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IS INVALID N304 MISSING/INCOMPLETE/INVALID DISPENSED DATE NDC MISSING M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) NDC INVALID FORMAT M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) QUANTITY DISPENSED IS MISSING N378 MISSING/INCOMPLETE/INVALID PRESCRIPTION QUANTITY QUANTITY DISPENSED IS INVALID N378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

21 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 3104 REVENUE / PA CONFLICT 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 DESCRIPTION 3105 MEMBER# ON CLAIM AND PA N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED MISMATCH SERVICES SERV DATE BEFORE PA EFFECTIVE N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES SERV DATE AFTER PA EXPIRED 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N351 SERVICE DATE OUTSIDE OF THE APPROVED TREATMENT PLAN SERVICE DATES PA INSUFFICIENT AVAIL UNITS 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PA UNITS PRESENTLY EXHAUSTED 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES PA EXHUSTED - CANNOT BE USED IN 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED PRICING SERVICES PRIOR AUTH PROCEDURE/MODIFIER MISMATCH 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N REFERRAL REQUIRED ON CLAIM 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES 3121 REFERRAL NUMBER INVALID 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 N NO MORE UNITS AVAILABLE ON REFERRAL 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED SERVICES RENDERING PROVIDER DOES NOT 185 THE RENDERING PROVIDER IS NOT ELIGIBLE TO PERFORM MATCH REFERRAL AUTHORIZATION THE SERVICE BILLED MEMBER IN CLAIM DOES NOT MATCH 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N54 CLAIM INFORMATION IS INCONSISTENT WITH PRE-CERTIFIED/AUTHORIZED REFERRAL SERVICES SERVICE DATE IS OUTSIDE 198 PRECERTIFICATION/AUTHORIZATION EXCEEDED. N351 SERVICE DATE OUTSIDE OF THE APPROVED TREATMENT PLAN SERVICE DATES. REFERRAL AUTHORIZATION 3300 J GIVEN WITH INVALID NDC M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) LTC CLAIM REQUIRES A PATIENT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT. LIABILITY AMOUNT 3302 UNABLE TO DETERMINE RATE ID N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 3303 INVALID PROCEDURE/TOOTH N75 MISSING/INCOMPLETE/INVALID TOOTH SURFACE INFORMATION. SURFACE COMBINATION 3304 MANUFACTURERS INVOICE 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT M53 MISSING INVOICE. REQUIRED 3305 INVALID PATIENT PAY AMOUNT N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT SPAD RATE NOT ALLOWED FOR N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR TRANSFER PATIENT STATUS 3307 NO PATIENT LIABILITY ON FILE OR N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT. ON THE CLAIM 3310 CURRENT SUPPLIERS INVOICE REQUIRED 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT M53 MISSING INVOICE ACQUISTION COST MISSING 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT M23 MISSING INVOICE MAX FEE RELATIVE VALUE MUST BE > 0 ON DOS 3314 POS INVALID FOR RADIOLOGY M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE ICD9-CM STERILIZATION PROC 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N3 MISSING CONSENT FORM. REQUIRES ATTACHMENT ADJUDICATE THIS CLAIM/SERVICE ICD9-CM HYSTERECTOMY PROC 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N3 MISSING CONSENT FORM. REQUIRES ATTACHMENT ADJUDICATE THIS CLAIM/SERVICE ICD9-CM ABORTION PROC REQUIRES 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N3 MISSING CONSENT FORM. ATTACHMENT ADJUDICATE THIS CLAIM/SERVICE NON COVRD DAYS MUST BE NUMERIC FOR PROV TYPE 70/ BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PRIMARY DIAG 3320 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. SECOND DIAG

22 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 3321 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. THIRD DIAG 3322 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. FOURTH DIAG 3323 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. FIFTH DIAG 3324 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. SIXTH DIAG 3325 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. SEVENTH+ DIAG 3326 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. ADMIT DIAG 3327 TYPE OF BILL CANNOT BE CROSS MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL. WALKED TO A PLACE OF SERVICE 3335 NO VALID DERIVED RATE ID N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 3602 CLAIM AND EOB DIFFER N48 CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED FROM OTHER INSURANCE CARRIER BENEFIT PLAN BILLING PROVIDER 12 THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. TYPE RESTRICTION ON DIAGNOSIS TYPE NDC INDICATES A NON-COVERED M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG DRUG ON DOS (NDC) ATTACH REV ON STERIL/HYST DIAG 251 THE ATTACHMENT/OTHER DOCUMENTATION CONTENT N228 INCOMPLETE/INVALID CONSENT FORM NDC NOT ON FILE M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG (NDC) NON-COVERED NDC DUE TO CMS M119 MISSING/INCOMPLETE/INVALID/ DEACTIVATED/WITHDRAWN NATIONAL DRUG TERMINATION (NDC) HEALTH PROGRAM MISMATCH ON MULTIPLE DETAILS 4009 ALLOWED AMOUNT LESS THAN 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR DRUG CHARGE VARIANCE CONTRACTED/LEGISLATED FEE ARRANGMENT 4010 MODIFIER REQUIRES MEDICAL 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING REVIEW FURTHER REVIEW INVALID MODIFIER/MODIFIER 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. COMBINATION 4012 ABORTION PROCEDURE INDICATED 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N3 MISSING CONSENT FORM. ADJUDICATE THIS CLAIM/SERVICE PROCEDURE IS NOT COVERED N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR FOR DATE OF SERVICE 4014 NO PRICING SEGMENT ON FILE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 4015 MULTIPLE PRICING MODIFIERS ON 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. CLAIM 4016 BENEFIT PLAN PERF PR TYP RESTRICTION ON DIAGNOSIS 4017 BENEFIT PLAN BILL PR TYP RESTRICTION ON DRG 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 BENEFIT PLAN PERF PR TYP RESTRICTION ON DRG 4019 PROCEDURE REQUIRES 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART. ATTACHMENT ADJUDICATE THIS CLAIM/SERVICE PROV CONTRACT UNIT RESTRICTION 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. ON PROCEDURE 4021 PROCEDURE NOT COVERED FOR BENEFIT PLAN 4022 ABORTION DIAGNOSIS INDICATED 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N28 CONSENT FORM REQUIREMENTS NOT FULFILLED. ADJUDICATE THIS CLAIM/SERVICE GENDER IS NOT ALLOWED FOR 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH COVERED NDC THE PATIENT'S GENDER MAXIMUM NUMBER OF REFILLS HAS N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. BEEN REACHED 4025 NDC VS. AGE RESTRICTION 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. THE PATIENT'S AGE NDC VS. DAYS SUPPLY M53 Missing/incomplete/invalid days or units of service DIAGNOSIS NOT COVERED 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FOR DATE OF SERVICE REPORTED BENEFIT PLAN GENDER RESTRICTION ON DIAGNOSIS 10 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S GENDER. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES.

23 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4029 BENEFIT PLAN POS RESTRICTION ON M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. DIAGNOSIS 4030 BENEFIT PLAN AGE RESTRICTION ON 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAGNOSIS 4031 PROV CONTRACT GENDER 10 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON DIAGNOSIS GENDER PROCEDURE NOT ON FILE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 4033 INVALID PROC MOD COMBINATION 4 THE PROCEDURE IS INCONSISTENT WITH THE N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES BENEFIT PLAN AGE RESTRICTION ON 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. PROCEDURE THE PATIENT'S AGE BENEFIT PLAN GENDER 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N517 RESTRICTION ON PROCEDURE THE PATIENT'S GENDER PROV CONTRACT POS RESTRICTION 171 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N428 NOT COVERED WHEN PERFORMED IN THIS PLACE OF SERVICE. ON PROCEDURE TYPE OF PROVIDER IN THIS TYPE OF FACILITY PROCEDURE VS. DIAGNOSIS 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION 4038 SERVICE NOT COVERED FOR LIMITED BP 4039 DIAGNOSIS CANNOT BE USED AS MA63 MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS. PRINCIPAL DIAGNOSIS 4040 PRIMARY DIAGNOSIS NOT ON 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE MA63 MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS. FILE REPORTED SECONDARY DIAGNOSIS NOT M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS ON FILE 4042 THIRD DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS FILE OR INACTIVE 4043 FOURTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS FILE OR INACTIVE 4044 REIMBURSEMENT RULE AGE 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. RESTRICTION THE PATIENT'S AGE REIMBURSEMENT RULE/BENEFIT PLAN RESTRICTION 4046 NO REIMBURSEMENT RULE FOR RATE ID 4047 FIFTH DIAGNOSIS NOT ON FILE 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS REPORTED SIXTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4049 SEVENTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4050 EIGHTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4051 NINTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4052 TENTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4053 PRINCIPAL PROCEDURE NOT N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR ON FILE 4054 FIRST OTHER PROCEDURE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR NOT ON FILE 4055 SECOND OTHER PROCEDURE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR NOT ON FILE 4056 THIRD OTHER PROCEDURE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR NOT ON FILE 4057 FOURTH OTHER PROCEDURE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR NOT ON FILE 4058 FIFTH OTHER PROCEDURE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR NOT ON FILE 4059 REVENUE NOT ON FILE M50 MISSING/INCOMPLETE/INVALID REVENUE (S) ELEVENTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4061 REIMBURSEMENT RULE CLAIM TYPE RESTRICTION 4062 REIMBURSEMENT RULE COND RESTRICTION 4063 ICD-9-CM PROCEDURE /AGE 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. RESTRICTION THE PATIENT'S AGE BENEFIT PLAN GENDER RESTRICTION ON ICD9 PROC 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH THE PATIENT'S GENDER. N517

24 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4065 ICD9-CM PROCEDURE REQUIRES ATTACHMENT 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO ADJUDICATE THIS CLAIM/SERVICE. N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/ CHART ICD9-CM PROCEDURE/DIAGNOSIS 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION 4067 NON-COVERED ICD-9-CM N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR PROCEDURE 4068 REIMBURSEMENT RULE/PROV CONTRACT RESTRICTION 4069 REIMBURSEMENT RULE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS RESTRICTION ON DIAGNOSIS ROLE 4070 REIMBURSEMENT RULE MODIFIER 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. RESTRICTION 4071 REIMBURSEMENT RULE PAYER RESTRICTION 4072 REIMBURSEMENT RULE TAXONOMY 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION PROVIDER/SPECIALTY (TAXONOMY) TWELFTH DIAGNOSIS NOT ON M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FILE 4077 NON-COVERED REVENUE M50 MISSING/INCOMPLETE/INVALID REVENUE (S) INPATIENT PSYCH HOSP FOR 204 THE SERVICE/EQUIPMENT/DRUG IS NOT COVERED UNDER N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. MEMBERS AGE REIMBURSEMENT RULE UNIT 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. RESTRICTION 4096 MODIFIER 99 NOT ALLOWED 4 THE PROCEDURE IS INCONSISTENT WITH THE N INVALID PROCESSING MODIFIER/RATE NOT FOUND 4098 FUND FOR AID CAT/LOC NOT FOUND 4099 DRG NOT ON FILE N208 MISSING/INCOMPLETE/INVALID DRG UNIT DOSE PACKAGING COVERED 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. FOR LTC RESIDENTS ONLY TYPE OF PROVIDER NO RBRVS CONVERSION FACTOR 4117 ICD9 PROCEDURE IS NOT VALID FOR 181 PROCEDURE WAS INVALID ON THE DATE OF SERVICE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DATES OF SERVICE 4120 PROCEDURE REQUIRES N346 MISSING/INCOMPLETE/INVALID ORAL CAVITY DESIGNATION. QUADRANT 4128 ICD9 PROCEDURE 7-24 NOT ON FILE 181 PROCEDURE WAS INVALID ON THE DATE OF SERVICE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES DRG GROUPER UNABLE TO ASSIGN DRG 4135 APC GROUPER UNABLE TO GROUP/PRICE 4136 BENEFIT PLAN BILLING PROVIDER TYPE RESTRICTION ON ICD9 PROC 4137 BENEFIT PLAN PERF PR TYP RESTRICTION ON ICD9 PROC 4138 BILLING PROVIDER TYPE SPECIALTY NOT VALID FOR COVERED-NDC A8 UNGROUPABLE DRG. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 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. 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. TYPE OF PROVIDER PERFORMING PROVIDER TYPE SPECIALTY NOT VALID FOR COVERED-NDC 4140 BENEFIT PLAN BILLING PROVIDER TYPE RESTRICTION ON PROCEDURE 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF PROVIDER. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. 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 BENEFIT PLAN PERFORMING PROVIDER TYPE RESTRICTION ON PROCEDURE 4142 BENEFIT PLAN BILLING PROVIDER TYPE RESTRICTION ON REVENUE 4143 BENEFIT PLAN PERFORMING PROVIDER TYPE RESTRICTION ON REVENUE N130 N130 N130 CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT

25 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4144 PROV CONTRACT PERFORMING 12 THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PROVIDER TYPE RESTRICTION ON DIAGNOSIS TYPE PROVIDER CONTRACT BILLING 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON DRG TYPE OF PROVIDER PROVIDER CONTRACT PERFORMING 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON DRG TYPE OF PROVIDER PROVIDER CONTRACT PERFORMING 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON ICD9 PROC TYPE OF PROVIDER PERF PROV TYPE SPEC NOT VALID N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. FOR CONTRACT-NDC 4149 PROVIDER CONTRACT BILLING 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON PROCEDURE PROVIDER/SPECIALTY (TAXONOMY) PROVIDER CONTRACT PERFORMING 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON PROCEDURE PROVIDER/SPECIALTY (TAXONOMY) PROVIDER CONTRACT BILL 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON REVENUE TYPE OF PROVIDER PROVIDER CONTRACT PERFORMING 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER TYPE RESTRICTION ON REVENUE TYPE OF PROVIDER PRIMARY NDC ON MEDICAL REVIEW N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. FOR PROV. CONTRACT 4155 REIMBURSEMENT RULE POS M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. RESTRICTION 4156 REIMBURSEMENT RULE PROV LOCAT RESTRICTION 4157 PROVIDER CONTRACT/PROVIDER 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. CONTRACT RESTRICTION ON DIAGNOSIS TYPE OF PROVIDER PROVIDER CONTRACT/PROVIDER CONTRACT RESTRICTION ON DRG 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF PROVIDER. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE PROVIDER CONTRACT/PROVIDER CONTRACT RESTRICT ON ICD9 PROCEDURE 4160 PROVIDER CONTRACT RESTRICTION FOR CONTRACT NDC 4161 PROVIDER CONTRACT/PROVIDER CONTRACT RESTRICT ON PROCEDURE 4162 PROVIDER CONTRACT/PROVIDER CONTRACT RESTRICT ON REVENUE 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF PROVIDER. N657 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 PROVIDER/SPECIALTY (TAXONOMY). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. TYPE OF PROVIDER INACTIVE DRUG N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES MAX DAY RESTRICTION FOR COVERED NDC 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 4166 REIMBURSEMENT RULE MEMB M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. LOCAT RESTRICTION 4167 PROV CONTRACT UNIT RESTRICTION M50 MISSING/INCOMPLETE/INVALID REVENUE (S). ON REVENUE 4168 BENEFIT PLAN UNIT RESTRICTION ON REVENUE 4170 UNITS BILLED GREATER THAN ALLOWED 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 4171 UNITS BILLED LESS THAN ALLOWED M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE PROVIDER CONTRACT BILLING PROVIDER TYPE RESTRICTION ON ICD9 PROCEDURE 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF PROVIDER. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE SECOND DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 4181 THIRD DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 4182 FOURTH DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 4183 FIFTH DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. M64 M64 M64 M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS

26 EOB EOB DESCRIPTION 4184 SIXTH DIAGNOSIS NOT COVERED FOR DATE OF SERVICE DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 4186 ADMITTING DIAGNOSIS NOT COVERED FOR DATE OF SERVICE 4187 EMERGENCY DIAGNOSIS NOT COVERED FOR DATE OF SERVICE ADJUSTMENT ADJUSTMENT REASON DESCRIPTION REASON 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED. M64 M64 MA65 M64 DESCRIPTION MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. MIAAING/INCOMPLETE/INVALID ADMITTING DIAGNOSIS MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS DIAGNOSIS NOT COVERED 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. FOR DATE OF SERVICE(DTL) REPORTED SECOND DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED THIRD DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED FOURTH DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED FIFTH DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED SIXTH DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED DIAGNOSIS NOT 146 DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS COVERED FOR DATE OF SERVICE(DTL) REPORTED CLAIM PRICED AT ZERO 4203 MODIFIER IS NOT COVERED 4 THE PROCEDURE IS INCONSISTENT WITH THE N CLIA NUMBER NOT ON FILE FOR MA120 MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER. DATES OF SERVICE 4208 INVALID CLIA B23 PROCEDURE BILLED IS NOT AUTHORIZED PER YOUR MA120 MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER. CERTIFICATION/PROCEDURE COMBINAT CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) PROFICIENCY TEST NO PRICING SEGMENT FOR 4 THE PROCEDURE IS INCONSISTENT WITH THE N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PROCEDURE/MODIFIER COMBINAT 4210 MILEAGE RATE NOT ON FILE FOR DATE OF SERVICE 4211 TOOTH NUMBER/PROCEDURE N37 MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER. COMBINATION INVALID 4212 INVALID CLIA LAB /PROC /MODIFIER COMBINAT B23 PROCEDURE BILLED IS NOT AUTHORIZED PER YOUR CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) PROFICIENCY TEST SERVICE DATE PRIOR TO CLIA CERTIFICATION DATE MA CLIA NUMBER TERMINATED MA NDC REQUIRES REVIEW N BENEFIT PLAN REVIEW RESTRICTION N130 ON PROCEDURE 4224 BENEFIT PLAN UNIT RESTRICTION N130 ON PROCEDURE 4227 REVENUE NOT COVERED FOR N130 BENEFIT PLAN 4229 BENEFIT PLAN REVIEW RESTRICTION N569 ON DIAGNOSIS 4231 MAXIMUM UNIT RESTRICTION FOR N657 BILLED NDC 4232 MAXIMUM DAY RESTRICTION FOR N657 BILLED NDC 4233 DIAGNOSIS REQUIRES ADDITIONAL 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 DOCUMENTATION ADJUDICATE THIS CLAIM/SERVICE IMPROPER MODIFIER FOR 4 THE PROCEDURE IS INCONSISTENT WITH THE N657 PROCEDURE BILLED 4236 INVALID USE OF E DIAGNOSIS M INVALID TYPE OF LEAVE FOR LTC CLAIM MA66 MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE. MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER. MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER. THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART. THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION.

27 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4240 PROCEDURE MUST BE BILLED 96 NON-COVERED CHARGE(S). N61 REBILL SERVICES ON SEPARATE CLAIMS. SEPARATELY FOR EACH DOS 4244 DIAGNOSIS NOT COVERED FOR BENEFIT PLAN 4245 FOURTH MODIFIER NOT COVERED 182 PROCEDURE MODIFIER WAS INVALID ON THE DATE OF N517 SERVICE ADJUSTMENT PAID AMOUNT M79 MISSING/INCOMPLETE/INVALID CHARGE. EXCEEDS THE CASH RECEIPT BA 4248 MISSING MODIFIER FOR THIS 4 THE PROCEDURE IS INCONSISTENT WITH THE N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PROCEDURE 4250 REIMBURSEMENT RULE PROVIDER 170 PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. TYPE RESTRICTION TYPE OF PROVIDER DX 6-24 NOT ON FILE M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION BENEFIT PLAN REVIEW RESTRICTION ON REVENUE 4254 BENEFIT PLAN AGE RESTRICTION ON 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. REVENUE THE PATIENT'S AGE BENEFIT PLAN MODIFIER RESTRICTION ON PROCEDURE 4257 PROVIDER CONTRACT MODIFIER 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 RESTRICTION ON PROCEDURE 4258 SECONDARY DIAGNOSIS M64 MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS. RESTRICTION FOR BILLED NDC 4260 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 THE ASSIGNMENT REQUEST 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. NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS PROVIDER CONTRACT ADMIT DIAG RESTRICTION ON PROCEDURE N PROVIDER CONTRACT EMERG DIAG 96 NON-COVERED CHARGE(S). N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. RESTRICTION ON PROC 4312 PROVIDER CONTRACT PRIM DTL 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAG RESTRICT ON PROCEDURE 4313 PROVIDER CONTRACT PRIM/SEC DTL 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAG RESTRICT ON PROC 4314 BENEFIT PLAN CLAIM TYPE N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. RESTRICTION ON DIAGNOSIS 4315 PROVIDER CONTRACT HDR 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAGNOSIS RESTRICTION ON PROCEDURE 4316 PROVIDER CONTRACT DETAIL DIAGNOSIS RESTRICTION ON PROCEDURE 4317 PROVIDER CONTRACT ADMITTING DIAGNOSIS RESTRICTION ON ICD PROVIDER CONTRACT DETAIL DIAGNOSIS RESTRICTION ON ICD PROVIDER CONTRACT HEADER DIAGNOSIS RESTRICTION ON ICD PROVIDER CONTRACT ADMITTING DIAGNOSIS RESTRICTION ON REVENUE 4321 PROVIDER CONTRACT DETAIL DIAGNOSIS RESTRICTION ON REVENUE 4322 PROVIDER CONTRACT PRIM/SEC DTL DIAG RESTRICT ON REV 4362 PROVIDER CONTRACT TOB RESTRICTION ON DIAGNOSIS 4363 PROVIDER CONTRACT TOB RESTRICTION ON DRG 4364 PROVIDER CONTRACT TOB RESTRICTION ON ICD9 PROC 4365 PROVIDER CONTRACT TOB RESTRICTION ON PROCEDURE 4371 BENEFIT PLAN CLAIM TYPE RESTRICTION ON PROCEDURE 4373 NDC COVERED BENEFIT CLAIM TYPE RESTRICTION 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. M76 M76 M76 N569 N569 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. 96 NON-COVERED CHARGE(S). N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER/SPECIALTY (TAXONOMY). 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.

28 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4374 BENEFIT PLAN CLAIM TYPE RESTRICTION ON REVENUE 4376 BENEFIT PLAN CLAIM TYPE RESTRICTION ON ICD9 PROCEDURE 4711 PROVIDER CONTRACT AGE 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON ADMITTING DIAGNOSIS 4712 PROV CONTRACT AGE RESTRICTION 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. ON DRG THE PATIENT'S AGE PROVIDER CONTRACT AGE 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. RESTRICTION ON ICD9 PROCEDURE THE PATIENT'S AGE PROVIDER CONTRACT AGE 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. RESTRICTION ON REVENUE THE PATIENT'S AGE AGE RESTRICTION FOR BILLED ICD9 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. THE PATIENT'S AGE PROVIDER CONTRACT PRIM/SEC DTL N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. DIAG RESTRICTION ON DRG 4723 BENEFIT PLAN DETAIL DIAGNOSIS M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. RESTRICTION ON ICD BENEFIT PLAN 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. PRIMARY/SECONDARY DETAIL DIAGNOSIS RESTRICTION ON ICD BENEFIT PLAN ADMIT DIAG 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON ICD REIMBURSEMENT RULE M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. RESTRICTION ON DIAGNOSIS 4731 BENEFIT PLAN DETAIL DIAGNOSIS 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON PROCEDURE 4732 BENEFIT PLAN ADMITTING DIAGNOSIS RESTRICTION ON REVENUE 4733 PROVIDER CONTRACT ADMITTING 96 NON-COVERED CHARGE(S). N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. DIAGNOSIS RESTRICTION ON DRG 4734 PROVIDER CONTRACT DETAIL N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. DIAGNOSIS RESTRICTION ON DRG 4736 BENEFIT PLAN DETAIL DIAGNOSIS RESTRICTION ON REVENUE 4741 BENEFIT PLAN ADMITTING 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAGNOSIS RESTRICTION ON PROCEDURE 4742 BENEFIT PLAN EMERGENCY 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DIAGNOSIS RESTRICTION ON PROCEDURE 4743 BENEFIT PLAN PRIMARY/SECONDARY DETAIL DIAGNOSIS RESTRICTION ON PROCEDURE 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES BENEFIT PLAN PRIMARY/SECONDARY DETAIL DIAGNOSIS RESTRICTION ON REVENUE 4745 BENEFIT PLAN HEADER DIAGNOSIS RESTRICTION ON PROCEDURE 4746 BENEFIT PLAN PRIM DETAIL DIAGNOSIS RESTRICTION ON PROCEDURE 4751 PROVIDER CONTRACT TOB RESTRICTION ON REVENUE 4760 PROVIDER CONTRACT REVIEW RESTRICTION ON ICD9 PROC 4762 PROVIDER CONTRACT POS RESTRICTION ON ICD9 PROC 4765 ICD9 PROCEDURE NOT COVERED FOR BENEFIT PLAN 4766 BENEFIT PLAN AGE RESTRICTION ON ICD9 PROCEDURE 4767 BENEFIT PLAN POS RESTRICTION ON ICD9 PROCEDURE 4768 BENEFIT PLAN REVIEW RESTRICTION ON ICD9 PROCEDURE 4776 PROVIDER CONTRACT BILLING PROVIDER TYPE RESTRICTION ON DIAGNOSIS M76 MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION. 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. MA30 MISSING/INCOMPLETE/INVALID TYPE OF BILL. 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. M77 N130 N130 N130 N THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER N657 TYPE. MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT CONSULT PLAN BENEFIT DOCUMENTS/GUIDELINES FOR INFORMATION ABOUT THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES.

29 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 4801 PROCEDURE NOT COVERED BY 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER CONTRACT PROVIDER/SPECIALTY (TAXONOMY) DIAGNOSIS NOT COVERED BY N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. PROVIDER CONTRACT 4804 REVENUE NOT COVERED BY N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. PROVIDER CONTRACT 4805 DRG NOT COVERED BY PROVIDER CONTRACT 4806 ICD9 PROCEDURE NOT COVERED BY 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. PROVIDER CONTRACT PROVIDER/SPECIALTY (TAXONOMY) PROVIDER CONTRACT REVIEW N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. RESTRICTION ON DIAGNOSIS 4813 PROVIDER CONTRACT REVIEW 8 THE PROCEDURE IS INCONSISTENT WITH THE N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION ON PROCEDURE PROVIDER/SPECIALTY (TAXONOMY) PROVIDER CONTRACT REVIEW 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION ON REVENUE 4821 BENEFIT PLAN POS RESTRICTION ON M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. PROCEDURE 4822 PROVIDER CONTRACT POS N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. RESTRICTION ON DIAGNOSIS 4825 MIXED HOLIDAY/WEEKEND/WEEKDAY M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. DATES 4831 NO REIMBURSEMENT RULE FOR 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. SERVICE 4845 PROVIDER CONTRACT REVIEW 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION ON DRG 4863 NDC COVERED FOR A PORTION OF THE DOS 4866 BENEFIT PLAN POS RESTRICTION ON M77 MISSING/INCOMPLETE/INVALID PLACE OF SERVICE. REVENUE 4867 PROVIDER CONTRACT POS RESTRICTION ON REVENUE 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 PROVIDER CONTRACT CLAIM TYPE N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. RESTRICTION ON PROCEDURE 4872 PROVIDER CONTRACT CLAIM TYPE 12 THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON DIAGNOSIS TYPE PROVIDER CONTRACT CLAIM TYPE N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE. RESTRICTION ON REVENUE 4875 PROVIDER CONTRACT CLAIM TYPE 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION ON DRG 4876 PROVIDER CONTRACT CLAIM TYPE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR RESTRICTION ON ICD9 PROC 4881 PROVIDER CONTRACT POS 96 NON-COVERED CHARGE(S). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. RESTRICTION ON DRG 4882 DRG NOT COVERED FOR BENEFIT PLAN 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 BENEFIT PLAN REVIEW RESTRICTION ON DRG 4884 BENEFIT PLAN AGE RESTRICTION ON 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. DRG THE PATIENT'S AGE BENEFIT PLAN CLAIM TYPE RESTRICTION ON DRG 4887 BENEFIT PLAN POS RESTRICTION ON DRG 4890 PROVIDER CONTRACT AGE 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. RESTRICTION ON PRIMARY DIAG 4891 PROVIDER CONTRACT AGE RESTRICTION ON SECONDARY DIAG 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES PROVIDER CONTRACT AGE RESTRICTION ON THIRD DIAG 4893 PROVIDER CONTRACT AGE RESTRICTION ON FOURTH DIAG 4894 PROVIDER CONTRACT AGE RESTRICTION ON FIFTH DIAG 4895 PROVIDER CONTRACT AGE RESTRICTION ON SIXTH DIAG 4896 PROVIDER CONTRACT AGE RESTRICTION ON SEVENTH DIAG 4900 BENEFIT PLAN/BENEFIT PLAN RESTRICTION ON DIAGNOSIS 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. 9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE. N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS.

30 EOB EOB DESCRIPTION ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 4901 BENEFIT PLAN CONDITION RESTRICTION ON DIAGNOSIS 4902 BENEFIT PLAN OCCURENCE RESTRICTION ON DIAGNOSIS 4903 BENEFIT PLAN RESTRICTION ON DIAGNOSIS ROLE 4910 PROVIDER CONTRACT/BENEFIT PLAN RESTRICTION ON DIAGNOSIS 4911 PROVIDER CONTRACT CONDITION RESTRICTION ON DIAGNOSIS 4912 PROVIDER CONTRACT OCCURENCE RESTRICTION ON DIAGNOSIS 4913 PROVIDER CONTRACT RESTRICTION ON DIAGNOSIS ROLE 4920 BENEFIT PLAN/BENEFIT PLAN RESTRICTION ON DRG 4921 BENEFIT PLAN COND RESTRICTION ON DRG 4922 BENEFIT PLAN OCCUR RESTRICTION ON DRG 4930 BENEFIT PLAN RESTRICTION FOR CONTRACT DRG 4931 PROVIDER CONTRACT COND 8 THE PROCEDURE IS INCONSISTENT WITH THE RESTRICTION ON DRG PROVIDER/SPECIALTY (TAXONOMY) BENEFIT PLAN GENDER 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH RESTRICTION ON DRG THE PATIENT'S GENDER PROVIDER CONTRACT GENDER 8 THE PROCEDURE IS INCONSISTENT WITH THE RESTRICTION ON DRG PROVIDER/SPECIALTY (TAXONOMY) BENEFIT PLAN/BENEFIT PLAN RESTRICTION ON ICD9 PROC 4941 BENEFIT PLAN COND RESTRICTION ON ICD9 PROC 4942 BENEFIT PLAN OCCUR RESTRICTION ON ICD9 PROC 4944 PROVIDER CONTRACT GENDER 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH RESTRICTION ON ICD9 PROCEDURE THE PATIENT'S GENDER PROVIDER CONTRACT/BENEFIT PLAN RESTRICT ON ICD9 PROC 4951 PROVIDER CONTRACT CONDITION 8 THE PROCEDURE IS INCONSISTENT WITH THE RESTRICTION ON ICD9 PROVIDER/SPECIALTY (TAXONOMY). PROCEDURE 4952 PROVIDER CONTRACT OCCURENCE RESTRICTION ON ICD9 PROCEDURE 4963 PROVIDER CONTRACT GENDER RESTRICTION ON PROCEDURE 4964 PROVIDER CONTRACT GENDER RESTRICTION ON REVENUE 4967 BENEFIT PLAN GENDER RESTRICTION ON REVENUE 4970 BENEFIT PLAN/BENEFIT PLAN RESTRICTION ON REVENUE 4971 BENEFIT PLAN COND RESTRICTION ON REVENUE 4972 BENEFIT PLAN OCCUR RESTRICTION ON REVENUE 4975 PROVIDER CONTRACT/BENEFIT PLAN RESTRICT ON REVENUE 4976 PROVIDER CONTRACT CONDITION RESTRICTION ON REVENUE 4977 PROVIDER CONTRACT OCCURENCE RESTRICTION ON REVENUE 4980 BENEFIT PLAN/BENEFIT PLAN RESTRICTION ON PROCEDURE 4981 BENEFIT PLAN CONDITION RESTRICTION ON PROCEDURE 4982 BENEFIT PLAN OCCURENCE RESTRICTION ON PROCEDURE 4990 PROVIDER CONTRACT/BENEFIT PLAN RESTRICT ON PROCEDURE 4991 PROVIDER CONTRACT COND RESTRICTION ON PROCEDURE 8 THE PROCEDURE IS INCONSISTENT WITH THE PROVIDER/SPECIALTY (TAXONOMY). 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH THE PATIENT'S GENDER. 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH THE PATIENT'S GENDER. 7 THE PROCEDURE/REVENUE IS INCONSISTENT WITH THE PATIENT'S GENDER. 8 THE PROCEDURE IS INCONSISTENT WITH THE PROVIDER/SPECIALTY (TAXONOMY). 8 THE PROCEDURE IS INCONSISTENT WITH THE PROVIDER/SPECIALTY (TAXONOMY). 8 THE PROCEDURE IS INCONSISTENT WITH THE PROVIDER/SPECIALTY (TAXONOMY). 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER REVIEW. DESCRIPTION N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N569 NOT COVERED WHEN PERFORMED FOR THE REPORTED DIAGNOSIS. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. N517 N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. N517 N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. N517 N517 N517 N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE. N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE.

31 EOB EOB DESCRIPTION 4992 PROVIDER CONTRACT OCCUR RESTRICTION ON PROCEDURE ADJUSTMENT ADJUSTMENT REASON DESCRIPTION REASON 133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER REVIEW. DESCRIPTION 4999 THIS DRUG NOT COVERED BY MEDICARE PART D 5000 EXACT DUPLICATE - INPATIENT CLAIM 5001 SUSPECT DUPLICATE - INPATIENT CLAIM- DIFFERENT PROVIDER 5002 CONFLICT - INPATIENT VS OUTPATIENT 5003 CONFLICT - INPATIENT VS LONG TERM CARE 5004 EXACT DUPLICATE - INPATIENT/LTC CROSSOVER A 5005 SUSPECT DUPLICATE - INPATIENT/LTC CROSSOVER A 96 NON-COVERED CHARGE(S). M THIS PROCEDURE IS NOT PAID SEPARATELY. M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT. 234 THIS PROCEDURE IS NOT PAID SEPARATELY. M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT. 96 NON-COVERED CHARGE(S). M EXACT DUPLICATE - PHYSICIAN CROSSOVER 96 NON-COVERED CHARGE(S). M SUSPECT DUPLICATE - PHYSICIAN CROSSOVER- DIFFERENT PROVIDER 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M CONFLICT- PHYSICIAN VS CROSSOVER B 5009 CONFLICT-LONG TERM CARE VS CROSSOVER A 5010 EXACT DUPLICATE-OUTPATIENT CLAIM 5011 SUSPECT DUPLICATE-OUTPATIENT CLAIM-DIFFERENT PROVIDER 96 NON-COVERED CHARGE(S). M EXACT DUPLICATE - OUTPATIENT/HOMEHEALTH CROSSOVER C 5013 SUSPECT DUPLICATE - OUTPATIENT/HOMEHEALTH CROSSOVER C 5014 EXACT DUPLICATE-OUTPATIENT LAB SERVICES 5015 SUSPECT DUPLICATE OUTPATIENT LAB SERVICES DIFFERENT PROVIDER 5016 EXACT DUPLICATE OUTPATIENT RADIOLOGICAL SERVICES 5017 SUSPECT DUPLICATE-OUTPATIENT RADIOLOGY SERVICES 18 EXACT DUPLICATE CLAIM/SERVICE. N522 DUPLICATE OF A CLAIM PROCESSED, OR TO BE PROCESSED, AS A CROSSOVER CLAIM. 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M SUSPECT DUPLICATE OUTPATIENT SURGICAL SERVICES (OPERATION ROOM / AMB SURG CTR) 5019 SUSPECT DUPLICATE OUTPATIENT SERGICAL SERVICES (OPER ROOM/AMB SWG CTR)-DIFFEREN 5020 SUSPECT DUPLICATE OUTPATIENT PROCEDURE

32 EOB EOB DESCRIPTION 5021 SUSPECT DUPLICATE OUTPATIENT PROCEDURE(OPER ROOM/AMB SURG CTR) DIFFERENT PROVID 5022 SUSPECT DUPLICATE OUTPATIENT PROCEDURES (OPER ROOM/ AMB SURG CTR) 5023 SUSPECT DUPLICATE OUTPATIENT PROCEDURE (OPER ROOM/ AMB SURG CTR) DIFFERENT PROV 5024 SUSPECT DUPLICATE OUTPATIENT SERGICAL SERVICES ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION DESCRIPTION 5025 SUSPECT DUPLICATE OUTPATIENT SERGICAL SERVICES (EMERG ROOM/ CLINIC) DIFFERENT P 5026 SUSPECT DUPLICATE OUTPATIENT SERGICAL SERVICES EMERGENCY ROOM/ CLINIC 5027 SUSPECT DUPLICATE OUTPATIENT SURGICAL SERVICES- EMERG ROOM/CLINIC- DIFFERENT PR 5028 OPD EXACT DUP CRITERIA=E- CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=E- CLAIM TYPE O -UB4 INV XACT DUPLICATE OUTPATIENT PROCEDURES (OPER ROOM/AMB SURG CTR/EMERG ROOM/CLINIC) 5031 SUSPECT DUPLICATE OUTPATIENT PROCEDURE (OR/AMB SURG CTR/ER/CLINIC) -DIFFERENT P 18 EXACT DUPLICATE CLAIM/SERVICE. N522 DUPLICATE OF A CLAIM PROCESSED, OR TO BE PROCESSED, AS A CROSSOVER CLAIM. 96 NON-COVERED CHARGE(S). M EXACT DUPLICATE-OUTPATIENT 96 NON-COVERED CHARGE(S). M86 PROCEDURES (OPER ROOM / EMERG ROOM/ CLINIC) 5033 SUSPECT DUPLICATE OUTPATIENT PROCEDURES- DIFFERENT PROVIDER 5034 OPD EXACT DUP CRITERIA=E1-CLAIM 96 NON-COVERED CHARGE(S). M86 TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=E1- CLAIM TYP O -UB4 INV 3 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M OPD EXACT DUP CRITERIA=F- CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=F- CLAIM TYP O -UB4 INV 3 96 NON-COVERED CHARGE(S). M OPD EXACT DUP CRITERIA=F1-CLAIM 96 NON-COVERED CHARGE(S). M86 TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=F1- CLAIM TYP O -UB4 INV 3 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M OPD EXACT DUP CRITERIA=G-CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=G - CLAIM TYP O -UB4 INV 3 96 NON-COVERED CHARGE(S). M86

33 EOB EOB DESCRIPTION 5042 OPD EXACT DUP CRITERIA=H-CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=H - CLAIM TYP O -UB4 INV EXACT DUPLICATE - PHYSICAN CLAIM 5045 SUSPECT DUPLICATE-PHYSICIAN CLAIM- DIFFERENT PROVIDER 5046 EXACT DUPLICATE OUTPATIENT PROCEDURES (CLINIC) 5047 SUSPECT DUPLICATE OUTPATIENT PROCEDURES (CLINIC) ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION DESCRIPTION 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M SUSPECT DUPLICATE OUTPATIENT PROCEDURES (CLINIC) 5049 SUSPECT DUPLICATE OUTPATIENT PROCEDURE (CLINIC) 5050 EXACT DUPLICATE HOME HEALTH CLAIM 96 NON-COVERED CHARGE(S). M SUSPECT DUPLICATE- HOME HEALTH -DIFFERENT PROVIDER 5052 EXACT DUPLICATE - LONG TERM CARE 5053 SUSPECT DUPLICATE-LONG TERM CARE-DIFFERENT PROVIDER 5054 OPD EXACT DUP CRITERIA=M-CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=M- CLAIM TYP O -UB4 INV 3 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M DUPLICATE SERVICE (DENTAL ONLY) 96 NON-COVERED CHARGE(S). M DUPLICATE SERVICE (PHARMACY ONLY) 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M OPD EXACT DUP CRITERIA=M1-CLAIM 96 NON-COVERED CHARGE(S). M86 TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=M1- CLAIM TYP O -UB4 INV 3 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M OPD EXACT DUP CRITERIA=N-CLAIM TYPE O-UB04 INV OPD SUSPECT DUP CRITERIA=N- CLAIM TYP O -UB04 INV EXACT DUPLICATE OUTPATIENT PROCEDURES (TREATMENT ROOM) 5063 SUSPECT DUPLICATE OUTPATIENT PROCEDURES (TREATMENT ROOM) 5064 CONFLICT: INPATIENT VS. CROSSOVER A 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M86 96 NON-COVERED CHARGE(S). M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT.

34 EOB EOB DESCRIPTION 5065 CONFLICT: HOME HEALTH VS. OUTPATIENT ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION DESCRIPTION 5066 CONFLICT: HOME VS. PHYSICIAN 5067 CONFLICT: HOME VS. CROSSOVER B 5068 CONFLICT: HOME HEALTH VS. CROSSOVER A 5069 CONFLICT: HOME HEALTH VS. CROSSOVER C 5070 CONFLICT: OUTPATIENT VS. CROSSOVER C 5071 PA IS REQUIRED FOR BASIC MEMBERS 5072 CONFLICT: LTC VS. PROV TYPE CONFLICT: HOSPICE VS. LONG TERM CARE 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N EXACT DUPLICATE - DIFFERENT PHYSICIAN CLAIM 5075 EXACT DUPLICATE - DIFFERENT HOME HEALTH CLAIM 5076 EXACT DUPLICATE - DIFFERENT CROSSOVER B CLAIM 5077 LTC MLOA CLAIM SUSP W INP / PART A 5078 S5160 & S5161 CAN NOT BE BILLED WITH LTC SAME DOS 5079 CONFLICT: LTC VS PHYSICIAN(S5160 & S5161) SAME DOS 18 EXACT DUPLICATE CLAIM/SERVICE. N702 DECISION BASED ON REVIEW OF PREVIOUSLY ADJUDICATED CLAIMS OR FOR CLAIMS IN PROCESS FOR THE SAME/SIMILAR TYPE OR SERVICES. 18 EXACT DUPLICATE CLAIM/SERVICE. N702 DECISION BASED ON REVIEW OF PREVIOUSLY ADJUDICATED CLAIMS OR FOR CLAIMS IN PROCESS FOR THE SAME/SIMILAR TYPE OR SERVICES. 18 EXACT DUPLICATE CLAIM/SERVICE. N702 DECISION BASED ON REVIEW OF PREVIOUSLY ADJUDICATED CLAIMS OR FOR CLAIMS IN PROCESS FOR THE SAME/SIMILAR TYPE OR SERVICES. 96 NON-COVERED CHARGE(S). M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT SURG/ASSIST SURG SAME DOS SAME 54 MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN N646 REIMBURSEMENT HAS BEEN ADJUSTED BASED ON THE GUIDELINES FOR AN PROVIDER THIS CASE. ASSISTANT CONFLICT: ASC FACILITY VS OPD FACILITY 5082 ONE PRIMARY SURGERY PER DAY 96 NON-COVERED CHARGE(S). M LIMIT 1 SURGICAL WITH 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. DIFFERENT MOD PER DAY 5084 ASST SURGERY BILATERAL LIMIT 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. MOD ONE PRIMARY ASSIST SURGERY PER 54 MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN N646 REIMBURSEMENT HAS BEEN ADJUSTED BASED ON THE GUIDELINES FOR AN DAY THIS CASE. ASSISTANT ASST SURGERY BILATERAL LIMIT 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. MOD ASST SURGERY BILATERAL LIMIT 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. MOD CONFLICT: ASC FACILITY VS. OPD FACILITY 5089 CONFLICT: ASC FACILITY VS. HLHC HOSPITAL 5090 CONFLICT: ASC FACILITY VS. HLHC FACILITY 5091 DIFFERENT PROVIDER FROM SAME GROUP NOT ALLOWED 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS.

35 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 5092 CONFLICT:HOME HEALTH VS. 96 NON-COVERED CHARGE(S). M2 NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT. INPATIENT 5093 CONFLICT:HOME HEALTH VS. LTC 5094 MODIFIER 'SG' REQUIRED FOR ALL 4 THE PROCEDURE IS INCONSISTENT WITH THE N519 INVALID COMBINATION OF HCPCS MODIFIERS. PROCEDURE S 5095 BILATERAL SURGERY 1 OF SAME PROCEDURE PER DAY (WITH OR WITHOUT MOD 50) 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M NCCI CONFLICT WITH ADJUSTED OTH SERV PREV PAID 5097 SERVICE HAS BEEN PAID ON AN INSTITUTIONAL CROSSOVER 5200 PAPE SERVICES SHOULD BE ON SINGLE CLAIM 5210 ATP SERVICES SHOULD BE ON SINGLE CLAIM 5906 SERVICE INCLUDED IN COMPREHENSIVE 5907 COMPREHENSIVE SERVICE ALREADY PAID FOR COMPONENT B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT. 18 EXACT DUPLICATE CLAIM/SERVICE. N522 DUPLICATE OF A CLAIM PROCESSED, OR TO BE PROCESSED, AS A CROSSOVER CLAIM. 107 THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT IDENTIFIED ON THIS CLAIM. 107 THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT IDENTIFIED ON THIS CLAIM. 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. 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 COMPREHENSIVE SERVICE REQUIRES REVIEW 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 CONTENT OF SERVICE - CURRENT 5925 CONTENT OF SERVICE - PRO-RATED 96 NON-COVERED CHARGE(S). M80 NOT COVERED WHEN PERFORMED DURING THE SAME SESSION/DATE AS A (CURRENT/HISTORY) PREVIOUSLY PROCESSED SERVICE FOR THE PATIENT COMPREHENSIVE SERVICE IS ALREADY PAID FOR COMPONEN 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 NCCI - ANOTHER SERVICE PREV B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY PAID SAME CLAIM HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT NCCI ANOTHER SERVICE PREV B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY PAID OTHER CLAIM HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT NCCI CONFLICT WITH OTHER B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY SERVICE PREV PAID HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT MUE UNITS EXCEEDED 50 THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A 'MEDICAL NECESSITY' BY THE PAYER. N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 5935 LABORATORY PANELS DENIED 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 MANUAL PRICING REQUIRED 6001 MANUAL PRICING NOT ALLOWED ON ADJUSTMENT 6002 INVALID UNIT FOR M53 MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE. ANESTHESIA 6003 PAID AMOUNT IS LESS THAN MINIMUM THRESHOLD - HDR 6004 PAID AMOUNT EXCEEDS THRESHOLD 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR - HDR CONTRACTED/LEGISLATED FEE ARRANGMENT 6005 COPAY REVIEW AMOUNT WAS REACHED 6007 PAID AMOUNT LESS THAN MINIMUM THRESHOLD - DTL 6008 AMOUNT EXCEEDS MAXIMUM 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR THRESHOLD - DTL CONTRACTED/LEGISLATED FEE ARRANGMENT 6010 MULTIPLE SURGERIES OR VISITS WITHIN THE GLOBAL TIME PERIOD P14 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE THAT HAS BEEN PPERFORMED THE SAME DAY. N525 THESE SERVICES ARE NOT COVERED WHEN PERFORMED WITHIN THE GLOBAL PERIOD OF ANOTHER SERVICE 6011 UNABLE TO PRICE RBRVS 16 CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 6012 REND PROV ON B CLAIM - CONTRACT NOT FOUND N65 N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR

36 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 6013 REND PROV ON B CLAIM - REIMBURS N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR RULE NOT FOUND 6014 REND PROV ON B CLAIM - N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR PRICING/RATE TYP NOT FOUND 6018 EXCESSIVE MLOA DAYS TAKEN 6019 EXCESSIVE MLOA DAYS TAKEN 96 NON-COVERED CHARGE(S). N43 BED HOLD OR LEAVE DAYS EXCEEDED MLOA DAYS EXCEEDS MAX 96 NON-COVERED CHARGE(S). N43 BED HOLD OR LEAVE DAYS EXCEEDED ATP ELIGIBLE B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST ATP BUNDLED CLAIM B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST ATP PROCEDURE NOT ON MAX FEE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR TABLE (PROFESSIONAL) 6024 ATP PROCEDURE NOT ON MAX FEE N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR TABLE (OUTPATIENT) 6025 ATP PROCEDURE NOT ON ATP N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR TABLE (PROFESSIONAL) 6026 ATP PROCEDURE NOT ON ATP N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR TABLE (OUTPATIENT) 6027 NO TPL PRICING METHOD FOUND FOR ATP PRICING FOR PROFESSIONAL CLAIM 6028 NO TPL PRICING METHOD FOUND FOR ATP PRICING FOR OUTPATIENT CLAIM 6030 PROVIDER PRICING METHOD NOT FOUND (OUTPATIENT) 6031 PAPE ELIGIBLE PROCEDURE 97 THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE M15 N65 N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE PAYMENT IS NOT ALLOWED SYSTEM GENERATED CLAIM PAYING PAPE PRICE 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 NMLOA AUDIT 6041 NMLOA AUDIT 6125 RETURN MONEY VOID / MATCHED B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY CLM ADJUSTED OR VOIDED HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT MODIFIER MANUALLY PRICED 6140 CLAIM WAS MANUALLY PRICED 6760 CLAIM SUSPENDED FOR ATTACHMENT REVIEW 6761 DCN IS INVALID AND ATTACHMENT 163 ATTACHMENT/OTHER DOCUMENTATION REFERENCED ON N706 MISSING DOCUMENTATION. REQUIRED FOR SERVICE THE CLAIM WAS NOT RECEIVED ATTACHMENT MISSING FOR 163 ATTACHMENT/OTHER DOCUMENTATION REFERENCED ON N706 MISSING DOCUMENTATION. PODIATRIC SERVICES THE CLAIM WAS NOT RECEIVED CLAIM FAILED A PRODUR ALERT 7001 INFORMATIONAL PRODUR ALERT 7002 CLAIM DENIED FOR PRODUR REASONS 7003 CLAIM DENIED - FORCED VOID TRANSACTION A1 CLAIM/SERVICE DENIED LTC MEMBER - NON-COMPOUND DRUG BILLED 7026 LTC DRUG ONLY 7027 DRUG QUANTITY PER DAY HAS BEEN EXCEEDED 7028 POS PROCESSING ERROR

37 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 7030 TIER 2 NSAID NO RECORD OF TIER 1 S ON FILE 7033 INACTIVE DRUG 7035 DRUG NOT APPROVED 7036 SUBMIT PAPER CLAIM N34 INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE STEP THERAPY REQUIREMENTS NOT MET FOR THIS DRUG 7062 PDUR INGREDIENT DUPLICATION 7063 PDUR THERAPUTIC DUPLICATION 7064 PDUR DRUG - DRUG INTERATION 7065 PDUR HIGH DOSE PRECAUTION 7066 PDUR LOW DOSE PRECAUTION 7067 PDUR PREGNANCY PRECAUTION 7068 PDUR DURATION OF THERAPY 7069 PDUR LATE REFILL PRECAUTION 7070 DRUG DISEASE MARKER 7071 DISEASE STATE MANAGEMENT 7072 PDUR DRUG AGE PEDIATRIC 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. PRECAUTION THE PATIENT'S AGE PDUR DRUG AGE GERIATRIC 6 THE PROCEDURE/REVENUE IS INCONSISTENT WITH N129 NOT ELIGIBLE DUE TO THE PATIENT'S AGE. PRECAUTION THE PATIENT'S AGE PDUR OVERUTILIZATION PRECAUTION 7075 PDUR DRUG/DISEASE PRECAUTION 7100 SERVICE REPLACED DUE TO X-RAY RECODING 7101 MISSING PROCEDURE REPROCESS AN ENCOUNTER LEVEL PAYMENT 7102 UNIQUE PRODUCT COULD NOT BE IDENTIFIED FOR CLAIM 7103 ENTR PMT DENIED - NO OTHER VALID SERVICES BILLED M51 MISSING/INCOMPLETE/INVALID PROCEDURE (S). M81 YOU ARE REQUIRED TO TO THE HIGHEST LEVEL OF SPECIFITY. N58 MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 7105 RESUBMIT WITH D8999 FOR BAL AND M51 LAST DATE ELIGIBLE PA TRANSACTION SUSPENDED 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N PATIENT DID NOT MEET WAITING PERIOD FOR SERVICE 7108 SERVICE REPLACED BY ALTERNATIVE BENEFIT MISSING/INCOMPLETE/INVALID PROCEDURE (S) 96 NON-COVERED CHARGE(S). M86 B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST AMALGAM/RESIN REPLACED B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST /SUB SWITCH PERFORMED B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST MEMBER ADDRESS NOT FOUND MA37 MISSING/INCOMPLETE/INVALID PATIENT'S ADDRESS.

38 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 7112 INSURER NOT FOUND MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE INVALID OR UNREALISTIC DATE OF N329 MISSING/INCOMPLETE/INVALID PATIENT BIRTH DATE. BIRTH 7115 PROVIDER LOCATION RESTRICTION 5 THE PROCEDURE /BILL TYPE IS INCONSISTENT WITH M77 MISSING/INCOMPLETE/INVALID/INAPPROPRIATE PLACE OF SERVICE. FOR BILLED PROCEDURE THE PLACE OF SERVICE SERVICE DENIED DUE TO DOWNCODING B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST SERVICE REPLACED DUE TO DOWNCODING 7118 SERVICE REPLACED DUE TO QUANTITY RECODING 7119 DATE OF SERVICE BEFORE SMILE FOR CHILDREN 07/01/2005 B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST. B10 ALLOWED AMOUNT HAS BEEN REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS PAID. THE BENEFICIARY IS NOT LIABLE FOR MORE THAN THE CHARGE LIMIT FOR THE BASIC PROCEDURE/TEST. 109 CLAIM/SERVICE NOT COVERED BY THIS PAYER/CONTRACTOR. YOU MUST SEND THE CLAIM/SERVICE TO THE CORRECT PAYER/CONTRACTOR. N216 WE DO NOT OFFER COVERAGE FOR THIS TYPE OF SERVICE OR THE PATIENT IS NOT ENROLLED IN THIS PORTION OF OUR BENEFIT PACKAGE PLAN NOT EFFECTIVE, BILL PRIOR ADMINISTRATOR 26 EXPENSES INCURRED PRIOR TO COVERAGE INVALID DATE OF SERVICE N301 MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S) SERVICE REQUIRES 1ST 95 PLAN PROCEDURES NOT FOLLOWED. PROCEDURE BEFORE EACH ADDITIONAL PROCEDURE BILLED 7125 SERVICE DENIED - NOT COVERED OVER RESTORATIONS 7126 SERVICE NOT BILLABLE AFTER DENTURES CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR N65 PROCEDURE OR PROCEDURE RATE COUNT CANNOT BE DETERMINED, OR 7710 MEMBER NOT ELIGIBLE (DTL) - FINAL 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED MEMBER NOT ELIGIBLE (DTL) - FINAL 31 PATIENT CANNOT BE IDENTIFIED AS OUR INSURED CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 7730 FINAL EDIT - RECYCLE PA/PAS NOT READY 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N147 N147 N147 N517 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. 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. 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 MEMBER HAS SELF REPORTED 22 THIS CARE MAY BE COVERED BY ANOTHER PAYER PER MA92 MISSING PLAN INFORMATION FOR OTHER INSURANCE. OTHER INSURANCE - NOT VERIFIED CLAIM/SERVICE LACKS INFORMATION OR HAS SUBMISSION/BILLING ERROR(S) WHICH IS NEEDED FOR 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 FINAL EDIT - HOLD MEDICARE 169 ALTERNATE BENEFIT HAS BEEN PROVIDED. CLAIMS WITH TOB 111 OR FINAL EDIT PROCEDURE NOT COVERED BY PROVIDER CONTRACT 8 THE PROCEDURE IS INCONSISTENT WITH THE PROVIDER/SPECIALTY (TAXONOMY). N95 THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS SERVICE PAPER CLAIM NOT ALLOWED 96 NON-COVERED CHARGE(S). M117 NOT COVERED UNLESS SUBMITTED VIA ELECTRONIC CLAIM DENIED AFTER REVIEW OF NCCI/MUE B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY MA46 THE NEW INFORMATION WAS CONSIDERED BUT ADDITIONAL PAYMENT WAS NOT REQUEST HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT. ISSUED INSUFFICIENT INFORMATION FOR 252 AN ATTACHMENT/OTHER DOCUMENTATION IS REQUIRED TO N29 MISSING DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART. NCCI/MUE REQUEST ADJUDICATE THIS CLAIM/SERVICE DUPLICATE NCCI/MUE REQUEST 96 NON-COVERED CHARGE(S). M DENIED AS PPC 7760 PRE-PAYMENT SELECTION BYPASSED BY USER

39 EOB EOB DESCRIPTION CASE CONSULT IN 3 MONTHS = 2 UNITS 8001 LIMIT 1 PROC PER MEMBER PER DAY-VARIOUS S 8002 ESRD RELATED SERVICES 1 PER MONTH 8003 PA IS REQUIRED FOR BASIC MEMBERS ADJUSTMENT REASON ADJUSTMENT REASON DESCRIPTION 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 DESCRIPTION THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8004 MODIFIER 26 REQUIRED IN HOSPITAL 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 SETTING 8005 CONTRACEPTIVE INJECTABLE 3MTH. 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE DEPRO-PROVERA 8006 CONTRACEPTIVE INJECTABLE 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE LUNELLE 1 PER MONTH 8007 T1028, 1 ASSESSMENT = BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE COMPONENTS/UNITS PER YEAR 8008 T1024, 3 TEAM MEETINGS = BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE UNITS/COMPONENTS PER YR ASSIST AT SURGERY/PER MEMB/PER DAY 54 MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN THIS CASE. N646 REIMBURSEMENT HAS BEEN ADJUSTED BASED ON THE GUIDELINES FOR AN ASSISTANT LIMIT 1 ANESTHESIA PER 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE MEMBER PER DAY MONURAL V BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE DISPENSING FEES IN 5 YEARS VISITS ALLOWED FOR 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE CHC/FP PER YEAR REEVALUATIONS (99456-TS) PER 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE YEAR 8014 PHARMACY S - MAX 31 UNITS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE PER MONTH 8015 ORTHOTICS - 1 UNIT IN 1 YEAR FROM 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE DOS 8016 ORTHOTICS 2 UNITS IN 1 YEAR FROM 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE DOS 8017 ORTHOTICS 4 UNITS IN 1 YEAR FROM 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE DOS 8018 ORTHOTICS 3 UNITS IN 6 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8019 ORTHOTICS 6 UNITS IN 1 YEAR 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8020 ORTHOTICS 8 UNITS IN 1 YEAR 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8021 ORTHOTIC 1 UNIT IN 3 YEARS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8022 PROSTHETICS 12 UNITS IN 1 YEAR 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE STOCKINGS IN 7 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE LITHIUM ION BATTERY CHARGER IN 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 2 YEARS 8025 HOME HEALTH PT LIM 20 VIS ( BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE UNITS) 12 MONTHS 8026 HOME HEALTH OT LIM 20 VIS ( BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE UNITS) 12 MONTHS 8027 HOME HEALTH ST LIM 35 VIS ( BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE UNITS)12 MONTHS 8028 DME 1 UNIT IN 1 CALENDAR MONTH 8029 DME 2 UNITS IN 1 CALENDAR MONTH 8030 DME 3 UNITS IN 1 CALENDAR MONTH 8031 DME 4 UNITS IN 1 CALENDAR MONTH 8032 DME 10 UNITS IN 1 CALENDAR MONTH 8033 DME LIMIT 6 UNITS IN 1 MONTH 8034 DME 12 UNITS IN 1 CALENDAR MONTH

40 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 8035 DME 18 UNITS IN 1 CALENDAR MONTH 8036 DME LIMIT 20 UNITS IN 1 CALENDAR MONTH 8037 DME LIMIT 30 UNITS IN 1 CALENDAR MONTH 8038 DME LIMIT 31 UNITS IN 1 CALENDAR MONTH 8039 DME LIMIT 35 UNITS IN 1 CALENDAR MONTH 8040 DME LIMIT 40 UNITS IN 1 CALENDAR MONTH 8041 DME LIMIT 60 UNITS IN 1 CALENDAR MONTH 8042 DME LIMIT 93 UNITS IN 1 CALENDAR MONTH 8043 DME LIMIT 100 UNITS IN 1 CALENDAR MONTH 8044 DME LIMIT 120 UNITS IN 1 CALENDAR MONTH 8045 DME LIMIT 250 UNITS IN 1 CALENDAR MONTH 8046 DME LIMIT 720 UNITS IN 1 CALENDAR MONTH 8047 DME LIMIT 1000 UNITS IN 1 CALENDAR MONTH 8048 DME LIMIT 1 UNIT IN 3 CALENDAR 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE MONTHS 8049 DME LIMIT 2 UNIT IN 3 CALENDAR MONTHS 8050 DME LIMIT 3 UNITS IN 3 MONTHS MOD=KS ONLY 8051 DME LIMIT 4 UNITS IN 3 CALENDAR MONTHS 8052 DME LIMIT 5 UNITS IN 3 MTHS MODIFR KS ONLY 8053 DME LIMIT 6 UNITS IN 3 MONTHS 8054 DME LIMIT 15 UNITS IN 3 MTHS MOD KX ONLY 8055 DME LIMIT 8 UNITS IN 3 MTHS MOD KX ONLY 8056 DME LIMIT 9 UNITS IN 3 CALENDAR MTHS 8057 DME LIMIT 10 UNITS IN 6 MONTHS 8058 DME LIMIT 1 UNIT IN 6 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE 8059 DME LIMIT 2 UNITS IN 6 MONTHS 8060 DME LIMIT 16 UNITS IN 6 MONTHS 8061 DME LIMIT 1 UNIT IN 12 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE 8062 DME LIMIT 2 UNITS IN 12 MONTHS 8063 DME LIMIT 4 UNITS IN 12 MONTHS 8064 DME LIMIT 8 UNITS IN 12 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8065 DME LIMIT 12 UNITS IN 12 MONTHS 8066 DME LIMIT 1 UNIT IN 24 MONTHS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE 8067 DME LIMIT 1 UNIT IN 3 YEARS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE 8068 DME LIMIT 2 UNITS IN 3 YEARS 8069 DME LIMIT 1 UNIT IN 5 YEARS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE 8070 LIMIT 27 UNITS PER MONTH

41 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 8071 DME LIMIT 36 UNITS PER MONTH 8072 DME LIMIT 12 PER MNTH PER WOUND=108 UNITS 8073 DME LIMIT 30 PER MTH PER WOUND=27O UNITS 8074 DME LIMIT 31 PER MTH PER WOUND=279 UNITS 8075 DME LIMIT 45 PER MTH PER WOUND=405 UNITS 8076 DME LIMIT 60 PER MTH PER WOUND=540 UNITS 8077 DME LIMIT 80 PER MTH PER WOUND=720 UNITS 8078 DME LIMIT 100 PER MTH PER WOUND=900 UNITS 8079 DME LIMIT 160 PER MTH PER WOUND=1440 UNITS 8080 DME LIMIT 200 PER MTH PER WOUND=1800 UNITS 8081 DME LIMIT 240 PER MTH PER WOUND=2160 UNITS 8082 DME LIMIT 100 PER WOUND IN 3 MTHS =900 UNITS 8083 DME LIMIT 11 UNITS PER MONTH 8084 DME LIMIT 150 UNITS PER MONTH 8085 DME LIMIT 124 UNITS PER MONTH 8086 DME LIMIT 15 UNITS PER MONTH 8087 DME LIMIT 90 UNITS PER MONTH 8088 SCREENING/INTAKE 8 UNITS T BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE PER MBR PER 12 MTHS 8089 DAY HABILITATION LIMIT 1 PER DAY 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE EXCEPT MOD PA REQUIRED FOR MOBILITY REPAIR 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES N517 OVER $1, MODIFIER 26 OR TC REQUIRED FOR PROCEDURE S IN GROUP THE PROCEDURE IS INCONSISTENT WITH THE N ORTHOTIC AND PROSTHETIC LIMIT - 4 UNITS PER MEMBER PER YEAR FROM LAST DOS 8093 ORTHOTIC AND PROSTHETIC LIMIT - 6 UNITS PER MEMBER PER YEAR FROM LAST DOS 8094 ORTHOTIC AND PROSTHETIC LIMIT - 8 UNITS PER MEMBER PER YEAR FROM LAST DOS 8095 ORTHOTIC AND PROSTHETIC LIMIT - 12 UNITS PER MEMBER PER YEAR FROM LAST DOS 8096 ORTHOTIC LABOR AND REPAIR S REQUIRE PA IF OVER $ PER MONTH 8097 PROSTHETIC LABOR AND REPAIR S REQUIRE PA IF OVER $ PER MONTH 8098 MODIFIER REQUIRED FOR VARIOUS CAPPED RENTAL/PURCHASE S. MODIFIERS VALUES KH 8099 MODIFIER REQUIRED FOR VARIOUS OXYGEN S.MODIFIERS VALUES QF QG RR U2. 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES 15 THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES 4 THE PROCEDURE IS INCONSISTENT WITH THE 4 THE PROCEDURE IS INCONSISTENT WITH THE 8100 TOOTH PREVIOUSLY EXTRACTED 149 LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED FOR THIS SERVICE/BENEFIT CATEGORY MODIFIER REQUIRED FOR CHRONIC 4 THE PROCEDURE IS INCONSISTENT WITH THE THERAPY SERVICES N517 N517 N517 N517 N587 N517 POLICY BENEFITS HAVE BEEN EXHAUSTED.

42 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 8102 DME SURGICAL S REQUIRE 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 ONE OF THE A1 THROUGH A9 MODIFIERS HIT NURSING VISIT S THE PROCEDURE IS INCONSISTENT WITH THE N517 AND REQUIRE MODIFIER SD DIABETIC SUPPLIES/INFUSION 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 SUPPLIES REQR MODIFIER 8105 PROFESSIONAL COMPONENT NOT ALLOWED FOR THIS SERVICE ENTERAL PROCEDURE S 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 REQUIRE A MODIFIER 8107 ORTHOTIC AND PROSTHETIC S 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 REQUIRE LT/RT MODIFIER 8108 PA REQUIRED FOR MONAURAL M62 MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION. HEARING AIDS IF COSTS EXCEEDS $ PA IS REQUIRED FOR BINAURAL, CROS AND BICROS HEARING AIDS IF COSTS EXCEEDS $1, ORTHOTIC AND PROSTHETIC LIMIT - M62 MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION. 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 1 UNIT PER MEMBER IN 1 YEAR FROM LAST DOS 8111 ORTHOTIC - PROSTHETIC - LIMIT 2 UNITS PER MEMBER PER YEAR FROM DOS 8112 LIMIT 10 UNITS PER DAY PROC BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8113 LIMIT 13 UNITS PER DAY PROC BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8114 LIMIT 1 UNIT PER DAY - VARIOUS 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE S 8115 DME LIMIT 2 UNITS IN 5 YEARS 8116 LIMIT 4 UNITS PER DAY PROC BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8117 LIMIT ONE DIAPER S PER MONTH 8118 LIMIT 1 CESAREAN PER DAY (SURG) 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N DME LIMIT 225 UNITS IN 1 MONTH 8120 LIMIT 1 LAPAROSCOPIC 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N517 CHOLECYSTECTOMY PER DAY(SURG) 8121 ADULT DAY CARE SERVICE LIMIT 1 PER DAY 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8122 FIRST MONTHS RENTAL OF VARIOUS CAPPED RENTAL S LIMIT 1 IN 5 YEARS WITH MODI 8123 SECOND AND THIRD MONTHS RENTAL OF VARIOUS CAPPED RENTAL S LIMIT 2 IN 5 YEAR MONTHS CAPPED RENTAL ALLOWED IN 5 YEARS FOR VARIOUS CAPPED RENTAL S LIMI 8125 VARIOUS REPAIR/MOBILITY S REQUIRE A MOD. MOD VALUES NU RP RR UB UC UE U MODIFIER REQUIRED FOR S A4450, A4452 AND A5120. MODIFIER VALUES AU AV AW TRANSPORTATION T2003 LIMIT - 2 ONE WAY TRIPS / DAY 8128 AFC S5140 TF/U5 LIMIT 14 UNITS PER CAL YEAR 8129 PHARMACY PLACE OF SERVICE 01 NOT ALLOWED 8130 T4536 T4538 T4539 NOT ALLOWED W DIAPER BILLED 8131 DME LIMIT 1 UNIT PER MONTH (RENTAL ONLY) 4 THE PROCEDURE IS INCONSISTENT WITH THE 4 THE PROCEDURE IS INCONSISTENT WITH THE N517 N BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE N59 PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL PROGRAM AND 5 THE PROCEDURE /BILL TYPE IS INCONSISTENT WITH M77 Missing/incomplete/invalid place of service. THE PLACE OF SERVICE.

43 EOB EOB DESCRIPTION ADJUSTMENT ADJUSTMENT REASON DESCRIPTION DESCRIPTION REASON 8132 DME LIMIT 13 UNITS IN 3 YEARS (MOD RR ONLY) 8133 DME CONFLICT: PURCHASE VS RENTAL IN 3 YEARS 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE LIMIT 1 IN 3 YEARS ON 1ST MONTH OF CAPPED RENTAL ND & 3RD MONTHS CAPPED RENTAL- LIMIT 2 IN 3 YEARS 8136 LIMIT 10 IN 3 YEARS FOR 10 MONTHS OF CAPPED RENTAL 8137 DME RENTAL NOT ALLOWED AFTER PURCHASE IN 3 YEARS 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE DME LIMIT 13 UNITS IN 5 YEARS (MOD RR ONLY) 8139 DME CONFLICT: PURCHASE VS RENTAL IN 5 YEARS 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE DME RENTAL NOT ALLOWED AFTER PURCHASE IN 5 YEARS 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE DME CONFLICT: PURCHASE VS RENTAL IN 1 YEAR 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE DME CONFLICT: PURCHASE VS RENTAL IN 24 MONTHS 108 RENT/PURCHASE GUIDELINES WERE NOT MET. M7 NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE DME LIMIT 13 UNITS IN 24 MONTHS (MOD RR ONLY) 8144 NDC - UNITS - & UNIT N657 THIS SHOULD BE BILLED WITH THE APPROPRIATE FOR THESE SERVICES. DESCRIPTOR REQUIRED 8145 MAX UNITS 1 PER DAY FOR NON- SCHOOL BASED PROVIDERS 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8146 MAX UNITS 3 PER DAY FOR NON- SCHOOL BASED PROVIDERS 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8147 MAX UNITS 4 PER DAY FOR NON- SCHOOL BASED PROVIDERS 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8148 MAX UNITS 6 PER DAY FOR NON- SCHOOL BASED PROVIDERS 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8149 MAX UNITS 7 PER DAY FOR NON- SCHOOL BASED PROVIDERS 96 NON-COVERED CHARGE(S). N362 THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR ACCEPTABLE 8150 NEW AND DELETED S CANNOT B13 PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY BE BILLED ON SAME DAY HAVE BEEN PROVIDED IN A PREVIOUS PAYMENT.