co 256 denial code descriptions

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim/service denied. Reason Code 42: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: To be used for pharmaceuticals only. Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. (Note: To be used by Property & Casualty only). Reason Code 253: Service not payable per managed care contract. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. The qualifying other service/procedure has not been received/adjudicated. Submit these services to the patient's Pharmacy plan for further consideration. co 256 denial code descriptions . This non-payable code is for required reporting only. This Payer not liable for claim or service/treatment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). Contact Our Denial Management Experts Now. Expenses incurred after coverage terminated. Claim/service denied. Based on entitlement to benefits. Reason Code 138: Claim spans eligible and ineligible periods of coverage. We are receiving a denial with the claim adjustment reason code (CARC) CO/PR B7. Adjustment for administrative cost. These services were submitted after this payers responsibility for processing claims under this plan ended. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Indemnification adjustment - compensation for outstanding member responsibility. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Reason Code 20: The impact of prior payer(s) adjudication including payments and/or adjustments. The expected attachment/document is still missing. Reason Code 7: The diagnosis is inconsistent with the patient's gender. Services denied at the time authorization/pre-certification was requested. Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 33: Balance does not exceed co-payment amount. Claim lacks indication that service was supervised or evaluated by a physician. Monthly Medicaid patient liability amount. Reason Code 217: The applicable fee schedule/fee database does not contain the billed code. To be used for Property and Casualty Auto only. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. The applicable fee schedule/fee database does not contain the billed code. This service/equipment/drug is not covered under the patient's current benefit plan. B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. Payment reduced to zero due to litigation. Reason Code 71: Indirect Medical Education Adjustment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Patient has not met the required residency requirements. Reason Code 176: Patient has not met the required waiting requirements. Missing patient medical record for this service. : The procedure code is inconsistent with the provider type/specialty (taxonomy). Internal liaisons coordinate between two X12 groups. Reason Code A1: Medicare Claim PPS Capital Day Outlier Amount. Insurance will deny the claim with denial reason code CO 16 Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The procedure code/type of bill is inconsistent with the place of service. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. X12 has submitted the first two in a series of recommendations related to advancing the version of already adopted and mandated transactions and proposing additional transactions for adoption. Are you looking for more than one billing quotes ? (Handled in QTY, QTY01=LA). Balance does not exceed co-payment amount. If so read About Claim Adjustment Group Codes below. This procedure is not paid separately. Medicare Claim PPS Capital Day Outlier Amount. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. All X12 work products are copyrighted. (Handled in QTY, QTY01=CD), Patient Interest Adjustment (Use Only Group code PR). Stuck at medical billing? Claim received by the medical plan, but benefits not available under this plan. Reason Code 47: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Procedure code was invalid on the date of service. To be used for Workers' Compensation only, Based on subrogation of a third party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Reason Code 27: Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. X12 produces three types of documents tofacilitate consistency across implementations of its work. (Use only with Group Code PR). Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 03 Co-payment amount. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). The diagnosis is inconsistent with the patient's age. External liaisons represent X12's interests to another organization as defined in a formal agreement between the two organizations. Note: Refer to the 835 Healthcare Policy Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Reason Code 263: Adjustment for compound preparation cost. Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. (Handled in CLP12). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). CO/31/ CO/31/ Medi-Cal specialty mental health billing. Reason Code 35: Services not provided or authorized by designated (network/primary care) providers. The format is always two alpha characters. The provider cannot collect this amount from the patient. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only. This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. Reason Code 32: Lifetime benefit maximum has been reached. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 75: Non-Covered days/Room charge adjustment. Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Information about the X12 organization, its activities, committees & subcommittees, tools, products, and processes. This Payer not liable for claim or service/treatment. This payment is adjusted based on the diagnosis. Service not paid under jurisdiction allowed outpatient facility fee schedule. This change effective 7/1/2013: Claim is under investigation. Payment made to patient/insured/responsible party/employer. Services not provided by network/primary care providers. Claim/Service lacks Physician/Operative or other supporting documentation. WebDENY-NDC UNITS OF MEASURE MISSING OR INVALID 18 33 DENIED - THIS SERVICE IS AN EXACT DUPLICATE OF A PRIOR CLAIM MA67 22 *ADJUSTMENT - DENY, TAKEBACK DUPLICATE PAYMENT 2a ADJUSTMENT - DENIED, THIS IS A DUPLICATE CLAIM M13 N113 lM DENIED - SERVICE LIMITED TO 1 PER 3 YEARS, SAME PROV 239a Reason Code 265: The Claim spans two calendar years. Reason Code 5: The procedure code is inconsistent with the provider type/specialty (taxonomy). Expenses incurred during lapse in coverage, Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. Submit these services to the patient's medical plan for further consideration. This change effective 1/1/2013: Exact duplicate claim/service. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Precertification/authorization/notification/pre-treatment absent. Reason Code 139: Monthly Medicaid patient liability amount. Reason Code 99: Major Medical Adjustment. Reason Code 189: Non-standard adjustment code from paper remittance. This payment reflects the correct code. Per regulatory or other agreement. Refund to patient if collected. This injury/illness is the liability of the no-fault carrier. 50. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Workers' Compensation only. Reason Code 132: Interim bills cannot be processed. Reason Code A0: Medicare Secondary Payer liability met. Claim/service does not indicate the period of time for which this will be needed. (Use only with Group Code PR). Flexible spending account payments. Reason Code 57: Charges for outpatient services are not covered when performed within a period of time prior to orafter inpatient services. To be used for Property and Casualty only. Reason Code 178: Procedure code was invalid on the date of service. Just hold control key and press F. This product/procedure is only covered when used according to FDA recommendations. Payment is denied when performed/billed by this type of provider. Reason Code 118: Indemnification adjustment - compensation for outstanding member responsibility. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. Claim received by the medical plan, but benefits not available under this plan. To be used for Property and Casualty only. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). (Note: To be used for Property and Casualty only). Reason Code 101: Managed care withholding. Claim/service lacks information which is needed for adjudication. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment adjusted based on Preferred Provider Organization (PPO). Medicare contractors are permitted to use the following group codes: CO Contractual Obligation (provider is financially liable); MCR 835 Denial Code List. Claim lacks prior payer payment information. This service/equipment/drug is not covered under the patients current benefit plan, National Provider identifier - Invalid format. Reason Code 142: Premium payment withholding. Reason Code 18: This injury/illness is the liability of the no-fault carrier. Reason Code 157: Injury/illness was the result of an activity that is a benefit exclusion. Basically, its a code that signifies a denial and it No current requests. HIPAA Compliant. Appeal procedures not followed or time limits not met. Contact our Account Receivables Specialist today! Transportation is only covered to the closest facility that can provide the necessary care. Charges are covered under a capitation agreement/managed care plan. Service not furnished directly to the patient and/or not documented. Note: To be used for pharmaceuticals only. Identity verification required for processing this and future claims. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). Reason Code 192: Refund issued to an erroneous priority payer for this claim/service. Reason Code 173: Prescription is not current. Reason Code 104: The related or qualifying claim/service was not identified on this claim. Reason Code 134: Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. This injury/illness is covered by the liability carrier. Claim/Service denied. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. For example, using contracted providers not in the member's 'narrow' network. CO 24 Charges are covered under a capitation agreement or managed care plan . Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 245: Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. The provider cannot collect this amount from the patient. Applicable federal, state or local authority may cover the claim/service. Procedure postponed, canceled, or delayed. Reason Code 220: Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. The referring provider is not eligible to refer the service billed. (Note: To be used for Property and Casualty only), Based on entitlement to benefits. Services not authorized by network/primary care providers. The attachment/other documentation that was received was incomplete or deficient. Reason Code 255: Claim/service not covered when patient is in custody/incarcerated. Payer deems the information submitted does not support this level of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Chartered by the American National Standards Institute for more than 40 years, X12 develops and maintains EDI standards and XML schemas which drive business processes globally. Reason Code 248: The attachment/other documentation that was received was incomplete or deficient. (Use only with Group Code CO). Claim received by the dental plan, but benefits not available under this plan. Usage: To be used for pharmaceuticals only. Attachment/other documentation referenced on the claim was not received. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lace of premium payment). Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Administrative surcharges are not covered. This non-payable code is for required reporting only. Reason Code 86: Professional fees removed from charges. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an alert. Reason Code 121: Payer refund amount - not our patient. Reason Code 8: The diagnosis is inconsistent with the procedure. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 97: Payment made to patient/insured/responsible party/employer. Revenue code and Procedure code do not match. Sequestration - reduction in federal payment. Submission/billing error(s). Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Reason Code 36: Services denied at the time authorization/pre-certification was requested. Policies and procedures specific to a committee's subordinate groups, like subcommittees, task groups, action groups, and work groups, are also listed in the committee's section. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. Patient payment option/election not in effect. Claim/service denied. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Sequestration - reduction in federal payment. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes. Reason Code 188: Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Reason Code: 204. Denial code CO16 is a Contractual Obligation claim adjustment reason code (CARC). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Diagnosis was invalid for the date(s) of service reported. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). ), Reason Code 225: Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication. More information is available in X12 Liaisons (CAP17). Webco 256 denial code descriptions Einsatz fr Religionsfreiheit weltweit. This (these) diagnosis(es) is (are) missing or are invalid, Reimbursement was adjusted for the reasons to be provided in separate correspondence. Reason Code 106: Claim/service not covered by this payer/contractor. Procedure/treatment/drug is deemed experimental/investigational by the payer. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Handled in QTY, QTY01=LA). WebMedical Billing Denial Codes are standard letters used to describe information to patient for why an insurance company is denying claim. Claim lacks indicator that 'x-ray is available for review.'. Reason Code 146: Lifetime benefit maximum has been reached for this service/benefit category. ), This change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. The advance indemnification notice signed by the patient did not comply with requirements. Failure to follow prior payer's coverage rules. Claim received by the Medical Plan, but benefits not available under this plan. Legislated/Regulatory Penalty. Reason Code 51: Multiple physicians/assistants are not covered in this case. Attachment referenced on the claim was not received in a timely fashion. Submit these services to the patient's Behavioral Health Plan for further consideration. Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Workers' compensation jurisdictional fee schedule adjustment. CO/200/ CO/26/N30. (Use only with Group Code OA). Reason Code 54: Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many service, this length of service, this dosage, or this day's supply. (Note: To be used for Property and Casualty only). Reason Code 38: Discount agreed to in Preferred Provider contract. Low Income Subsidy (LIS) Co-payment Amount. Payment adjusted based on Voluntary Provider network (VPN). Claim/service lacks information or has submission/billing error(s). Payment is adjusted when performed/billed by a provider of this specialty. (Use only with Group Code CO). (Use with Group Code CO or OA). This is not patient specific. It also happens to be super easy to correct, resubmit and overturn. Reason Code 205: National Provider Identifier - Not matched. Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Refund to patient if collected. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Note: To be used for pharmaceuticals only. Not authorized to provide work hardening services. The diagnosis is inconsistent with the procedure. Reason Code 177: Patient has not met the required residency requirements. Cost outlier - Adjustment to compensate for additional costs. Reason Code 194: Precertification/authorization/notification absent. OA Group Reason code applies when other Group reason code cant be applied. X12 welcomes the assembling of members with common interests as industry groups and caucuses. Reason Code 109: Service not furnished directly to the patient and/or not documented. Procedure code was incorrect. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Service/equipment was not prescribed by a physician. 04 The procedure code is inconsistent with the modifier used, or a required modifier is missing. Coverage/program guidelines were not met or were exceeded. Reason Code 26: The time limit for filing has expired. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Payment denied for exacerbation when supporting documentation was not complete. Claim/service denied based on prior payer's coverage determination. Attending provider is not eligible to provide direction of care. Reason Code 31: Insured has no coverage for new borns. This change effective 7/1/2013: Failure to follow prior payer's coverage rules. Failure to follow prior payer's coverage rules. Per regulatory or other agreement. ), Reason Code 224: Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR). Reason Code 148: Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Reason Code 94: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Based on subrogation of a third-party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. However, this amount may be billed to subsequent payer. Reason Code 246: This claim has been identified as a resubmission. This page lists X12 Pilots that are currently in progress. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Usage: To be used for pharmaceuticals only. Contact work hardening reviewer at (360)902-4480. Reason Code 103: Patient payment option/election not in effect. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Services not provided by Preferred network providers. WebCompare physician performance within organization. Indemnification adjustment - compensation for outstanding member responsibility. Vote Summary: Votes. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Services by an immediate relative or a member of the same household are not covered. Reason Code 53: Procedure/treatment has not been deemed 'proven to be effective' by the payer. The procedure or service is inconsistent with the patient's history. Did you receive a code from a health plan, such as: PR32 or CO286? MCR 835 Denial Code List. Note: Use code 187. ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. Services not provided or authorized by designated (network/primary care) providers. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case.

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