid provider name, city, state, or zip code.


915 ‐ Invalid units for revenue code



915 ‐ Trauma response cc code without rev code 068X and CPT 99291

N59 Please refer to your provider manual for additional program and provider information.


915 ‐ Claim lacks allowed procedure code



915 ‐ Claim lacks required radiolabeled product



915 ‐ G0379 only allowed with G0378



915 ‐ G0379 only allowed with G0378

N357 Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.


915 ‐ Revenue code not recognized by Medicare

M50 Missing/incomplete/invalid revenue code(s).


915 ‐ Claim lacks required device code



915 ‐ Incorrect billing of blood and blood products



915 ‐ Incorrect billing of blood and blood products

N750 Incomplete/invalid Blood Gas Report.


915 ‐ Units greater than one for bilateral proC billed with mod 50



915 ‐ Multiple observations overlap in time



915 ‐ Multiple observations overlap in time

N20 Service not payable with other service rendered on the same date.


915 ‐ Code 2 of a code pair allowed with modifier



915 ‐ Invalid revenue code M50 Missing/incomplete/invalid revenue code(s).


915 ‐ Codes G0378 and G0379 only allowed with bill type 13x



915 ‐ Codes G0378 and G0379 only allowed with bill type 13x

MA30 Missing/incomplete/invalid type of bill.


915 ‐ Code 2 of a code pair that is not allowed by NCCI




N345 Date range not valid with units submitted.


915 ‐ Terminated bilateral procedure



915 ‐ implanted/administered not consistent with implant/procedure



915 ‐ Transf or blood product exchange w/o spec of blood product



915 ‐ Transf or blood product exchange w/o spec of blood product



915 ‐ Obs rev code on line item with non‐obs HCPCS code



915 ‐ HCPC Code not Valid on a HCFA Claim



915 ‐ Revenue center requires HCPCS code



915 ‐ REMIT Claim with Enrollment Status Change

N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package


915 ‐ REMIT Claim with External Enrollment Coverage Type Change



915 ‐ REMIT LOI Records Added or Changed

N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.


915 ‐ REMIT E/R Claim reversed due to receipt of inpatient claim.

M2 Not paid separately when the patient is an inpatient.


915 ‐ REMIT retro term enrollment



915 ‐ REMIT denied claim with valid enrollment



915 ‐ Pricing cannot be determined based on units billed



915 ‐ Servicing provider required on claim

N257 Missing/incomplete/invalid billing provider/supplier primary identifier.


915 ‐ Skin substitute application procedure without appropriate skin substitute product code



915 ‐ Resubmit With Operative Report/Medical Records



915 ‐ "Medical Records required, fax records to 207‐828‐7857 ATTN HMD"



915 ‐ A valid HCPC code available for NDC number.



915 ‐ ABA Therapy codes need to be billed on a separate claim.



915 ‐ ABA Therapy codes need to be billed on a separate claim.

N61 Rebill services on separate claims.


915 ‐ Need breakout of Anesthesia time for the MD and CRNA

N29 Missing documentation/orders/notes/summary/report/ chart.


915 ‐ Service not rendered in place of service billed

N38 Missing/incomplete/invalid place of service.


915 ‐ Incorrect Billing 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.


915 ‐ Incorrect Billing N34 Incorrect claim form/format for this service.


915 ‐ Bill with a valid J‐Code M20 Missing/incomplete/invalid HCPCS.


915 ‐ Incomplete claim form. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.


915 ‐ Submit appropriate claim form

N34 Incorrect claim form/format for this service.


915 ‐ Non Contracted Code, Use corresponding S Code



915 ‐ EOB is Missing Information. N4 Missing/incomplete/invalid prior insurance carrier EOB.


915 ‐ Invoice does not match services billed

N354 Incomplete/invalid invoice


915 ‐ Unable to determine patient responsibility based upon the submitted EOB.



915 ‐ Please resubmit with remit remark code key.

MA69 Missing/incomplete/invalid remarks.


915 ‐ Invalid ICD9 Procedure Code



915 ‐ Invalid ICD‐9 Diagnosis Code



915 ‐ Diagnosis not valid for Benefit



915 ‐ Pay and Educate 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.


915 ‐ Pay and Educate N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.


915 ‐ Service only payable as inpatient.



915 ‐ Explanation of Benefits illegible. Please submit legible Explanation of Benefits.


915 ‐ The Medical Records Submitted are not for the Rendering Provider on the claim.



915 ‐ Resubmit claim with Medicare FQHC/Rural Health per diem rate sheet

N66 Missing/incomplete/invalid documentation.


915 ‐ Invalid Type of Bill for a Corrected Claim



915 ‐ Invalid Type of Bill for a Corrected Claim



915 ‐ Invalid billing. Please report the appropriate HCPCS G code.



915 ‐ Invalid/Missing occurrence code



915 ‐ Invalid Place of Service M77 Missing/incomplete/invalid place of service.


915 ‐ Invalid billing ‐multiple service locations billed on one claim

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.


915 ‐ Paid Incorrect Provider MA67 Correction to a prior claim.


915 ‐ Paid Incorrect Provider N694 Alert: This reversal is due to a resubmission/change to the claim by the provider.


915 ‐ Invalid Approved Provider Service for Provider



915 ‐ Therapy Threshold not met 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.


915 ‐ Therapy Threshold not met N486 Incomplete/invalid Physical Therapy Certification.


915 ‐ Claim Doesn't have any Service Lines

M79 Missing/incomplete/invalid charge.


915 ‐ Ambulance Run Report Doesn’t match units billed on claim.



915 ‐ Patient not enrolled with plan.



915 ‐ CPT code invalid on DOS.


915 ‐ No response to COB inquiry.

N245 Incomplete/invalid plan information for other insurance


915 ‐ Revenue code missing / invalid.



915 ‐ DOS incorrect. MA52 Missing/incomplete/invalid date.


915 ‐ Incorrect Discharge Status Submitted



915 ‐ Treatment Authorization Needed

M62 Missing/incomplete/invalid treatment authorization code.


915 ‐ Procedure code not on file. M51 Missing/incomplete/invalid procedure code(s).


915 ‐ Diagnosis code not on file. M64 Missing/incomplete/invalid other diagnosis.


915 ‐ Diagnostic Pointer Missing or Invalid



915 ‐ Member ID number invalid.


915 ‐ Category of service invalid.


915 ‐ Member not enrolled on DOS.



915 ‐ Member was not enrolled with this Medical Group on DOS .



915 ‐ Resubmit claim with Medicare EOB.



915 ‐ Resubmit with primary EOB. N4 Missing/incomplete/invalid prior insurance carrier EOB.


915 ‐ Primary Diagnosis Required MA63 Missing/incomplete/invalid principal diagnosis.


915 ‐ Triage only ‐ not life threatening.



915 ‐ Triage only ‐ not life threatening.

N358 Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.


915 ‐ No Attending Physician ID (Outpatient)

M68 Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.


915 ‐ Negative charge on claim line



915 ‐ Invalid Admit Hour N46 Missing/incomplete/invalid admission hour.


915 ‐ Invalid Discharge Hour N317 Missing/incomplete/invalid discharge hour.


915 ‐ Claim Doesn't have any Service Lines



915 ‐ Provider requires a specialty code

N270 Missing/incomplete/invalid other provider primary identifier.


915 ‐ PCP is solely responsible for services



915 ‐ PCP is solely responsible for services

N450 Covered only when performed by the primary treating physician or the designee.


915 ‐ Services are not eligible with diagnosis provided by physician.



915 ‐ Service is not related to direct treatment of an illness or injury.



915 ‐ Service is not related to direct treatment of an illness or injury.

N576 Services not related to the specific incident/claim/accident/loss being reported.


915 ‐ Discharge Status Required for Inpatient and SNF Claims

MA43 Missing/incomplete/invalid patient status.


915 ‐ Missing Primary Diagnosis MA63 Missing/incomplete/invalid principal diagnosis.


915 ‐ Admit Type Required MA41 Missing/incomplete/invalid admission type.


915 ‐ Discharge Status Required MA43 Missing/incomplete/invalid patient status.


915 ‐ Member has no active enrollment on DOS



915 ‐ Invalid CPT/HCPCS M20 Missing/incomplete/invalid HCPCS.


915 ‐ No Enrollment N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package


915 ‐ Invalid Accomodation Days MA32 Missing/incomplete/invalid number of covered days during the billing period.


915 ‐ Admit Date Required for Inpatient Claim

MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.


915 ‐ Attending Physician Required for Inpatient Claims

N31 Missing/incomplete/invalid prescribing provider identifier.


915 ‐ Invalid Bill Type MA30 Missing/incomplete/invalid type of bill.


915 ‐ Revenue Code Requires HCPCS and/or Modifier



915 ‐ Physicians Assistant requires Modifier 80 or 27

M78 Missing/incomplete/invalid HCPCS modifier.


915 ‐ CRNA requires Modifier AA M78 Missing/incomplete/invalid HCPCS modifier.


915 ‐ Invalid Line Date of Service MA52 Missing/incomplete/invalid date.


915 ‐ Invalid Start Date M52 Missing/incomplete/invalid "from" date(s) of service.


915 ‐ Invalid End Date M59 Missing/incomplete/invalid "to" date(s) of service.


915 ‐ Invalid Discharge Status MA43 Missing/incomplete/invalid patient status.


915 ‐ Invalid Revenue Code for Bill Type



915 ‐ Invalid HCPCS for Revenue Code



915 ‐ Transferred to Patient Advocates for processing; Expect payment determination from Patient Advocates

N196 Alert: Patient eligible to apply for other coverage which may be primary.


915 ‐ Rendering and billing provider NPIs cannot match

N433 Resubmit this claim using only your National Provider Identifier (NPI)


915 ‐ No rendering provider NPI billed on HCFA



915 ‐ Not valid for SNF 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.


915 ‐ Occurrence Code 55 and the date of death must be present when patient discharge status 20, 40, 41, or 42 is present



915 ‐ Another service line for the same DOS is missing information to process this line


915 ‐ OPPS Claim Denial‐Return to Provider



915 ‐ OPPS Claim Denial‐Return to Provider

N142 The original claim was denied. Resubmit a new claim, not a replacement claim.


915 ‐ Resubmit Claim to OptumHealth



915 ‐ Resubmit Claim to OptumHealth



915 ‐ No Enrollment N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package


915 ‐ NDC Number is missing or Invalid

M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).


915 ‐ Bill to Pharmacare 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.


915 ‐ Bill to Pharmacare N196 Alert: Patient eligible to apply for other coverage which may be primary.


915 ‐ Billing with invalid NPI for provider submitted on claim.


915 ‐ Mental Health NPI number Missing or invalid for Mental Health Services billed on claim.



915 ‐ The billing group NPI in Box 33A is not valid or missing for the dates of service on the claim.

M57 Missing/incomplete/invalid provider identifier.


915 ‐ Denied‐Benefit Requires submission by member



915 ‐ Denied‐Benefit Requires submission by member



915 ‐ Claim cannot be submitted with any negative charges



915 ‐ If you have any questions concerning this claim, please call your provider or member inquiry number. Located on the back of your ID card.



915 ‐ If you have any questions concerning this claim, please call your provider or member inquiry number. Located on the back of your ID card.

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.


915 ‐ Missing/Invalid Value Code M49 Missing/incomplete/invalid value code(s) or amount(s).


915 ‐ Submit to Patient Advocates

N418 Misrouted claim. See the payer's claim submission instructions.


915 ‐ Coverage change during pregnancy/Resubmit covered services.



915 ‐ Coverage change during pregnancy/Resubmit covered services.



915 ‐ Diagnosis Code on Claim does not Match Term



915 ‐ Admit type does not match admit source



915 ‐ Other agency may be responsible for payment



915 ‐ Other agency may be responsible for payment

N193 Specific federal/state/local program may cover this service through another payer.


915 ‐ Admit type requires 450 revcode



915 ‐ Admission source required MA42 Missing/incomplete/invalid admission source.


915 ‐ Invalid patient status for bill type



915 ‐ Surgical procedure requires HCPCS



915 ‐ Admit type required for 11x bill type



915 ‐ Invalid ICD‐9 procedure code



915 ‐ Insufficient Units For Date Span



915 ‐ Final Episode claim never received, anticipated claim retracted per 60 day CMS guideline.

N560 The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.


915 ‐ Missing/Incomplete/Invalid Investigational Device Exemption number for FDA‐approved clinical trial services.



915 ‐ Service Requires a diagnosis for both the underlying cause as well as a systemic disease.



915 ‐ Re‐Processed Claim from Denial



915 ‐ Re‐Processed Claim from Denial

N11 Denial reversed because of medical review.


915 ‐ Resubmit with run sheet Time/Milage



915 ‐ Please bill with the appropriate RUG Code.



915 ‐ MaineSense does not accept Split Billing. Payment is included in Professional Charges. Member is held Harmless.

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.


915 ‐ MaineSense does not accept Split Billing. Payment is included in Professional Charges. Member is held Harmless.



915 ‐ Denied‐Awaiting Third Party Liability Information/ MVA

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.


915 ‐ Denied‐Awaiting Third Party Liability Information/ PL

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.


6033 ‐ Present On Admission indicator required but not submitted



6034 ‐ Present On Admission indicator required but is not valid



551 ‐ Diagnosis Requires POA Indicator for Inpatient Claim



9519 ‐ (mDEY) Physician Order or Prescription Required

N455 Missing Physician Order.


308 ‐ Invalid Admit Hour (0 ‐‐ 23) N46 Missing/incomplete/invalid admission hour.


990 ‐ Missing Claim Information N463 Missing support data for claim.


335 ‐ HIPPS RUGS DOS is not within assessment modifier time period

N471 Missing/incomplete/invalid HIPPS Rate Code.


336 ‐ HIPPS RUGS billed amount should not have a dollar amount

N471 Missing/incomplete/invalid HIPPS Rate Code.


306 ‐ Discharge status is required for inpatient and SNF claims



9031 ‐ Invalid procedure code N569 Not covered when performed for the reported diagnosis.


9477 ‐ (038IIP) No implant procedure for implanted device



9211 ‐ Billed service requires device code



9216 ‐ (076TRC) Trauma code billed without rev 068x and CPT 99291



6091 ‐ implanted/administered not consistent with implant/procedure






6097 ‐ Obs rev code on line item with non‐obs HCPCS code



6115 ‐ Claim lacks required device code



6119 ‐ Trauma response cc code without rev code 068X and CPT 99291



6135 ‐ Payment included in composite rate



113 ‐ Specialty code required for provider



6196 ‐ CLIENT CUSTOM EDIT N750 Incomplete/invalid Blood Gas Report.


6180 ‐ E/M condition not met and line item date for code G0244



991 ‐ Claim Document or Information Not Received

N66 Missing/incomplete/invalid documentation.


9462 ‐ (mM54/mM55/mM56/mM78) Payment adjusted based on modifier

N701 Payment adjusted based on the Value‐based Payment Modifier.


6216 ‐ Only mental health education and training services provided

N731 Incomplete/Invalid mental health assessment.


9036 ‐ (DOB/DOBf) Missing or Invalid Date of Birth

N329 Missing/incomplete/invalid patient birth date.


635 ‐ Invalid Claim Form Type N34 Incorrect claim form/format for this service.


9024 ‐ (ASD) ANESTHESIA SECONDARY PROCEDURE

N250 Missing/incomplete/invalid assistant surgeon secondary identifier.


9239 ‐ (LRD/LCRD) LCD Review/Request Documents



163 ‐ Benefit requires documentation



9130 ‐ (OCCf) Invalid Occurrence Code

N299 Missing/incomplete/invalid occurrence date(s).


9148 ‐ Age invalid; not in range 0‐ 124 years



9178 ‐ (025AGE) Age is non‐ numeric or outside 0‐124 years range



6203 ‐ Mental health code not approved for partial hosp program



6204 ‐ Mental health service not payable outside the p/h program



224 ‐ Benefit Requires Manual Review



225 ‐ Contract Term Requires Manual Review



6182 ‐ CLIENT CUSTOM EDIT N357 Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.


128 ‐ Remaining visits less than date span. Units not allocated.

N362 The number of Days or Units of Service exceeds our acceptable maximum.


9027 ‐ (BPS) MISSING OR INVALID POS



9223 ‐ (BPO) Missing Required LCD Place of Service



162 ‐ Contract term requires documentation

N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.


6157 ‐ Code2 of column1/column2 CCI edit

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.


6166 ‐ Code2 of col1/col2 CCI edit, allow appropriate modifier



6218 ‐ Service provided prior to date of (NCD) approval


http://www.cms.gov/mcd/search.asp







6206 ‐ Service provided on or after effective date of NCD rule



9244 ‐ Medicare add‐on procedure without primary procedure



6006 ‐ No rates or weights (no matching record)

N19 Procedure code incidental to primary procedure.


9149 ‐ (DIBW) Invalid newborn birth weight (not within 200‐ 9000 gm)

N207 Missing/incomplete/invalid weight.


9235 ‐ (LBS/LCS) Missing Required LCD Secondary Diagnosis



9236 ‐ (LBT/LCT) Missing Required LCD Tertiary Diagnosis



9181 ‐ (029NMH) Partial hospitalization‐non‐mental health diagnosis





512 ‐ Invalid Thru DOS M59 Missing/incomplete/invalid "to" date(s) of service.


6121 ‐ Claim lacks required radiolabeled product



9464 ‐ (mMP5) Operative report required for number of procedures

M29 Missing operative note/report.


9126 ‐ Missing or invalid condition code



9193 ‐ (046PHC)Cond code 41 invalid for TOB‐partial hospitalization



9190 ‐ (042MMV) Multiple visits same day/rev w/o cond code G0



291 ‐ Invalid Condition Code on DOS



9234 ‐ (LBP/LCP) Missing Required LCD Primary Diagnosis



9198 ‐ (055NRS) Non‐reportable code for site of service

M77 Missing/incomplete/invalid place of service.


659 ‐ Invalid Place of Service Code



9171 ‐ (001ICM) Invalid diagnosis code



9150 ‐ Missing or invalid diagnosis



538 ‐ Diagnosis Pointer Required on Srvce Line for Diagnosis Codes






6083 ‐ Inappropriate specification of bilateral procedure



6090 ‐ Terminated bilateral procedure



9097 ‐ (MB2) Medicare bilateral adjustment does not apply



521 ‐ Procedure code not found or invalid for date of service



174 ‐ Procedure code on claim does NOT match terms valid procedure



6209 ‐ Skin application procedure w/o appropriate skin product code



6186 ‐ Code not recognized by the OPPS, alternate may be available



9205 ‐ (062CNR) Invalid OPPS code; alternate code may be available



9476 ‐ Terminated procedure is bilateral or multiple units



9155 ‐ (DNSP) Claim O.R. procedures nonspecific



9157 ‐ (DPCB) Proposed alternate closed biopsy code



9164 ‐ Missing, invalid, or inappropriate procedure



9031 ‐ Invalid procedure code M51 Missing/incomplete/invalid procedure code(s).


9191 ‐ (043TBP) Blood transfusion billed with no blood product



9166 ‐ (DPNC2) Invalid open biopsy code



9201 ‐ (058OAP) HCPCS G0379 only allowed with G0378



9217 ‐ (077DPC/LNAP1)Device billed without allowed procedure code



9218 ‐ (078DNM) Claim lacks required radiopharmaceutical



511 ‐ Invalid From DOS M52 Missing/incomplete/invalid "from" date(s) of service.


128 ‐ Remaining visits less than date span. Units not allocated.



338 ‐ HIPPS RUGS length of stay not in sync with accommodation day



204 ‐ Invalid accommodation days



6127 ‐ Invalid units for this modifier



6131 ‐ Invalid units for revenue code



6134 ‐ Invalid units for modifier M53 Missing/incomplete/invalid days or units of service.


9214 ‐ (074UBP) Invalid units for bilateral procedure with mod 50



9184 ‐ (032PHS) Insufficient services for partial hosp. < 3 days



9185 ‐ (033PHM) LOS > 3 but mental health services < 57%



9186 ‐ (034PHN) LOS > 3; partial hospitalization criteria not met



9037 ‐ (DTU) DATES OF SERVICE TO UNITS DISCREPANCY



9013 ‐ Units Expansion Detected M53 Missing/incomplete/invalid days or units of service.


6205 ‐ Charge exceeds token charge ($1.01)



303 ‐ Claim Total Mismatch M54 Missing/incomplete/invalid total charges.





819 ‐ Claim Check: Claim Stop audit



916 ‐ Claim does not have any service lines



305 ‐ Primary diagnosis code is required



6029 ‐ Non‐Specific code as principal



9485 ‐ (067SPA/068PCD/(069SOP) DOS outside approval window

MA06 Missing/incomplete/invalid beginning and/or ending date(s).


195 ‐ Date of Onset is Missing on Claim

MA100 Missing/incomplete/invalid date of current illness or symptoms


6188 ‐ Activity therapy can only be billed on partial hosp

MA125 Per legislation governing this program, payment constitutes payment in full.


9127 ‐ Missing or invalid From or Thru date

MA52 Missing/incomplete/invalid date.


9025 ‐ (BDS/023BDS) Invalid claim or line DOS

MA52 Missing/incomplete/invalid date.


9054 ‐ (ICM/ICMf) Missing Principal Diagnosis Code



9160 ‐ (DPDI3) Non‐specific code cannot be used as principle DX



9161 ‐ (DPDI4) Principal DX indicates questionable admission



9163 ‐ Unacceptable principal DX w/o required secondary DX



6183 ‐ Clinical trial requires diag code V707 not be primary diag



9221 ‐ (BCC/LCC) LCD Code to Code Missing or Invalid



9152 ‐ (DIS) Sex invalid; not 1 or 2, M or F




9079 ‐ Missing patient gender MA39 Missing/incomplete/invalid gender.


9179 ‐ (026SEX) Patient gender not F or M (alpha) or 0‐2 (numeric)



9115 ‐ (MVM) MEDICARE VENTILATOR MANAGEMENT

N130 Consult plan benefit documents/guidelines for information about restrictions for this service.


6141 ‐ Invalid Admit Diagnosis MA65 Missing/incomplete/invalid admitting diagnosis.


9169 ‐ (DXE1) E‐code used as admit diagnosis

MA65 Missing/incomplete/invalid admitting diagnosis.


9170 ‐ (DXE2) Invalid admit DX (cannot be manifestation code)

MA65 Missing/incomplete/invalid admitting diagnosis.


301 ‐ Invalid or missing admission date

MA40 Missing/incomplete/invalid admission date.


316 ‐ Admit type does not match admit source



518 ‐ Admit type required for 11x bill type



9134 ‐ (TOAf) Missing or Invalid Type of Admission (Inpatient)



9133 ‐ Missing or invalid source of admission

MA42 Missing/incomplete/invalid admission source.


328 ‐ Admission Source Required MA42 Missing/incomplete/invalid admission source.


9132 ‐ Missing or invalid patient status code



9151 ‐ (DIDS) Invalid discharge disposition / patient status.



9210 ‐ (070CA) Modifier CA requires patient status code 20



9078 ‐ (PRZ) PROVIDER ZIP IS EMPTY

MA29 Missing/incomplete/invalid provider name, city, state, or zip code.


9135 ‐ (TOBf/LTOB) Missing or Invalid Type of Bill



6177 ‐ CLIENT CUSTOM EDIT MA30 Missing/incomplete/invalid type of bill.


9206 ‐ (063OPH)OT code only valid for partial hospitalization claim



9207 ‐ (064TPH)AT code only valid for partial hospitalization claim



9196 ‐ (053OTB) Codes G0378 and G0379 only allowed with 13x or 85x



175 ‐ Bill type on claim does NOT match contract term



335 ‐ HIPPS RUGS DOS is not within assessment modifier time period

MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.


6074 ‐ Invalid from‐thru dates MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.


6140 ‐ Invalid modifier for pricing M78 Missing/incomplete/invalid HCPCS modifier.


336 ‐ HIPPS RUGS billed amount should not have a dollar amount






9012 ‐ Review Billed Amount and/or Units



9195 ‐ (052OCN) Invalid DX, reason or units for Observation billing


9128 ‐ (IPAf) Invalid Other Procedure Code and/or Date (Inpatient)


9129 ‐ (IPPf) Missing Principal Procedure Code and/or Date


9131 ‐ (OSCf) Invalid Occurrence Span Code and/or Dates


267 ‐ COB: LOI No Response or Outdated ‐ Pursue and Pay


214 ‐ Bill Type does NOT match Benefit


6076 ‐ Invalid procedure code


6092 ‐ MUP that would be allowed if modifier were present


6129 ‐ ZIP code missing or inv (for Ambulance)


6130 ‐ Device intensive procedure without device


811 ‐ Claim Check: Pre‐Op Audit M144 Pre‐/post‐operative care payment is included in the allowance for the surgery/procedure.


812 ‐ Claim Check: Post‐Op Audit M144 Pre‐/post‐operative care payment is included in the allowance for the surgery/procedure.


9209 ‐ (066CMP) Code requires manual pricing

M116 Paid under the Competitive Bidding Demonstration project. Project is ending, and future services may not be paid under this project.


1001 ‐ Invalid NDC Code M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).


623 ‐ NDC Code Mismatch on UM M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).


6187 ‐ OT code only billed on partial hospitalization claims

M125 Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.


829 ‐ Claim Check: Split Lines/Unit Exp/Mult Modifiers/Modifier‐51

M16 Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.


6136 ‐ Invalid HCPCS code M20 Missing/incomplete/invalid HCPCS.


507 ‐ Revenue Code Requires HCPCS



508 ‐ Invalid Modifier Code on Date of Service



9500 ‐ Invalid HCPCS M20 Missing/incomplete/invalid HCPCS.


9529 ‐ (mUBh) Medicare Other Unbundle in History



9252 ‐ Incorrect billing of rev code with HCPCS



9465 ‐ HCPCS not valid for line DOS



9192 ‐ (044ORC) Invalid HCPCS billed with Observation rev code



289 ‐ Invalid Occurrence Code on DOS

M45 Missing/incomplete/invalid occurrence code(s).


290 ‐ Invalid Occurrence Span Code on DOS

M46 Missing/incomplete/invalid occurrence span code(s).


990 ‐ Missing Claim Information M47 Missing/incomplete/invalid internal or document control number.


292 ‐ Invalid Value Code on DOS M49 Missing/incomplete/invalid value code(s) or amount(s).


9136 ‐ Missing or invalid value code

M49 Missing/incomplete/invalid value code(s) or amount(s).


9189 ‐ (041IRC) Rev code not valid ‐ Medicare Outpatient PPS



9208 ‐ (065RNM) Invalid revenue code under Medicare OPPS



9508 ‐ Missing, invalid, or inappropriate revenue code



6189 ‐ CLIENT CUSTOM EDIT M50 Missing/incomplete/invalid revenue code(s).


6211 ‐ Incorrect revenue code reported for FQHC payment code



337 ‐ HIPPS RUG rate code requires rehabilitation therapy



505 ‐ Invalid Revenue Code M50 Missing/incomplete/invalid revenue code(s).


345 ‐ Detail line REV code not 0023



6094 ‐ Invalid revenue code M50 Missing/incomplete/invalid revenue code(s).


6142 ‐ ACE Edit Return to Provider

164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion. New as of 6/04

967 ‐ COB claim exceeds submission window

166 These services were submitted after this payers responsibility for processing claims under this plan ended. New as of 2/05

915 ‐ Submitted to plan in error. 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.

166 These services were submitted after this payers responsibility for processing claims under this plan ended. New as of 2/05

915 ‐ Submit to Patient Advocates

17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. Changed as of 2/02

915 ‐ REMIT Claim was opened or adjusted based on request by NxPBA


915 ‐ REMIT Claim was reversed or voided by Post Connect Adjust


915 ‐ Prior authorization is awaiting medical review.

M85 Subjected to review of physician evaluation and management services.


915 ‐ Adjusted Due to Retro‐ Authorization on file.


915 ‐ Adjusted due to retro rate update‐QNXT

N419 Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.


915 ‐ Adjusted due to contract assignment error‐QNXT



915 ‐ Adjusted due to benefit clarification/reconfiguration‐ QNXT



915 ‐ Adjusted due to Special Project/Business Decision.



915 ‐ Adjusted due to processing error‐CES


915 ‐ Adjust to authorized level of care.



915 ‐ Reprocessing claim/Sending to Judge Advocates Office

170 Payment is denied when performed/billed by this type of provider. New as of 6/05

915 ‐ Rural Health and FQHC claims need to be submitted on a CMS1500.



915 ‐ Provider not contracted for service.


9020 ‐ (ANE) ANES PERFORMED BY NON‐ANESTHETIST


114 ‐ Provider does not match required type

N521 Mismatch between the submitted provider information and the provider information stored in our system.


152 ‐ Provider type does not match type required by benefit


171 Payment is denied when performed/billed by this type of provider in this type of facility. New as of 6/05

915 ‐ Invalid Bill Type for Provider Billed.


915 ‐ Invalid facility type or county



915 ‐ FQHC claims for Evaluation and Management (E/M) codes are required to be billed on a UB‐ 04 form

M97 Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.

172 Payment is adjusted when performed/billed by a provider of this specialty. New as of 6/05

154 ‐ Benefit requires Specialty Code not found on Provider


177 Payment denied because the patient has not met the required eligibility requirements. New as of 6/05

421 ‐ No other enrollment exists for service line dates

N650 This policy was not in effect for this date of loss. No coverage is available.


201 ‐ No enrollment exists for claim start date

N650 This policy was not in effect for this date of loss. No coverage is available.


217 ‐ Member has an active restriction on enrollment


915 ‐ Patient not enrolled with Plan.



915 ‐ Not eligible for service under plan

18 Duplicate claim/service. 915 ‐ Payment for this procedure is included with the payment made for the surgical procedure.


18 Duplicate claim/service. 915 ‐ Payment for this consultation is included in the payment for anesthesia. No separate payment can be made.


18 Duplicate claim/service. 915 ‐ Payment for this procedure is included with the payment made for medical treatment rendered on the same day by a different provider.


18 Duplicate claim/service. 915 ‐ Payment for prenatal and postnatal care is included in the payment for the obstetrical procedure. No additional payment can be made.


18 Duplicate claim/service. 915 ‐ Duplicate Claim (Member/DOS)

18 Duplicate claim/service. 915 ‐ Duplicate Claim Line(Member/DOS/CPT(Rev))

18 Duplicate claim/service. 915 ‐ This is a duplicate of a claim that has been previously processed.

18 Duplicate claim/service. 915 ‐ Duplicate Claim (Provider/Member/DOS)

18 Duplicate claim/service. 915 ‐ Duplicate Line on Same Claim

18 Duplicate claim/service. 915 ‐ Duplicate to a denied service.

18 Duplicate claim/service. 915 ‐ Med visit on same day as a type “T” or “S” proc w/o mod 25 for a minor procedure or mod 57 for major procedures.


18 Duplicate claim/service. 519 ‐ Duplicate Claim Line (Same Member/DOS/CPT(Rev))

18 Duplicate claim/service. 813 ‐ Claim Check: Medical Visit 18 Duplicate claim/service. 826 ‐ Claim Check: Duplicates 18 Duplicate claim/service. 9034 ‐ (DCP) DUPLICATE CLAIM

BY PROVIDER

18 Duplicate claim/service. 9038 ‐ (DUP/DUPIf/DUPOf) Possible Duplicate Claim

18 Duplicate claim/service. 522 ‐ Duplicate Claim Line (Same Provider/Member/DOS/CPT(Rev) )

N522 Duplicate of a claim processed, or to be processed, as a crossover claim.

18 Duplicate claim/service. 834 ‐ Claim Check: Procedure has a Day Limit; Limit Exceeded


18 Duplicate claim/service. 6087 ‐ Med visit on same day as a type “T” or “S” proc w/o mod 25


18 Duplicate claim/service. 9156 ‐ (DPBC) Bilateral procedures identified


18 Duplicate claim/service. 9153 ‐ (DMBP) Multiple different bilateral joint procedures


18 Duplicate claim/service. 9521 ‐ (mEV) Same day Procedure as History Claim for same Condition


18 Duplicate claim/service. 831 ‐ Claim Check: Proc has unilateral or bilateral Performance


18 Duplicate claim/service. 832 ‐ Claim Check: Procedure is a bilateral Code; Duplicate found


18 Duplicate claim/service. 833 ‐ Claim Check: Procedure has a Lifetime Limit; Limit Exceeded

N117 This service is paid only once in a patient's lifetime.

181 Payment adjusted because this procedure code was invalid on the date of service. New as of 6/05

6143 ‐ CLIENT CUSTOM EDIT M51 Missing/incomplete/invalid procedure code(s).


504 ‐ Invalid CPT/HCPCS code M51 Missing/incomplete/invalid procedure code(s).


158 ‐ Invalid Service Code on DOS

182 Payment adjusted because the procedure modifier was invalid on the date of service. New as of 6/05. Modified on 8/8/2005


182 Payment adjusted because the procedure modifier was invalid on the date of service. New as of 6/05. Modified on 8/8/2005

6088 ‐ Invalid modifier N519 Invalid combination of HCPCS modifiers.

185 The rendering provider is not eligible to perform the service billed. New as of 6/05

150 ‐ No contract term found for service


915 ‐ Provider not credentialed ‐ Do not bill member


915 ‐ Same Provider as Anesthesiologist/CRNA is Invalid


915 ‐ Provider's specialty does not match authorized specialty



915 ‐ Provider's group does not match authorized group



915 ‐ Provider's network does not match authorized network



915 ‐ Provider's participation status does not match authorized



915 ‐ Provider type does not match authorized provider type


188 This product/procedure is only covered when used according to FDA recommendations. New as of 6/05

915 ‐ Service provided prior to FDA approval

188 This product/procedure is only covered when used according to FDA recommendations. New as of 6/05

6111 ‐ Service provided prior to FDA approval

189 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. New as of 6/05

827 ‐ Claim Check: Obsolete/Invalid Codes (proc/modifier/diag)

189 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. New as of 6/05

9202 ‐ Obsolete – (059CTD) Clinical trial requires DX V707 (nonprim

19 Claim denied because this is a work‐related injury/illness and thus the liability of the Worker's Compensation Carrier.

9154 ‐ (DMSP) Possible secondary payer to Auto, Work Comp (Dx)


9147 ‐ (DDSP/004MSA) Possible secondary payer to Auto, Work Comp


366 ‐ Workers Compensation Claim


915 ‐ Denied‐Workers Comp Claim


915 ‐ Denied: Workmens Compensation.


915 ‐ Denied‐ Bill third party insurance


915 ‐ Denied‐ Bill personel liability carrier

194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician. New as of 2/06

9490 ‐ (105AON/105hAON) Anesthesia billed by operating physician

195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service. New as of 2/06

915 ‐ Provider Requested Takeback

197 Precertification/authorization/notification absent. 915 ‐ Authorization Amount overrides Contract Amount

N45 Payment based on authorized amount.

197 Precertification/authorization/notification absent. 915 ‐ REMIT retro auth change N54 Claim information is inconsistent with pre‐ certified/authorized services.

197 Precertification/authorization/notification absent. 915 ‐ Authorization does not match claim dates


197 Precertification/authorization/notification absent. 915 ‐ Prior authorization is closed.


197 Precertification/authorization/notification absent. 915 ‐ Authorization number invalid for DOS.


197 Precertification/authorization/notification absent. 915 ‐ Requires authorized referral.

197 Precertification/authorization/notification absent. 915 ‐ Incorrect authorization number.


197 Precertification/authorization/notification absent. 915 ‐ Requires prior authorization.


197 Precertification/authorization/notification absent. 915 ‐ Prior authorization is denied.


197 Precertification/authorization/notification absent. 915 ‐ Prior authorization is pended.


197 Precertification/authorization/notification absent. 915 ‐ Prior authorization not found.


197 Precertification/authorization/notification absent. 915 ‐ Claim Tiers Do Not Match Referral


197 Precertification/authorization/notification absent. 915 ‐ Benefit Requires Prior Authorization

197 Precertification/authorization/notification absent. 915 ‐ Prior Authorization is required after first 12 PT visits.

197 Precertification/authorization/notification absent. 915 ‐ Prior Authorization is required after first 20 PT visits.

197 Precertification/authorization/notification absent. 367 ‐ Contract term requires UM

197 Precertification/authorization/notification absent. 603 ‐ UM is Pended

197 Precertification/authorization/notification absent. 604 ‐ UM is Denied

197 Precertification/authorization/notification absent. 611 ‐ UM has no available units

197 Precertification/authorization/notification absent. 614 ‐ No Available Bed Days on UM

197 Precertification/authorization/notification absent. 616 ‐ UM Service Line Denied

197 Precertification/authorization/notification absent. 619 ‐ Provider's network does not match authorized network

197 Precertification/authorization/notification absent. 205 ‐ Benefit requires UM

197 Precertification/authorization/notification absent. 609 ‐ UM dates do not match Claim


197 Precertification/authorization/notification absent. 601 ‐ UM is Closed N351 Service date outside of the approved treatment plan service dates.

197 Precertification/authorization/notification absent. 607 ‐ UM is not for same Member

N454 Incomplete/invalid Consultation Report.

197 Precertification/authorization/notification absent. 236 ‐ Benefit requires either a UM or a UM Supporting Document


198 Precertification/authorization exceeded. 915 ‐ Prior authorization has no units available.


198 Precertification/authorization exceeded. 915 ‐ Prior authorization has insufficent units remaining.


198 Precertification/authorization exceeded. 915 ‐ Prior authorization cost estimate exceeded.


198 Precertification/authorization exceeded. 915 ‐ Claim line exceeds available bed days on auth.

198 Precertification/authorization exceeded. 915 ‐ Prior authorization services do not match claim.


199 Revenue code and Procedure code do not match. 915 ‐ Invalid Revenue Code M50 Missing/incomplete/invalid revenue code(s).

199 Revenue code and Procedure code do not match. 6109 ‐ Revenue code not recognized by Medicare

199 Revenue code and Procedure code do not match. 6173 ‐ CLIENT CUSTOM EDIT

199 Revenue code and Procedure code do not match. 6199 ‐ Trauma code without revenue code 068x and CPT 99291

199 Revenue code and Procedure code do not match. 6170 ‐ Observation Room revenue code require observation HCPCS

199 Revenue code and Procedure code do not match. 901 ‐ Invalid Revenue‐HCPCS for claim line DOS


199 Revenue code and Procedure code do not match. 6215 ‐ HCPCS or revenue code missing for partial hospitalization


199 Revenue code and Procedure code do not match. 6100 ‐ Revenue center requires HCPCS code


20 Claim denied because this injury/illness is covered by the liability carrier.

263 ‐ Auto Accident indicated on claim ‐ Pursue and Pay

20 Claim denied because this injury/illness is covered by the liability carrier.

818 ‐ Claim Check: TPL Audit N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.

203 Discontinued or reduced service. 915 ‐ Reduce to urgent care. 204 This service/equipment/drug is not covered under the

patient’s current benefit plan 202 ‐ No Benefit for Service

204 This service/equipment/drug is not covered under the patient’s current benefit plan

172 ‐ Term does NOT meet date criteria of the claim

204 This service/equipment/drug is not covered under the patient’s current benefit plan

149 ‐ Benefit does NOT meet date criteria of the claim

21 Claim denied because this injury/illness is the liability of the no‐fault carrier.

915 ‐ Denied‐ Bill motor vehicle insurance

22 Payment adjusted because this care may be covered by another payer per coordination of benefits. Changed as of 2/01

915 ‐ Denied‐Awaiting Third Party Liability Information



915 ‐ Third party liability form never returned



915 ‐ Benefit Requires Payment from Primary Ins. First



915 ‐ Possible TLP claim/auth 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.


915 ‐ Member enrolled in a Clinical Trial, Standard Medicare is Primary.



915 ‐ Services need to be billed to the Veterans Administration (VA)

N193 Specific federal/state/local program may cover this service through another payer.


265 ‐ Other Insurance indicated on claim ‐ Pursue and Pay


266 ‐ Other Insurance information unknown ‐ Pursue and Pay


262 ‐ Claim requires Pursue and Pay


384 ‐ Potential Other Accident 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.


420 ‐ Other enrollment exists for service line dates



1102 ‐ Accident: LOI No Response or Outdated ‐ Pursue and Pay



377 ‐ EOB not received on Claim 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.


378 ‐ No COB Amount on claim 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.


216 ‐ Member has other coverage;submit to primary insurance first


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.

6151 ‐ Units exceed maximum (MUE)


6117 ‐ Units greater than one for bilateral proC billed with mod 50


9255 ‐ (082CET) Charge exceeds token charge

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.)

915 ‐ Missing/incomplete/invalid assumed or relinquished care date.

N310 Missing/incomplete/invalid assumed or relinquished care date.

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.)

403 ‐ Third Party Review N420 Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.

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.)

403 ‐ Third Party Review N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.

23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. Changed as of 2/01, and 6/05

253 ‐ Internal enrollment and COB amounts entered



254 ‐ Medicare non‐allowed claim submitted hard copy



915 ‐ MPHC is Primary, Refund Other Health Insurance


915 ‐ Service Paid in Full by Primary Carrier


915 ‐ Refund Medicare 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.


915 ‐ Refund Other Health Insurance

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.


915 ‐ Invalid Co‐Insurance Days for 11x Bill Type

MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.


915 ‐ MPHC is Primary, Refund Medicare.



915 ‐ Electronic claim has COB


915 ‐ Paid by other insurance. M86 Service denied because payment already made for same/similar procedure within set time frame.


915 ‐ Third Party Insurance Paid‐ Exceeds MPHC Allowable‐ Do not bill member.



915 ‐ Invalid lifetime reserve days MA35 Missing/incomplete/invalid number of lifetime reserve days.


915 ‐ Life reserve days exceed maximum

MA35 Missing/incomplete/invalid number of lifetime reserve days.


915 ‐ Invalid coinsurance days for 21x bill type



915 ‐ Coinsurance days exceeds covered days



915 ‐ Coinsurance days missing associated value codes



915 ‐ Covered days and coinsured days exceed maximum for hospital



915 ‐ Covered days exceeds maximum for hospital



915 ‐ Covered days and coinsured days exceed maximum for SNF



915 ‐ Covered days exceed maximum for SNF


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.

915 ‐ Mutually exclusive procedure


6158 ‐ Medical visit same day significant procedure needs mod 25


6085 ‐ Mutually exclusive procedure


802 ‐ Claim Check: Mutually Exclusive Service


9471 ‐ (019MEP/019hMEP) Mutually exclusive procedures on claim


9478 ‐ (039MEO/039hMEO) Mutually exclusive procedures w/o modifier


6156 ‐ Mutually exclusive procedure, not allowed even with modifier

M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

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.)

6171 ‐ CLIENT CUSTOM EDIT M2 Not paid separately when the patient is an inpatient.


6172 ‐ CLIENT CUSTOM EDIT M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.


9114 ‐ (MUN) Medicare Unbundle on Current Line



6149 ‐ Separate payment for services is not provided by Medicare



9250 ‐ (UNB/sUN/sUNf) Unbundled Procedure on Current Line



9483 ‐ (049SIP) Service same day as inpatient‐only procedure



9197 ‐ (054MCS) Multiple codes for same service (blood components)



9194 ‐ (051MOO) Multiple observations overlap in time



6101 ‐ Service on same day as inpatient procedure



6106 ‐ Multiple codes for the same service



6098 ‐ Inpatient separate procedures not paid



6099 ‐ Service is not separately payable



915 ‐ Service on same day as inpatient procedure



915 ‐ Inpatient separate procedures not paid



915 ‐ Service is not separately payable



915 ‐ Multiple codes for the same service


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.



9086 ‐ (UED) CODING RELATIONSHIP ERROR


9087 ‐ (UER) CODING RELATIONSHIP ERROR, REVIEW


9088 ‐ (UES) CODING RELATIONSHIP ERROR, SECONDARY




9041 ‐ (HED) CODING RELATIONSHIP ERROR, DENY


9042 ‐ (HER) CODING RELATIONSHIP ERROR, REVIEW


9043 ‐ (HES) CODING RELATIONSHIP ERROR, SECONDARY


9183 ‐ (031PHE) Partial hosp same day as ECT or T‐service


9188 ‐ (036EMS) Extensive mental hlth same day as ECT or T‐ service

239 Claim spans eligible and ineligible periods of coverage. Rebill separate claims.

628 ‐ Claim Line date span crosses calendar/policy year

N74 Resubmit with multiple claims, each claim covering services provided in only one calendar month.

24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Changed as of 6/00

208 ‐ Benefit Applies to PCP Only N52 Patient not enrolled in the billing provider's managed care plan on the date of service.


171 ‐ Term Applies to assigned members only


915 ‐ Additional capitation dollars


915 ‐ Service is capitated to PCP or IPA


915 ‐ No Employer Fee For Service

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.

915 ‐ Invalid birthweight in grams 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.


915 ‐ Conflicting birthweight 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.


915 ‐ Non‐specific birthweight as derived from diagnosis codes



915 ‐ Invalid birthweight; not in range 200‐9000 grams


242 Services not provided by network/primary care providers.

915 ‐ Remit PCP claim with PCP change


915 ‐ Remit Non PCP claim with PCP change



915 ‐ Provider is not part of Network required for Benefit


211 ‐ Provider is not part of network required for benefit


243 Services not authorized by network/primary care providers.

196 ‐ Benefit requires non‐ contracted (NONPAR) provider


192 ‐ Benefit requires contracted (PAR) provider


915 ‐ Unauthorized provider.

251 The attachment content received did not contain the content required to process this claim or service.

915 ‐ Invoice is Missing M23 Missing invoice.

258 Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. Start: 11/01/2013

915 ‐ Member was Incarcerated at the time of service, collect from the Federal/State/Local authority as Appropriate.

29 The time limit for filing has expired. 915 ‐ Claim exceeds timely filing limit.

29 The time limit for filing has expired. 915 ‐ Exceeds timely filing limitations for corrected claim.

29 The time limit for filing has expired. 915 ‐ Claim submit time exceeded.

29 The time limit for filing has expired. 915 ‐ Plan not notified in time. 29 The time limit for filing has expired. 541 ‐ Claim Line Submission

Window Exceeded

29 The time limit for filing has expired. 543 ‐ Inpatient Claim Submission Window Exceeded (claim Thru date)

29 The time limit for filing has expired. 311 ‐ Claim exceeds timely filing limit

29 The time limit for filing has expired. 313 ‐ Covered days do not match accommodation revcode days

3 Co‐payment Amount 915 ‐ A $10.00 co‐pay has been taken. A $10.00 cost share has been taken.

3 Co‐payment Amount 915 ‐ CMS pays covered clinical trial services. MP will make a payment if CMS costshare is more than the members costshare as a MP member. CMS costshare for this claim is the same or less than the costshare for MP. Member is responsible for CMS costshare

31 Claim denied as patient cannot be identified as our insured.

915 ‐ Member Not On File

35 Lifetime benefit maximum has been reached. Changed as of 10/02

915 ‐ Lifetime Benefit Max Exceeded

35 Lifetime benefit maximum has been reached. Changed as of 10/02

136 ‐ Plan Lifetime Amount Exceeded

4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

245 ‐ Multiple surgeries ‐ claim submitted missing modifier 51


407 ‐ Modifier(s) is invalid for Medical Policy


6093 ‐ Code 2 of a code pair allowed with modifier


6118 ‐ Incorrect billing of modifier FB or FC


6165 ‐ Mutually exclusive procedure allow with appropriate modifier


6168 ‐ Multiple medical visits, same date, needs condition code G0


9241 ‐ (mEH) Medicare E/M and Surgery without Modifier ‐ History


9242 ‐ (mEM) Medicare E/M and Surgery without Modifier


9233 ‐ (LBM/LCM) Missing LCD Modifier


9203 ‐ (060MCA) Modifier CA billed with multiple procedures




9523 ‐ Required modifier missing


9479 ‐ (040CCO/040hCCO) Component and comprehensive billed w/o mod


9474 ‐ (022IMO) HCPCS modifier invalid under OPPS


9509 ‐ (mANM) Medicare Anesthesia Modifier Missing


9510 ‐ (mGT) Invalid Modifier‐ Global Test Only Code


9511 ‐ (mIC) Invalid Modifier‐ Incident To Code


9512 ‐ (mPC) Invalid Modifier‐ Professional Component Only Code


9513 ‐ (mPS) Invalid Modifier‐ Physician Service Code


9514 ‐ (mPI) Invalid Modifier‐ Physician Interpretation Code


9515 ‐ (mTC) Invalid Modifier‐ Technical Component Only Code


9469 ‐ (016MBP/017IBP) Invalid specification of bilateral procedure


9057 ‐ Inappropriate modifier combination


9058 ‐ (IMO) MODIFIER INVALID




6184 ‐ Use of modifier CA with more than one procedure not allowed




9060 ‐ Invalid patient gender for diagnosis code


9061 ‐ (M26) MOD ‐26 REQUIRED


9064 ‐ Modifier not appropriate


9105 ‐ (MIM) MEDICARE INAPPROPRIATE MODIFIER


817 ‐ Claim Check: Cross Provider Total Audit



915 ‐ Invalid Modifier Association


915 ‐ CMS guidelines for Modifier 55 not met.


915 ‐ Modifier required for CPT/HCPCS


915 ‐ Invalid CPT Modifier


915 ‐ This is a clinical trial claim and it is missing the required Modifier.




915 ‐ MUP that would be allowed if modifier were present


915 ‐ Invalid modifier

40 Charges do not meet qualifications for emergent/urgent care.

915 ‐ Non‐emergent services. Medical review denial.

45 Charges exceed your contracted/ legislated fee arrangement.

915 ‐ Service a part of lab contract.



915 ‐ Service a part of Rx contract.



915 ‐ Included in capitation. N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.


915 ‐ Billed amount exceeds UCR. N59 Please refer to your provider manual for additional program and provider information.


915 ‐ Not a covered benefit‐ authorization required for private room rate‐ Claim paid up to the semi‐private room rate.

N153 Missing/incomplete/invalid room and board rate.


915 ‐ Denied‐Facility Fees included in professional payment.



915 ‐ Claim amount exceeds maximum allowed during Mass Adjudication


915 ‐ Claim amount exceeds Maximum allowed


915 ‐ Out‐of‐Area Claim ‐ Pay at 80%



915 ‐ Non‐Participating Differential Contract Pricing Applied



915 ‐ Benefits for the above charges are subject to a reduction because of the modifiers billed.


915 ‐ Payment has been made at 85% of the eligible amount.


915 ‐ Payment has been made at 100% of the eligible amount.


915 ‐ Price UB by CPT billed yes/no



915 ‐ Claim payment amt exceeds max allowed for mass adjudication


915 ‐ Claim payment amount exceeds maximum allowed


915 ‐ Claim payment amt exceeds max allowed for mass adjudication


915 ‐ Paid in accordance with the PHCS discount rate agreement.


915 ‐ Payment reduced by 10% because authorization was not requested prior to the service event. Do not bill patient for this amount.



915 ‐ CPT code subject to multiple procedure payment reduction (MPPR)



915 ‐ Paid in accordance with the MultiPlan discount rate agreement.


915 ‐ The hospital has by contract agreed to accept as payment in full.


915 ‐ The payment amount has been reduced by the amount paid by the modifier billed.


915 ‐ The amount shown as eligible is the maximum amount allowable


915 ‐ Code not recognized by Medicare


915 ‐ Line item denial or rejection from ACE edits


915 ‐ Internal Claim Recovery MA67 Correction to a prior claim.


915 ‐ This history claim was adjusted to pay/deny as recommended by ClaimCheck



915 ‐ Denied per APC pricing Methodology


915 ‐ No separate payment for ASC. Code not on ASC Fee Schedule.



915 ‐ Service is paid partial Cap and partial Fee for Service.



915 ‐ Pay Exceeds MPHC Allowable‐ Do not bill member


915 ‐ Claim or claim line paid in excess of the billed charge.


915 ‐ Refund/Received Check


915 ‐ Refund Initiated by AIM


915 ‐ Clm Recovery Appeal MA67 Correction to a prior claim.


915 ‐ Clm Recovery NA MA67 Correction to a prior claim.


915 ‐ Adjustment due to DRG audit



915 ‐ ESRD‐Reimburse Deductible and Co‐insurance only



915 ‐ HHC takeback MA67 Correction to a prior claim.


915 ‐ Covered days do not match accomodation revcode days

N153 Missing/incomplete/invalid room and board rate.


915 ‐ Non‐covered days less than leave of absence



915 ‐ Paid in accordance with the PHCS discount rate agreement.


915 ‐ Paid in accordance with the MultiPlan discount rate agreement.


9014 ‐ Claim History Issues Detected



9522 ‐ (mFPh) Medicare Global Follow‐Up by Provider in History



9219 ‐ (ASH) Anesthesia Secondary Procedure in History



190 ‐ Negotiated Rate overriding Provider Contract Rate

N45 Payment based on authorized amount.


6126 ‐ Line item denial or rejection from ACE edits


6089 ‐ Code not recognized by Medicare

5 The procedure code/bill type is inconsistent with the place of service.

179 ‐ Location specific term does NOT match claim


185 ‐ Location‐specific benefit does NOT match claim


9071 ‐ (OFS) OFFICE SETTING PROCEDURE


9074 ‐ POS not typical for procedure


662 ‐ Contract for service location on claim was not found



915 ‐ Rejected‐POS incompatible with procedure


50 These are non‐covered services because this is not deemed a `medical necessity' by the payer.

915 ‐ Medically unlikely edit


915 ‐ Medical necessity not established for services rendered.


809 ‐ Claim Check: Unlisted Procedure

N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.


808 ‐ Claim Check: Cosmetic Surgery


822 ‐ Claim Check: Exceeded 40 Claim Lines



6132 ‐ Medically unlikely edit



51 These are non‐covered services because this is a pre‐ existing condition

246 ‐ Member has Preexisting Condition on DOS for Diagnosis

51 These are non‐covered services because this is a pre‐ existing condition

247 ‐ Preexisting Condition May Exist

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

803 ‐ Claim Check: Assistant Surgeon


9075 ‐ (PRD) Assist/Co/Team Surgeon Reduction


9112 ‐ (MTS) TEAM SURGEONS NOT PERMITTED – MEDICARE


9100 ‐ (MCO) CO‐SURGEONS NOT PERMITTED


9101 ‐ (MD1) DOCUMENT ASSISTANT AT SURGERY


9102 ‐ (MD2) DOCUMENT CO‐ SURGEONS – MEDICARE


9103 ‐ (MD3) DOCUMENT TEAM SURGERY MEDICARE


9096 ‐ (MAS) NO PAYMENT FOR ASSISTANT SURGEONS

55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.

9059 ‐ (INV) TYPICALLY INVESTIGATIONAL


810 ‐ Claim Check: Experimental Procedure


915 ‐ Service appears to be experimental and is not covered by the

58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Changed as of 2/01

915 ‐ Inpatient procedure


6084 ‐ Inpatient procedure


404 ‐ Place of Service invalid for Medical Policy



9470 ‐ (018INP) Inpatient only procedure under Medicare

59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. Changed as of 6/00

6197 ‐ Units greater than one for bilateral proc billed w/ mod 50


800 ‐ Claim Check: Rebundling


6152 ‐ Multiple bilateral procedures without modifier 50




6163 ‐ Terminated procedure with bilateral modifier or units > 1


9536 ‐ Procedure reduction scenario identified

N670 This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02



6077 ‐ Procedure and age conflict


804 ‐ Claim Check: Age Conflict


805 ‐ Claim Check: Age Replacement


401 ‐ Age is invalid for Medical Policy


168 ‐ Member does NOT meet age criteria for term


915 ‐ Procedure and age conflict


915 ‐ Age invalid; not in range 0 ‐ 124



915 ‐ Benefit has age restrictions N129 Not eligible due to the patient's age.


915 ‐ Incorrect age for Nursery charges

N129 Not eligible due to the patient's age.


915 ‐ Age Incorrect for Nursery Charges

60 Charges for outpatient services with this proximity to inpatient services are not covered.

915 ‐ Admit within 24 hours of prior Inpatient stay.

M2 Not paid separately when the patient is an inpatient.


915 ‐ Admit within 24 hours of prior Inpatient stay.



915 ‐ 3 Day Payment Window M2 Not paid separately when the patient is an inpatient.


915 ‐ 3 Day Payment Window 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.


998 ‐ Claim ‐ Inpatient claim/UM exists for same DOS as ER claim

M133 Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.


998 ‐ Claim ‐ Inpatient claim/UM exists for same DOS as ER claim

MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.

7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02

6042 ‐ Sex invalid; not 1 or 2, M or F



6078 ‐ Procedure and sex conflict


806 ‐ Claim Check: Gender Conflict


807 ‐ Claim Check: Gender Replacement




400 ‐ Gender is invalid for Medical Policy


9225 ‐ (BSX/LCG) Procedure Not Typical for Patient Sex


9168 ‐ (DPSC) Patient gender inconsistent with procedure


915 ‐ Procedure and sex conflict


915 ‐ Invalid sex

8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Changed as of 6/02

915 ‐ Provider does not match required type


9224 ‐ Missing or invalid provider specialty


156 ‐ Provider type does NOT match type required by contract term


151 ‐ Non Contracted Service N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.

9 The diagnosis is inconsistent with the patient's age. 6017 ‐ age conflict; patient's age and diagnosis are inconsistent

9 The diagnosis is inconsistent with the patient's age. 6038 ‐ Age conflict; patient's age and diagnosis are inconsistent

9 The diagnosis is inconsistent with the patient's age. 9051 ‐ (IAG/002IAG) Invalid patient age for diagnosis code

9 The diagnosis is inconsistent with the patient's age. 9028 ‐ Patient age invalid for service

9 The diagnosis is inconsistent with the patient's age. 9139 ‐ Patient age inconsistent with diagnosis

9 The diagnosis is inconsistent with the patient's age. 9141 ‐ (DASC3) Patient gender and age inconsistent with diagnosis

9 The diagnosis is inconsistent with the patient's age. 9142 ‐ (DDAS1) Patient age and diagnosis inconsistent

9 The diagnosis is inconsistent with the patient's age. 9143 ‐ (DDAS2) Patient gender and diagnosis inconsistent

9 The diagnosis is inconsistent with the patient's age. 9144 ‐ Patient age and gender inconsistent with diagnosis

9 The diagnosis is inconsistent with the patient's age. 915 ‐ age conflict; patient's age and diagnosis are inconsistent

9 The diagnosis is inconsistent with the patient's age. 915 ‐ patient's age and sex are inconsistent with the patient's dx

9 The diagnosis is inconsistent with the patient's age. 915 ‐ Age and sex conflict

9 The diagnosis is inconsistent with the patient's age. 915 ‐ Age conflict; patient's age and diagnosis are inconsistent

96 Non‐covered charge(s). 915 ‐ Non‐covered for reasons other than statute

N425 Statutorily excluded service(s).

96 Non‐covered charge(s). 915 ‐ Quality Reporting Measure‐ no reimbursement

96 Non‐covered charge(s). 915 ‐ This is not a covered benefit under your Medicare Plan. However, you may have coverage through Northeast Delta Dental as a supplemental benefit. Please contact Delta Dental at 800–260–3788.

96 Non‐covered charge(s). 915 ‐ Non Reimbursable HCPC code

96 Non‐covered charge(s). 915 ‐ Resubmit with Medical Records.


96 Non‐covered charge(s). 915 ‐ Authorization Line Manually Denied


96 Non‐covered charge(s). 915 ‐ This a non covered service under this benefit.

96 Non‐covered charge(s). 915 ‐ Code not covered by

Medicare. 96 Non‐covered charge(s). 915 ‐ Requires additional

information. N29 Missing

documentation/orders/notes/summary/report/ chart.

96 Non‐covered charge(s). 915 ‐ Requires anesthesia time. N203 Missing/incomplete/invalid anesthesia time/units

96 Non‐covered charge(s). 915 ‐ Non‐covered based on statutory exclusion

96 Non‐covered charge(s). 915 ‐ Service provider prior to NCD


96 Non‐covered charge(s). 915 ‐ Service provided outside approval period


96 Non‐covered charge(s). 915 ‐ CA modifier requires patient status code 20


96 Non‐covered charge(s). 915 ‐ Mult med vis on same day same rev code w/o cc GO or mod 27


96 Non‐covered charge(s). 915 ‐ Observation does not meet minimum hours, qualifying dx


96 Non‐covered charge(s). 915 ‐ Observation does not meet minimum hours, qualifying dx


96 Non‐covered charge(s). 915 ‐ Service provided on or after effective date of NCD non‐coV


96 Non‐covered charge(s). 915 ‐ Code not recognized by OPPS


96 Non‐covered charge(s). 915 ‐ No payment made on charge amount.

96 Non‐covered charge(s). 915 ‐ Not covered or not covered under the OPPS


96 Non‐covered charge(s). 915 ‐ Well child care is not eligible under the plan.


96 Non‐covered charge(s). 915 ‐ Annual/Routine Physicals, or routine lab or x‐rays are not excluded.


96 Non‐covered charge(s). 915 ‐ Routine eye exams are not eligible under the plan.


96 Non‐covered charge(s). 915 ‐ Not Covered Benefit N431 Service is not covered with this procedure. 96 Non‐covered charge(s). 915 ‐ Not covered by Part B,

Please submit to Part D.

96 Non‐covered charge(s). 915 ‐ Not Valid for Medicare. 96 Non‐covered charge(s). 915 ‐ Quality Reporting Measure‐

Zero Reimbursement

96 Non‐covered charge(s). 915 ‐ No Benefit for Service N431 Service is not covered with this procedure. 96 Non‐covered charge(s). 915 ‐ Itemization Required N29 Missing


96 Non‐covered charge(s). 915 ‐ Measurement codes ‐ used for reporting purposes only

96 Non‐covered charge(s). 915 ‐ Service not a plan benefit. N431 Service is not covered with this procedure. 96 Non‐covered charge(s). 915 ‐ No stat order. N29 Missing


96 Non‐covered charge(s). 915 ‐ Please resubmit claim with ER report.


96 Non‐covered charge(s). 915 ‐ Stat charges are not covered.


96 Non‐covered charge(s). 915 ‐ N/C. Routine well baby. 96 Non‐covered charge(s). 915 ‐ Resubmit to dental plan. 96 Non‐covered charge(s). 915 ‐ Requires discharge

summary. N29 Missing


96 Non‐covered charge(s). 915 ‐ Member responsible for charges.

96 Non‐covered charge(s). 915 ‐ Please resubmit claim with a copy of the consult report.


96 Non‐covered charge(s). 915 ‐ Resubmit with dialysis reports.


96 Non‐covered charge(s). 915 ‐ Resubmit with OP report. N29 Missing documentation/orders/notes/summary/report/ chart.

96 Non‐covered charge(s). 915 ‐ Requires H&P. N29 Missing documentation/orders/notes/summary/report/ chart.

96 Non‐covered charge(s). 915 ‐ Please resubmit claim with physician notes.


96 Non‐covered charge(s). 915 ‐ Itemized statement required.


96 Non‐covered charge(s). 915 ‐ Need ambulance EMS report.


96 Non‐covered charge(s). 915 ‐ Service is excluded from benefit plan.


96 Non‐covered charge(s). 915 ‐ No Reimbursement for Backup Transport.

N158 Transportation in a vehicle other than an ambulance is not covered.

96 Non‐covered charge(s). 915 ‐ Non‐covered days exceed statement‐covered period

96 Non‐covered charge(s). 915 ‐ No Government Pay Procedure Code List‐Code not recognized under TRICARE

96 Non‐covered charge(s). 915 ‐ No Government Pay Procedure Code List‐ Unproven/experimental

96 Non‐covered charge(s). 915 ‐ No Government Pay Procedure Code List‐Excluded by policy or statute

96 Non‐covered charge(s). 915 ‐ Self Administered Drugs are not covered.

96 Non‐covered charge(s). 915 ‐ No payment made for State Supplied Drug.


96 Non‐covered charge(s). 9165 ‐ (DPNC1) Procedure not covered by Medicare

96 Non‐covered charge(s). 9104 ‐ (MFP) MEDICARE GLOBAL FOLLOWUP BY PROVIDER

96 Non‐covered charge(s). 9106 ‐ (MIN) INJECTION SERVICE – MEDICARE

96 Non‐covered charge(s). 9107 ‐ (MNP) NON‐PHYSICIAN SERVICE – MEDICARE

96 Non‐covered charge(s). 9108 ‐ (MNS/mNE) Medicare Non‐Covered Service

96 Non‐covered charge(s). 9109 ‐ (MNV) NOT VALID FOR

MEDICARE PAYMENT 96 Non‐covered charge(s). 9110 ‐ (MPT) PHYSICAL THERAPY

SERVICE

96 Non‐covered charge(s). 9212 ‐ (072SNB) Service not billable to Medicare FI

96 Non‐covered charge(s). 9534 ‐ Non covered, bundled, restricted, or reporting only

96 Non‐covered charge(s). 9524 ‐ (mMGY) Not Eligible for Payment ‐ Modifier GY present

96 Non‐covered charge(s). 9525 ‐ (mNC) Medicare Non Covered HCPCS Codes and Modifiers

96 Non‐covered charge(s). 9526 ‐ (mPV) Medicare Preventative Vaccines

96 Non‐covered charge(s). 9484 ‐ (050NCE) Service not covered‐Medicare statutory exclusion

96 Non‐covered charge(s). 9466 ‐ (009NCS) Medicare noncovered service indicator

96 Non‐covered charge(s). 9467 ‐ (013NSP) Not covered based on bill type and condition code

96 Non‐covered charge(s). 9475 ‐ (028NRM) Code not recognized by Medicare for OPPS

96 Non‐covered charge(s). 9482 ‐ Revenue code requires HCPCS

96 Non‐covered charge(s). 9245 ‐ Non‐covered service 96 Non‐covered charge(s). 9173 ‐ (010DNY) Claim submitted

for denial (Cond Code 21)

96 Non‐covered charge(s). 9167 ‐ (DPNC3) Medicare covers procedure in limited situation only

96 Non‐covered charge(s). 9187 ‐ (035FMS) Only Mental Health education/training provided

96 Non‐covered charge(s). 9175 ‐ (012QCS)Questionable covered service ‐ Medicare

96 Non‐covered charge(s). 203 ‐ Benefit is excluded from benefit plan

96 Non‐covered charge(s). 374 ‐ Medicare Excluded Service ‐

Other Insurance Dollars on Claim 96 Non‐covered charge(s). 6185 ‐ Service can only be billed

to the DMERC M11 DME, orthotics and prosthetics must be billed to

the DME carrier who services the patient's zip code.

96 Non‐covered charge(s). 6164 ‐ Conflict between implanted device and implanted procedure


96 Non‐covered charge(s). 6167 ‐ CLIENT CUSTOM EDIT M50 Missing/incomplete/invalid revenue code(s). 96 Non‐covered charge(s). 9176 ‐ (014ISS) Service not

payable ‐ Medicare Outpatient PPS


96 Non‐covered charge(s). 6138 ‐ Not covered or not covered under the OPPS


96 Non‐covered charge(s). 6124 ‐ Service provided on or after effective date of NCD non‐ coV


96 Non‐covered charge(s). 6112 ‐ Service provider prior to NCD


96 Non‐covered charge(s). 6113 ‐ Service provided outside approval period


96 Non‐covered charge(s). 6114 ‐ CA modifier requires patient status code 20


96 Non‐covered charge(s). 6108 ‐ Code not recognized by OPPS


96 Non‐covered charge(s). 6102 ‐ Non‐covered based on statutory exclusion

N643 The services billed are considered Not Covered or Non‐Covered (NC) in the applicable state fee schedule.

96 Non‐covered charge(s). 6212 ‐ Item or service not covered under FQHC PPS


96 Non‐covered charge(s). 6161 ‐ Code not recognized by Medicare for outpatient claims


96 Non‐covered charge(s). 6169 ‐ Blood service without specification of blood product


96 Non‐covered charge(s). 6155 ‐ CLIENT CUSTOM EDIT N56 Procedure code billed is not correct/valid for the services billed or the date of service billed.

96 Non‐covered charge(s). 155 ‐ Benefit has age restriction N130 Consult plan benefit documents/guidelines for information about restrictions for this service.

96 Non‐covered charge(s). 197 ‐ Procedure code on claim NOT valid for benefit


96 Non‐covered charge(s). 6195 ‐ Service not billable to the MAC

N200 The professional component must be billed separately.

96 Non‐covered charge(s). 6192 ‐ CLIENT CUSTOM EDIT N351 Service date outside of the approved treatment plan service dates.

96 Non‐covered charge(s). 6175 ‐ CLIENT CUSTOM EDIT N20 Service not payable with other service rendered on the same date.

96 Non‐covered charge(s). 6174 ‐ CLIENT CUSTOM EDIT N425 Statutorily excluded service(s). 96 Non‐covered charge(s). 6079 ‐ Non‐covered for reasons

other than statute N425 Statutorily excluded service(s).

96 Non‐covered charge(s). 6176 ‐ Observation does not meet minimum conditions


96 Non‐covered charge(s). 6181 ‐ Observation E/M service criteria are not met


96 Non‐covered charge(s). 6200 ‐ CLIENT CUSTOM EDIT MA66 Missing/incomplete/invalid principal procedure code.

96 Non‐covered charge(s). 6095 ‐ Mult med vis on same day same rev code w/o cc GO or mod 27


96 Non‐covered charge(s). 6207 ‐ Claim lacks required primary code

M67 Missing/incomplete/invalid other procedure code(s).

96 Non‐covered charge(s). 6208 ‐ Claim lacks required device code or required procedure code

M67 Missing/incomplete/invalid other procedure code(s).

96 Non‐covered charge(s). 6201 ‐ CLIENT CUSTOM EDIT M99 Missing/incomplete/invalid Universal Product Number/Serial Number.

96 Non‐covered charge(s). 6162 ‐ Insufficient partial hospitalization services

MA32 Missing/incomplete/invalid number of covered days during the billing period.

96 Non‐covered charge(s). 911 ‐ Invalid For Male MA39 Missing/incomplete/invalid gender. 96 Non‐covered charge(s). 912 ‐ Invalid For Female MA39 Missing/incomplete/invalid gender. 96 Non‐covered charge(s). 6213 ‐ Device‐dependent

procedure code billed without device code


96 Non‐covered charge(s). 6194 ‐ CLIENT CUSTOM EDIT MA50 Missing/incomplete/invalid Investigational Device Exemption number for FDA‐approved clinical trial services.

96 Non‐covered charge(s). 6150 ‐ Code indicates a site of service not included in OPPS


96 Non‐covered charge(s). 6179 ‐ Non‐reportable for site of M77 Missing/incomplete/invalid place of service.

service 96 Non‐covered charge(s). 6095 ‐ Mult med vis on same day

same rev code w/o cc GO or mod 27


96 Non‐covered charge(s). 6147 ‐ Service submitted for MAC review (condition code 20)


96 Non‐covered charge(s). 6160 ‐ Invalid date M52 Missing/incomplete/invalid "from" date(s) of service.

97 Payment is included in the allowance for another service/procedure. Changed as of 2/99

6133 ‐ Service billed as panel M80 Not covered when performed during the same session/date as a previously processed service for the patient.


9180 ‐ (027OIS) All services incidental; no primary submitted



9249 ‐ (UIN) Unbundle Procedure ‐ Incidental



6214 ‐ Incidental services reported only



9473 ‐ (021EMO) Invalid medical visit same day as procedure

M144 Pre‐/post‐operative care payment is included in the allowance for the surgery/procedure.


9528 ‐ (mUB) Medicare Other Unbundle



382 ‐ Global payment allocated M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.


801 ‐ Claim Check: Incidental Services



9228 ‐ (HEX) Unbundled Procedure on Separate Claim is Exclusive



9229 ‐ (HIN) History Unbundle Procedure ‐ Incidental



9230 ‐ (HNB) Unbundle History Procedure ‐ Unbundled or Incidental



9048 ‐ (HUD) UNBUNDLE PROCEDURE, DENY



9049 ‐ (HUR) UNBUNDLE PROCEDURE, REVIEW



9050 ‐ (HUS) UNBUNDLE PROCEDURE, SECONDARY



9113 ‐ (MUH) Unbundled Procedure (per Medicare) on Separate Claim



9098 ‐ (MBC) MEDICARE BUNDLED CODE



9099 ‐ (MBI) BUNDLED ITEM OR SERVICE



9093 ‐ (UUD) UNBUNDLE PROCEDURE, DENY



9094 ‐ (UUR) UNBUNDLE PROCEDURE, REVIEW



9095 ‐ (UUS) UNBUNDLE PROCEDURE, SECONDARY



9076 ‐ (PRE) PRE‐OP PROCEDURE 1 DAY BEFORE SURGERY



9248 ‐ (UEX) Unbundled Procedure on Current Line is Exclusive



6128 ‐ Incorrect coding of lab panel components (Prior to V0804 )



915 ‐ SNF benefit valid within 14 days of inpatient hospital stay



915 ‐ Provider overlaps global days period



915 ‐ Services are Inclusive to the Rental Payment



915 ‐ Service included as component of inpatient reimbursement.



915 ‐ DRG‐Included in Global Rate/Do Not Bill Patient



915 ‐ Service included in payment for surgical procedure.



915 ‐ Service Included In Global Charge



915 ‐ Services are included in global payment.



915 ‐ Credit applied for prior RAP payment



915 ‐ When multiple procedures are performed on the same day, payment is made based on the highest amount allowed.



915 ‐ Service billed as panel M80 Not covered when performed during the same session/date as a previously processed service for the patient.


915 ‐ Incorrect coding of lab panel components (Prior to V0804 )



915 ‐ Due to Contract; CRNA payment included in MD payment.



915 ‐ According to Medicare, payment for this service is already included in the payment for another global service.



915 ‐ Included in Per Diem. M80 Not covered when performed during the same session/date as a previously processed service for the patient.

A0 Patient refund amount. 915 ‐ Advanced Payment/Reimburse Member

A0 Patient refund amount. 915 ‐ Member met OOP MAX‐ possible member reimbursement

A1 Claim denied charges. 915 ‐ Device intensive procedure without device


A1 Claim denied charges. 915 ‐ Mental health code not app for partial hospital program


A1 Claim denied charges. 915 ‐ Mental health service not pay outside the partial hosp prog


A1 Claim denied charges. 915 ‐ Non‐Payment/Zero Paid Claim Bill Type


A1 Claim denied charges. 915 ‐ REMIT contract change N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.

A1 Claim denied charges. 915 ‐ REMIT contract term change


A1 Claim denied charges. 915 ‐ Nurse Audit/ Unsupported charges

N206 The supporting documentation does not match the claim

A1 Claim denied charges. 915 ‐ Billing two NDC numbers with one HCPC is Invalid

M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).

A1 Claim denied charges. 915 ‐ Service should be done by a PAR‐Provider

A1 Claim denied charges. 915 ‐ Service included as component of inpatient DRG reimbursement.

N525 These services are not covered when performed within the global period of another service.

A1 Claim denied charges. 915 ‐ Claim was billed as a clinical trial, Martin’s Point has not been notified that the member is enrolled in a clinical trial. Please re‐bill appropriately.


A1 Claim denied charges. 915 ‐ Professional services should be billed on CMS1500


A1 Claim denied charges. 915 ‐ Service unit out of range for procedure

N430 Procedure code is inconsistent with the units billed.

A1 Claim denied charges. 915 ‐ We received a claim for health care services to a GA member during a time our records indicate your license to practice was censured, reprimanded, and/or placed on probation. We cannot pay your claim and you may not bill our member for payment.


A1 Claim denied charges. 915 ‐ We received a claim for health care services to a MaineSense member during a time our records indicate your license to practice was censured, reprimanded, and/or placed on probation. We cannot pay your claim and you may not bill our member for payment


A1 Claim denied charges. 915 ‐ We received a claim for health care services to a USFHP member during a time our records indicate your license to practice was censured, reprimanded, or placed on probation. We cannot pay your claim and you may not bill our member for payment.


A1 Claim denied charges. 915 ‐ Provider Not on File N253 Missing/incomplete/invalid attending provider primary identifier.

A1 Claim denied charges. 915 ‐ Part of OptumHealth's Global Negotiation

N525 These services are not covered when performed within the global period of another service.

A1 Claim denied charges. 915 ‐ Claim denied manually A1 Claim denied charges. 915 ‐ Generate 1500 From EPSDT

Form N34 Incorrect claim form/format for this service.

A1 Claim denied charges. 915 ‐ Claim Total Mismatch M79 Missing/incomplete/invalid charge. A1 Claim denied charges. 915 ‐ Benefit Applies to PCP Only N381 Consult our contractual agreement for

restrictions/billing/payment information related to these charges.

A1 Claim denied charges. 915 ‐ Invalid For Male MA39 Missing/incomplete/invalid gender. A1 Claim denied charges. 915 ‐ Invalid For Female MA39 Missing/incomplete/invalid gender. A1 Claim denied charges. 915 ‐ Incidental Procedure N19 Procedure code incidental to primary procedure.

A1 Claim denied charges. 915 ‐ Provider Incomplete N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.

A1 Claim denied charges. 915 ‐ No Contract Term found for Service


A1 Claim denied charges. 915 ‐ Referral Required by Contract


A1 Claim denied charges. 915 ‐ No Active Provider Contract N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.

A1 Claim denied charges. 915 ‐ Provider Not Active for Plan on DOS


A1 Claim denied charges. 915 ‐ Authorization line item denied.

N41 Authorization request denied.

A1 Claim denied charges. 915 ‐ Place of service does not match authorized

N428 Service/procedure not covered when performed in this place of service.

A1 Claim denied charges. 915 ‐ Maintenance Benefit Max has been exceeded.

N372 Only reasonable and necessary maintenance/service charges are covered.

A1 Claim denied charges. 915 ‐ Plan not advised in 72 hrs. Medical review denial.

A1 Claim denied charges. 915 ‐ Claim has been denied. At DOS, assigned to other PCP.

A1 Claim denied charges. 915 ‐ The Provider is not a member of the UHC PPO Network.


A1 Claim denied charges. 915 ‐ DME rental costs have exceeded purchase price.

M7 No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price.

A1 Claim denied charges. 915 ‐ Included in OB package. N252 Missing/incomplete/invalid attending provider name.

A1 Claim denied charges. 915 ‐ Split billing required. N61 Rebill services on separate claims. A1 Claim denied charges. 915 ‐ Included in other

procedure. N20 Service not payable with other service rendered

on the same date. A1 Claim denied charges. 915 ‐ Assistant surgeon not

covered. M86 Service denied because payment already made

for same/similar procedure within set time frame.

A1 Claim denied charges. 915 ‐ Member Not Eligible on Date of Service


A1 Claim denied charges. 915 ‐ We received a claim for health care services to a GA member during a time our records indicate you were sanctioned and excluded from participation in Medicare. Federal law prohibits us from paying your claim and you may not bill our member for payment.


A1 Claim denied charges. 915 ‐ We received a claim for health care services to a MaineSense member during a time our records indicate you were sanctioned and excluded


from participation in Medicare. We cannot pay your claim and you may not bill our member for payment.

A1 Claim denied charges. 915 ‐ We received a claim for services to a USFHP member during a time our records indicate you were sanctioned and excluded from participation in TRICARE. Federal law prohibits us from paying your claim and you may not bill our member for payment.


A1 Claim denied charges. 915 ‐ Final bill Received A1 Claim denied charges. 915 ‐ A Medicare Set Aside

Account exist for the services rendered on this claim. Please bill responsible administrator.

MA48 Missing/incomplete/invalid name or address of responsible party or primary payer.

A1 Claim denied charges. 9480 ‐ (045SNA) Medicare separate procedure


A1 Claim denied charges. 9491 ‐ (106SLP/106hSLP) Lab panel billed as separate services


A1 Claim denied charges. 9527 ‐ (mSPh) Medicare Post‐Op Surgery By Provider in History


A1 Claim denied charges. 9111 ‐ (MSP) MEDICARE POST‐OP SURGERY BY PROVIDER


A1 Claim denied charges. 9077 ‐ (PRH) PRE‐OP PROC IN HISTORY 1 DAY B4 SURGERY


A1 Claim denied charges. 641 ‐ Multiple Instances of Revenue Code 0024 on Claim


A1 Claim denied charges. 408 ‐ Line failed for Medical Policy Rule


A1 Claim denied charges. 9008 ‐ External Claim Editing Bypassed

A1 Claim denied charges. 294 ‐ Claim Line Overlaps Contract Affiliation Term Date

A1 Claim denied charges. 296 ‐ Claim Line Overlaps Contract Term Termination Date

A1 Claim denied charges. 9089 ‐ (UID) INCIDENTAL PROCEDURE, DENY


A1 Claim denied charges. 9090 ‐ (UIR) INCIDENTAL PROCEDURE, REVIEW


A1 Claim denied charges. 9091 ‐ (UIS) INCIDENTAL PROCEDURE, SECONDARY


A1 Claim denied charges. 9253 ‐ (080MHA) Service not approved for partial hospitalization

N188 The approved level of care does not match the procedure code submitted.

A1 Claim denied charges. 9044 ‐ (HID) INCIDENTAL PROCEDURE, DENY


A1 Claim denied charges. 9045 ‐ (HIR) INCIDENTAL PROCEDURE, REVIEW


A1 Claim denied charges. 9046 ‐ (HIS) INCIDENTAL PROCEDURE, SECONDARY


A1 Claim denied charges. 917 ‐ Manually‐altered pay 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.

A1 Claim denied charges. 921 ‐ Claim manually priced with no balance checks or validation


A1 Claim denied charges. 347 ‐ RAP has more than one detail line


A1 Claim denied charges. 348 ‐ Line #1 date must equal episode start date


A1 Claim denied charges. 235 ‐ Override Reimburse Member option


A1 Claim denied charges. 258 ‐ Emergency Claim does not match Emergency Benefit


A1 Claim denied charges. 341 ‐ HH PPS No Rap present for claim


A1 Claim denied charges. 130 ‐ Program Watch 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.

A1 Claim denied charges. 127 ‐ Sponsor Watch 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.

A1 Claim denied charges. 402 ‐ Maximum units exceeded for Medical Policy

N362 The number of Days or Units of Service exceeds our acceptable maximum.

A1 Claim denied charges. 170 ‐ Claim and contract term type of service do NOT match


A1 Claim denied charges. 6082 ‐ Service unit out of range for procedure

N430 Procedure code is inconsistent with the units billed.

A1 Claim denied charges. 9254 ‐ (081MHP) Service only valid for partial hospitalization


A1 Claim denied charges. 6122 ‐ Mental health code not app for partial hospital program


A1 Claim denied charges. 6123 ‐ Mental health service not pay outside the partial hosp prog


A1 Claim denied charges. 9182 ‐ (030PHI)Insufficient services‐day of partial hospitalization


A1 Claim denied charges. 9030 ‐ (COS) TYPICALLY COSMETIC PROCEDURE

N383 Services deemed cosmetic are not covered

A1 Claim denied charges. 9256 ‐ (083NCD) Service provided on or after end of NCD coverage


A1 Claim denied charges. 9032 ‐ Patient gender invalid for service


A1 Claim denied charges. 9220 ‐ (BAG/LCAG) Inappropriate Age for LCD


A1 Claim denied charges. 9237 ‐ (LDY/LCDY) LCD Deny 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.

A1 Claim denied charges. 9458 ‐ (LCD) LCD Part B policy requirements not met for procedure


A1 Claim denied charges. 194 ‐ Restrict Benefit by Date of ONSET


A1 Claim denied charges. 173 ‐ Diagnosis on claim does NOT match terms valid range


A1 Claim denied charges. 6028 ‐ Manifestation code as principal


A1 Claim denied charges. 9068 ‐ (NPD) NOT A PRIMARY DIAGNOSIS


A1 Claim denied charges. 9162 ‐ Unacceptable principal MA63 Missing/incomplete/invalid principal diagnosis.






diagnosis A1 Claim denied charges. 9172 ‐ (005EPD) E‐diagnosis code

invalid as principal diagnosis MA63 Missing/incomplete/invalid principal diagnosis.

A1 Claim denied charges. 9158 ‐ E‐code cannot be used as principal diagnosis


A1 Claim denied charges. 9159 ‐ Manifestation code cannot be used as principle DX


A1 Claim denied charges. 9145 ‐ Diagnosis code duplicate of claim principal diagnosis


A1 Claim denied charges. 9138 ‐ Admit diagnosis invalid MA65 Missing/incomplete/invalid admitting diagnosis. A1 Claim denied charges. 9257 ‐ (mDT) Medicare

Diagnostic Testing in Hospital Setting


A1 Claim denied charges. 169 ‐ Claim and contract term modifiers do NOT match


A1 Claim denied charges. 9146 ‐ Diagnosis code duplicate of other secondary diagnosis


A1 Claim denied charges. 9137 ‐ (LDDX01) Diagnosis denied by Medicare


a1 Claim denied charges. 6125 ‐ No available APC/fee schedule rate

a1 Claim denied charges. 6116 ‐ Incorrect billing of blood and blood products

B1 Non‐covered visits. 915 ‐ Medical review denial. 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.

9463 ‐ (mMP/MPh) Medicare Multiple Procedure Reduction

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.

9460 ‐ (mDR/mDRh) Medicare Diagnostic Radiology Reduction


9461 ‐ (mER/mERh) Medicare Multiple Endoscopy Reduction


9472 ‐ (020CCP/020hCCP) Component billed with comprehensive code


9026 ‐ Bilateral procedure reduction


9065 ‐ Multiple procedure reductions

B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

915 ‐ CPT codes billed include bundled and unbundled


B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

915 ‐ CPT codes billed include bundled and unbundled CPTs


B15 Payment adjusted because this procedure/service is not paid separately. Changed as of 2/01

915 ‐ Services not separately payable under OPPS



915 ‐ Team Surgeon not covered N20 Service not payable with other service rendered on the same date.


915 ‐ Co‐Surgeon not Covered N20 Service not payable with other service rendered on the same date.


915 ‐ Co‐Surgeon Not Covered N20 Service not payable with other service rendered on the same date.


915 ‐ Team Surgeon Not Covered N20 Service not payable with other service rendered on the same date.


915 ‐ Assistant surgeon not allowed



915 ‐ Co‐surgeon not allowed N20 Service not payable with other service rendered on the same date.


915 ‐ Team surgeon not allowed N20 Service not payable with other service rendered on the same date.


9481 ‐ (047SSP) Service is not separately payable per Medicare


B16 Payment adjusted because ̀ New Patient' qualifications were not met. Changed as of 2/01

9070 ‐ (NPT) NEW PATIENT CODE FOR EST PATIENT

B16 Payment adjusted because ̀ New Patient' qualifications were not met. Changed as of 2/01

814 ‐ Claim Check: New Visit E&M Audit

B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. Changed as of 2/01

271 ‐ Benefit Restriction Group Validation Failed


6202 ‐ Incorrect billing of revenue code with HCPCS code


272 ‐ Member does not have coverage code required on benefit



915 ‐ Coverage Period Insufficient for Benefit Coverage


915 ‐ Provider doesn't meet criteria required to provide service



915 ‐ No Contract with Provider N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges.


915 ‐ No Provider Affiliation with Health Plan



915 ‐ Service Not Covered by Contract with Provider



915 ‐ Non‐Payment adjustment‐ information adjusted due to requirements of the Department of Defense.

B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Changed as of 10/98

915 ‐ Provider type does not match term


405 ‐ Provider Type is invalid for Medical Policy



406 ‐ Physician specialty is invalid for Medical Policy


B9 Services not covered because the patient is enrolled in a Hospice.

915 ‐ Hospice related services are not separately reimbursable, only non‐hospice related services are.


B9 Services not covered because the patient is enrolled in a Hospice.

915 ‐ Hospice claims require Original Medicare Explanation of Benefits (EOB)

N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

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. Start: 11/01/2013 Notes: This code replaces deactivated code 191

915 ‐ No Third Party Involvement

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. Start: 11/01/2013 Notes: This code replaces deactivated code 191

915 ‐ No Third Party Involvement or Exhausted