MAPPING OF MED-QUEST CLAIM REASON CODES TO HIPAA ADJUSTMENT REASON AND REMARK CODES ON THE 835 REMITTANCE ADVICE TRANSACTION 5/20/2003

Transcription

1 Mapped Med-QUEST Claim values appear on the matrix below in Med-QUEST sequence. Med-QUEST Edit/Result s are mapped separately. One of the first five ment values documented at the beginning of this matrix will always appear as an initial ment when there has been a claim or service line level adjustment to the Charged Amount. For payer initiated adjustments (Claim ment Group = PI ), additional ment s, if generated from HPMMIS and Edit/Result s, will appear on 835 Transactions with zero ment Amounts. s will appear whenever HPMMIS s translate to them. Both ment and s are unduplicated on the 835. This means that particular code values will appear only once when multiple HPMMIS s for a claim or line translate to the same code values on the 835. ADJUSTMENT REASON CODE FOR SHARE OF COST PAYMENTS AND OTHER PATIENT CONTRIBUTIONS (Claim ment Group [CAS01] = PR [Patient Responsibility]) ADJUSTMENT REASON CODE FOR PAYMENTS MADE BY OTHER CARRIERS (Claim ment Group [CAS01] = OA [Other ments]) ADJUSTMENT REASON CODE FOR PREVIOUS PAYMENTS BY MED-QUEST (Claim ment Group [CAS01] = OA [Other ments]) 3 Co-payment Amount Each ment Amount within a PR CAS Segment represents a separate copayment applied to the claim. 22 Payment adjusted because this care may be covered by another payer per coordination of benefits. B13 Each ment Amount within a OA CAS Segment represents a separate payment from another carrier for this claim. Previously paid. Payment for this claim/service may have been provided in a previous payment. 1

2 INITIAL ADJUSTMENT REASON CODE FOR CLAIM OR SERVICE LINE DENIALS (Claim ment Group [CAS01] = PI [Payer Initiated Reductions]) INITIAL ADJUSTMENT REASON CODE FOR ADJUSTED PAYMENTS THAT ARE LESS THAN CHARGED AMOUNTS (Claim ment Group [CAS01] = PI [Payer Initiated Reductions]) A1 A2 Claim denied charges. The initial ment Amount within a PI CAS Segment for a denied claim or service line is the same as the corresponding Charged Amount. Any subsequent ment s that have been translated from Med-QUEST and Edit/Result s appear with zero ment Amounts. Contractual ment The initial ment Amount within a PI CAS Segment when a claim or service line payment reduction is greater than zero but less than the corresponding Charged Amount. Any subsequent ment s that have been translated from Med-QUEST and Edit/Result s appear with zero ment Amounts. One of the five ment s listed above will always appear as the initial ment when a claim or service line is adjusted (i.e., paid at less than the Charged Amount). Initial ment s are generated from claim conditions. Following the initial, additional ment s translated from the mapping can be added within CAS Segments. For subsequent ment s, ment Amounts are always zero and ment Quantities are absent. Designated s also appear on 835 Transactions but are not associated with payments. AD002 AD003 DENIED PER MEDICAL REVIEW CLAIM CHARGES SHOULD BE COMBINED B15 Payment adjusted because this procedure/service is not paid separately N109 This claim was chosen for complex review and was denied after reviewing the medical records. 2

3 AD004 DOCUMENTATION VS. MEDICAL NECESSITY N109 This claim was chosen for complex review and was denied after reviewing the medical records. AD005 NON-COVERED CHARGES 96 Non-covered charges. AD007 NEED ADDITIONAL DOCUMENTATION PER MED RV AD009 DUPLICATE CLAIM 18 Duplicate claim/service. AD010 CONTACT CLAIM SERVICES Proposed not yet final: Call help desk. AD012 EOMB REQUIRED N4 Prior insurance carrier EOB received was insufficient. AD013 PROVIDER NOT ELIGIBLE FOR SURGICAL TIER 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/perform the service billed. AD015 EOMB DOES NOT MATCH CLAIM N4 Prior insurance carrier EOB received was insufficient. AD016 FEDERAL CONSENT FORM N28 Consent form requirements not fulfilled. NOT SIGNED AD017 FED CONSENT FORM NOT N28 Consent form requirements not fulfilled. DATED ON PHY STMNT AD018 DOS NOT >30 DAYS FROM N28 Consent form requirements not fulfilled. CONSENT FORM DATE AD019 FEDERAL CONSENT FORM N28 Consent form requirements not fulfilled. DATE EXPIRED AD020 DOS MUST BE >72 HOURS N28 Consent form requirements not fulfilled. FROM CONSENT DATE AD021 FEDERAL CONSENT FORM N28 Consent form requirements not fulfilled. REQUIRED AD022 FAM PLAN PROC N/C 96 Non-covered charges. AD023 MUST REPORT MEDICARE COINS./DEDUCTIBLE 2 Coinsurance Amount 3

4 AD024 AD026 AD027 AD028 AD031 AD033 ADO34 AD035 AD036 AD038 AD040 DENIED FOR BUNDLED SERVICES RCP. NAME/DATE OF BIRTH NOT MATCHED CAPPED ENROLLMENT FOR PARTIAL DOS SPAN FEDERAL CONSENT FORM NOT COMPLETE RECIP HAS OTHER INS; MUST BE BILLED FIRST IHS REFERRAL DOES NOT MATCH CLAIM 1 ST 90 DAYS OF LTC/HEALTH PLAN RESPONSIBLE NO COINSURANCE/DEDUCTIBLE DUE ON SERVICE MUST BILL WITH PRESCRIBING PROVIDER ID REQUESTED DOCUMENTATION NOT RECEIVED PHARMACY MUST BE BILLED ON PHARMACY FORM 97 Payment is included in the allowance for another service/procedure. 140 Patient/Insured health identification number and name do not match. 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 62 Payment denied/reduced for absence of, 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. 2 Coinsurance amount. B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. M15 N28 N102 N34 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. Consent form requirements not fulfilled. This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely. Incorrect claim form for this service. 4

5 AD041 AD042 AD043 AD044 AD045 AD046 AD052 AD053 AD056 AD057 AD058 AD059 AD060 BILL E/R FACILITY CHARGES ON O/P UB92 SEND DR S ORDER FOR TEST(S) DIAG NOTES OR DR S PROGRESS NOTES REQ SEND DIAG CODES & DR S ORDER FOR TEST INVALID BILL TYPE FOR SERVICE REPORTED SEND PROG NOTES & DR S ORDER FOR TESTS REVENUE CODE 175 NO LONGER VALID RECIPIENT IS QMB MEDICARE ELIG. ONLY DIAG NOT MATCHED ON PRIOR AUTH PROVIDER MUST BILL DESDD OR HEALTH PLAN PAID AS PART OF TRANSPLANT PACKAGE FEDERAL CONSENT FORM NOT SIGNED OR DATED PRENATAL SERVICES NOT COVERED >= 7/1/97 5 The procedure code/bill type is inconsistent with the place of service. 30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 62 Payment denied/reduced for absence of, 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. 97 Payment is included in the allowance for another service/procedure. N34 M50 N28 Incorrect claim form for this service. Incomplete/invalid revenue code(s) Consent form requirements not fulfilled. 5

6 AD062 PROVIDER ID DOES NOT MATCH NAME M57 Incomplete/invalid provider number. AD063 RECEIVED GREATER THAN 29 The time limit for filing has expired. 12 MONTHS FROM DOS AD064 INCLUDED IN BASE CODE 97 Payment is included in the allowance for another service/procedure. AD070 SERVICE INCLUDED IN COMPOSITE RATE 97 Payment is included in the allowance for another service/procedure. AD071 PROVIDER NOT CERTIFIED LICENSED FOR LAB. B7 This provider was not certified/eligible to be paid for this procedure/service on this AD072 AD073 AD074 AD075 AD076 AD077 AD078 AD079 AD082 LABORATORY SVCS. MUST BE BILLED BY LAB. NO DOC. TO SUPPORT MEDICAL NECESSITY DOC. DOES NOT SUPPORT MEDICAL NECESSITY DOC. DOES NOT SUPPORT SERVICES/CHARGES SERVICE NOT RELATED TO ESRD CONDITION EPO DENIED BECAUSE HEMATOCRIT > 36% EPO DENIED BECAUSE HEMATOCRIT AVG. >36% EPO DENIED - HEMATOCRIT NOT ON CLAIM TOTAL EPO>100,000 UNITS;SUBMIT DOCUMENTS date of service. 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. report/ invoice needed to adjudicate. 6

7 AD083 AD084 EPO>10,000 UNITS/ADMIN; SUBMIT DOCUMENTS HEMODIALYSIS >14 UNITS; SUBMIT DOCUMENTS report/ invoice needed to adjudicate. report/ invoice needed to adjudicate. AD085 UNITS/CHARGE FLD. MISSING;LINE NON-CVRD. AD086 SPLIT DIALYSIS BILL NOT ALLOWED AD088 TESTS NOT ORDER BY PHYSICIAN AD091 SEND PROGRESS NOTES report/ invoice needed to adjudicate. AD092 SEND LAB TEST RESULTS report/ invoice needed to adjudicate. AD093 SEND PHYSICIANS ORDERS report/ invoice needed to adjudicate. AD094 SEND PATIENT HISTORY AND PHYSICAL report/ invoice needed to adjudicate. AD095 SEND ITEMIZED STATEMENT N26 Itemized bill required for claim adjudication. AD101 INCORRECT PROCEDURE CODE FOR SERVICE AD198 BILLED CHARGES DO NOT MATCH EOMB AD199 RECEIVED GREATER THAN 9 MONTHS FROM DOS AD200 RECEIVED MORE THAN 6 MONTHS FROM DOS 29 The time limit for filing has expired. 29 The time limit for filing has expired. N56 N4 Procedure code billed is not correct for the service billed. Prior insurance carrier EOB received was insufficient. 7

8 AD235 AD333 AD800 AD850 AD851 AD875 AD876 AD878 AD900 AD901 AD950 AD951 MC011 UNCLEAR RECIPIENT DESIGNATION ALREADY PAID FFS; RECOUP DUPLICATE REDENIAL OF A PREVIOUSLY DENIED CLAIM ALREADY PAID-BILLED TO APACHE COUNTY ALREADY PAID-BILLED TO NAVAJO COUNTY ALREADY DENIED-BILLED TO APACHE CTY. ALREADY DENIED-BILLED TO NAVAJO COUNTY RCP. ENROLLED IN HEALTH PLAN PARTIAL DOS CTY ELIG. DENIED/PREV. PAID CTY ELIG. DENIED OR USED TOWARDS SPND DW APACHE COUNTY RESPONSIBILITY NAVAJO COUNTY RESPONSIBILITY NOT AN MED-QUEST COVERED SERVICE 31 Claim denied as patient cannot be identified as our insured. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. 23 Payment adjusted because charges have been paid by another payer. 23 Payment adjusted because charges have been paid by another payer. 23 Payment adjusted because charges have been paid by another payer. 23 Payment adjusted because charges have been paid by another payer. 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. 30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 96 Non-covered service(s). 8

9 MC012 MC013 MC014 MC015 MC016 MC018 REDUCED BY MEDICAL REVIEW OUTCOME REDUCED BY MANUAL PRICING OPI REVIEW RESULTED IN UNITS DECREASE UNIT(S)-1500 CUTBACK AFTER MED REVIEW DOCUMENTATION DSN'T SUPPRT LNGTH OF STAY CUTBACK OF GLOBAL CODE TO DELIVERY ONLY documentation/orders/notes/summary 9

10 MC019 MC031 MC032 MC033 MC040 MC041 MC042 MC043 CUTBACK OF POSTPARTUM CHARGES LESSER TIER LEVEL PER DOCUMENTATION CMRU TIER CUTBACK FROM NICU (C) CMRU TIER CUTBACK FROM ICU (C) SERVICE INCLUDED IN COMPOSITE RATE PROVIDER NOT CERTIFIED/LICENSED FOR LAB. LAB SERVICES MUST BE BILLED BY LAB PROV. NO DOC./ACCEPTABLE DX TO SUPPORT NECESSI 97 Payment is included in the allowance for another service/procedure. B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/perform the service billed. 10

11 MC044 MC045 MC046 MC047 MC048 MC049 MC052 MC053 MC054 MC055 MC056 MC057 DOC. DOES NOT SUPPORT MEDICAL NECESSITY DOC. DOES NOT SUPPORT SERVICES/CHARGES SERVICE NOT RELATED TO ESRD EPO DENIED - HEMATOCRIT > 36% EPO DENIED - HEMAOTCRIT ROLLING AVG.>36% EPO DENIED - HEMATOCRIT NOT ON CLAIM REVENUE CODE NOT COVERED FOR DIALYSIS CPT/HCPCS CODING INCORRECT/MISSING TOTAL EPO>100,000 UNITS;SUBMIT DOCUMENTS EPO>10,000 UNITS/ADMIN; SUBMIT DOCUMENTS HEMODIALYSIS>14 UNITS; SUBMIT DOCUMENTS VACCINES/TB TST NOT CVRD FOR ESP RCPTS. N56 Procedure code billed is not correct for the service billed. 11

12 MC060 UNITS/CHARGE FLD MISSING;LINE NON-CVRD. MC061 SEND PROGRESS NOTES MC062 SEND LAB TEST RESULTS MC063 SEND PHYSICIANS ORDERS report/ invoice needed to adjudicate. MC064 SEND PATIENT HISTORY AND PHYSICAL report/ invoice needed to adjudicate. MC065 SEND ITEMIZED STATEMENT N26 Itemized bill required for claim adjudication. MD001 MEDICAL REVIEW DENIAL N109 This claim was chosen for complex review and was denied after reviewing the medical records. MD002 DENY/STERIL. CONSENT N28 Consent form requirements not fulfilled. FORM NOT ATTACHED MD003 ITEMIZED N26 Itemized bill required for claim adjudication. BILL MD004 H&P MD005 MD006 MD007 OPERATIVE REPORT DISCHARGE SUMMARY PATHOLOGY REPORT M29 M30 Claim lacks the operative report. Claim lacks the pathology report. 12

13 MD008 MD009 MD010 MD011 MD012 MD013 MD014 MD015 MD016 MD017 MD018 PROGRESS NOTES MEDICATION RECORDS NURSES NOTES PHYSICIANS ORDERS ANESTHESIA RECORDS LABOR/DELIVERY RECORDS PROCEDURE RECORDS CONSULT REPORT X-RAY REPORT ULTRASOUND REPORT EMERGENCY ROOM RECORDS M31 Claim lacks the radiology report. 13

14 MD019 MD020 MD021 MD022 MD023 MD024 MD025 MD026 MD028 MD029 MD030 MD031 MD032 OFFICE/CLINIC NOTES TRANSPORT RECORDS OBSERVATION ORDERS OBSERVATION RECORDS H&P, OP,D/C, ER RECORDS MD ORDERS & PROGRESS NOTES STERILIZATION CHGS REMOVED RESUBMIT ON A UB-92 FORM NOT AN ESP COVERED SERVICE NON-ACUTE PSYCH SERVICES NOT COVERED TRANS NOT COVERED BEYOND NEAREST FACIL SERVICES DENIED PER CONCURRENT REVIEW STERILIZATION-MEMBER NOT 21 YRS OLD N34 N109 Incorrect claim form for this service. This claim was chosen for complex review and was denied after reviewing the medical records. 14

15 MD033 DOES NOT MEET OBSERVATION CRITERIA MD034 EMERGENCY CRITERIA NOT MET 40 Charges do not meet qualifications for emergent/urgent care. MD035 LENGTH OF STAY NOT SUBSTANTIATED MD036 CHARGES NOT SUBSTANTIATED MD037 SERVICES REQUIRE PA 62 Payment denied/reduced for absence of, MD038 CHGS/SERVICES DO NOT MATCH DOCUMENTATION MD039 MEDICAL RECORDS DO NOT MATCH DOS BILLED MD040 REQUESTED DOCUMENTATION NOT RECEIVED MD041 NO MEDICAL DOCUMENTATION SUBMITTED MD042 ALS LEVEL OF SERVICE NOT SUBSTANTIATED MD043 ACUTE PSYCH EPISODE NOT DOCUMENTED MD044 EMERG ROOM MUST BE BILLED AS INPATIENT MD045 INCIDENTAL PROCEDURES NOT COVERED MD046 PROCEDURE INVALID FOR FAMILY PLANNING MD048 NEAR DUPLICATE OF PAID 18 Duplicate claim/service. PROCEDURE N109 N34 N56 This claim was chosen for complex review and was denied after reviewing the medical records. Incorrect claim form for this service. Procedure code billed is not correct for the service billed. 15

16 MD050 CPT CODING INCORRECT N56 Procedure code billed is not correct for the service billed. MD051 HCPCS CODING INCORRECT N56 Procedure code billed is not correct for the service billed. MD054 MD055 MD056 MD057 MD058 MD059 MD060 ASSISTANT SURGEON MUST BILL SEPARATELY ORIGINAL CLAIM WAS PAID CORRECTLY INCLUDED IN GLOBAL PACKAGE INCLUDED IN PRIOR CHARGE BUNDLED INTO OTHER PROCEDURE OUT MODIFIER INVALID MODIFIER COMBINATION B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. 97 Payment is included in the allowance for another service/procedure. 97 Payment is included in the allowance for another service/procedure. 97 Payment is included in the allowance for another service/procedure. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 31 Claim denied as patient cannot be identified as our insured. MD061 INMATE OF A PUBLIC INSTITUTION MD063 FEDERAL CONSENT FORM NOT SIGNED MD064 FEDERAL CONSENT FORM DATE EXPIRED MD065 CO-SURGERY NOT REIMBURSABLE MD066 MODIFIER MISSING 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. N32 M15 M78 N28 N28 Provider performing service must submit claim. Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. Did not complete or enter accurately an appropriate HCPCS modifier(s). Consent form requirements not fulfilled. Consent form requirements not fulfilled. 16

17 MD067 INCORRECT MODIFIER 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. MD070 MD071 MD080 MD230 MD231 AUTHORIZATION FOR SERVICES DENIED NOT AN MED-QUEST COVERED SERVICE UNABLE TO DETERMINE PREG./EMG. FROM DX. TEST INC. IN COMPOSITE;SEND PROG. NOTES LAB TEST. REQUIRES PROGRESS NOTES 62 Payment denied/reduced for absence of, SC001 PA UNITS PARTIALLY USED 62 Payment denied/reduced for absence of, SC020 PSYCHIATRIC EPISODE > 35 Benefit maximum has been reached. THAN 3 DAYS SC021 PSYCH LIMIT FOR CONTRACT YEAR EXCEEDED 119 Benefit maximum for this time period has been reached. SC022 DETOX SERVICE LIMITS EXCEEDED SC023 ICU/NICU W/O PA CUTBACK TO 1 DAY SC024 NON ICU/NICU W/O PA CB TO 3 DAYS SC025 LENGTH OF STAY CUTBACK/PA EXCEEDED SC026 NURSERY STAY EXCEEDS 3 DAYS FOR ESP 35 Benefit maximum has been reached. 62 Payment denied/reduced for absence of, 62 Payment denied/reduced for absence of, 62 Payment denied/reduced for absence of, 35 Benefit maximum has been reached. 17

18 SC027 INTERIM BILL W/O PA CUT TO 3 DAYS 62 Payment denied/reduced for absence of, SC028 KIDSCARE BH 30 INPATIENT 35 Benefit maximum has been reached. LIMIT EXCEEDED SC029 KIDSCARE BH 30 VISIT LIMIT 35 Benefit maximum has been reached. EXCEEDED SC030 OXYGEN/SUPPLIES, W/O TRANSPORTATION PA 62 Payment denied/reduced for absence of, SC031 KIDSCARE VISION EXAM 35 Benefit maximum has been reached. LIMIT EXCEEDED SC032 KIDSCARE VISION LENS 35 Benefit maximum has been reached. LIMIT EXCEEDED SC033 IMD LIMITS EXCEEDED->30 35 Benefit maximum has been reached. CONSEC DAYS SC034 IMD LIMITS EXCEEDED->60 35 Benefit maximum has been reached. DAYS/FISCAL YR SC040 ANESTHESIA MAX. VALUE 35 Benefit maximum has been reached. EXCEEDED SC041 SELF DIALYSIS TRAINING 35 Benefit maximum has been reached. LIMIT EXCEEDED SC042 BIRTHING CENTER SERVICE 35 Benefit maximum has been reached. LIMIT EXCEEDED SC043 RESPITE SERVICE LIMIT 35 Benefit maximum has been reached. EXCEEDED SC044 BED HOLD DAYS EXCEEDED 35 Benefit maximum has been reached. SC045 THERAPEUTIC DAYS LIMIT 35 Benefit maximum has been reached. EXCEEDED SC046 DAILY SERVICE LIMIT 35 Benefit maximum has been reached. EXCEEDED SC050 SYSTEM CUTBACK TO A2 Contractual adjustment. LOWER CARE LEVEL SC060 FREQUENCY LIMIT EXCEEDED/LIFETIME 35 Benefit maximum has been reached. 18

19 SC061 SC062 SC080 SC083 FREQUENCY LIMIT EXCEEDED/OTHER LTC SERVICE LIMIT DAYS EXCEEDED NCVRD CHRGS APPLIED/ REV CD NOT CV ALLOWED SERVICE UNITS EXCEEDED 35 Benefit maximum has been reached. 35 Benefit maximum has been reached. B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. SC085 DELIVERY ONLY SC086 POSTPARTUM DISALLOWED B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. SC200 SYSTEM CUTBACK TO LOWER TIER SC400 REVENUE CODE NOT COVERED SC401 REVENUE CODE NOT COVERED FOR BILL TYPE SC999 NET ALLOW OFFSET 88 ment amount represents collection against receivable created in prior overpayment. 19