The following table provides descriptions of Adjustment Codes and the corresponding Explanation Codes. Adjustment Code Description Description CHARGES APPLIED TO CALENDAR YEAR 01 Deductible Amount LN OSTOMY SUPPLY/EQUIPMENT DEDUCTIBLE CHARGES APPLIED TO CONTRACT YEAR 01 Deductible Amount T5 DEDUCTIBLE CHARGE APPLIED TO DME CALENDAR YEAR 01 Deductible Amount M5 DEDUCTIBLE CHARGES APPLIED TO CALENDAR YEAR 01 Deductible Amount LK DISPOSABLE SUPPLY DEDUCTIBLE CHARGES APPLIED TO CALENDAR YEAR DME 01 Deductible Amount LJ DEDUCTIBLE CHARGES APPLIED TO CALENDAR YEAR 01 Deductible Amount L4 DEDUCTIBLE THIS CHARGE APPLIED TO THE CALENDAR 01 Deductible Amount D2 YEAR DEDUCTIBLE CHARGES APPLIED TO CALENDAR YEAR 01 Deductible Amount D6 DEDUCTIBLE COINSURANCE AMOUNT HAS BEEN APPLIED TO 02 Coinsurance Amount O2 CAL YEAR OUT-OF-POCKET CHARGES APPLIED TO OUT OF POCKET 02 Coinsurance Amount K8 MAXIMUM CHARGES APPLIED TO IN-NETWORK 02 Coinsurance Amount 6H CALENDAR YEAR OUT-OF-POCKET. CHARGES APPLIED TO CALENDAR YEAR OUT- 02 Coinsurance Amount L6 OF-POCKET 02 Coinsurance Amount E6 COINSURANCE AMOUNT HAS BEEN APPLIED CHARGES APPLIED TO CONTRACT YEAR OUT- 02 Coinsurance Amount T7 OF-POCKET 04 04 04 05 05 05 05 05 05 05 05 05 05 06 06 07 The procedure code is inconsistent with the modifier used or a required modifier is missing. M9 MODIFIER 22 DOES NOT APPEAR APPROPRIATE BASED ON REVIEW OF DOCUMENTATION The procedure code is inconsistent with the modifier BILATERAL IS INHERENT IN THIS CPT CODE, used or a required modifier is missing. OT RESUBMIT 1 UNIT WITHOUT MODIFIER The procedure code is inconsistent with the modifier DENIED - PLEASE RESUBMIT WITH MODIFIER used or a required modifier is missing. A0 APPROPRIATE FOR MIDLEVEL PROVIDER The procedure code/bill type is inconsistent with the CC - DENIED - DIAGNOSIS AND PROCEDURE place of service. CE COMBINATION NOT VALID The procedure code/bill type is inconsistent with the CI - PROCEDURE CODE ISN'T PAYABLE FOR place of service. 0W THIS LOCATION The procedure code/bill type is inconsistent with the DENIED - SERVICES RENDERED NOT COVERED place of service. N2 IN THIS PLACE OF SERVICE. The procedure code/bill type is inconsistent with the DENIED - PROCEDURE NOT COVERED IN THIS place of service. OP PLACE OF SERVICE The procedure code/bill type is inconsistent with the DENY-NOT ALLOWED IN OFFICE LOCATION, place of service. 9Y MEMBER NOT LIABLE The procedure code/bill type is inconsistent with the LOCATION CODE AND PROCEDURE CODE DO place of service. IV NOT MATCH, PLEASE RESUBMIT CLAIM The procedure code/bill type is inconsistent with the CI - TECHNICAL SERVICES NOT PAYABLE TO place of service. 4K MD PROVIDERS FOR THIS LOCATION The procedure code/bill type is inconsistent with the LOCATION DOES NOT MATCH SERVICES ON place of service. 4C FILE-PLEASE RESUBMIT CORRECT CODING The procedure code/bill type is inconsistent with the CLAIM DENIED. PROVIDER MUST RESUBMIT place of service. ZJ WITH VALID DRG NUMBER. The procedure code/bill type is inconsistent with the DENY, USE 99213 FOR OFFICE, 99431 FOR place of service. A7 INPATIENT The procedure/revenue code is inconsistent with CC - PROCEDURE OR DIAGNOSIS NOT VALID the patient's age. BU FOR MEMBER'S AGE The procedure/revenue code is inconsistent with the patient's age. CA PROCEDURE NOT VALID FOR MEMBER'S AGE The procedure/revenue code is inconsistent with PROCEDURE IS NOT VALID FOR MEMBER'S the patient's gender. BY GENDER Page 1 of 21
07 Adjustment Code Description The procedure/revenue code is inconsistent with the patient's gender. 09 The diagnosis is inconsistent with the patient's age. BX BS Description CC - PROCEDURE OR DIAGNOSIS NOT VALID FOR MEMBER'S GENDER MEMBER'S AGE IS NOT VALID FOR SECONDARY DIAGNOSIS 11 The diagnosis is inconsistent with the procedure. UB DENIED - PLEASE RESUBMIT AS URGENT CARE 11 The diagnosis is inconsistent with the procedure. I3 PER CFC IPA, PROCEDURE LEVEL NOT VALID FOR DIAGNOSIS 11 The diagnosis is inconsistent with the procedure. 95 INCONSISTENT/INVALID DIAG/PROCEDURE/MODIFIER/DRG. RESUBMIT CORRECTED CLM 11 The diagnosis is inconsistent with the procedure. 4H CI-INCONSISTENT/INVALID DIAGNOSIS - RESUBMIT CORRECTED CLAIM 13 The date of death precedes the date of service. 3D DENIED - SERVICE POSTDATES MEMBERS DEATH 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. FY THE AUTHORIZATION NUMBER IS NOT ON FILE. 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. 9C DATE OF SERVICE IS NOT WITHIN THE DATE RANGE OF THE AUTHORIZATION using appropriate D0 using appropriate IU using appropriate B8 using appropriate JK using appropriate HO using appropriate SE using appropriate RD using appropriate 93 using appropriate NR using appropriate FN DENIED - RESUBMIT WITH DRUG NAME AND DOSAGE OR CORRECT HCPCS CODE PLEASE RESUBMIT SUPPLIES WITH APPROPRIATE HCPCS CODE MORE INFO NEEDED-PLEASE SUBMIT DETAIL SHEET W/ D.O.S. FOR PART. HOSP PRG DENIED- PLEASE SUBMIT A COPY OF THE PURCHASE INVOICE. DENIED-OFFICE NOTES NEEDED FOR CONSIDERATION OF BENEFITS ON THIS CLAIM. CC - PLEASE SUBMIT CLINICAL DOCUMENTATION FOR REVIEW DENIED-REFERRING PHYSICIAN CANNOT BE IDENTIFIED ON CLAIM PLEASE RESUBMIT WITH COMPLETE PROVIDER INFORMATION REFERRING PROVIDER INFO FROM REFERRAL NEEDED MORE SPECIFIC/CORRECTED BILLING INFOREQ.CONTACT PROV REL AT 860-674-5850 Page 2 of 21
17 17 17 17 Adjustment Code Description using appropriate using appropriate 53 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the 5A Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the 59 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the RX Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the UG Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the 3E Description CORRECTED BILLING INFO.IS REQUIRED. PLEASE CALL 1-800-828-3407. PLEASE SUBMIT CLINICAL DOCUMENTATION FOR REVIEW DENIED-CLINICAL DOCU. IS ILLEGIBLE AND THEREFORE CONSIDERED NOT DONE. BENEFITS WILL BE RECONSIDERED UPON RECEIPT OF REQUESTED DOCUMENTATION CLAIM WILL BE RECONSIDERED UPON RECEIPT OF REQUESTED DOCUMENTATION DENIED - PLEASE RESUBMIT WITH APPROPRIATE URGENT CARE ID NUMBER DENIED - ER/URGENT CARE - QUESTIONNAIRE REQUESTED WAS NEVER RECEIVED 17 18 Duplicate claim/service. 36 DENIED - DUPLICATE CLAIM. DENIED-ORIGINAL CLAIM SUBMISSION WAS 18 Duplicate claim/service. HE PREVIOUSLY DENIED 18 Duplicate claim/service. DENIED-DUPLICATE CLAIM 18 Duplicate claim/service. 0Q CI - DENIED-DUPLICATE CLAIM DENIED-ORIGINAL CLAIM SUBMISSION IS 18 Duplicate claim/service. HD PENDING FURTHER REVIEW Claim denied because this is a work-related injury/illness and thus the liability of the Worker's DENIED-INFORMATION INDICATES CLAIM 19 Compensation Carrier. 31 QUALIFIES FOR WORKER'S COMPENSATION. Claim denied because this injury/illness is covered 20 by the liability carrier. KZ PLEASE FORWARD TO APPROPRIATE CARRIER Claim denied because this injury/illness is the 21 liability of the no-fault carrier. 68 CHARGE WAS APPLIED TO NO-FAULT BENEFIT. Payment adjusted because charges have been paid MEMBERS ALTERNATE COVERAGE IS 23 by another payer. 22 SECONDARY Payment adjusted because charges have been paid MEMBERS ALTERNATE COVERAGE IS 23 by another payer. 23 UNAVAILABLE Payment for charges adjusted. Charges are covered under a capitation agreement/managed AMOUNT ALLOWED BASED ON PROVIDER'S 24 care plan. 08 CAPITATED SERVICE CONTRACT 24 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. 28 SERVICE INCLUDED IN PROVIDER'S CAPITATED SERVICE CONTRACT Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. JO DENIED, SERVICE IS CAPITATED Page 3 of 21
Adjustment Code Description Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Description CAPITATED SERVICES BY NEW ENGLAND EYE 24 NE CARE DENIED - THE CONTRACT IS INELIGIBLE AT THE 26 Expenses incurred prior to coverage. CN TIME OF SERVICE. DENIED - THE GROUP IS INELIGIBLE DURING 27 Expenses incurred after coverage terminated. GY AUTHORIZATION PERIOD. DENIED-SERVICE DATE BEYOND PREM PD TO 27 Expenses incurred after coverage terminated. 65 DATE PLUS GRACE PER FOR DIR PAY GR DENIED - THE SUBSCRIBER IS INELIGIBLE AT 27 Expenses incurred after coverage terminated. HA THE TIME OF SERVICE. DENIED-THE CONTRACT IS INELIGIBLE DURING 27 Expenses incurred after coverage terminated. GW AUTHORIZED PERIOD. CCI NO LONGER ADMINISTERS THIS PLAN. 27 Expenses incurred after coverage terminated. VL CONTACT YOUR EMPLOYER. DENIED - THE GROUP IS INELIGIBLE AT THE 27 Expenses incurred after coverage terminated. CS TIME OF SERVICE. THIS GROUP HAS TERMINATED, SUBMIT ALL 27 Expenses incurred after coverage terminated. NW CLAIMS TO YOUR BENEFITS OFFICE DENIED - PATIENT IS NOT ELIGIBLE ON CLAIM 27 Expenses incurred after coverage terminated. 39 DATE OF SERVICE. CLAIM NOT ELIGIBLE FOR PAYMENT - THIS 27 Expenses incurred after coverage terminated. JZ GROUP HAS TERMINATED. DENIED-THE MEMBER IS INELIGIBLE DURING 27 Expenses incurred after coverage terminated. GU AUTHORIZED PERIOD. DENIED-SERVICE DATE BEYOND PREM PD TO 27 Expenses incurred after coverage terminated. 64 DATE PLUS GRACE PER FOR COBRA GRPS DENIED-THE DIVISION IS INELIGIBLE DURING 27 Expenses incurred after coverage terminated. GX AUTHORIZED PERIOD. DENIED - THE DIVISION IS INELIGIBLE AT THE 27 Expenses incurred after coverage terminated. CP TIME OF SERVICE. RECEIVED PAST FILING LIMIT - PARTICIPATING 29 The time limit for filing has expired. 30 PROVIDER CANNOT BILL MEMBER DATES OF SERVICE PRIOR TO 1/1/92 CANNOT 29 The time limit for filing has expired. B2 BE PROCESSED ON AMISYS DENIED-CLAIM SUBMITTED PAST FILING LIMIT. 29 The time limit for filing has expired. 0A PAR PROVIDER CANNOT BILL MBR. 29 The time limit for filing has expired. P8 DENIED CLAIM SUBMITTED PAST FILING LIMIT Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or SERVICES ARE NOT PAYABLE UNTIL 91ST DAY 30 residency requirements. WR OF CONFINEMENT 30 30 30 31 31 31 31 31 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or C4 DENIED-GROUP/INDIVIDUAL NON PAYMENT OF PREMIUM residency requirements. PC DENIED-MEMBER DID NOT SELECT A PCP Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or DENIED-OVERAGE DEPENDENT VERIFICATION residency requirements. C3 HAS NOT BEEN RECEIVED Claim denied as patient cannot be identified as our DENIED - THE GROUP DOES NOT HAVE A insured. CR GROUP-SPAN RECORD. Claim denied as patient cannot be identified as our DENIED - THE CONTRACT RECORD IS NOT ON insured. CM FILE. Claim denied as patient cannot be identified as our DENIED - NO DIVISION-SPAN RECORD EXIST insured. CT FOR MEMBER'S DIVISION#. Claim denied as patient cannot be identified as our insured. CQ DENIED - THE GROUP RECORD IS NOT ON FILE. Claim denied as patient cannot be identified as our DENIED - THE DIVISION RECORD IS NOT ON insured. CO FILE. Page 4 of 21
31 31 31 32 Adjustment Code Description Description Claim denied as patient cannot be identified as our MEMBER ID NUMBER WITH ORIGINAL CLAIM IS insured. 91 NOT ON FILE. Claim denied as patient cannot be identified as our insured. FT MEMBER IS NOT ON FILE. Claim denied as patient cannot be identified as our DENIED - THE SUBSCRIBER'S RECORDS COULD insured. GZ NOT BE FOUND. Our records indicate that this dependent is not an DENIED - DEPENDENT NOT ELIGIBLE FOR eligible dependent as defined. OB SERVICES 34 Claim denied. Insured has no coverage for newborns. C6 NEWBORN HAS NOT BEEN FORMALLY ADDED, PLEASE CALL CUSTOMER RELATIONS 35 Lifetime benefit maximum has been SC CHIRO FEE SCHEDULE MAXIMUM PER DAY HAS BEEN MET-MEMBER MAY NOT BE BILLED 35 Lifetime benefit maximum has been 70 LIFETIME ALLERGY TESTING MAX EXHAUSTED -- MEMBER CANNOT BE BILLED. 35 Lifetime benefit maximum has been PT PT FEE SCHEDULE MAXIMUM PER DAY HAS BEEN MET-MEMBER MAY NOT BE BILLED 35 Lifetime benefit maximum has been 6D DENIED - EARLY INTERVENTION SERVICES LIFETIME MAX EXHAUSTED 35 Lifetime benefit maximum has been 81 DENIED-BENEFIT LIFETIME MAXIMUM EXHAUSTED 35 Lifetime benefit maximum has been 14 DENIED-BENEFIT LIMITS HAVE BEEN EXCEEDED 35 Lifetime benefit maximum has been 13 DENIED-BENEFIT LIMITS HAVE BEEN EXCEEDED 35 Lifetime benefit maximum has been PB CONTRACT DAILY MAXIMUM HAS BEEN MET- MEMBER CANNOT BE BILLED 35 Lifetime benefit maximum has been 15 DENIED-BENEFIT LIFETIME MAX.EXCEEDED MEMBER CANNOT BE BILLED. BO REFERRING PROVIDER IS NOT INPLAN. TR DENIED. TRANSPLANTS REQUIRE PRE- AUTHORIZATION. MEMBER MAY BE BILLED. NA DENIED-SERVICES ARE AVAILABLE IN PLAN K5 DENY SERVICES NOT AUTHORIZED ND DENIED-PRIOR AUTHORIZATION REQUIRED FOR MEDICAL EQUIPMENT/SUPPLIES. K7 DENY UNAUTHORIZED NON PARTICIPATING PROVIDER MEMBER MAY BE BILLED MB PRIOR AUTH REQUIRED IN AN OUTPATIENT SETTING - MEMBER CANNOT BE BILLED R9 SERVICES DENIED, NO AUTHORIZATION OR PRE-CERTIFICATION RECEIVED 8F CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. RF PAYMENT REVERSED, NON-REFERRED SERVICES, MEMBER MAY BE BILLED PO NO AFFILIATION WITH PTPN AFTER 9/30/98 83 AN ADMISSION AUTHORIZATION IS NOT ON FILE. 3Y DENIED-NO PRIOR AUTHORIZATION RECEIVED- MEMBER CANNOT BE BILLED 6F CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. US MEDICAL RECORDS & EXPLANATION NEEDED IN ORDER TO PROCESS UNAUTH SERVICES Page 5 of 21
Adjustment Code Description 6G Description CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. 39 39 39 39 39 39 39 39 39 40 40 40 42 42 42 42 42 3W DENIED - ANESTHESIA PROCEDURE REQUIRED PRE-AUTH - IN NETWORK PROVIDER DENIED - LAB PROCEDURE REQUIRED 3U PREAUTH - IN NETWORK PROVIDER DENIED-INPATIENT/PROCEDURE REQUIRE 17 CERTIFICATION. Services denied at the time authorization/precertification was requested. G0 THIS SERVICE DENIED AFTER MEDICAL REVIEW Services denied at the time authorization/precertification CC - SERVICE DENIED BASED ON CLINICAL was requested. H6 CODING REVIEW Services denied at the time authorization/precertification was requested. 49 DENIAL BASED ON MEDICAL REVIEW Services denied at the time authorization/precertification DENIED-INPT/PROCEDURE CERTIFICATION was requested. 19 DENIED Services denied at the time authorization/precertification DENIED NOT MEDICALLY NECESSARY - was requested. 7I MEMBER MAY BE BILLED Services denied at the time authorization/precertification was requested. UP DENIAL UPHELD - PER IPA MEDICAL DIRECTOR Services denied at the time authorization/precertification was requested. UQ DENIAL UPHELD - PER CCI MEDICAL DIRECTOR Services denied at the time authorization/precertification CC - PROCEDURE DENIED AFTER CLINICAL was requested. JI DOCUMENTATION REVIEW Services denied at the time authorization/precertification SERVICES DENIED AFTER MEDICAL REVIEW - was requested. 2C MEMBER CANNOT BE BILLED Charges do not meet qualifications for emergent/urgent care. 58 DENIED-DOC SUBMITTED DID NOT REFLECT URGENT/EMERGENT NATURE OF PROCEDURE Charges do not meet qualifications for emergent/urgent care. JD DENIED-NON COVERED URGENT CARE VISIT Charges do not meet qualifications for emergent/urgent care. DENIED-INAPPROPRIATE USE OF EMERGENCY ROOM BASED ON CLAIM INFORMATION. Charges exceed our fee schedule or maximum DENIED - LIMIT FOR MULTIPLE SURGERIES HAS allowable amount. MR BEEN REACHED Charges exceed our fee schedule or maximum CI - PAYMENT HAS BEEN REDUCED BY USE OF allowable amount. 0V THIS MODIFIER Charges exceed our fee schedule or maximum THE MAXIMUM PAYABLE FOR THIS BENEFIT allowable amount. L1 HAS BEEN REACHED. Charges exceed our fee schedule or maximum MAXIMUM AMOUNT HAS BEEN PAID FOR THIS allowable amount. 73 SERVICE Charges exceed our fee schedule or maximum FEE SCHEDULE DAILY MAXIMUM HAS BEEN allowable amount. J5 MET- MEMBER CANNOT BE BILLED INCLUDED IN UNITED RESOURCE NETWORK arrangement. J8 CONTRACTUAL RATE arrangement. TA CASE AGREEMENT-TRANSPLANT GLOBAL FEE PROVIDER NOT CONTRACTED FOR THIS arrangement. 2D SERVICE - MEMBER MAY NOT BE BILLED DENIED-SERVICES EXCEED PROVIDER arrangement. 46 CONTRACT.MEMBER CANNOT BE BILLED. PROVIDER CONTRACT EXCEEDED-MEMBER arrangement. AJ CANNOT BE BILLED arrangement. AZ PROCEDURE IS INCLUDED IN PER DIEM RATE AMOUNT EXCEEDS CAPITATED SERVICES arrangement. 5P CONTRACT - MEMBER CANNOT BE BILLED INCLUDED IN CASE RATE - MEMBER CAN NOT arrangement. E0 BE BILLED. Page 6 of 21
Adjustment Code Description arrangement. YY arrangement. 75 arrangement. GL arrangement. LM Description MAXIMUM CONTRACT AMOUNT HAS BEEN PAID FOR THIS SERVICE. PROVIDER CONTRACT EXCEEDED-MEMBER CANNOT BE BILLED. INCLUDED IN GLOBAL PT FEE - MEMBER CANNOT BE BILLED MAXIMUM CONTRACT AMOUNT HAS BEEN PAID FOR THIS SERVICE arrangement. TB INCLUDED IN CASE AGREEMENT TRANSPLANT GLOBAL-MEMBER CAN NOT BE BILLED arrangement. KX PAYABLE ONLY WITH LEVEL I & II TREATMENTS arrangement. E9 MODALITIES ARE INCLUDED IN THE ERN CASE RATE- MEMBER CANNOT BE BILLED 46 This (these) service(s) is (are) not covered. WC FIRST 91 DAYS OF CONFINEMENT ARE NOT PAID BY CONNECTICARE FOR WESLEYAN 46 This (these) service(s) is (are) not covered. B3 THE BENEFIT HAS NOT BEEN PURCHASED 47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid. 7H DENIED - TMJ IS NOT COVERED UNDER YOUR PLAN. 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. R8 ROUTINE FOLLOW-UP CARE IN URGENT CARE/WALK-IN IS NOT COVERED 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. 9G ROUTINE CARE NOT COVERED OUT OF NETWORK 50 These are non-covered services because this is not deemed a `medical necessity' by the payer. 3H DENIED - AMBULANCE (NOT MEDICALLY NECESSARY) 50 These are non-covered services because this is not deemed a `medical necessity' by the payer. TH NOT A COVERED SERVICE-MEDICAL NECESSITY GUIDELINES BEING DEVELOPED 50 These are non-covered services because this is not deemed a `medical necessity' by the payer. I1 PER CFC IPA, DENIED-SERVICE NOT MEDICALLY NEC BASED ON CLM INFORMATION 50 50 50 50 51 52 52 52 52 52 These are non-covered services because this is not deemed a `medical necessity' by the payer. 54 These are non-covered services because this is not deemed a `medical necessity' by the payer. 47 These are non-covered services because this is not deemed a `medical necessity' by the payer. 48 These are non-covered services because this is not deemed a `medical necessity' by the payer. 57 These are non-covered services because this is a pre-existing condition PI The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. 94 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. BL The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. R1 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. BR The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. JQ DENIED-PROCEDURE CONSIDERED COSMETIC IN NATURE. NOT A COVERED BENEFIT. DENIED-PROC DOES NOT MEET CRITERIA OF MED NEC PROG.PT MAY NOT BE BILLED. DENIED-SERVICES NOT MEDICALLY NECESSARY BASED ON CLAIM INFORMATION. DENIED-THIS PROCEDURE DOES NOT APPEAR TO BE MEDICALLY NECESSARY DENY,SERVICES RELATED TO A PRE-EXISTING CONDITION. REFERRING PROVIDER ID NUMBER IS INVALID - MEMBER CANNOT BE BILLED REFERRING PROVIDER WAS NOT EFFECTIVE AT TIME OF SERVICE DENIED-REFERRING PHYSICIAN WAS NOT ON CLAIM OR WAS NON-PARTICIPATING REFERRING PROVIDER NO LONGER PARTICIPATING WITH CONNECTICARE DENIED-PROVIDER SPECIALTY CAN NOT DISPENSE DME Page 7 of 21
52 52 54 54 55 59 59 59 59 Adjustment Code Description The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. JN Multiple physicians/assistants are not covered in this case. 55 Multiple physicians/assistants are not covered in this case. 0Z Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer. FQ Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. AI IX Description DENIED-REFERRING PROVIDER IS NOT A PARTICIPATING PROVIDER. DENIED - PROVIDER CANNOT DISPENSE DME OR SUPPLIES CC - ASSISTANT MD IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE CI - ASSISTANT MD IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE DENIED - PROCEDURE IS EXPERIMENTAL/INVESTIGATIONAL. AMBULATORY SURGERY PAID ACCORDING TO MEDICARE GROUPINGS CC - INFORMATIONAL ONLY, PROCEDURE Charges are adjusted based on multiple surgery PROCESSED THROUGH OUR CODING rules or concurrent anesthesia rules. JX SOFTWARE Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. 07 PRICED PER ANESTHESIA CALCULATIONS. Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. PH SURGEON'S REIMBURSEMENT FEE REDUCED BENEFITS REDUCED TO COINSURANCE RATE - 9F REFERRAL OF SERVICE WAS REQUIRED. 3X DENIED - ANESTHESIA PROCEDURE REQUIRED PREAUTH - OUT OF NETWORK PROVIDER DENIED-HOSPITAL ADMISSION REQUIRES PREexceeded, pre-certification/authorization. 41 AUTHORIZATION. DENIED - NO PRIOR AUTH/REFERRAL 42 RECEIVED-MEMBER CANNOT BE BILLED L8 CHARGES PAID AT 50% RATE DENIED - UNAUTHORIZED DIALYSIS OUT OF 3F PLAN BENEFITS REDUCED BY 50% - PRIOR 63 AUTHORIZATION IS REQUIRED PENALTY APPLIED TO PAYMENT DUE TO PZ ADVANCED NOTIFICATION REQUIREMENTS DENIED - CERTIFIED LENGTH OF STAY 18 EXCEEDED. PENALTY APPLIED TO PAYMENT DUE TO LACK KP OF PRE AUTHORIZATION PEND-SERVICES/BENEFIT NOT AUTHORIZED BY 80 THE PLAN 43 DENIED-NO REFERRAL ON FILE 8E UA 3S 1C KS JG REDUCED PAYMENT-NO REFERRAL RECD-MBR MAY BE BILLED UP TO CONTRACTED RATE PAID AT 50%, NO PRE-AUTHORIZATION RECEIVED. DENIED - SKILLED NURSING FACILITY (NOT AUTHORIZED) PAYMENT REVERSED. NON-REFERRED SERVICES, MEMBER MAY BE BILLED. REDUCED RATE NO REFERRAL RCVD MEMBER MAY BE BILLED CONTRACTED RATE DENIED- SERVICE EXCEEDS PRE-AUTHORIZED LIMIT Page 8 of 21
Adjustment Code Description Description CHARGES APPLIED TO $200.00 PENALTY FOR R5 LACK OF PRE-CERTIFICATION DENIED-PROC REQUIRES PRE-AUTH. PROVIDER MUST SUBMIT PRE-OPERATIVE 1R NOTES. PENALTY APPLIED TO PAYMENT DUE TO LACK B4 OF PRE-AUTHORIZATION 3N DENIED - HOME HEALTH (NOT AUTHORIZED) NO PRIOR AUTH/REFERRAL RECEIVED - 4D MEMBER MAY BE BILLED DENIED-UNAUTHORIZED NON-PARTICIPATING 3V PROVIDER-MEMBER MAY BE BILLED 3Z F7 DENIED - RADIOLOGY PROCEDURE REQUIRED PREAUTH - OUT OF NETWORK PROVIDER DENIED - UNAUTHORIZED NON-PARTICIPATING PROVIDER 6E PAYMENT FOR THIS SERVICE HAS BEEN REDUCED DUE TO NON RECEIPT OF REFERRAL 35 DENIED-PRIOR AUTHORIZATION REQUIRED FOR MEDICAL EQUIPMENT/SUPPLIES. DENIED - UNAUTHORIZED NON-PARTICIPATING PROVIDER-MEMBER MAY BE BILLED HP SERVICE EXCEEDS AUTHORIZED DAYS BY ^. 4B DENIED - SERVICE EXCEEDS PRE AUTHORIZATION LIMIT 85 Interest amount. OI PAYMENT WAS DELAYED - INTEREST WAS PAID ON THIS CLAIM 88 Adjustment amount represents collection against receivable created in prior overpayment. JM PAYMENT DUE APPLIED TO OVERPAYMENT 88 Adjustment amount represents collection against receivable created in prior overpayment. RM PAID, USED TO OFFSET OUTSTANDING REFUND REQUEST (L&R) 96 Non-covered charge(s). 27 THE SERVICE IS NO LONGER A BENEFIT. 96 Non-covered charge(s). 74 DENIED-NOT A COVERED BENEFIT 96 Non-covered charge(s). HN THE BENEFIT HAS NOT BEEN PURCHASED. 96 Non-covered charge(s). RG DENIED-NOT A COVERED BENEFIT UNDER YOUR PLAN 96 Non-covered charge(s). 12 DENIED - PROCEDURE IS NOT COVERED. 96 Non-covered charge(s). MV DENIED - PROVIDER MUST BILL WITH THE APPROPRIATE ANESTHESIA CODE 96 Non-covered charge(s). 1B DENIED - NOT COVERED UNDER ERISA PLAN 96 Non-covered charge(s). D8 DENIED-NON COVERED DME/SUPPLIES 96 Non-covered charge(s). 26 CONTRACT HAS NOT SELECTED THIS SUPPLEMENTAL MEDICAL RIDER. 96 Non-covered charge(s). NC NOT A COVERED PROCEDURE - MEMBER CANNOT BE BILLED 96 Non-covered charge(s). 3Q DENIED - SHOE ORTHOTICS NOT A COVERED BENEFIT 96 Non-covered charge(s). H2 DENIED - PROCEDURE NOT COVERED. MEMBER CANNOT BE BILLED. 96 Non-covered charge(s). JE DENIED-NON COVERED DENTAL SERVICES 96 Non-covered charge(s). FX THE PROCEDURE MUST BE A MAJOR SURGICAL PROCEDURE 96 Non-covered charge(s). 25 THERE IS NO BASIC OTHER COVERAGE FOR THIS MEDICAL RIDER. 96 Non-covered charge(s). JF DENIED-NON COVERED ORTHOTICS,DME OR SUPPLIES. Page 9 of 21
Adjustment Code Description Description DENIED - ROUTINE FOOT CARE - NOT A 96 Non-covered charge(s). 3P COVERED BENEFIT DENIED - PERSONAL COMFORT ITEMS - NOT A 96 Non-covered charge(s). 3T COVERED BENEFIT DENIED - DENTAL SERVICES ARE NOT A 96 Non-covered charge(s). 3J COVERED BENEFIT NOT A COVERED BENEFIT - MEMBER MAY BE 96 Non-covered charge(s). 3C BILLED NOT A COVERED BENEFIT - MEMBER CANNOT 96 Non-covered charge(s). 3A BE BILLED 96 Non-covered charge(s). R6 NON-COVERED DME/SUPPLIES 96 Non-covered charge(s). JH NON COVERED HANDLING & DRAWING FEE 96 Non-covered charge(s). 34 DENIED-NOT A COVERED BENEFIT 96 Non-covered charge(s). FS THE PROCEDURE IS NOT A MAJOR SURGICAL PROCEDURE G3 CC - INFORMATIONAL ONLY, CORRECTED PROC CODE ADDED BY CODING SOFTWARE 37 PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE WW ST RAPHAEL'S HOSPITAL AMBISURG- ANCILLARY'S HISTORY ONLY M0 ORAL MEDICATIONS/SUPPLIES INCLUDED IN OFFICE VISIT-MEMBER CANNOT BE BILL Y4 CI - MORE APPROPRIATE PROCEDURE HAS BEEN ADDED Y3 CI - SERVICE HAS BEEN RECODED BASED ON PREVIOUSLY BILLED SERVICES YQ CI - PROCEDURE IS INCLUDED IN PHYSICIAN VISIT SERVICE. 52 DENIED-THIS PROCEDURE IS CONSIDERED PART OF ANOTHER CPT CODE ON CLAIM. KM SVCS ARE INCL IN GLOBAL FEE FOR SOME SURG CODES -MEMBER CANNOT BE BILLED SF CC - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE 0S CI-THIS SERVICE IS INCLUDED IN A RELATED PROC BILLED BY SAME PROVIDER 00 CLAIM LEVEL PRICING DENY YZ CI - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE J3 CC - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE A5 CLAIM CHECK REVIEW 9B INFO EX FOR REPLACEMENT SERVICES 9A DENY EX FOR REPLACED SERVICES 90 HISTORY ONLY G2 CC - THIS SERVICE IS INCLUDED IN A RELATED PROC BILLED BY SAME PROVIDER G9 CC - SERVICE AFFECTED BY PROVIDER SPLIT BILLING/RELATED CLAIM I2 PER CFC IPA,DENIED-INCLUDED IN GLOBAL FEE OF PRIMARY SURGICAL PROCEDURE VP MEMBER MAY NOT BE BILLED, SERVICE INCLUDED AS PART OF ROUTINE PAYMENT LG HISTORY ONLY Page 10 of 21
Adjustment Code Description Description WA SERVICE INCLUDED IN GLOBAL AMBULATORY SURGICAL REIMBURSEMENT RATE 60 ZERO AMOUNT BILLED. HISTORY ONLY. W9 PAY $0.00-FEE FOR THIS SERVICE IS INCLUDED IN THE PRIMARY PROCEDURE G7 CC - PROCEDURE REPLACED THROUGH OUR CODING SOFTWARE 100 Payment made to patient/insured/responsible party. MY PHCS PPO - PREFERRED PAR PROVIDER ALLOWABLE APPLIED. MEMBER NOT LIABLE. 100 Payment made to patient/insured/responsible party. JL AMOUNT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE 100 Payment made to patient/insured/responsible party. MU PAID AT ESTIMATED MEDICARE RATE, ADVISE IF UNACCEPTABLE 100 Payment made to patient/insured/responsible party. 20 FOR REPORTING PURPOSES ONLY. 100 Payment made to patient/insured/responsible party. HC APPROVED BY CASE MANAGEMENT 100 Payment made to patient/insured/responsible party. B7 CLAIM HAS BEEN RECODED FOR THE CORRECT BENEFIT/PRICING 100 Payment made to patient/insured/responsible party. HJ MEMBER'S ALTERNATE COVERAGE HAS TERMINATED - CONNECTICARE IS PRIMARY 100 Payment made to patient/insured/responsible party. A8 AS OF 03/01/2001 PLEASE CALL 888-946-4658 TO AUTHORIZE THIS SERVICE 100 Payment made to patient/insured/responsible party. T6 CONTRACT YEAR DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. P4 PAY & EDUCATE - INAPPROPRIATE USE OF EMERGENCY ROOM 100 Payment made to patient/insured/responsible party. O1 CALENDAR YEAR OUT-OF-POCKET MAXIMUM HAS BEEN MET. 100 Payment made to patient/insured/responsible party. EQ CLAIM REVERSED DUE TO PARTIAL REFUND. COPAY OR 20% COINSURANCE, WHICHEVER 100 Payment made to patient/insured/responsible party. LS LESS, APPLIED TO THIS SERVICE 100 Payment made to patient/insured/responsible party. W1 CC - POTENTIAL COB PAY EX CODE 100 Payment made to patient/insured/responsible party. W2 CC - PAY-AUDIT COMPONENT BILLING 100 Payment made to patient/insured/responsible party. EK 100 Payment made to patient/insured/responsible party. EL CLAIM DENIAL REVERSED DUE TO APPEAL THROUGH EMERGENCY ROOM APPEAL COMM. CLAIM DENIAL REVERSED DUE TO APPEAL THROUGH GRIEVANCE COMMITTEE. 100 Payment made to patient/insured/responsible party. EM CLAIM DENIAL REVERSED DUE TO APPEAL. 100 Payment made to patient/insured/responsible party. LT EMERGENCY ROOM LETTER SENT TO MEMBER 100 Payment made to patient/insured/responsible party. EP CLAIM REVERSED DUE TO FULL REFUND. 100 Payment made to patient/insured/responsible party. 06 AMT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE-MEMBER CANNOT BE BILLED 100 Payment made to patient/insured/responsible party. 5B PEND-IF BILLED W/DENTAL PX*RECODE TO D9220,D9221 100 Payment made to patient/insured/responsible party. MM MANUALLY PRICED CLAIMS FOR PRO-AMERICA PROVIDERS 100 Payment made to patient/insured/responsible party. OV OVER FILING LIMIT-PROCESSED TO PAY MANUAL PRICE - NY PROVIDER, PRICING 100 Payment made to patient/insured/responsible party. NY REQUIRED SEE NETWORK OPS FOR RATES Page 11 of 21
Adjustment Code Description 100 Payment made to patient/insured/responsible party. LE 100 Payment made to patient/insured/responsible party. Q3 100 Payment made to patient/insured/responsible party. SZ Description CALENDAR YEAR DME DEDUCTIBLE HAS BEEN MET AS OF 7/1/2000 PREAUTHORIZATION WILL BE REQUIRED FOR THIS SERVICE. FUTURE CLAIMS WITH INCOMPLETE DIAGNOSIS CODES WILL BE DENIED 100 Payment made to patient/insured/responsible party. P3 PAY & EDUCATE - REFERRAL CI - PAYMENT REDUCED 8% SINCE NON-IONIC 100 Payment made to patient/insured/responsible party. YU CONTRAST WAS USED 100 Payment made to patient/insured/responsible party. 29 MANUALLY PRICED BY CLAIMS SPECIALIST 100 Payment made to patient/insured/responsible party. K9 OUT OF POCKET MAXIMUM HAS BEEN MET 100 Payment made to patient/insured/responsible party. YO CLAIMS ADJUSTED - PAID INCORRECT FEE - MASS REVERSAL 100 Payment made to patient/insured/responsible party. PR CLAIMS PENDING FOR PRICING CONFIGURATION IS NOT COMPLETED 100 Payment made to patient/insured/responsible party. OA NON-REIMBURSABLE CHARGES, DISCOUNT GIVEN AT TIME OF PURCHASE. 100 Payment made to patient/insured/responsible party. YT CI - SERVICE COUNT HAS BEEN CORRECTED TO ALLOWABLE # OF UNITS 100 Payment made to patient/insured/responsible party. MK APPEAL PAY & EDUCATE - INNAPPROPRIATE USE OF ER ROOM 100 Payment made to patient/insured/responsible party. T8 CONTRACT YEAR OUT-OF-POCKET MAXIMUM HAS BEEN MET 100 Payment made to patient/insured/responsible party. KA PAID IN ACCORDANCE W/ MULTIPLAN INC DISCOUNT RATE AGREEMNT 100 Payment made to patient/insured/responsible party. YL TAX ID AND PROVIDER ID SUBMITTED DO NOT MATCH OUR RECORDS. 100 Payment made to patient/insured/responsible party. HH MEMBER AGE 65 AND NO MEDICARE COVERAGE ON FILE 100 Payment made to patient/insured/responsible party. YK DENIED - SERVICE COUNT HAS BEEN CORRECTED TO ALLOWABLE # OF UNITS 100 Payment made to patient/insured/responsible party. YJ EXCLUDED FROM ICM - SEE CLAIM REMARKS 100 Payment made to patient/insured/responsible party. 3B BIRTH TO THREE MEMBER 100 Payment made to patient/insured/responsible party. UC HCFA REQUIREMENT 100 Payment made to patient/insured/responsible party. J7 100 Payment made to patient/insured/responsible party. 21 100 Payment made to patient/insured/responsible party. C2 REPRICED ACCORDING TO UNITED RESOURCE NETWORK CONTRACTUAL AGREEMENT PRICED PER DISCOUNT UP TO MAXIMUM ALLOWABLE INFORMATION SUBMITTED ON CLAIM INDICATES POSSIBLE SUBROGATION 100 Payment made to patient/insured/responsible party. HF DIAGNOSIS NOT PRESENT ON AUTHORIZATION 100 Payment made to patient/insured/responsible party. C1 MVA INVESTIGATION 100 Payment made to patient/insured/responsible party. HY CHP MEMBER - PAID PER SPECIAL ARRANGEMENT 100 Payment made to patient/insured/responsible party. PG CLAIM PROCESSED USING DRG PRICER GROUPER. 100 Payment made to patient/insured/responsible party. RU DENIAL REVERSED - PER IPA MEDICAL DIRECTOR 100 Payment made to patient/insured/responsible party. RN CLAIM DENIAL REVERSED - CASE MANAGER DECISION 100 Payment made to patient/insured/responsible party. MJ APPEAL PAY & EDUCATE REFERRAL Page 12 of 21
Adjustment Code Description Description 100 Payment made to patient/insured/responsible party. MQ UP & UP/ AHP CONTRACTUAL ADJUSTMENT PCP AND MEMBER AGREED UTILIZE CCI 100 Payment made to patient/insured/responsible party. UT NETWORK. 100 Payment made to patient/insured/responsible party. G6 THIS IS A PAYABLE SERVICE. POSP 28899 IS NOT APPLICABLE 100 Payment made to patient/insured/responsible party. UJ INFORMATIONAL FOR PROVIDER ONLY 100 Payment made to patient/insured/responsible party. G8 CC - FOLD STATUS-INFO ONLY 100 Payment made to patient/insured/responsible party. UH POSP 28899 - INFORMATIONAL FOR PROVIDER ONLY 100 Payment made to patient/insured/responsible party. Y2 CI - PROCEDURE HAS BEEN REPLACED WITH MORE APPROPRIATE CODE 100 Payment made to patient/insured/responsible party. 2A PAYMENT MUST BE MADE TO THE MEMBER DENIED-NON-PARTICIPATING PROVIDERS ARE 100 Payment made to patient/insured/responsible party. OC NOT COVERED 100 Payment made to patient/insured/responsible party. KK A REFERRAL IS REQUIRED FOR THIS SERVICE 100 Payment made to patient/insured/responsible party. 09 AMOUNT ALLOWED BASED ON PROVIDER'S CONTRACTED RATE 100 Payment made to patient/insured/responsible party. KG CLAIM DISCOUNTED PER FEE AGREEMENT THRU ADVANCED FOCUS/JOHN ALDEN LIFE 100 Payment made to patient/insured/responsible party. MX CLAIM PRICED PER MULTIPLAN DISCOUNT 100 Payment made to patient/insured/responsible party. TK PAYMENT OF TAX 100 Payment made to patient/insured/responsible party. RL CLAIM ADJUSTED DUE TO OVERPAYMENT REFUND (L&R) 100 Payment made to patient/insured/responsible party. Q2 AS OF 7/1/2000 PREAUTHORIZATION WILL BE REQUIRED FOR THIS SERVICE. 100 Payment made to patient/insured/responsible party. D1 THE PAYMENT ALLOWED AMOUNT IS CALCULATED AUTOMATICALLY 100 Payment made to patient/insured/responsible party. RC COB RECOVERY 100 Payment made to patient/insured/responsible party. 86 PROVIDER ACCEPTS ASSIGNMENT. 100 Payment made to patient/insured/responsible party. X2 EMERGENCY/URGENT CARE SERVICES RENDERED. 100 Payment made to patient/insured/responsible party. RA ST. RAPHAEL'S HEALTH CARE SYSTEM ADJUSTMENT FACTOR PAYMENT 100 Payment made to patient/insured/responsible party. 4E CI - SERVICE IS CORRECTLY CODED CALENDAR YEAR OUT-OF-POCKET MAXIMUM 100 Payment made to patient/insured/responsible party. L7 HAS BEEN MET 100 Payment made to patient/insured/responsible party. R2 PAID AT MAXIMUM ALLOWABLE RATE 100 Payment made to patient/insured/responsible party. LB PAID PER DISCOUNTED LAB RATE 100 Payment made to patient/insured/responsible party. CF PAID-EXTRA CONTRACTUAL AGREEMENT ON FILE 100 Payment made to patient/insured/responsible party. LF CALENDAR YEAR DISPOSABLE SUPPLY DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. LH CALENDAR YEAR OSTOMY SUPPLY/EQUIPMENT DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. WJ MULTIPLE SURGERY CODE-MANUALLY PRICED 100 Payment made to patient/insured/responsible party. D7 CALENDAR YEAR DEDUCTIBLE HAS BEEN MET Page 13 of 21
Adjustment Code Description 100 Payment made to patient/insured/responsible party. W3 100 Payment made to patient/insured/responsible party. 04 MANUALLY PRICED. Description CC - INFORMATIONAL ONLY, ORIGINAL CODE SUBMITTED ON CLAIM 100 Payment made to patient/insured/responsible party. 01 PAID ACCORDING TO AMOUNT BILLED ALLOWED FEE AT 110% OF USUAL TO INCLUDE 100 Payment made to patient/insured/responsible party. MF PRIMARY CARE MANAGEMENT FEE 100 Payment made to patient/insured/responsible party. 02 PRICED AT RELATIVE VALUE SCHEDULE. 100 Payment made to patient/insured/responsible party. MD CLAIM DENIAL REVERSED - MEDICAL DIRECTOR DECISION 100 Payment made to patient/insured/responsible party. 03 AMOUNT ALLOWED BASED ON PROVIDER'S CONTRACTED FEE SCHEDULE 100 Payment made to patient/insured/responsible party. 6T INFORMATIONAL ONLY YOUR INDIVIDUAL CALENDAR YEAR 100 Payment made to patient/insured/responsible party. D3 DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. IMCC HISTORY DATA DENIAL REVERSED - PER CCI MEDICAL 100 Payment made to patient/insured/responsible party. RT DIRECTOR 100 Payment made to patient/insured/responsible party. LX SERVICE EXEMPT FROM DEDUCTIBLE 100 Payment made to patient/insured/responsible party. LW MEMBER RESPONSIBILITY CALCULATION BASED ON TOTAL AMOUNT ALLOWED 100 Payment made to patient/insured/responsible party. VH VARIABLE RISK WITHHOLD FOR HARTFORD PHO 100 Payment made to patient/insured/responsible party. E8 CLAIM DENIAL REVERSED-REFERRAL REC'D FROM PCP 100 Payment made to patient/insured/responsible party. LV MEMBER RESPONSIBILITY CALCULATION BASED ON TOTAL AMOUNT BILLED 100 Payment made to patient/insured/responsible party. V8 CONNECTICARE 65 IS PRIMARY CARRIER 100 Payment made to patient/insured/responsible party. 89 PAYMENT HAS BEEN MADE DIRECTLY TO THE IRS. 100 Payment made to patient/insured/responsible party. Y9 CI - BILLED MODIFIER REMOVED-DOESN'T APPLY TO THIS SERVICE 100 Payment made to patient/insured/responsible party. L5 CALENDAR YEAR DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. MP AMERICA'S HEALTH PLAN PROVIDER UTILIZED 100 Payment made to patient/insured/responsible party. RP REFERRAL MODIFIED BY PRIMARY CARE PHYSICIAN.PLEASE CALL PCP FOR INFO. 100 Payment made to patient/insured/responsible party. 6I CALENDAR YEAR IN-NETWORK OUT-OF- POCKET MAXIMUM HAS BEEN MET. 104 Managed care withholding. VR VARIABLE RISK WITHHOLD FOR MIDDLESEX PROFESSIONAL SERVICES 104 Managed care withholding. VN VARIABLE RISK WITHHOLD FOR NEW BRITAIN IPA 104 Managed care withholding. VM VARIABLE RISK WITHHOLD FOR MANCHESTER/ROCKVILLE 107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. ON PAYABLE ONLY WHEN BILLED WITH OTHER SERVICES 108 Payment adjusted because rent/purchase guidelines were not met. KR DENIED - PER CONTRACT MEMBER HAS REACHED CAPPED RENTAL OPTION FOR DME 92 CONNECTICARE IS NOT THE CARRIER FOR THIS BENEFIT Page 14 of 21
Adjustment Code Description Description JT THIS GROUP HAS TERMINATED, SUBMIT ALL CLAIMS TO NEW CARRIER. NU PLEASE SUBMIT SERVICE TO NEU'S MH/SA CARRIER PER INFO ON MBR'S ID CARD. KE DENIED - PLEASE SUBMIT THE MEDICARE EXPLANATION OF BENEFITS KD DENIED - SUBMIT ALL-INCLUSIVE BILL FOR COB PROCESSING KF DENIED - PLEASE SUBMIT THE OTHER INSURANCE EXPLANATION OF BENEFITS 0B SEND CLAIMS TO MENTAL HEALTH VENDOR, CALL CONNECTICARE FOR ASSISTANCE 6A DENIED-NOT PRIMARY CARRIER. SUBMIT TO THIRD PARTY CARRIER. MH CCI IS NOT THE CARRIER FOR THIS SERVICE/SUBMIT CLAIM TO PATHWISE 51 66 67 DENIED-CONNECTICARE NOT PRIMARY CARRIER. SUBMIT TO AUTO INS CARRIER. DENIED-NOT PRIM CARR.SUBMIT TO PARTY RESPONSIBLE FOR THE PERSONAL INJURY DENIED-NOT PRIM CARR.PT SELF-INS $5,000 DUE TO LACK OF NO-FAULT COVERAGE SD PLEASE SUBMIT SERVICE TO MH/SA CARRIER PER INFO ON MBR'S ID CARD. 6C PLEASE SUBMIT CLAIM TO PRO AMERICA FOR PRICING V2 PLEASE SUBMIT SERVICE TO CCI'S VISION CARE VENDOR. HQ DENIED-PRIM PAYOR IS BASIC/MAJ MED PLAN. BOTH EXPLAIN OF BENEFITS NEEDED H9 DENIED-REBILL VISION VENDOR WITH ROUTINE DIAG OR SUBMIT CLINICAL DOC. V4 CLAIM FORWARDED.SEND FUTURE VISION CLAIMS TO ROCKY MOUNT,NORTH CAROLINA. P7 DENIED - PLEASE SUBMIT LEGIBLE CLINICAL DOCUMENT TO PODIATRIC IPA R3 DENIED SERVICES, SUBMIT TO PHARMACY PLAN 110 Billing date predates service date. JV SERVICES NOT YET RENDERED. PLEASE RESUBMIT AFTER SERVICES ARE RENDERED. Page 15 of 21
115 115 Adjustment Code Description Description Payment adjusted as procedure postponed or OBSOLETE PROCEDURE CODE - MEMBER canceled. 11 CANNOT BE BILLED Payment adjusted as procedure postponed or CI - OBSOLETE PROCEDURE CODE-MEMBER canceled. YX CANNOT BE BILLED MAXIMUM NUMBER OF REHABILITATION VISITS R4 PAID FOR THIS CALENDAR YEAR. PHYSICAL THERAPY MAXIMUM HAS BEEN MET - 88 MEMBER CANNOT BE BILLED BENEFIT MAXIMUM FOR THIS CALENDAR YEAR 77 HAS BEEN EXHAUSTED OSTOMY SUPPLY/EQUIPMENT MAXIMUM FOR OE CALENDAR YEAR HAS BEEN EXHAUSTED CALENDAR YEAR MAXIMUM FOR ANTIGENS 71 EXHAUSTED IMPLANT REMOVAL PAYMENT SUBJECT TO LR $1000.00 YEARLY BENEFIT LIMIT BENEFIT MAXIMUM FOR THIS CALENDAR YEAR 78 HAS BEEN EXHAUSTED DENIED ONLY 1 ROUTINE VISION VISIT IS 7A ALLOWED EVERY 2 YEARS. MAXIMUM REHAB VISITS FOR THIS CONDITION 7C HAS BEEN EXHAUSTED V1 MAXIMUM SKILLED NURSING BENEFIT USED BENEFIT MAXIMUM FOR THIS CALENDAR YEAR 76 HAS BEEN EXHAUSTED MAXIMUM HOME HEALTH CARE VISITS PAID L9 FOR THIS CALENDAR YEAR CALENDAR YEAR REHAB THERAPY MAXIMUM 72 HAS BEEN EXHAUSTED DENIED, EYEWEAR MAXIMUM EXHAUSTED FOR 7G THIS 12 MONTH PERIOD DENIED, BENEFIT ALLOWS FOR 2 EYE EXAMS 7F PER 12 MONTH PERIOD EYEWEAR MAXIMUM HAS BEEN EXHAUSTED 7D FOR THIS YEAR VISION BENEFIT FOR THIS YEAR HAS BEEN 7E EXHAUSTED MAXIMUM NUMBER OF SESSIONS USED FOR M1 THIS CALENDAR YEAR CHIRO FEE SCHEDULE DAILY MAXIMUM HAS 87 BEEN MET- MEMBER CANNOT BE BILLED MAXIMUM BENEFIT HAS BEEN EXHAUSTED FOR KL THIS BENEFIT PERIOD MAXIMUM AMBULANCE BENEFIT HAS BEEN M2 PAID DENIED - BENEFIT LIMITS HAVE BEEN 9S EXCEEDED. DENIED-THIS SERVICE CAN ONLY BE 1M BILLED/PAID ONCE PER MONTH. TWO YEAR ALLERGY TESTING MAXIMUM PF EXHAUSTED DENIED-BENEFIT LIMITS HAVE BEEN 33 EXCEEDED DME MAXIMUM FOR THIS CALENDAR YEAR HAS 8A BEEN EXHAUSTED DENIED - MEMBER HAS EXHAUSTED HEARING 3K AID BENEFIT K4 MAXIMUM BENEFIT REACHED Page of 21
Adjustment Code Description KH M6 M4 K3 6B 3G 79 7B K2 85 0U 98 32 VC YW PA 96 61 P9 HG Description THE 2 CALENDAR YEAR MAXIMUM HAS BEEN MET. $300.00 CALENDAR YEAR SUPPLY MAX HAS BEEN MET MAXIMUM NUMBER OF IN PATIENT DAYS PAID FOR THIS CALENDAR YEAR DENIED BENEFIT MAXIMUM FOR SKILLED NURSING HAS BEEN MET DENIED - EARLY INTERVENTION SERVICES CALENDAR YEAR MAX EXHAUSTED DENIED - INPATIENT PSYCHIATRIC - MEMBER HAS REACHED MAXIMUM BENEFIT SKILLED NURSING DAYS FOR BENEFIT PERIOD EXCEEDED. DENIED-LIMIT ONE VISION MAXIMUM PER CONTRACT YEAR CALENDAR YEAR CHIRO THERAPY MAXIMUM HAS BEEN EXHAUSTED DME SUPPLY MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED CI - THIS DIAGNOSIS DOESN'T MATCH THIS PROCEDURE CLAIM CANNOT BE ACCEPTED ELECTRONICALLY.PLEASE RESUBMIT CLAIM ON PAPER. CODING NOT WITHIN CONTRACT - MEMBER CANNOT BE BILLED PLEASE RESUBMIT WITH ALLOWABLE ALLERGY SERVICE CPT CODE. CI - PROCEDURE NOT VALID FOR MEMBER'S AGE OR GENDER DENIED - PLEASE RESUBMIT WITH PROVIDER SITE NUMBER. ONLY ONE DATE OF SERVICE CAN BE ACCEPTED PER CLAIM LINE.RESUBMIT CLAIM. CLAIM COORDINATED WITH PAYMENT MADE BY PRIMARY CARRIER DENIED - PLEASE RESUBMIT WITH APPROPRIATE HCPCS CODE DENIED - PROCEDURE CODE IS NO LONGER VALID.PLEASE CORRECT AND RESUBMIT. Page 17 of 21
Adjustment Code Description 69 131 Claim specific negotiated discount. 05 4G D9 PD Y7 4I 0T L3 Description DENIED-SUBMITTED CLAIM & PRIMARY EXPLANATION OF BENEFITS DO NOT MATCH CI-PROCEDURE IS INCORRECT BASED ON THIS,OR PREVIOUSLY BILLED CLAIMS OBSOLETE DIAGNOSIS CODE - MEMBER CANNOT BE BILLED PLEASE RESUBMIT CLAIM WITH CPT-4/HCPC CODE. CI - THIS PROCEDURE IS NOT TYPICALLY BILLED FOR THIS DIAGNOSIS CI-DUPLICATE OF A PREVIOUSLY PAID NEW OR SOON TO BE OBSOLETE PROC CODE CI-SERVICE AT FACILITY LOCATION ISN'T PAYABLE TO MD.FACILITY BILLS THIS CANNOT BILL DISCHARGE DAY, PLEASE RE- BILL WITH CORRECTED DAYS AMOUNT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE 131 Claim specific negotiated discount. UR PAID IN ACCORDANCE WITH UNITED RESOURCE NETWORK DISCOUNT AGREEMENT 131 Claim specific negotiated discount. TF PAID ACCORDING TO ENVISIONCARE ALLIANCE, INC. NEGOTIATED DISCOUNT. 131 Claim specific negotiated discount. TD PAID IN ACCORDANCE WITH NEGOTIATED TRANSPLANT DISCOUNT. 136 Claim Adjusted. Plan procedures of a prior payer were not followed. FL CLAIM ADJUSTED 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. UN DENIED - PLEASE RESUBMIT WITH APPROPRIATE PROVIDER IDENTIFICATION NUMBER 150 150 150 150 150 Payment adjusted because the payer deems the information submitted does not support this level of service. Payment adjusted because the payer deems the information submitted does not support this level of service. Payment adjusted because the payer deems the information submitted does not support this level of service. Payment adjusted because the payer deems the information submitted does not support this level of service. Payment adjusted because the payer deems the information submitted does not support this level of service. 3M 3R 3I WS 3L DENIED - HOME HEALTH (MEMBER NOT HOMEBOUND) DENIED - SKILLED NURSING FACILITY (CUSTODIAL CARE OR NOT DAILY SNF CARE) DENIED-CHIRO-DOES NOT MEET BENEFIT CRITERIA FOR CHIROPRATIC COVERAGE DENY-PLEASE RESUBMIT WITH DENTAL HCPCS CODE OR CLINICAL DOCUMENTATION. DENIED - HOME HEALTH (DOES NOT MEET SKILLED NURSING GUIDELINES) Page 18 of 21
151 151 Adjustment Code Description Payment adjusted because the payer deems the information submitted does not support this many services. Payment adjusted because the payer deems the information submitted does not support this many services. Payment adjusted because the payer deems the information submitted does not support this many services. YS H7 Description CI - BILLED PROCEDURES EXCEEDS NUMBER OF UNITS ALLOWED CC - BILLED PROCEDURES EXCEEDS # OF UNITS ALLOWED DENIED - THIS SERVICE CAN BE BILLED / PAID 1 151 Z9 UNIT PER DATE OF SERVICE A0 Patient refund amount. A6 REIMBURSEMENT FOR COPAY DENIED-NON PARTICIPATING VISION VENDOR A1 Claim denied charges. B5 PROVIDER-NO BENEFITS ARE PAYABLE. CLAIM ADJUSTED - INCORRECT DEDUCTIBLE A2 Contractual adjustment. FE TAKEN. A2 Contractual adjustment. AO ADJUSTMENT FACTOR FOR MIDDLESEX PROFESSIONAL SERVICES A2 Contractual adjustment. ET CLAIM ADJUSTED - SERVICES PAID IN ERROR A2 Contractual adjustment. FG VOID CHECK - PAYMENT MADE TO INCORRECT PROVIDER A2 Contractual adjustment. EU CLAIM ADJUSTED - INCORRECT DATE OF SERVICES. A2 Contractual adjustment. 1E CLAIM ADJUSTED PER IPA/ EK A2 Contractual adjustment. ER CLAIM ADJUSTED - DENIED IN ERROR DUE TO ELIGIBILITY ISSUE A2 Contractual adjustment. EV CLAIM ADJUSTED - PAID INCORRECT NUMBER OF SERVICES. A2 Contractual adjustment. EG CLAIM ADJUSTED - PAYMENT MADE TO INCORRECT PROVIDER A2 Contractual adjustment. EH CLAIM ADJUSTED - PAYMENT MADE TO INCORRECT MEMBER A2 Contractual adjustment. FF CLAIM ADJUSTED - INCORRECT CO-INSURANCE TAKEN. A2 Contractual adjustment. F8 STATISTICAL CLAIM ADJUSTMENT DUE TO FUND A2 Contractual adjustment. FD CLAIM ADJUSTED - INCORRECT CO-PAYMENT TAKEN. A2 Contractual adjustment. FB CLAIM ADJUSTED - PAID DUE TO ADDITIONAL INFORMATION RECEIVED FROM MEMBER A2 Contractual adjustment. EX CLAIM ADJUSTED - DUE TO CHANGE IN HOSPITAL PER DIEM RATE. A2 Contractual adjustment. F4 ADJUSTMENT FACTOR PAYMENT A2 Contractual adjustment. I5 PER CFC IPA, CLAIM ADJUSTED, SERVICES PAID IN ERROR A2 Contractual adjustment. EZ CLAIM ADJUSTED - ADDITIONAL CHARGES RECEIVED A2 Contractual adjustment. EY CLAIM ADJUSTED - DUE TO CHANGE IN FEE SCHEDULE. A2 Contractual adjustment. FC CLAIM ADJUSTED - PAID DUE TO ADDITIONAL INFO RECEIVED FROM PROVIDER. A2 Contractual adjustment. FA CLAIM ADJUSTED - PAID - REFERRING PHYSICIAN INFORMATION RECEIVED. A2 Contractual adjustment. H3 HARTFORD PHYSICIAN HOSPITAL ORGANIZATION ADJUSTMENT FACTOR PAYMENT A2 Contractual adjustment. ES CLAIM ADJUSTED - DENIED IN ERROR SERVICES WERE APPROVED A2 Contractual adjustment. FI VOID CHECK - PAID INCORRECT FEES/CHARGES. A2 Contractual adjustment. FJ VOID CHECK - DUPLICATE PAYMENT MADE TO PROVIDER A2 Contractual adjustment. FK VOID CHECK - CHECK LOST/NOT RECEIVED. Page 19 of 21
Adjustment Code Description Description VOID CHECK - PAYMENT MADE TO INCORRECT A2 Contractual adjustment. FH SUBSCRIBER A2 Contractual adjustment. EW CLAIM ADJUSTED - MISSING CLAIM LINE(S). ADJUSTMENT FACTOR FOR A2 Contractual adjustment. 0M MANCHESTER/ROCKVILLE A2 Contractual adjustment. 0H ADJUSTMENT FACTOR FOR HARTFORD PHO A2 Contractual adjustment. VD THIS TRANSACTION HAS BEEN VOIDED. PER CFC IPA, CLAIM ADJUSTED, PAID A2 Contractual adjustment. I4 INCORRECT FEE ST MARY'S PHYSICIAN HOSPITAL ORGANIZATION ADJUSTMENT FACTOR A2 Contractual adjustment. M7 PAYMENT A2 Contractual adjustment. RV REVERSAL OF VOID A2 Contractual adjustment. 0N ADJUSTMENT FACTOR FOR NEW BRITAIN IPA A2 Contractual adjustment. 1K CLAIM ADJUSTED PER IPA/ LS A2 Contractual adjustment. EO STATISTICAL ADJUSTMENT PER FINANCE A2 Contractual adjustment. EN CLAIM ADJUSTED - INCORRECTLY PAID AS PRIMARY CARRIER A2 Contractual adjustment. EJ CLAIM ADJUSTED - DUPLICATE CLAIM PAYMENT A2 Contractual adjustment. EI CLAIM ADJUSTED - PAYMENT BASED ON INCORRECT FEE A2 Contractual adjustment. 99 DELETED CLAIM LINE. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. TX TAX DENIED - CCI WILL REIMBURSE THE N.Y. TAX DIRECTLY TO THE STATE B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. TE PLEASE SUBMIT CLAIM TO ENVISIONCARE ALLIANCE, INC. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. BV ROUTINE VISION - CLAIM HAS BEEN FORWARDED TO VENDOR FOR PROCESSING. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. U3 CLAIM WILL BE FORWARDED TO YALE MSO FOR PROCESSING B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. TC PLEASE SUBMIT CLAIM TO URN. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. 0C CLAIM HAS BEEN FORWARDED TO CCI'S MENTAL HEALTH/SUBSTANCE ABUSE CARRIER. B11 B12 B15 B15 B15 B15 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. OH Services not documented in patients' medical records. RJ Payment adjusted because this procedure/service is not paid separately. I8 Payment adjusted because this procedure/service is not paid separately. Y8 Payment adjusted because this procedure/service is not paid separately. 0R Payment adjusted because this procedure/service is not paid separately. 56 ROUTINE VISION - CLAIM HAS BEEN FORWARDED TO VENDOR FOR PROCESSING. SERVICE DENIED NOT ON CLINICAL DOCUMENTATION DENIED-SERVICES INCLUDED IN FACILITY PER DIEM. SUBMIT TO FACILITY. CI-VISIT ISN'T IDENTIFIED AS BEING SEPARATE FROM OTHER VISIT SAME DATE CI - THE FREQUENCY OF THIS PROCEDURE EXCEEDS CLINICAL RECOMMENDATIONS DENIED-CHARGES ARE INCLUDED IN GLOBAL FEE OF PRIMARY CHARGES Page 20 of 21
B15 B15 Adjustment Code Description Payment adjusted because this procedure/service is not paid separately. Payment adjusted because this procedure/service is not paid separately. YR JY Description CI-SERVICE IS NOT TYPICALLY PERFORMED ALONG WITH OTHER SERVICES BILLED CC-THIS SERVICE ISN'T TYPICALLY PERFORMED ALONG WITH OTHER SERVS BILLED B15 Payment adjusted because this procedure/service is not paid separately. JB DENIED-PROCEDURE IS MUTUALLY EXCLUSIVE TO ANOTHER PROCEDURE ON CLAIM B15 Payment adjusted because this procedure/service is not paid separately. JA CC - THIS SERVICE IS INCLUDED IN A RELATED PROC BILLED ON SEPARATE CLAIM B15 Payment adjusted because this procedure/service is not paid separately. 4J CI - SAME/SIMILAR SERVICE WAS RECENTLY BILLED FOR THIS CONDITION B18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission. IY UNLISTED PROC CODE NOT ACCEPTABLE- PLEASE REBILL WITH APPROPRIATE CODE B19 Claim/service adjusted because of the finding of a Review Organization. A4 DENIED AFTER REVIEW B19 Claim/service adjusted because of the finding of a Review Organization. RK SERVICE RECODED BASED ON REVIEW OF DOCUMENTATION B22 This payment is adjused based on the diagnosis. CG THIS PROCEDURE IS NOT VALID FOR SECONDARY DIAGNOSIS B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. IW PAYMENT FOR SERVICE EXCLUDED UNDER CONTRACT - MEMBER CANNOT BE BILLED B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. 5C CO SURGEON IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. 4F CI - CO-SURGEON IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. 40 PAYMENT FOR SERVICE EXCLUDED UNDER CONTRACT - MEMBER CANNOT BE BILLED B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Y5 CI - THIS SERVICE IS NOT TYPICALLY PAYABLE FOR YOUR SPECIALTY B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Y6 CI - SURGEON AND SURGICAL ASSIST CANNOT BE THE SAME PROVIDER B6 B7 B7 B7 B9 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. This provider was not certified/eligible to be paid for this procedure/service on this date of service. This provider was not certified/eligible to be paid for this procedure/service on this date of service. This provider was not certified/eligible to be paid for this procedure/service on this date of service. Services not covered because the patient is enrolled in a Hospice. YP 4A JC JP MT CI - MORE THAN 1 ASSISTANT MD IS NOT ALLOWED FOR THIS SERVICE PROVIDER NO LONGER PARTICIPATING WITH CONNECTICARE DENIED-PROCEDURE CODE NOT ON PROVIDER'S CONTRACTED FEE SCHEDULE DENIED, PROCEDURE NOT ON PROVIDER FEE SCHEDULE MEMBER CANNOT BE BILLED. DENIED - MEMBER ELECTED HOSPICE. SUBMIT TO CARRIER/INTERMEDIARY. Page 21 of 21