Claim Adjustment Reason Codes and Remittance Advice Remark Codes (CARCs and RARCs)--Effective 09/05/2015

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1 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0203 MEMBER I.D. NUMBER 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. MISSING/INVALID 0204 HOSPITAL DISCHARGE DATE INVALID N318 MISSING/INCOMPLETE/INVALID DISCHARGE OR END OF CARE DATE PRESCRIBING PRACTITIONER S 184 THE PRESCRIBING/ORDERING PROVIDER IS NOT ELIGIBLE TO N574 OUR RECORDS INDICATE THE ORDERING/REFERRING PROVIDER IS OF A LICENSE NO. MISSING PRESCRIBE/ORDER THE SERVICE BILLED. TYPE/SPECIALTY THAT CANNOT ORDER OR REFER. PLEASE VERIFY THAT THE CLAIM ORDERING/REFERRING PROVIDER INFORMATION IS ACCURATE OR CONTACT THE ORDERING/REFERRING PROVIDER PRESCRIBING PRACTITIONER LICENSE NO. FORMAT INVALID 184 THE PRESCRIBING/ORDERING PROVIDER IS NOT ELIGIBLE TO PRESCRIBE/ORDER THE SERVICE BILLED. N574 OUR RECORDS INDICATE THE ORDERING/REFERRING PROVIDER IS OF A TYPE/SPECIALTY THAT CANNOT ORDER OR REFER. PLEASE VERIFY THAT THE CLAIM ORDERING/REFERRING PROVIDER INFORMATION IS ACCURATE OR CONTACT THE ORDERING/REFERRING PROVIDER. MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION PREGNANCY INDICATOR INVALID M BRAND MEDICALLY NECESSARY 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND INDICATOR INVALID 0211 REFILL INDICATOR INVALID N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES PRESCRIPTION NUMBER IS MISSING N388 MISSING/INCOMPLETE/INVALID PRESCRIPTION NUMBER 0213 DATE PRESCRIBED IS MISSING N57 MISSING/INCOMPLETE/INVALID PRESCRIBING DATE DATE PRESCRIBED IS INVALID N57 MISSING/INCOMPLETE/INVALID PRESCRIBING DATE DATE DISPENSED IS MISSING N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE DATE DISPENSED IS INVALID N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE NDC MISSING M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) NDC INVALID FORMAT M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) QUANTITY DISPENSED IS MISSING N378 MISSING/INCOMPLETE/INVALID PRESCRIPTION QUANTITY QUANTITY DISPENSED IS INVALID N378 MISSING/INCOMPLETE/INVALID PRESCRIPTION QUANTITY DAYS SUPPLY MISSING M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE DAYS SUPPLY INVALID M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE PROC REQUIRES DIAGNOSIS M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS., NONE FOUND ON CLAIM 0224 DIAGNOSIS TREATMENT INDICATOR M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. INVALID 0225 MISSING PRESCRIBING PROVIDER N318 MISSING/INCOMPLETE/INVALID DISCHARGE OR END OF CARE DATE. NUMBER 0226 REFERRAL PROV ID REQUIRED FOR N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER PROCEDURE GROUP 0227 THIRD PARTY PAYMENT AMOUNT MA04 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY OF OR INVALID PAYMENT INFORMATION FROM THE PRIMARY PAYER. THE INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE 0228 BILLING PROVIDER SIGNATURE MA70 MISSING/INCOMPLETE/INVALID PROVIDER REPRESENTATIVE SIGNATURE MISSING 0229 SOURCE OF ADMISSION MISSING MA42 MISSING/INCOMPLETE/INVALID ADMISSION SOURCE 0231 RENDERING PROVIDER NUMBER IS N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER MISSING 0233 UNITS OF SERVICE MISSING M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE 0234 PROCEDURE MISSING M51 MISSING/INCOMPLETE/INVALID PROCEDURE (S) 0235 PROCEDURE NOT IN VALID 181 PROCEDURE WAS INVALID ON THE DATE OF SERVICE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. FORMAT 0236 DETAIL DOS DIFFERENT THAN THE M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE. HEADER DOS 0237 OUTPATIENT CLAIMS CANNOT SPAN N62 DATES OF SERVICE SPAN MULTIPLE RATE PERIODS. RESUBMIT SEPARATE DATES CLAIMS MEMBER NAME IS MISSING MA36 MISSING/INCOMPLETE/INVALID PATIENT NAME 0239 THE DETAIL "TO" DATE OF SERVICE M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE IS MISSING

2 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0240 THE DETAIL "TO" DATE IS INVALID M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE 0241 ACCIDENT INDICATOR IS INVALID 95 PLAN PROCEDURES NOT FOLLOWED SECONDARY DIAGNOSIS M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS INVALID FORMAT 0243 MISSING MEDICARE PAID DATE N307 MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE THIRD DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0245 MISSING OCCURRENCE M45 MISSING/INCOMPLETE/INVALID OCCURRENCE (S) FOURTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0248 PLACE OF SERVICE IS MISSING OR M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. BLANK 0249 PLACE OF SERVICE IS INVALID M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE CLAIM HAS NO DETAILS 107 THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT IDENTIFIED ON THIS CLAIM FIRST MODIFIER NOT COVERED 182 PROCEDURE MODIFIER WAS INVALID ON THE DATE OF N517 SERVICE SECOND MODIFIER NOT COVERED 182 PROCEDURE MODIFIER WAS INVALID ON THE DATE OF N517 SERVICE THIRD MODIFIER NOT COVERED 182 PROCEDURE MODIFIER WAS INVALID ON THE DATE OF N517 SERVICE BILLING PROVIDER LOCATION M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. MISSING 0255 BILLING PROVIDER LOCATION M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. INVALID 0256 MISSING MEDICARE PAID DATE - N307 MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE. DETAIL 0257 PLACE OF SERVICE IS INVALID - M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE DETAIL 0258 PRIMARY DIAGNOSIS MISSING M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0259 DATE BILLED IS MISSING/INVALID MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD BILLED UNITS OF SERVICE NOT IN VALID M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE FORMAT 0261 TOOTH NUMBER MISSING N37 MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER 0262 TOOTH NUMBER INVALID N37 MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER 0263 TOOTH SURFACE INVALID N75 MISSING/INCOMPLETE/INVALID TOOTH SURFACE INFORMATION 0264 DETAIL FROM DATE OF SERVICE IS M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE MISSING 0265 DETAIL FROM DATE OF SERVICE IS M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE INVALID 0266 INSUFFICIENT NUMBER OF VALID N75 MISSING/INCOMPLETE/INVALID TOOTH SURFACE INFORMATION TOOTH SURFACE S 0268 BILLED AMOUNT MISSING M54 MISSING/INCOMPLETE/INVALID TOTAL CHARGES 0269 DETAIL BILLED AMOUNT INVALID M79 MISSING/INCOMPLETE/INVALID CHARGE HEADER TOTAL BILLED AMOUNT M79 MISSING/INCOMPLETE/INVALID CHARGE MISSING 0271 HEADER TOTAL BILLED AMOUNT M54 MISSING/INCOMPLETE/INVALID TOTAL CHARGES. INVALID 0272 PRIMARY DIAGNOSIS INVALID MA63 MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS TYPE OF BILL MISSING MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL TYPE OF BILL INVALID MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL ADMIT DATE MISSING MA40 MISSING/INCOMPLETE/INVALID ADMISSION DATE ADMIT DATE INVALID MA40 MISSING/INCOMPLETE/INVALID ADMISSION DATE ADMIT HOUR INVALID N46 MISSING/INCOMPLETE/INVALID ADMISSION HOUR.

3 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 0278 ADMIT TYPE MISSING MA INVALID TYPE OF ADMISSION MA PATIENT STATUS IS MISSING MA PATIENT STATUS IS INVALID MA COVERED DAYS MISSING MA COVERED DAYS INVALID MA PRIMARY CONDITION INVALID M SECOND CONDITON INVALID M THIRD CONDITION INVALID M FOURTH CONDITION INVALID M FIFTH CONDITION INVALID M SIXTH CONDITION INVALID M SEVENTH CONDITION INVALID M REVENUE 183 REQUIRES OSC M46 = REVENUE 185 REQUIRES OSC M50 = PAYER RESPONSIBILTY/OTHER MA04 PAYER COUNT MISMATCH 0302 INSURED GROUP NAME (HSN TYPE) IS MISSING OR INVALID 0303 DESTINATION PAYER ID MUST BE 995 M PYR RESPONSIB AND INSURED GRP MA04 NAME NOT COMPATIBLE MA04 DESCRIPTION MISSING/INCOMPLETE/INVALID ADMISSION TYPE. MISSING/INCOMPLETE/INVALID ADMISSION TYPE. MISSING/INCOMPLETE/INVALID PATIENT STATUS. MISSING/INCOMPLETE/INVALID PATIENT STATUS. MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE BILLING PERIOD. MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE BILLING PERIOD. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID CONDITION. MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN (S). MISSING/INCOMPLETE/INVALID REVENUE (S). 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. 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. MISSING/INCOMPLETE/INVALID PAYER IDENTIFIER. 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 G1 REF REQUIRED WHEN HSN INSURED GROUP IS CA OR MH 0308 AID CAT MUST BE HB WHEN INSURED GROUP IS BD 0309 AID CAT MUST BE HC OR HD WHEN INSURED GROUP IS CA 0310 AID CAT MUST BE HA WHEN INSURED GROUP IS MH 0315 HSN PARTIAL CLM PAT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT RESPONSIBILITY AMT NOT PRESENT 0320 INVALID TOB FOR HSN MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL HSN MH CLAIM SUBMISSION >18 MONTHS FROM LDOS 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0330 HSN BD CLAIM SUBMISSION <= 120 DAYS FROM DOS 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0335 OCCURRENCE A2 REQUIRED ON HSN BD CLAIM 0339 REVENUE IS MISSING M50 MISSING/INCOMPLETE/INVALID REVENUE (S) REVENUE IS INVALID M50 MISSING/INCOMPLETE/INVALID REVENUE (S) CERTIFICATION INVALID N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES PAYER PRIOR PAYMENT IS INVALID 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 NO. OF DETAILS NOT EQUAL TO SUBMITTED DETAIL COUNT N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE.

4 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0351 REFILL NOT ALLOWED FOR NARCOTIC DRUGS 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0355 FIFTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0356 SIXTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0357 SEVENTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0358 EIGHTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0359 NINTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0360 TENTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS ELEVENTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS TWELFTH DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS PRINCIPAL ICD9 PROCEDURE MA66 MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE. IS INVALID 0365 PRINCIPAL PROCEDURE DATE N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). INVALID 0366 FIRST OTHER PROCEDURE M67 MISSING/INCOMPLETE/INVALID OTHER PROCEDURE (S). INVALID 0368 FIRST OTHER PROCEDURE DATE N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). INVALID 0369 SECOND OTHER PROCEDURE M67 MISSING/INCOMPLETE/INVALID OTHER PROCEDURE (S). INVALID 0371 SECOND OTHER PROCEDURE DATE N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). INVALID 0372 THIRD OTHER PROCEDURE M67 MISSING/INCOMPLETE/INVALID OTHER PROCEDURE (S). INVALID 0375 FOURTH OTHER PROCEDURE M67 MISSING/INCOMPLETE/INVALID OTHER PROCEDURE (S). INVALID 0378 FIFTH OTHER PROCEDURE M67 MISSING/INCOMPLETE/INVALID OTHER PROCEDURE (S). INVALID 0382 ATTENDING PHYSICIAN ID INVALID N253 MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER FIRST OTHER PHYSICIAN ID INVALID N270 MISSING/INCOMPLETE/INVALID OTHER PROVIDER PRIMARY IDENTIFIER REVENUE REQUIRES A M20 MISSING/INCOMPLETE/INVALID HCPCS. CORRESPONDING HCPCS/CPT MEDICARE DEDUCTIBLE AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT MISSING-DETAIL 0392 MEDICARE PAID AMOUNT NOT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT NUMERIC-DETAIL 0393 MEDICARE DEDUCTIBLE AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT MISSING 0394 MEDICARE CO-INSURANCE AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT MISSING 0395 HEADER STATEMENT COVERS M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE PERIOD "FROM" DATE MISSING 0396 HEADER STATEMENT COVERS M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE PERIOD "FROM" DATE INVALID 0397 HEADER STMT COVERS PERIOD M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE "THROUGH" DATE MISSING 0398 STATEMENT COVERS PERIOD M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE "THROUGH" DATE INVALID 0400 DETAIL UNITS OF SERVICE MUST BE M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. GREATER THAN ZERO 0401 PRESENT ON ADMISSION INDICATOR N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR. MISSING 0402 PRESENT ON ADMISSION INDICATOR N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR. INVALID 0403 PRESENT ON ADMISSION IND N434 MISSING/INCOMPLETE/INVALID PRESENT ON ADMISSION INDICATOR. PRESENT WHERE NOT ALLOWED 0405 PAID PAPE WITH 0 ALLOWED UNITS B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT MEDICARE DENIAL ON CROSSOVER N8 CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM DATA CLAIM NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO PROVIDE ADEQUATE DATA FOR

5 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0427 ACCIDENT DATE INVALID N305 MISSING/INCOMPLETE/INVALID ACCIDENT DATE DEDUCTIBLE AMOUNT INVALID- N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT DETAIL 0432 COINSURANCE AMOUNT INVALID- N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT DETAIL 0433 MEDICARE DEDUCTIBLE AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT INVALID 0434 MEDICARE COINSURANCE AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT INVALID 0436 TOTAL MEDICARE ALLOWED N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE AMOUNT INVALID 0437 MEDICARE PSYCH ADJUSTMENT M49 MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S). AMOUNT INVALID 0438 TOTAL MEDICARE ALLOWED N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE AMOUNT INVALID-DETAIL 0439 PSYCH ADJUSTMENT (PR122) N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT AMOUNT INVALID-DETAIL 0440 MCARE PAID 100% OF CLAIM- 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. HEADER 0441 MCARE PAID 100% OF CLAIM-DETAIL 169 ALTERNATE BENEFIT HAS BEEN PROVIDED MEDICARE PAID AMOUNT NOT NUMERIC-HEADER 0443 MEDICARE PAID AMOUNT NOT NUMERIC-DETAIL MA04 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 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 0444 MEDICARE APPROVED AMOUNT = ALTERNATE BENEFIT HAS BEEN PROVIDED. HEADER 0445 MEDICARE APPROVED AMOUNT = ALTERNATE BENEFIT HAS BEEN PROVIDED. DETAIL 0450 INVALID QUADRANT N346 MISSING/INCOMPLETE/INVALID ORAL CAVITY DESIGNATION DTL RENDERING/PERFORMING M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. PROVIDER SERV LOC MISSING 0453 HDR RENDERING/PERFORMING M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. PROVIDER SERV LOC MISSING 0454 INVALID ASSIGNMENT 111 NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT INVALID PROCEDURE TYPE ACC. TO N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PROCEDURE QUALIFIER 0457 INVALID PRINCIPAL/OTHER M51 MISSING/INCOMPLETE/INVALID PROCEDURE (S) PROCEDURE TYPE 0458 DIAGNOSIS INVALID M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS 0459 DETAIL DIAGNOSIS TREATMENT M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. INDICATOR INVALID 0461 VALUE IS INVALID M49 MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S) VALUE AMOUNT IS MISSING M49 MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S) VALUE AMOUNT IS INVALID M49 MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S) CONDITION 8-24 INVALID M44 MISSING/INCOMPLETE/INVALID CONDITION ICD9 PROCEDURE 7-24 INVALID M51 MISSING/INCOMPLETE/INVALID PROCEDURE (S) 0474 ICD-9 PROCEDURE 7-24 OR DATE N302 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). MISSING 0475 ICD9 PROCEDURE 7-24 DATE IS N302 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). INVALID 0476 DETAIL ATTENDING PHYSICIAN ID IS N253 MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER. INVALID 0477 DETAIL FIRST "OTHER PHYSICIAN" ID N270 MISSING/INCOMPLETE/INVALID OTHER PROVIDER PRIMARY IDENTIFIER. IS INVALID BILL CPT S TO N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. MASSHEALTH ON CMS 1500 FORM 0481 MLOA DAYS GREATER THAN HEADER MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD DAYS BILLED LOA OSC DATES CANNOT SPAN N62 DATES OF SERVICE SPAN MULTIPLE RATE PERIODS. RESUBMIT SEPARATE ACROSS DIFFERENT MONTHS CLAIMS.

6 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0485 TO DATE IS LESS THAN FROM DATE MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD FOR OCCUR SPAN BILLED MLOA DAYS AND DAYS BETWEEN MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD FROM AND TO DOS NOT EQUAL BILLED NMLOA DAYS AND DAYS BETWEEN MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD FROM AND TO DOS NOT SAME BILLED MLOA OSC DAYS SPANNED > DETAIL MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD FROM AND TO DOS BILLED THE OCCURRENCE SPAN FROM N300 MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN DATE(S) DATE IS INVALID 0490 THE OCCURRENCE SPAN TO DATE IS N299 MISSING/INCOMPLETE/INVALID OCCURRENCE DATE(S). INVALID 0491 DIFFERENT MLOA DAYS CANNOT MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD OVERLAP FROM AND TO DAYS BILLED DIFFERENT NMLOA DAYS CANT MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD OVERLAP FROM AND TO DAYS BILLED MLOA AND NMLOA DAYS CANT MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD OVERLAP FROM AND TO DAYS BILLED OCCURRENCE SPAN LOA DATES NOT MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD WITHIN CLAIM DATES BILLED THIS LTC CLAIM HAS LOA DAYS, BUT 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE WRONG 0496 OCCURRENCE SPAN FROM DATE N300 MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN DATE(S) MISSING 0497 OCCURRENCE SPAN TO DATE N300 MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN DATE(S) MISSING 0498 THE OCCURRENCE IS INVALID M46 MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN (S) DATE PRESCRIBED AFTER BILLING N57 MISSING/INCOMPLETE/INVALID PRESCRIBING DATE. DATE 0502 DATE DISPENSED EARLIER THAN N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE. DATE PRESCRIBED 0503 DATE DISPENSED AFTER BILLING N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE. DATE 0506 ICN DATE PRIOR TO DATE BILLED N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S) THE DETAIL "FROM" DATE IS AFTER M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE THE "TO" DATE 0508 TOTAL CHARGE DOES NOT EQUAL M54 MISSING/INCOMPLETE/INVALID TOTAL CHARGES. THE SUM OF ALL DETAILS 0512 CLAIM PAST 12 MONTH FILING LIMIT 29 THE TIME LIMIT FOR FILING HAS EXPIRED HEADER THRU DATE OF SERVICE MA32 MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE BILLING AFTER ICN DATE PERIOD 0518 COVERED DAYS EXCEED MA32 MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE BILLING STATEMENT PERIOD PERIOD ADMIT DATE IS AFTER STATEMENT MA40 MISSING/INCOMPLETE/INVALID ADMISSION DATE. PERIOD "FROM" DATE 0520 INVALID REVENUE 199 REVENUE AND PROCEDURE DO NOT MATCH. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. /PROCEDURE COMBINATION 0521 THROUGH DOS LATER THAN N318 MISSING/INCOMPLETE/INVALID DISCHARGE OR END OF CARE DATE. DISCHARGE DATE 0526 HEADER FROM DOS IS AFTER M52 MISSING/INCOMPLETE/INVALID "FROM" DATE(S) OF SERVICE. HEADER THROUGH DATE 0527 DETAIL FROM DATE OF SERVICE IS N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). AFTER ICN DATE 0529 SURGERY DATE IS BEFORE THE N341 MISSING/INCOMPLETE/INVALID SURGERY DATE. ADMIT DATE 0530 SURGERY DATE IS AFTER THE N341 MISSING/INCOMPLETE/INVALID SURGERY DATE. DISCHARGE DATE 0532 REVENUE /PROVIDER 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. SPECIALTY MISMATCH 0542 MEMBER INELIGIBLE SERV DATE 177 PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY REQUIREMENTS FINAL DEADLINE EXCEEDED 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0550 ADJUSTMENT FAILED 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0551 DISPOSITION AMT FOR ADJUSTMENT 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND IS LESS THAN ZERO 0552 PROVIDER MAY NOT ADJUST GENERATED ATP/PAPE CLAIM 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND

7 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0553 ADJUSTMENT NPI TRANSLATION ISSUE 206 NATIONAL PROVIDER IDENTIFIER - MISSING. N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY IDENTIFIER HEADER BILLED DATE IS PRIOR TO N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S). DATES OF SERVICE 0555 CLAIM PAST 24 MONTH FILING DEADLINE- DETAIL 29 THE TIME LIMIT FOR FILING HAS EXPIRED. N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0556 CLAIM PAST 24 MONTH FILING DEADLINE- HEADER 29 THE TIME LIMIT FOR FILING HAS EXPIRED. N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0557 COINS AND DEDUCT AMT MISSING - DTL 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0558 COINSURANCE AND DEDUCT AMT 96 NON-COVERED CHARGE(S). M49 MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S). MISSING 0559 M-CARE COIN AMT GREATER THAN M- 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND CARE PAID AMT-HDR 0560 M-CARE COIN AMT GREATER THAN M- 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND CARE PAID AMT-HDR 0561 INVALID AMOUNTS FOR CROSSOVER N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE 0568 HEADER DISCHARGE DATE IS LESS N50 MISSING/INCOMPLETE/INVALID DISCHARGE INFORMATION. THAN ADMIT DATE 0569 HDR DTE OF ACCIDENT GREATER N305 MISSING/INCOMPLETE/INVALID ACCIDENT DATE. THAN LAST DTE OF SERV 0570 HEADER TOTAL DAYS LESS THAN M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. COVERED DAYS 0571 DETAIL SURGICAL PROCEDURE M51 MISSING/INCOMPLETE/INVALID PROCEDURE (S) MISSING 0572 ROOM AND BOARD DAYS CONFLICT N153 MISSING/INCOMPLETE/INVALID ROOM AND BOARD RATE SERV DATES ARE NOT IN SAME N345 DATE RANGE NOT VALID WITH UNITS SUBMITTED. MONTH-HEADER 0575 SURGERY DATE CANNOT BE N341 MISSING/INCOMPLETE/INVALID SURGERY DATE. OUTSIDE HDR DATES OF SERVICE 0576 CLAIM HAS THIRD-PARTY PAYMENT 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER N598 HEALTH CARE POLICY COVERAGE IS PRIMARY SERV DATES ARE NOT IN SAME MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD MONTH-DETAIL BILLED ADMIT DATE NOT EQ TO 1ST DATE MA40 MISSING/INCOMPLETE/INVALID ADMISSION DATE. OF SERV FOR REV/DIAG COMBINATION 0589 SUSPEND ADJUSTMENT FOR REVIEW 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0590 DAYS OVERLAPP FISCAL YEAR N62 DATES OF SERVICE SPAN MULTIPLE RATE PERIODS. RESUBMIT SEPARATE END/BEGIN DATES CLAIMS UNITS/DOS CONFLICT M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE ATTACHMENT CONTROL NUMBER M47 MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL NUMBER MISSING 0600 UNITS NOT EQUAL TO QUADRANTS M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. BILLED 0601 TEETH NOT BILLABLE WITH N37 MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER QUADRANTS 0602 UNITS NOT EQUAL TO TEETH BILLED N37 MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER 0610 LOC NOT COMPATIBLE WITH LEAVE M59 MISSING/INCOMPLETE/INVALID "TO" DATE(S) OF SERVICE DAYS 0616 COMPONENT OF STAY EXCEEDED 0617 MEMBER AGE/PROGRAM CONFLICT 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. THE PATIENT'S AGE NO OUTLIER DAYS FOR HSNI 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0619 INVALID TYPE OF CLAIM FOR HSNI N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE OCCURRENCE 47 FDOS IS 69 DAY OUTLIER AMOUNT. INVALID FOR HSNI 0621 MISSING/INVALID K3 SEGMENT FOR N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. HSN 0622 INVALID INSURED GROUP NAME/K3 MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. RECORD TYPE FOR HSN 0623 INVALID K3 REFERENCE ID FOR HSN N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE.

8 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0624 INVALID K3 TERMS DISCOUNT FOR N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. HSN RECORD TYPE INVALID K3 PARTIAL START DATE FOR HSN 0626 INVALID INSURED GROUP NAME/K3 MA48 MISSING/INCOMPLETE/INVALID NAME OR ADDRESS OF RESPONSIBLE PARTY OR RECORD TYPE FOR HSN PRIMARY PAYER INVALID INSURED GROUP NAME/K3 REFERENCE ID FOR HSN 0628 K3 ESTIMATED AMT DUE FORMAT IS INVALID FOR HSN 0629 INVALID K3 WRITE-OFF DATE FOR N229 INCOMPLETE/INVALID CONTRACT INDICATOR HSN 0630 K3 ESTIMATED AMOUNT DUE IS NOT VALID FOR HSN 96 NON-COVERED CHARGE(S). N448 THIS DRUG/SERVICE/SUPPLY IS NOT INCLUDED IN THE FEE SCHEDULE OR CONTRACTED/LEGISLATED FEE ARRANGEMENT 0631 INVALID K3 TERMS DISCOUNT FOR HSN RECORD TYPE HSN BD CLM SUBMITTED >90 DAYS AFTER WRITE-OFF DATE 0634 A3 OCC REPORTED, HSN 59 PROCESSED BASED ON MULTIPLE OR CONCURRENT CLAIM MUST BE PRIMARY PROCEDURE RULES B3 OCC REPORTED, HSN 59 PROCESSED BASED ON MULTIPLE OR CONCURRENT CLAIM MUST BE SECONDARY PROCEDURE RULES C3 OCC REPORTED, HSN 59 PROCESSED BASED ON MULTIPLE OR CONCURRENT CLAIM MUST BE TERTIARY+ PROCEDURE RULES INVALID OTHER COVERAGE 0700 MULTIPLE PRIMARY ENDOSCOPIC FAMILIES CANNOT BE BILLED 234 THIS PROCEDURE IS NOT PAID SEPARATELY. M15 SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE PAYMENT IS NOT ALLOWED NO PRIMARY SURGICAL PROCEDURE MA66 MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE. INDICATED 0702 ENDOSCOPIC PRICE AMOUNT LESS THAN ZERO ENDO FAMILY MIXED PRIMARY/SECONDARY 234 THIS PROCEDURE IS NOT PAID SEPARATELY. 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. M15 SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE PAYMENT IS NOT ALLOWED. N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE. M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) INVALID DISPENSE STATUS 0800 HCPCS REQUIRES NDC 0801 SPECIAL HANDLING EDIT 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW SPECIAL HANDLING EDIT WITH CRITICAL ERROR 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW GENERIC SPECIAL HANDLING 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW GENERIC SPECIAL PAY 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW INVALID SPECIAL HANDLING 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW NOTE REQUIRED FOR PREEMPTIVE 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N708 MISSING ORDERS. ESC - DETAIL ADJUDICATE THIS CLAIM/SERVICE NOTE REQUIRED FOR PREEMPTIVE 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N708 MISSING ORDERS. ESC - HEADER ADJUDICATE THIS CLAIM/SERVICE CLERK ID REQUIRED FOR PREEMPTIVE ESC 0809 CLERK ID REQUIRED FOR PREEMPTIVE ESC 0810 INVALID SUBMITTER ID N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY IDENTIFIER INVALID SUBMITTER ID/BILLING N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY PROVIDER COMBINATION IDENTIFIER NO PCC SELECTED N270 MISSING/INCOMPLETE/INVALID OTHER PROVIDER PRIMARY IDENTIFIER SPECIAL PAY PRICED AT ZERO 96 NON-COVERED CHARGE(S). N10 ADJUSTMENT BASED ON THE FINDINGS OF A REVIEW ORGANIZATION/PROFESSIONAL CONSULT/MANUAL ADJUDICATION/MEDICAL ADVISOR/DENTAL ADVISOR/PEER REVIEW.

9 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0814 HIC NUMBER NOT PRESENT ON N382 MISSING/INCOMPLETE/INVALID PATIENT IDENTIFIER. CLAIM 0815 TYPE OF BILL MUST MATCH PATIENT MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL. STATUS 0816 DISALLOW ROOM AND BOARD FOR M50 MISSING/INCOMPLETE/INVALID REVENUE (S). LATE CHARGES 0817 INVALID DISCHARGE DATE N318 MISSING/INCOMPLETE/INVALID DISCHARGE OR END OF CARE DATE SPCL HANDLING 90 DAY WAIVER 226 INFORMATION REQUESTED FROM BILLING/RENDERING PROVIDER WAS NOT PROVIDED OR NOT PROVIDED TIMELY OR WAS INSUFFICIENT/INCOMPLETE SUSPEND CLAIM FOR TPL REVIEW 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER REVIEW NDC GIVEN WITH NO/INVALID UNITS M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. FOR HCPCS 0821 NDC GIVEN WITH NO/INVALID M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. MEASUREMENT FOR HCPCS 0822 NDC GIVEN WITH NO/INVALID UNIT N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR PRICE FOR HCPCS 0823 NO PCC SELECTED 96 NON-COVERED CHARGE(S). N52 PATIENT NOT ENROLLED IN THE BILLING PROVIDER'S MANAGED CARE PLAN ON THE DATE OF SERVICE 0828 CLAIM/ APPEAL IS UNDER REVIEW 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0829 NCCI APPEAL/SPECIAL HANDLE UNDER REVIEW 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0830 GROUPER UNABLE TO ASSIGN DRG A8 UNGROUPABLE DRG. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. TO CLAIM M GRP - DIAGNOSIS CANNOT MA63 MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS. BEUSED AS PRINCIPAL DIAGNOSIS M GRP - RECORD DOES NOT MEET A8 UNGROUPABLE DRG. CRITERIA FOR ANY DRG M GRP - INVALID AGE IN YEARS OR 96 NON-COVERED CHARGE(S). N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. ADMISSION AGE IN DAY M GRP - INVALID SEX MA39 MISSING/INCOMPLETE/INVALID GENDER M GRP - INVALID DISCHARGE N50 MISSING/INCOMPLETE/INVALID DISCHARGE INFORMATION. STATUS M GRP - INVALID BIRTH WEIGHT N207 MISSING/INCOMPLETE/INVALID WEIGHT M GRP - INVALID DISCHARGE AGE IN N50 MISSING/INCOMPLETE/INVALID DISCHARGE INFORMATION. DAYS M GRP - INVALID PRINCIPAL MA63 MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS. DIAGNOSIS M GRP - GESTATIONAL AGE/BIRTH N207 MISSING/INCOMPLETE/INVALID WEIGHT. WEIGHT CONFLICT 0850 BILLING DEADLINE EXCEEDED - DETAIL 0851 REBILL: ORIGINAL CLAIM DEADLINE 29 THE TIME LIMIT FOR FILING HAS EXPIRED. EXCEEDED 0852 BILLING DEADLINE EXCEEDED - 29 THE TIME LIMIT FOR FILING HAS EXPIRED. HEADER 0853 FINAL DEADLINE EXCEEDED - DETAIL 29 THE TIME LIMIT FOR FILING HAS EXPIRED TIMELY FILING - ORIGINAL ICN NOT 29 THE TIME LIMIT FOR FILING HAS EXPIRED. FOUND 0855 FINAL DEADLINE EXCEEDED - 29 THE TIME LIMIT FOR FILING HAS EXPIRED. HEADER 0856 DATE OF SERVICE EXCEEDS THE TIME LIMIT FOR FILING HAS EXPIRED. MONTHS - DETAIL 0857 DATE OF SERVICE EXCEEDS THE TIME LIMIT FOR FILING HAS EXPIRED. MONTHS - HEADER 0861 MEMBER MUST APPLY BEFORE 96 NON-COVERED CHARGE(S). N30 PATIENT INELIGIBLE FOR THIS SERVICE. ADMIN DAYS START 0862 EMERGENCY INDICATOR/POS M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. MISMATCH 0870 INVALID START/STOP TIME N443 MISSING/INCOMPLETE/INVALID TOTAL TIME OR BEGIN/END TIME VOID / ORIGINAL $ AMOUNT M79 MISSING/INCOMPLETE/INVALID CHARGE. CONFLICT 0872 MONTH/YEAR MISMATCH ON MA31 MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE PERIOD ADJUSTMENT BILLED.

10 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 0873 NDC SUBMITTED ON INVALID PROCEDURE 96 NON-COVERED CHARGE(S). N161 THIS DRUG/SERVICE/SUPPLY IS COVERED ONLY WHEN THE ASSOCIATED SERVICE IS COVERED 0874 PRESCRIPTION INVALID FOR 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION. COMPOUND DRUG 0875 PROCEDURE INVALID FOR N56 PROCEDURE BILLED IS NOT CORRECT/VALID FOR THE SERVICES BILLED OR COMPOUND DRUG THE DATE OF SERVICE BILLED 0876 INVALID PRODUCT QUALIFIER 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 0877 INVALID PRESCRIPTION QUALIFIER 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION INVALID PRESCRIPTION N668 INCOMPLETE/INVALID PRESCRIPTION. QUALIFIER/ID COMBINATION 0879 INVALID PRESCRIPTION 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION. QUALIFIER/ID COMBINATION 0880 INVALID PRESCRIPTION ID 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION INVALID PRESCRIPTION DATE 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION PRESCRIPTION DATE GREATER 175 PRESCRIPTION IS INCOMPLETE. N668 INCOMPLETE/INVALID PRESCRIPTION. THAN CLAIM DATE 0886 ATTACHMENT REQUIRED-PODIATRIC, 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/ SUSPEND FOR REVIEW ADJUDICATE THIS CLAIM/SERVICE. CHART 0888 DCN INVALID FOR ATTACHMENT M47 MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL NUMBER CROSS-REFERENCE 0889 CLAIM ATTACHMENT REQUIRED FOR 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/ PODIATRIC SERVICE ADJUDICATE THIS CLAIM/SERVICE. CHART 0890 EDI TRANS TYPE IS NON-COVERED CHARGE(S). N381 CONSULT OUR CONTRACTIAL AGREEMENT FOR RESTRICTIONS/BILLING/PAYMENT INFORMATION RELATED TO THESE CHARGES EDI TRANS TYPE IS RP 96 NON-COVERED CHARGE(S). N381 CONSULT OUR CONTRACTIAL AGREEMENT FOR RESTRICTIONS/BILLING/PAYMENT INFORMATION RELATED TO THESE CHARGES PROVIDER TYPE/SPECIALTY GROUP EMPTY 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF PROVIDER PROCEDURE GROUP EMPTY 0903 OCCURRENCE GROUP EMPTY 0904 VALUE GROUP EMPTY 0905 REVENUE GROUP EMPTY 0906 DIAGNOSIS GROUP EMPTY 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT 0907 ICD-9 PROCEDURE GROUP EMPTY 0908 MODIFIER GROUP EMPTY 4 THE PROCEDURE IS INCONSISTENT WITH THE 0909 PATIENT STATUS GROUP EMPTY 0910 BENEFIT PLAN GROUP EMPTY P7 THE APPLICABLE FEE SCHEDULE/FEE DATABASE DOES NOT CONTAIN THE BILLED. PLEASE RESUBMIT A BILL WITH THE APPROPRIATE FEE SCHEDULE/FEE DATABASE (S) THAT BEST DESCRIBE THE SERVICE(S) PROVIDED AND SUPPORTING DOCUMENTATION IF REQUIRED. N95 M51 M45 M49 M50 M64 M51 N517 MA43 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE MISSING/INCOMPLETE/INVALID PROCEDURE (S) MISSING/INCOMPLETE/INVALID OCCURRENCE (S). MISSING/INCOMPLETE/INVALID VALUE (S) OR AMOUNT(S). MISSING/INCOMPLETE/INVALID REVENUE (S). MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. MISSING/INCOMPLETE/INVALID PROCEDURE (S) MISSING/INCOMPLETE/INVALID PATIENT STATUS CLAIM IN PROCESS 0912 PROVIDER LOC GROUP EMPTY P7 THE APPLICABLE FEE SCHEDULE/FEE DATABASE DOES NOT CONTAIN THE BILLED. PLEASE RESUBMIT A BILL WITH THE APPROPRIATE FEE SCHEDULE/FEE DATABASE (S) THAT BEST DESCRIBE THE SERVICE(S) PROVIDED AND SUPPORTING DOCUMENTATION IF REQUIRED SPECIAL HANDLING GROUP EMPTY 0914 TYPE OF BILL GROUP EMPTY MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL COUNTY GROUP EMPTY P7 THE APPLICABLE FEE SCHEDULE/FEE DATABASE DOES NOT CONTAIN THE BILLED. PLEASE RESUBMIT A BILL WITH THE APPROPRIATE FEE SCHEDULE/FEE DATABASE (S) THAT BEST DESCRIBE THE SERVICE(S) PROVIDED AND SUPPORTING DOCUMENTATION IF REQUIRED.

11 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 0916 ZIP GROUP EMPTY P7 THE APPLICABLE FEE SCHEDULE/FEE DATABASE DOES NOT CONTAIN THE BILLED. PLEASE RESUBMIT A BILL WITH THE APPROPRIATE FEE SCHEDULE/FEE DATABASE (S) THAT BEST DESCRIBE THE SERVICE(S) PROVIDED AND SUPPORTING DOCUMENTATION IF REQUIRED. DESCRIPTION 0917 PLACE OF SERVICE GROUP EMPTY M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE MEMBER LOC GROUP EMPTY MA37 MISSING/INCOMPLETE/INVALID PATIENT'S ADDRESS ESC GROUP EMPTY 0920 MEMBER AID CATEGORY GROUP 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. EMPTY 0921 PROVIDER ID GROUP EMPTY 16 CLAIM/SERVICE LACKS INFORMATION OR HAS N253 MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER. SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 0922 REGION GROUP EMPTY ND OCCURRENCE POSITION NOT = M45 MISSING/INCOMPLETE/INVALID OCCURRENCE (S) ND OCCURRENCE OCDE = 22 BUT M45 MISSING/INCOMPLETE/INVALID OCCURRENCE (S). AMOUNT = ND OCCURRENCE AMOUNT > 0 BUT M45 MISSING/INCOMPLETE/INVALID OCCURRENCE (S). OSC NOT INP CLM BUT RATE ID NOT 71 OR 147 PROVIDER CONTRACTED/NEGOTIATED RATE EXPIRED OR ADM TYPE NE ELCTV[3] NOT ON FILE UB92 CLAIM BUT NO PATIENT ACCT N382 MISSING/INCOMPLETE/INVALID PATIENT IDENTIFIER. NUMBER (MRN) 0936 MEMBER ENROL/PCCP CNFLCT 96 NON-COVERED CHARGE(S). N52 PATIENT NOT ENROLLED IN THE BILLING PROVIDER'S MANAGED CARE PLAN ON THE DATE OF SERVICE 0937 DETAIL CANNOT SPAN DATES N62 DATES OF SERVICE SPAN MULTIPLE RATE PERIODS. RESUBMIT SEPARATE CLAIMS CLAIM SELECTED FOR MASSPRO 96 NON-COVERED CHARGE(S). N35 PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION. EXTRACT 1000 BILLING PROVIDER I.D. NUMBER NOT 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY ON FILE. IDENTIFIER COB-BENEFIT PLAN MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE DTL PERFORMING PROVIDER NOT N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. ELIGIBLE 1003 BILLING PROV NOT ELIGIBLE AT SERVICE LOCATION FOR PROGRAM 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY IDENTIFIER. BILLED 1007 DETAIL RENDERING PROVIDER I.D. N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. NOT ON FILE 1010 RENDERING PROVIDER NOT A 96 NON-COVERED CHARGE(S). N198 RENDERING PROVIDER MUST BE AFFILIATED WITH THE PAY-TO-PROVIDER. MEMBER OF BILLING GROUP 1012 RENDERING PROV SPECLTY NOT 185 THE RENDERING PROVIDER IS NOT ELIGIBLE TO PERFORM ELIGIBLE TO RENDER PROCEDURE THE SERVICE BILLED PROV ASSIGNMENT NOT ACCEPTED 111 NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT INVALID ASSIGNMENT INDICATOR 111 NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT PROVIDER RATE NOT ON FILE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 1019 NO PROVIDER LEVEL OF CARE RATE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR ON FILE 1020 ATTENDING PHYSICIAN ID NOT ON N253 MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER. FILE 1021 FIRST OTHER PHYSICIAN ID NOT ON 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. FILE 1023 LEVEL OF CARE BILLED NOT ON FILE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR FOR THIS PROVIDER 1024 BILLING PROVIDER NOT LISTED AS MEMBER LTC PROVIDER 1026 PRESCRIBING PHYSICIAN LICENSE NUMBER NOT ON FILE 1027 HEADER REFERRING PHYSICIAN ID NOT ON FILE N147 N THE REFERRING PROVIDER IS NOT ELIGIBLE TO REFER THE N630 SERVICE BILLED. LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST. MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER. REFERRAL NOT AUTHORIZED BY ATTENDING PHYSICIAN.

12 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 1032 BILLING PROVIDER NOT ELIGIBLE TO N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. BILL THIS CLAIM TYPE 1036 RENDERING PROVIDER NOT N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. ELIGIBLE TO BILL THIS CLAIM TYPE 1037 FACILITY PROVIDER NUMBER NOT N293 MISSING/INCOMPLETE/INVALID SERVICE FACILITY PRIMARY IDENTIFIER. ON FILE 1040 BILLING PROVIDER ON REVIEW 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 1041 BILLING PROVIDER ON REVIEW 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 1050 SERVICE CANNOT BE REFERRED BY THE SAME BILLING PROVIDER 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED HEADER RENDERING PROVIDER ID N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. NOT VALID 1053 DETAIL FIRST OTHER PHYSICIAN ID 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. NUMBER NOT ON FILE 1054 DETAIL ATTENDING PHYSICIAN ID N253 MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY IDENTIFIER. NUMBER NOT ON FILE 1055 DETAIL REFERRING PROV NOT ON 183 THE REFERRING PROVIDER IS NOT ELIGIBLE TO REFER THE N630 REFERRAL NOT AUTHORIZED BY ATTENDING PHYSICIAN. FILE SERVICE BILLED UNABLE TO CROSSWALK MA04 SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE IDENTITY OF OR ATTENDING/OTHER1/OTHER2 MEDICARE PROVIDER ID PAYMENT INFORMATION FROM THE PRIMARY PAYER. THE INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE UNABLE TO CROSSWALK RENDERING MEDICARE PROVIDER ID 1062 UNABLE TO CROSSWALK DETAIL RENDERING MEDICARE PROV 1063 UNABLE TO CROSSWALK BILLING MEDICARE PROVIDER ID N277 N277 MA04 MISSING/INCOMPLETE/INVALID OTHER PAYER RENDERING PROVIDER IDENTIFIER. MISSING/INCOMPLETE/INVALID OTHER PAYER RENDERING PROVIDER IDENTIFIER. 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 HEADER REFERRING PROVIDER CANNOT BE SAME AS BILLING 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED DETAIL REFERRING PROVIDER CANNOT BE SAME AS BILLING 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED BILLING PROVIDER NOT A VALID N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY BILLER IDENTIFIER RENDERING EQUALS BILLING AND NOT A VALID BILLER 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED REFERRING PROVIDER REQUIRED N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER. FOR INDEPENDENT CERTIFICATION 1069 REFERRING PROVIDERCANNOT BE SAME AS RENDERING-HEADER 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED REFERRING PROVIDER CANNOT BE SAME AS RENDERING-DETAIL 96 NON-COVERED CHARGE(S). N55 PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING PROVIDERS WERE NOT FOLLOWED PATIENT STILL IN THE HOSPITAL 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT BILLING PROVIDER OUT OF STATE N258 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER ADDRESS. CONTIGUOUS 1074 BILLING PROVIDER OUT OF STATE N258 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER ADDRESS. NON-CONTIGUOUS 1100 ADJUST: FORMER TCN INCORRECT M47 MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL NUMBER INVALID ADJUSTMENT FORMER TCN M47 MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL NUMBER REBILL : ORIGINAL CLAIM PAID B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT THIS ADJUSTMENT CLAIM IS B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY ALREADY ON HOLD HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT ITEM/SERVICE(S) PROVIDED NOT MOST COST EFFECTIVE 1116 SHOE PRESCRIPTION FORM MISSING 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART PROC REQ REPORT/ RPT MISSING 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART BILLING RID CONFLICT 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED CLAIM REQUIRES DOCUMENTATION N31 MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER. (CAF EDIT)

13 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 1121 STERILIZATION FORM INCOMPLETE 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM STERILIZATION REGS NOT MET B5 COVERAGE/PROGRAM GUIDELINES WERE NOT MET OR WERE EXCEEDED CLAIM NOT LEGIBLE N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE INCIDENTAL PROC NOT COVERED 234 THIS PROCEDURE IS NOT PAID SEPARATELY. M15 SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE PAYMENT IS NOT ALLOWED CHARGES NOT ITEMIZED M54 MISSING/INCOMPLETE/INVALID TOTAL CHARGES HYSTERECTOMY REGS NOT MET 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM INVALID STERILIZATION FORM 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM CLAIMS REQ SPECIAL HANDLING 1134 UR LETTER NOT ACCEPTABLE 50 THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A 'MEDICAL NECESSITY' BY THE PAYER. N225 INCOMPLETE/INVALID DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/ CHART CLAIM CONTAINS MEDICARE PART B 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COVERED CHARGES 1136 NOT AN ACCEPTABLE ATTACHMENT 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART. ADJUDICATE THIS CLAIM/SERVICE INVALID ABORTION FORM 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM ABORTION FORM INCOMPLETE 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM DUPE PREPAY REVIEW CLAIM OR RESUBMISSION ERROR 1149 PA# NOT ON FILE 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N IDENTIFY/DESCRIBE PROCEDURE N350 MISSING/INCOMPLETE/INVALID DESCRIPTION OF SERVICE FOR A NOT OTHERWISE WHEN BILLING AN UNLISTED CLASSIFIED (NOC) OR AN UNLISTED PROCEDURE COPAY EXEMPT - AGE 96 NON-COVERED CHARGE(S). N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE ASST SURG NOT COV FOR PROC 54 MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN THIS CASE. N646 REIMBURSEMENT HAS BEEN ADJUSTED BASED ON THE GUIDELINES FOR AN ASSISTANT UR DENIED ADMISSION 96 NON-COVERED CHARGE(S). N35 PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION INCORRECT PROC FOR N56 PROCEDURE BILLED IS NOT CORRECT/VALID FOR THE SERVICES BILLED OR SERVICE THE DATE OF SERVICE BILLED PROCEDURE / INVOICE N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. CONFLICT (PHARM) 1516 INCORRECT REVENUE FOR M50 MISSING/INCOMPLETE/INVALID REVENUE (S). SERVICE 1517 CLAIM MEDICAL NECESSITY FORM ERROR 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT M60 MISSING CERTIFICATE OF MEDICAL NECESSITY SERVICE PROVIDED REQUIRES A MORE DETAILED REPORT 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N225 INCOMPLETE/INVALID DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/ CHART INAPPROPRIATE PROCEDURE FOR SERVICE BILLED 96 NON-COVERED CHARGE(S). N56 PROCEDURE BILLED IS NOT CORRECT/VALID FOR THE SERVICES BILLED OR THE DATE OF SERVICE BILLED PAYMENT INCLUDED IN PRIMARY PROCEDURE 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M15 SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE PAYMENT IS NOT ALLOWED PAYMENT MADE TO ANOTHER PHYSICIAN B20 PROCEDURE/SERVICE WAS PARTIALLY OR FULLY FURNISHED BY ANOTHER PROVIDER REPORT NOT LEGIBLE 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT 1523 HYSTERECTOMY FORM INCOMPLETE 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT 1524 INVALID HYSTERECTOMY FORM 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N205 INFORMATION PROVIDED WAS ILLEGIBLE N228 INCOMPLETE/INVALID CONSENT FORM. N228 INCOMPLETE/INVALID CONSENT FORM.

14 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 1525 ABORTION REGS NOT MET 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT 1526 MEDICAL RECORD NOT SUBMITTED TO PREPAYMENT REVIEW 1527 MEDICAL RECORD INCOMPLETE AS DETERMINED BY PREPAY REVIEW 1528 MLOA DAYS NOT INDICATED ON CLAIM FORM 1530 INVALID PRESCRIBING PROVIDER TRANS 1662 BILLING PROVIDER I.D. NUMBER NOT 0N FILE 1801 NEED REFERRING PROVIDER FOR RADIOLOGY SERVICE 1802 MEDICARE ANCILLARY SERVICES PRICED AT ZERO N228 INCOMPLETE/INVALID CONSENT FORM. DESCRIPTION 96 NON-COVERED CHARGE(S). N102 THIS CLAIM HAS BEEN DENIED WITHOUT REVIEWING THE MEDICAL RECORD BECAUSE THE REQUESTED RECORDS WERE NOT RECEIVED OR WERE NOT RECEIVED-TIMELY. 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N237 INCOMPLETE/INVALID PATIENT MEDICAL RECORD FOR THIS SERVICE. M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. N31 MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER. 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY IDENTIFIER. N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER. 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M80 NOT COVERED WHEN PERFORMED DURING THE SAME SESSION/DATE AS A PREVIOUSLY PROCESSED SERVICE FOR THE PATIENT RECYCLE MEDICARE PART A CLAIMS WITH TOB 111 OR DENY MEDICARE PART A INTERIM STAY CLAIMS 1805 BILLING PROVIDER ID WAS TRANSLATED 1806 CROSSOVER PRICING PERFORMED - HEADER (PAY) 1807 CROSSOVER PRICING PERFORMED - DETAIL (PAY) 1808 UNABLE TO PERFORM CROSSOVER PRICING - HEADER (DENY) 129 PRIOR PROCESSING INFORMATION APPEARS INCORRECT. N48 CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED FROM OTHER INSURANCE CARRIER. MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL. 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N31 MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER. N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT UNABLE TO PERFORM CROSSOVER PRICING - DETAIL (DENY) N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT INVALID TAXONOMY - BILLING PROVIDER 1901 INVALID TAXONOMY -HEADER PERFORMING PROVIDER 1906 INVALID TAXONOMY FOR PROVIDER TYPE/SPECIALTY - BILLING N255 N288 N255 MISSING/INCOMPLETE/INVALID BILLING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID BILLING PROVIDER TAXONOMY INVALID TAXONOMY FOR PROVIDER TYPE/SPECIALTY - HEADER PERFORMING PROVIDER 1912 TAXONOMY MISSING - BILLING PROVIDER 1913 TAXONOMY MISSING - HEADER PERFORMING PROVIDER 1919 INVALID TAXONOMY - DETAIL PERFORMING PROVIDER 1921 INVALID TAXONOMY FOR PROVIDER TYPE/SPECIALTY - DETAIL PERFORMING PROVIDER 1925 TAXONOMY MISSING - DETAIL PERFORMING PROVIDER 1927 NPI REQUIRED HEALTHCARE=Y BILLING PROV 1928 NPI REQUIRED HEALTHCARE=Y PERFORMING PROV N288 N255 N288 N288 N288 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID BILLING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. N288 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY. N433 RESUBMIT THIS CLAIM USING ONLY YOUR NATIONAL PROVIDER IDENTIFIER (NPI) N433 RESUBMIT THIS CLAIM USING ONLY YOUR NATIONAL PROVIDER IDENTIFIER (NPI) 1929 NPI DEACTIVATION DUE TO FRAUD 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER NPI DEACTIVATION DUE TO DEATH, 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER. DISBANDMENT, OR OTHER 1934 DTL NPI REQUIRED HEALTHCARE=Y N433 RESUBMIT THIS CLAIM USING ONLY YOUR NATIONAL PROVIDER IDENTIFIER (NPI) PERFORMING PROVIDER 1936 INVALID BILLING PROVIDER MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. SPECIFIED 1937 INVALID PERFORMING PROVIDER N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. SPECIFIED 1943 INVALID DTL PERFORMING N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. PROVIDER SPECIFIED

15 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 1945 MULT SAK PROV LOCS FOR BILLING 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. PROV SPEC 1946 MULT SAK PROV LOCS FOR 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. PERFORMING PROV SPEC 1949 MULT SAK PROV LOCS FOR 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. RENDERING PROV SPEC 1950 NPI SUBMISSION ERROR 207 NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT. N286 MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY IDENTIFIER MULTIPLE SAK PROVIDER 208 NATIONAL PROVIDER IDENTIFIER - NOT MATCHED. LOCATIONS FOR DETAIL PERFORMING PROVIDER SPEC 1954 BILLING PROV ID NOT NPI BUT N433 RESUBMIT THIS CLAIM USING ONLY YOUR NATIONAL PROVIDER IDENTIFIER (NPI) THERE IS NPI ON FILE 1960 BILLING PROVIDER ON REVIEW 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE RENDERING PROVIDER ON REVIEW - 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. HEADER 1962 RENDERING PROVIDER ON REVIEW - 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. DETAIL 1995 RENDER/DISPENS/PERFORM PROV N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. ID IN OLD FORMAT - HDR 1997 UNABLE TO POPULATE DTL N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. PERFORMING PROV ID WITH HDR 1999 HEADER BILLING PROVIDER ID IN N257 MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY OLD FORMAT IDENTIFIER INVALID SEX 16 CLAIM/SERVICE LACKS INFORMATION OR HAS MA39 MISSING/INCOMPLETE/INVALID GENDER. SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 2001 MEMBER ID NUMBER NOT ON FILE 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED MEMBER NOT ELIGIBLE FOR HEADER 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. DATE OF SERVICE 2003 MEMBER INELIGIBLE ON DETAIL 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. DATE OF SERVICE 2004 MULTIPLE AID CATEGORY S COVER HEADER SERVICE 2005 MULTIPLE AID CATEGORY S COVER DETAIL SERVICE 2006 CLAIMS SUBMITTED WITH LEGACY 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. MEMBER ID 2007 QMB MEMBER- BILL MEDICARE FIRST 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 2008 MEMBER LEVEL OF CARE NOT ON N147 LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED FILE BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST ERROR WITH HSN ELIGIBILITY WEB SERVICE 2011 PHARMCY MEDICAL/NON-MEDICAL SUPPL. AND ROUTINE DME 2014 MENTAL HLTH/SUBSTANCE ABUSE ONLY, BILL PARTNERSHIP 109 CLAIM/SERVICE NOT COVERED BY THIS PAYER/CONTRACTOR. YOU MUST SEND THE CLAIM/SERVICE TO THE CORRECT PAYER/CONTRACTOR. 24 CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED CARE PLAN. N130 CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT 2017 MEMBER SERVICES COVERED BY MCO PLAN 2018 MEMBER IS ENROLLED IN HOSPICE B9 PATIENT IS ENROLLED IN A HOSPICE MEMBER ID IS INACTIVE 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED MEMBER# ON CLAIM AND PA MA36 MISSING/INCOMPLETE/INVALID PATIENT NAME. MISMATCH 2043 MEMBER IS ON REVIEW 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED CLAIM INDICATES MEMBER EXPIRED N330 MISSING/INCOMPLETE/INVALID PATIENT DEATH DATE LTC/HOSPICE CONFLICT B9 PATIENT IS ENROLLED IN A HOSPICE MEMBER NOT D FOR LTC N147 LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON TH-E ASSIGNMENT REQUEST LEVEL OF CARE/AID CAT CONFLICT 96 NON-COVERED CHARGE(S). N30 PATIENT INELIGIBLE FOR THIS SERVICE LTC/CASE MIX CONFLICT N147 LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST SUPPLEMENTAL ADULT SERVICE/LTC RECIPIENT CONFLICT 2056 MEMBER NOT D FOR CASEMIX N147 LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST.

16 EOB EOB DESCRIPTION 2057 DOS SPAN MONTHS-FILE SEPARATE CLAIMS FOR EACH MNTH ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 96 NON-COVERED CHARGE(S). N61 REBILL SERVICES ON SEPARATE CLAIMS MEMBER IS COVERED BY OTHER INSURANCE-PAY 2501 MEMBER IS COVERED BY OTHER INSURANCE - PAY AND CHASE 2502 MEMBER IS COVERED BY OTHER INSURANCE - DENY 2503 MEMBER IS COVERED BY OTHER INSURANCE - PAY & CHASE 2504 MEMBER IS COVERED BY OTHER INSURANCE - SUSPEND 2505 MEMBER COVERED BY MEDICARE- DENY 2509 MEMBER COVERED BY MEDICARE B (PHARMACY) - PROVIDER SHOULD BILL THROUGH POPS 2510 MEMBER MEDICAL SUPPORT BYPASS DTL 2511 CANNOT DETERMINE TPL PRICING METHOD 2512 DUPLICATE CAS AT HEADER AND DETAIL 2513 TPL ADJUDICATION DATE NOT PRESENT- DETAIL 2514 TPL ADJUDICATION DATE NOT PRESENT-HEADER 2515 OTHER INSURER REQUIRES ADDITIONAL DATA 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 109 CLAIM/SERVICE NOT COVERED BY THIS PAYER/CONTRACTOR. YOU MUST SEND THE CLAIM/SERVICE TO THE CORRECT PAYER/CONTRACTOR. 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. MA92 MA04 N418 MISSING PLAN INFORMATION FOR OTHER INSURANCE. 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. MISROUTED CLAIM. 129 PRIOR PROCESSING INFORMATION APPEARS INCORRECT. N48 CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED FROM OTHER INSURANCE CARRIER. N307 MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE. N307 MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE. 109 CLAIM/SERVICE NOT COVERED BY THIS N36 CLAIM MUST MEET PRIMARY PAYER'S PROCESSING REQUIREMENTS BEFORE WE PAYER/CONTRACTOR. YOU MUST SEND THE CLAIM/SERVICE CAN CONSIDER PAYMENT TO THE CORRECT PAYER/CONTRACTOR MEDICAID IS ALWAYS FINAL PAYOR 2517 TPL REVIEW - CLM/EOB DIFFER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 2518 OTHER PAYER HAS BUNDLED DETAILS 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE MA64 MA04 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. 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 2519 CLAIM POTENTIALLY COVERED BY MEDICARE 2520 MEMBER IS COVERED BY OTHER INSURANCE-PAY,HEADER 2521 MEMBER IS COVERED BY OTHER INSURANCE - PAY AND REPORT 2522 MEMBER IS COVERED BY OTHER INSURANCE - DENY (HDR) 2523 MEMBER IS COVERED BY OTHER INSURANCE - PAY, CHASE, HDR 2524 MEMBER IS COVERED BY OTHER INSURANCE - SUSPEND, HDR 2525 MEMBER COVERED BY MEDICARE - DENY (HDR) 2526 ZERO TPL AMOUNT AND NO ADJ RSN - HEADER 2527 ZERO TPL AMOUNT AND NO ADJ RSN -DETAIL 2528 LTC - POTENTIAL MEDICARE IN FIRST 100 DAYS 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 2529 TPL AT HEADER AND NOT AT DETAIL 2530 INVALID TPL CARRIER MA04 MA92 MA92 MA04 N8 N8 MA04 N4 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 MISSING PLAN INFORMATION FOR OTHER INSURANCE. MISSING PLAN INFORMATION FOR OTHER INSURANCE. 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 CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM DATA NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO PROVIDE ADEQUATE DATA FOR CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM DATA NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO PROVIDE ADEQUATE DATA FOR 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 MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER EOB. 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.

17 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 2531 MEDICARE COVERAGE INDICATED 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER N197 ON CLAIM, NOT ON FILE 2532 HEBREW REHAB LTC TPL MA CARRIER IS 000 AND TPL AMOUNT > 0 MA04 - HEADER 2534 CARRIER IS 000 AND TPL AMOUNT > 0 MA04 -DETAIL DESCRIPTION THE SUBSCRIBER MUST UPDATE INSURANCE INFORMATION DIRECTLY WITH THE PAYER. MISSING PLAN INFORMATION FOR OTHER INSURANCE. 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. 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. INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE 2535 INCORRECT TPL BILLING N MEDICARE# ON CLAIM/FILE N382 MISSING/INCOMPLETE/INVALID PATIENT IDENTIFIER. CONFLICT 2537 INVALID BUNDLED LINE NO N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE ASSIGNED BY OTHER PAYER 2538 EOB DATE SHOULD EQUAL LAST DOS N4 MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER(S) EOB. FOR O/R COB CLAIMS 2539 EOB DATE SHOULD EQUAL LAST DOS N4 MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER(S) EOB. FOR O/R COB CLAIMS - DETAIL 2540 MEDICARE PAID > MEDICAID 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR ALLOWED - HEADER CONTRACTED/LEGISLATED FEE ARRANGMENT 2541 MEDICARE PAID > MEDICAID 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR ALLOWED - DETAIL CONTRACTED/LEGISLATED FEE ARRANGMENT 2542 MEDICARE PAYMENT OR PATIENT N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE RESPONSIBILITY IS > MEDICARE PAYMENT OR PATIENT 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING RESPONSIBILITY IS > 0 FURTHER REVIEW BENEFITS EXHAUSTED REPRICING 169 ALTERNATE BENEFIT HAS BEEN PROVIDED HEADER AND DETAIL COB N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE PAYMENTS DO NOT BALANCE 2546 DETAIL COB PAYMENTS DO NOT N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE BALANCE 2547 HEADER COB PAYMENTS DO NOT N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE BALANCE 2548 NON COVERED AMOUNT IS NOT M79 MISSING/INCOMPLETE/INVALID CHARGE. EQUAL TO BILLED 2549 REMAINING PATIENT LIABILITY PRESENT AT HEADER 2550 REMAINING PATIENT LIABILITY PRESENT AT DETAIL 2551 CLAIM HAS NON-COVERED AMOUNT, HDR IS NOT ELIGIBLE 2552 CROSSOVER CLAIM MISSING MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. MEDICARE CARRIER 2554 CLAIM HAS A PIP CARRIER P22 PAYMENT ADJUSTED BASED ON MEDICAL PAYMENTS COVERAGE (MPC) OR PERSONAL INJURY PROTECTION (PIP) BENEFITS JURISDICTIONAL REGULATIONS OR PAYMENT POLICIES, USE ONLY IF NO OTHER IS APPLICABLE INVALID FILING INDICATOR/CARRIER COMBINATION 2556 LTC - POTENTIAL MEDICARE C IN FIRST 100 DAYS 2557 LTC - POTENTIAL PRIVATE INSURANCE IN FIRST 100 DAYS 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER N4 MA04 MA04 MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER EOB. 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 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 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE 2558 OTHER PAYER DENIAL ARC IS NOT ON TABLE - HEADER N OTHER PAYER DENIAL ARC IS NOT N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE ON TABLE - DETAIL 2561 TPL DATA CONFLICT MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE BENEFITS EXHAUSTED TPL 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. REPRICING - DETAIL 2563 DETAIL ADJUSTMENT REASON N245 INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE IS NOT ON ARC XREF 2564 MEMBER HAS MEDICARE SUPP INS MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. DTL

18 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 2565 CLAIM REQUIRES TPL REVIEW 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 2566 MEMBER HAS MEDICARE SUPPLEMENTAL INSURANCE-DETAIL DESCRIPTION MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE INVALID SUBMITTER FOR COB CLAIM MA92 MISMATCH BETWEEN THE SUBMITTED PROVIDER INFORMATION AND THE PROVIDER INFORMATION STORED IN OUR SYSTEM CLAIM HAS NON-COVERED AMOUNT, N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. DETAIL IS NOT ELIGIBLE 2569 MEMBER HAS SELF-REPORTED MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. OTHER INSURANCE 2570 HEADER FOR EDIT FROM COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE TABLE 2571 HEADER FOR EDIT FROM COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE TABLE 2572 HEADER FOR EDIT FROM COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE TABLE 2573 HEADER FOR EDIT FROM COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE TABLE 2574 HEADER FOR EDIT FROM COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE TABLE 2575 DETAIL EDIT FROM COB OVERRIDE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. TABLE 2576 DETAIL EDIT FROM COB OVERRIDE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. TABLE 2577 DETAIL EDIT FROM COB OVERRIDE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. TABLE 2578 DETAIL EDIT FROM COB OVERRIDE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. TABLE 2579 DETAIL EDIT FROM COB OVERRIDE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. TABLE 2580 DETAIL, PROFESSIONAL OVERRIDE EDIT 2581 HEADER, INSTITUTIONAL OVERRIDE EDIT 2582 DETAIL, INSTITUTIONAL OVERRIDE EDIT 2583 NON COVERED AMT AND CAS N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. PRESENT FOR PAYER 2584 MEMBER MEDICAL SUPPORT BYPASS - HEADER 2585 EOB DATE AT HEADER AND DETAIL N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE MEDICARE EMERGENCY SERVICE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. COB OVERRIDE 2587 NON-CERTIFIED PROVIDER COB 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. OVERRIDE 2588 HEADER/COMMERCIAL/SUSPEND 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING EDIT FROM THE TPL DENY TABLE FURTHER REVIEW HEADER/MEDICARE/SUSPEND EDIT 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FROM THE TPL DENY TABLE FURTHER REVIEW DETAIL/COMMERCIAL/PAY EDIT 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. FROM THE TPL DENY TABLE 2591 DETAIL/MEDICARE/PAY EDIT FROM 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. THE TPL DENY TABLE 2592 DETAIL/COMMERCIAL/DENY EDIT FROM THE TPL DENY TABLE 96 NON-COVERED CHARGE(S). M41 WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL OBLIGATION TO PAY FOR THIS DETAIL/MEDICARE/DENY EDIT FROM THE TPL DENY TABLE 96 NON-COVERED CHARGE(S). M41 WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL OBLIGATION TO PAY FOR THIS DETAIL/COMMERCIAL/SUSPEND EDIT 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FROM THE TPL DENY TABLE FURTHER REVIEW DETAIL/MEDICARE/SUSPEND EDIT 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FROM THE TPL DENY TABLE FURTHER REVIEW HEADER/COMMERCIAL/PAY EDIT 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. FROM THE TPL DENY TABLE 2597 HEADER/MEDICARE/PAY EDIT FROM 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. THE TPL DENY TABLE 2598 HEADER/COMMERCIAL/DENY EDIT FROM THE TPL DENY TABL 96 NON-COVERED CHARGE(S). M41 WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL OBLIGATION TO PAY FOR THIS HEADER/MEDICARE/DENY EDIT FROM THE TPL DENY TABLE 96 NON-COVERED CHARGE(S). M41 WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL OBLIGATION TO PAY FOR THIS.

19 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 2608 MEMBER LOCKED-IN TO SPECIFIC NDC 2610 NON-COVERED DAYS > 0 MA33 MISSING/INCOMPLETE/INVALID NONCOVERED DAYS DURING THE BILLING PERIOD DMH OR DPH SUBCONTRACTOR NOT AUTHORIZED 2613 MANAGED CARE SERVICE 24 CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED CARE PLAN MANAGED CARE SERVICE SHOULD 24 CHARGES ARE COVERED UNDER A CAPITATION BE PAID BY RMC AGREEMENT/MANAGED CARE PLAN SENIOR PHARMACY MUST BE BILLED 24 CHARGES ARE COVERED UNDER A CAPITATION THROUGH POPS AGREEMENT/MANAGED CARE PLAN SERV NOT REIMBURSABLE BY MED ASSISTANCE PROGRAM 96 NON-COVERED CHARGE(S). N216 WE DO NOT OFFER COVERAGE FOR THIS TYPE OF SERVICE OR THE PATIENT IS NOT ENROLLED IN THIS PORTION OF OUR BENEFIT PACKAGE PROC REQUIRES REVIEW OF REPORT 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N225 INCOMPLETE/INVALID DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART REVENUE REQ REVIEW 2621 BILL EXTENDED BENEFITS 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER 2622 SERVICE NOT AUTHORIZED BY HMO 197 PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT PREPAYMENT TECHNICAL DENIAL 50 THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A 'MEDICAL NECESSITY' BY THE PAYER. N MODIFIER 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INAPPROPRIATE/INCORRECT FOR SERV BILLED 2626 REQUEST FOR 90 DAY WAIVER DENIED 2627 SERVICE COVERED BY CASE 24 CHARGES ARE COVERED UNDER A CAPITATION MANAGER AGREEMENT/MANAGED CARE PLAN. THIS CLAIM/SERVICE WAS CHOSEN FOR COMPLEX REVIEW AND WAS DENIED AFTER REVIEWING THE MEDICAL RECORDS. INVALID COMBINATION OF HCPCS MODIFIERS PREPAYMENT FULL DENIAL 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PREPAYMENT PARTIAL DENIAL 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES NO PAS APPROVAL FOUND IN PREPAYMENT 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES MCARE/BILL ALLOW PAID CONFLICT 129 PRIOR PROCESSING INFORMATION APPEARS INCORRECT. N48 CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED FROM OTHER INSURANCE CARRIER BENEFIT CONFLICT 2633 PREPAY PREVIOUSLY APPROVED 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PREPAY PREVIOUSLY DENIED 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PREPAY DECISION OVERTURNED 216 BASED ON THE FINDINGS OF A REVIEW ORGANIZATION 2640 NO RESPONSE TO OUR CAF 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N225 INCOMPLETE/INVALID DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART MEMBER NOT TIED TO HOSPICE ON DOS 96 NON-COVERED CHARGE(S). N143 THE PATIENT WAS NOT IN A HOSPICE PROGRAM DURING ALL OR PART OF THE SERVICE DATES BILLED NO BENEFIT PROGRAM FOR MEMBER 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED. FOUND 2803 PROCEDURE IS AGE RESTRICTED 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. THE PATIENT'S AGE PROCEDURE IS INVALID FOR PATIENT SEX 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH THE PATIENT'S GENDER MULTIPLE PPA SEGMENTS ON MEMBER FILE N147 LONG-TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING, INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST SPAD CLAIM HAS CONTIGUOUS AID CATEGORY COVERAGE 3000 PER UNIT PRICE ON CLAIM DOES NOT MATCH PRIOR AUTHORIZATION 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PA NOT FOUND ON DATABASE 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N NDC REQUIRES PA 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517

20 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 3003 PROCEDURE REQUIRES PA 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N INVALID PA/PASNUMBER 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES 3005 INVALID PA/PAS NUMBER 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 N517 DESCRIPTION 3006 PA DOLLARS EXCEEDED 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PA/PAS NUMBER NOT ON THE 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 DATABASE 3010 OUT OF STATE PROVIDER REQUIRES M62 MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION. REVIEW 3013 PA NUMBER NOT ON THE DATABASE 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES MODIFIER ON CLAIM AND PA MISMATCH 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES SELECT FOR MASSPRO PRE- 96 NON-COVERED CHARGE(S). N35 PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION. PAYMENT REVIEW 3023 INVALID RATE ID/PYMNT TYPE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR COMBINATION 3024 LINE ITEM NOT FOUND FOR PAS NUMBER 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES MULTIPLE ACTIVE LINE ITEMS FOR 96 NON-COVERED CHARGE(S). N35 PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION. PAS 3026 PAS NOT FOUND ON DATABASE 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N INVALID PAS NUMBER 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N NOT ENOUGH UNITS ON PAS 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES MEMBER ID FOR CLAIM AND PAS DONT MATCH 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES ADMISSION DATE FOR CLAIM AND PAS DONT MATCH 96 NON-COVERED CHARGE(S). N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PROVIDER ID FOR CLAIM AND PA/PAS 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 DO NOT MATCH 3032 PAS IS REQUIRED 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES 3033 PA/PAS IS NOT READY 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 N DUPLICATE CLAIM IN PRE-PAYMENT REVIEW 18 EXACT DUPLICATE CLAIM/SERVICE. N522 DUPLICATE OF A CLAIM PROCESSED, OR TO BE PROCESSED, AS A CROSSOVER CLAIM CLAIM SELECTED FOR PRE-PAYMENT 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING REVIEW FURTHER REVIEW RANDOM PRE-PAYMENT REVIEW 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING PROCESS FURTHER REVIEW PARTIAL DENIAL-PAY TPD 216 BASED ON THE FINDINGS OF A REVIEW ORGANIZATION 3038 PAS NOT REVIEWED BY PRO 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N PAS NOT APPROVED 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 3040 SURGERY/ASSIST USING SAME SERV N290 MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY IDENTIFIER. PROVIDER NUMBER 3041 MEMBER# OR PROV# ON CLAIM AND 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 PA MISMATCH 3101 PA STATUS IS VOID M62 MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION PA STATUS IS DENIED 96 NON-COVERED CHARGE(S). N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 3103 PROCEDURE NOT ON PA 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517