CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030

Transcription

1 CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 Missing service provider zip code (box 32) 031 Missing pickup zip code on the claim 032 Billed charges should be zero for home health claim 033 Hospital based ASC claim can't be submitted on UB form 034 Service dates are not in the same calendar year 035 Invalid place of service 036 Invalid type of bill 096 Member's gender is not the same between claim and membership 101 Subscriber not actively enrolled on service date 102 Member not actively enrolled on service date 105 No coverage during service period 108 Benefit not covered for spouse 109 Benefit not covered for dependent 130 Submit to Cofinity for Repricing 142 Type of Bill Deny Action 170 Service date after receive date 171 Date of service before date of birth 200 Missing diagnosis pointer OR Invalid HIPAA ICD9 code. 201 Additional digit is required for this ICD9 code 202 Unknown CPT code Please resubmit with a HIPAA valid CPT code 203 Inactive CPT code Please resubmit with a HIPAA valid CPT code 204 Unknown Modifier Please resubmit with a HIPAA valid Modifier 207 Unknown ICD9 Procedure code Please resubmit with a valid HIPAA code 213 Ben Cat Priority config issue 214 Denied due to B notice 215 Missing Admission source for the Revenue code submitted, for NONPPO provider 216 Invalid Value Codes for the Revenue codes submitted, for NONPPO provider 217 HOST claim cannot be submitted with zero total charges 218 Primary line is denied in inclusive group pricing. 221 Out of scope in Ancillary claim wrong claim type or wrong payee type.

2 222 Ancillary claim, need to bill local plan. 223 Referring provider NPI is missing in Ancillary claim. 228 Host Adjustment claim Void/adjustment claim 231 Current claim falls within the history claim date range 232 Current claim falls outside the history claim date range 233 Unknown Secondary ICD Code 243 Invalid Diagnosis Code 244 Invalid Secondary Diagnosis Code 245 Invalid Procedure code 300 Unlisted code Please resubmit using a more specific code and/or a description of code 304 Member in Hospice 333 Family lifetime max limit is met 343 Exceeded max allowed amount for claim 346 Member lifetime allowed amount exceeded max 348 Family annual allowed amount exceeded max 351 Family life max for benefit category exceeded 352 Family annual allowed amount for benefit category exceeded max 357 Member age excludes benefit coverage 361 Student age limitation in this plan 363 Service date is after COBRA termination date 369 Billed charges paid by Member 381 Void Claim 385 Fee schedule is not active 407 Code not in Fee Schedule. 431 Preexisting conditions 456 Authorization has been denied 500 Denied by Rebundler 502 Duplicate Line Item 503 Assistant Surgeon limit exceeded for this procedure 511 Rider Option Number of visits exceed allowable 528 Age is out of range for the given Primary Diagnosis 529 Gender is invalid for the given Primary Diagnosis. 530 Age is out of range for the given code 531 Gender code is invalid for the given CPT 533 MODIFIER NOT CONSIDERED ELIGIBLE BY SIGNATURE CARE PROV W/O 539 Claim being denied over filing limit 540 Total charges not equal to total charges of line items 601 Paid Manual 602 Denied Manual 604 Processed Injectable/infusion/Pathology/Lab code requires prior approval by the UR Department 605 Denied Inappropriate Coding 606 Denied Primary Carrier EOB Required or proof of termination of Primary carrier 607 Denied Not A Covered Benefit 608 Denied No Medical Coverage 609 Denied No Dental Coverage 610 Denied No Vision Coverage 611 Denied Duplicate Claim

3 612 Denied Eligibility Document Required (i.e., Birth Certificate, Marriage License, Divorce Decree) 613 Denied Exceeds filing limit Can Not Bill Patient 614 Denied Investigating Other Insurance 615 Denied Incidental Procedure 617 Denied Invalid/Deleted Diagnosis Code 618 Denied Invalid/Deleted Procedure Code 619 Denied Medical Records Must Be Submitted 620 Denied Other Insurance Information Required 621 Denied Part of Global Code 622 Do not use Do not change 623 Denied Prior/After UR Authorized Dates 624 Denied Over Plan Filing Limit 625 Denied Unlisted Procedure Submit Specific CPT/HCPCS or Description and Medical Necessity 626 Denied Not A Billable Service By This Provider 627 Denied An established patient E/M code should have been used 628 Denied Service Exceeds Plan Limit 629 Denied Charges Incurred After Term Date 630 Denied Duplicate line item 631 Denied Claim Exceeds Authorized Visits 632 Denied No UR Authorization/Authorization not approved 633 Denied Diagnosis Does Not Match Authorized Diagnosis 634 Penalty No Out Of Network Authorization 635 Denied Inappropriate Place of Service Billed 636 Denied Itemized Statement Required 637 Denied Related To Workmans Comp 638 Denied Provider Not Properly Credentialed 639 Paid/Processed as Secondary/No Primary Member Obligation 640 Denied Charges Incurred Prior To Effective Date 641 Processed Requested Information Received 642 Denied Require Copy Of Operative Report 643 Denied Pending For Medicare Effective Date 644 Denied Age Is Out Of Range For Given CPT 645 Denied Incorrect Patient Demographics 646 Denied Require Attending Physicians Name field Denied Requested Information Not Received 648 Denied Required Description of Primary's Remark Codes 649 Denied Exceeds allowed quantity/frequency 650 Denied Submit to Community Mental Health 651 Paid Allowable Applied to the Deductible 652 Processed This Is A Predetermination 653 Denied Eligible for, not enrolled in Medicare 654 Denied Subsequent PT/OT/ST visits must be authorized by Navant 655 Denied Submit Original Primary EOB 656 Maximum Pay Amount. Patient Owes Balance 657 Denied Resubmit With Anesthesia Code/Modifier 658 Denied Present on Admission Indicator Required, information may be missing or invalid. 659 Denied Exceeds Yearly Dental Maximum

4 660 Denied Primary diagnosis code not recognized by this DRG Grouper. Please map diagnosis to the prev. 661 Denied Missing Multiple Surgical Modifier 662 Denied Srvc not provided by a designated or contracted PCP 663 Denied No Secondary Consideration Until Primary's Request Satisfied 664 Denied Require Primary Carrier's EOB 665 Paid Additional 666 Denied Split Claim Needed for Non Covered Charges 667 Denied Require facility name and address where services were rendered, box Denied EOB and Claim Do Not Match 669 Denied The immunization must be billed with the immunization administration code. 670 Denied Forward claim to Psychcare Denied Submit claim to ValueOptions PO Box , Wixom, MI Denied Not Included In Case Rate 673 Resubmit illegible EOB 674 Processed Split Payment Due To Benefits 675 Denied Replacement/void claim received 676 Denied Require Copy of Birth Certificate 677 Denied Require eligibility verification form 678 Denied Claim Under Review by The Sentinel Group 679 Denied Submit Claim to Occupational Eyewear Network 680 Denied Claim not submitted with contracted TIN / payee information. 681 Paid per settlement 682 Denied Service Line Pending Fee Schedule Update 683 Denied Non Network/Inactive Provider/Non contracted Physician 684 Denied by Medical Director after Review 685 Denied Covered In Contracted Case Rate 686 Denied Per primary carrier EOB, This is a provider write off 687 Denied Exceeds annual maximum benefit limit 688 Denied Resubmission of a claim under review by Sentinel 689 Denied Submit to Cofinity for Pricing 690 Denied Non Emergent Ambulance Dx 691 Denied Not a THC Enrollee/Incorrect Member/Claimant 692 Denied Resubmit with a THC referral 693 Denied Resubmit with Prenatal Dates 694 Denied Invalid Place of Service 695 Denied Not covered by Medicaid/ Medicare 696 Denied Service Included 697 Denied Previously paid 698 Denied Capitated Service 699 Denied Service is not authorized on the referral or authorization 701 Number of visit exceeds annual allowable 704 Claim exceed EOB max pay amount 708 Missing accident date for accident related claim 711 Claim had been paid at header level 830 Exceed maximum allowed time for pended claim Denied 852 Denied based on ices edits 861 Denied based on pricing reduction

5 01Z Pricer No available APC/fee schedule rate. 04Z Not Covered Under OPPS 08Z Pricer Invalid modifier for pricing 10Z Pricer Line item denial or rejection from ACE 21Q Present on Admission Indicator Required 24Q Non covered claim (Kentucky Medicaid, Virginia Medicaid, and Medicare Inpatient) 41P Invalid billing of therapy services 62P Closed or inactive rate record E01 Denied Misrepresentation of Diagnosis E02 Denied Failure by referring provider to comply E03 Denied Failure by rendering provider to comply E04 Denied Unbundled Service/Exclusive or Incidental Relationship. E05 Denied Deliberate performance of unwarranted services E06 Denied Billing for services/supplies not provided E07 Denied Misrepresentation of services/supplies provided E08 Denied Treatment is not in accordance with standard of care E09 Denied No documentation in medical record of services billed; medical record does not support billed E10 Denied Auto insurance primary E11 Primary payment exceeds allowable E12 Denied HCPC Code Required E13 Processed THC primary carrier E14 Denied NDC Code Required in HCFA box 24 or in UB service line area per MSA Bulletin E15 Denied Invalid/missing or incorrect Modifier E16 Denied NDC is invalid for the billed service code E17 Denied Electronic Referral Required E18 Denied Injection is covered under Medicare Part D. E19 Denied Injection pending Part D filing submission E20 Denied No history of inpatient services or observation provided for Transitional Care Management Ser E21 Denied DOS is outside of the required timeframe E22 Denied Include date of visit(s) and EDC E23 Denied Prenatal global billing must be rebilled as separate services and include DOS and EDC E24 Denied by Medicare/Primary Insurer E25 Multiple procedure reduction of 50% applied per CMS guidelines E26 Denied Services not supported by patient history or documentation E27 Denied No additional payment, paid in full by Medicare/ primary insurer E28 Denied Awaiting eligibility determination from health insurance marketplace; nonpayment of premium E29 Resubmission of a claim under review by TC3 E30 Denied Claim under review by TC3 E31 Denied Medicare is primary E32 Denied Left against medical advice not a covered benefit E33 Denied The requisition form was not signed by the ordering physician. E34 Denied Inappropriate use of Modifier 59 E35 Denied Does not meet inpatient hospital claim requirements for newborns E40 Payment requires submission of completed HRA fax to E41 Denied Diagnosis describes external cause, or requires the ICD code for first underlying disease. E42 Denied service or supply may be considered investigational and experimental E44 Denied Drug code requires name of drug, dosage, and NDC of the drug furnished

6 F01 F02 F05 F70 XXX Member not eligible No saving claims history Invalid Group Same problem with account Visit falls before the event period. Updated 02/10/2015