EOB Code Crosswalk To HIPPA Standard Codes

HIPAA
ADJUSTM
ENT
EOB REASON
CODE EOB DESCRIPTION CODE
Consecutive Dates Of Service Cannot Be Billed. List Each Date
00003 Separately And Resubmit 16
Provider Number Missing Or Invalid. Enter Corrected Provider
00004 Number On The Claim And Submit As A New Claim 16
Provider Number Missing Or Invalid. Enter Corrected Provider
00004 Number On The Claim And Submit As A New Claim 16
Ndc Missing, Invalid Or Not On State File. Correct 11 Digi

Code Required. Valid Compound Ndc /Or Compound Indicator
00005 And All Ingredient Ndc'S Required, See Pharmacy Manual 16
Ndc Missing, Invalid Or Not On State File. Correct 11 Digi

Code Required. Valid Compound Ndc /Or Compound Indicator
00005 And All Ingredient Ndc'S Required, See Pharmacy Manual 16
Service Not Covered By The Medicaid Program; Pharmacy:

00009 See Non-Covered Items Under Scope Of Services In Manual 16
Service Not Covered By The Medicaid Program; Pharmacy:

00009 See Non-Covered Items Under Scope Of Services In Manual 16
Diagnosis Or Service Invalid For Recipient Age. Verify Mid,
Diagnosis, Procedure Code Or Procedure Code/Modifier
00010 Combination For Errors. Correct And Submit As A New Claim 16
00011 Recipient Not Eligible On Service Date 16

00012 Diagnosis Or Service Invalid For Recipient Sex 16
00012 Diagnosis Or Service Invalid For Recipient Sex 16
00013 Provider Id Is Not Eligible On Service Date 16

00014 Service Denied Per Medical Consultant Review 45
00018 Claim Denied. No History To Justify Time Limit Override 16
00018 Claim Denied. No History To Justify Time Limit Override 29

Primary And/Or Secondary Diagnosis Code Invalid. Verify,
00019 Correct, And Submit As A New Day Claim 9
Exact Duplicate-Same Dos/Same Procedure/Same

00021 Modifier/Same Amount 97
00023 Service Requires Prior Approval 197

Procedure Code, Procedure/Modifier Combination Or Revenue
Code Is Missing, Invalid Or Invalid For This Bill Type. Correct
00024 And Rebill Denied Detail As A New Claim 16


Diagnosis Code Missing Or Invalid. Verify And Enter The
00027 Correct Diagnosis Code And Submit As A New Claim 146

00030 Missing Or Invalid Gross Amount Due
Please Indicate Part B Medicare Payment In Form Locator 54

00034 And Resubmit As A New Claim 16
00036 Invalid Place Of Service For Procedure Or Revenue Code 16

Medicare Denied, No Coinsurance Or Deductible Or Medicaid
00039 Payment Due 16
Admission Date/Date Of Service Missing Or Invalid. Verify And
00040 Enter Correct Dos And Submit As A New Claim 16
00041 Federal Sterilization Consent Form Guidelines Not Met 16
00042 Sterilization/Abortion Guidelines Not Met 16

Units Of Service Are Not Consistent With Dates Of Service For
Physician Claims: If Dates Are Not Consecutive List Each Date
00047 Of Service On A Separate Line Correct And Resubmit 16
Units Of Service Are Not Consistent With Dates Of Service For
Physician Claims: If Dates Are Not Consecutive List Each Date
00047 Of Service On A Separate Line Correct And Resubmit 16
00049 Medical Necessity Is Not Apparent 50

From Date Of Service Is Invalid Or Greater Than The Receipt
Date. Verify And Enter Correct Dos And Submit As A New
00050 Claim 110
00054 Radiation Management Allowed Once Per Day 119
00054 Radiation Management Allowed Once Per Day 119

Dme And Orthotic Or Prosthetic Equipment Allowed Once In 2
00057 Yrs For Ages 00-20 108
00060 Not In Accordance With Medical Policy Guidelines B5
Only Provider Of Service May Bill This Procedure/Modifier
00065 Combination B20
00066 Duplicate Payment To Other Provider 97
00068 Bill Medicare Part B Carrier 22
00069 Bill Medicare Part A Carrier 22

Receipt Date Of Claim Is Prior To The Date Of Service.
00070 Correct And Resubmit 16
00074 Reimbursement Amount Exceeds Set Dollar Amount 16
00074 Reimbursement Amount Exceeds Set Dollar Amount 16

This Service Is Not Payable To Your Provider Taxonomy In
00079 Accordance With Medicaid Guidelines 16
This Service Is Not Payable To Your Provider Taxonomy In
00079 Accordance With Medicaid Guidelines 170
Sum Of Covered Days, Non-Covered Days, And Coinsurance
Days Is Greater Than Statementcovers Period Correct And
00080 Resubmit 16
Sum Of Covered Days, Non-Covered Days, And Coinsurance
Days Is Greater Than Statementcovers Period Correct And
00080 Resubmit 16
00081 Procedure Only Allowed Once In A Lifetime 149
Service Is Not Consistent With/Or Not Covered For This

00082 Diagnosis/Or Description Does Not Match Diagnosis 16
Recipient Is Partially Ineligible For Service Dates. Resubmit A
00084 New Claim Billing Only Eligible Dates Of Service 239
Recipient Is Partially Ineligible For Service Dates. Resubmit A
00084 New Claim Billing Only Eligible Dates Of Service 239
00090 Duplicate Charge Denied 97

Patient Deceased Per State Eligibility File. If Dos And
Recipient Mid Are Correct, Contact The Dss Office In The
00093 Beneficiary'S County Of Residence To Correct Date Of Death 13
Patient Deceased Per State Eligibility File. If Dos And

Recipient Mid Are Correct, Contact The Dss Office In The
00093 Beneficiary'S County Of Residence To Correct Date Of Death 16
Resubmit Claim Indicating Private Insurance Payment Or

Applicable Occurrence Code. If Documented Insurance Denial
00094 Required Submit With Claim On Provider Inquiry Form 16
Resubmit Claim Indicating Private Insurance Payment Or

Applicable Occurrence Code. If Documented Insurance Denial
00094 Required Submit With Claim On Provider Inquiry Form 16
00098 Fee Adjusted To Maximum Payable 45
00098 Fee Adjusted To Maximum Payable 45

Date Of Service Is Prior To Date Of Birth. If Dos And Recipient
Mid Are Correct, Submit Claim To Dma Claims Analysis Unit,
00105 See Billing Guidelines 16
Date Of Service Is Prior To Date Of Birth. If Dos And Recipient

Mid Are Correct, Submit Claim To Dma Claims Analysis Unit,
Recipient Mid Number Missing. Enter Mid And Submit As A
00120 New Claim 16
Recipient Mid Number Missing. Enter Mid And Submit As A
00120 New Claim 16
00122 Service Requires Out Of State Prior Approval 197
00122 Service Requires Out Of State Prior Approval 197
00128 Services Not Approved By Dental Consultant 45
00129 No Patient Liability On Claim For Partial Month Billing. 142
00129 No Patient Liability On Claim For Partial Month Billing. 16

Resubmit As A New Claim With Abortion Statement, Operative
Record And/Or Labor & Delivery Record, History & Physical,
00131 Discharge Summary, Pathology Report And Ultrasound Report 252


Rebill With Patient Liability Amount And/Or Correct Admission
00132 Date 16
Rebill With Patient Liability Amount And/Or Correct Admission
00132 Date 16
Enter Correct Bill Type In Form Locator 4 And Submit As A
00133 New Claim 16
Patient Status Missing/Not In Accordance With Medicaid
00135 Policy/Inconsistent With Days/Dates Billed 16


00139 Services Limited Presumptive Eligibility 177
Claim Denied. Procedure Service Only Allowed By State

00142 Optical Contractor 184
00143 Medicaid Id Number Not On State Eligibility File 16
00143 Medicaid Id Number Not On State Eligibility File 16
00145 No Hysterectomy Statement On File 16

00153 Ancillary Charges Included In Per Diem Rate 96
This Revenue Code Requires A Cpt Laboratory Procedure
00158 Code 16
This Revenue Code Requires A Cpt Laboratory Procedure
00158 Code 16
00160 Medicare Part D Eligible (Pos) 16
Dme Providers Must Bill Modifiers. Please Correct And

00163 Resubmit 4
No Charge Billed. Enter Billed Amount And Submit Detail As A
00167 New Claim 16
Through Date Of Service Invalid Or Greater Than Receipt
Date. Verify And Enter Correct Through Dos And Submit As A
00171 New Claim 16
00182 All Claims Suspended Pending Financial Review 133

Tooth Surface Missing Or Invalid. Correct Detail And Resubmit
00186 Claim 16
Tooth Surface Missing Or Invalid. Correct Detail And Resubmit
00186 Claim 16
00187 Quadrant Or Arch Indicator Missing Or Invalid 16
00187 Quadrant Or Arch Indicator Missing Or Invalid 16

Missing Or Invalid First Treatment Date For Dialysis Claim.
00189 Please Resubmit With First Treatment Date 11
00191 Medicaid Id Number Does Not Match Patient Name 16

Revenue Code Must Be Billed With A Dme/Medical Supply
00202 Hcpc Code 16
00202 Hcpc Code 16
00202 Hcpc Code 16
00202 Hcpc Code 16
Limited Oral Evaluation - Problem Focused Not Allowed Same

00209 Date Of Service As Dental Exam B15
Dates Of Service Not Within Authorized Time Period; For Date
Of Delivery Verification Resubmit Claim With Labor And
00211 Delivery Records. 198
00213 No Prior Approval On File 197
00213 No Prior Approval On File 197
Lab Services Have Been Billed And Paid To A Pathologist Or

00216 An Independent Lab 97
Resubmit As An Adjustment With Ambulance Call Reports To
00220 Justify Same Day One-Way And Round Trip Transports 16

Follow-Up Visits And Consults Not Allowed Same Day As

00224 Dialysis Treatment B15
00228 Service Included In Previously Paid Cystoscopy Code 97
Previously Paid Procedure 52005 Is Included In This Service.

00229 Please Refile As An Adjustment 97



Substance Abuse Intensive Outpatient Program (Saiop) Is Not
Allowed Same Date Of Service As Partial Hospitalization
00231 And/Or Day 96
00237 Total Billed Does Not Equal The Sum Of Details Billed 16
00237 Total Billed Does Not Equal The Sum Of Details Billed 16
00238 Prior Approval Is Required For Ach Services 197
00238 Prior Approval Is Required For Ach Services 197
Follow-Up Visits Or Consults Recouped. Follow-Up Visit Or

Consult Not Allowed Same Date Of Service As Dialysis
00239 Treatment B15
00245 Sterilization Form Missing/Incomplete 252
00246 Service Not Allowed For Undocumented Aliens 204
00249 Pended For Medical Review 133
00259 Non-Ionic Contrast Media Allowed 4 Units Per Day 119
Removal And Insertion Of Norplant System Included In

00261 Service Fee 97
Service Fee Includes Removal And Insertion Of Norplant

00262 System 97
00264 Adjustment Denied, Claim Denied Correctly 96
00264 Adjustment Denied, Claim Denied Correctly 96
00269 Bill Medicare Part A Carrier 22

Billing Provider Is Not The Recipient'S Carolina Access Pcp,
Authorization Is Missing Or Unresolved. Contact Pcp For
00270 Authorization Or Nctracks If Authorization Is Correct 242
Billing Provider Is Not The Recipient'S Carolina Access Pcp,
Authorization Is Missing Or Unresolved. Contact Pcp For
00270 Authorization Or Nctracks If Authorization Is Correct 242
Incorrect Authorization Number On Claim Form. Verify

00286 Number And Refile Claim 165
Incorrect Authorization Number On Claim Form. Verify

00286 Number And Refile Claim 165
Primary Diagnosis For Esrd Services Must Be End Stage Renal

00291 Disease 11
Qualified Medicare Bene-Mqb Recipient. Medicare Payment

Mus Be Indicated, Either As Medicare Crossover For Dos Prior
00292 To 10-1-02 Or Third Party If Dos 10-1-2002 Or After 16
Physician Visit Not Allowed Same Day As Health Check Screen

By Same Provider Or Member Of Same Group. Resubmit As
An Adjustment With Documentation Supporting Related
00301 Services B15
Physician Visit Not Allowed Same Day As Health Check Screen

By Same Provider Or Member Of Same Group. Resubmit As
An Adjustment With Documentation Supporting Related
00301 Services B15
Initial Reline Or Adjustment Of Complete Upper Dentures Not
Allowed Until 6 Months After Receipt Of Dentures Per State
00303 Limit 119
Initial Reline Or Adjustment Of Partial Upper Dentures Not
00304 Limit 119
00305 Panorex Not Allowed In Conjunction With Full Mouth Series B15
Core Buildup, Pin Retention, And Composite Or Amalgam

00306 Build Up Not Allowed On The Same Date Of Service B15
Initial Reline Or Adjustment Of Complete Lower Dentures Not
00307 Limit 119
Hospital And Psychiatric Visits Not Allowed On The Same Date

00310 Of Service B1
Initial Reline Or Adjustment Of Partial Lower Dentures Not
00311 Limit 119
00312 Surgery Fee Includes Charges For Casting/Bracing 97
00313 Surgery Fee Includes Cast Fee 97

Special Services Denied. Circumstances For Use Of This
Procedure Or Procedure/Modifier Combination Are Not
00316 Substantiated On The Claim/Records 16

File Adjustment Using Cbc Code That Includes All Components
00317 Billed And Combine Charges 16
Initial And/Or Established Office Visit Is Included In Fee For

00318 Service. Please Resubmit As An Adjustment 97
Initial And/Or Established Office Visit Is Included In Fee For

00318 Service. Please Resubmit As An Adjustment 97
Point Of Origin Code Submitted Is Missing Or Is Not In
Accordance With Medicaid Policy. Rebill With Correct Source
00319 Of Admission Code. Refer To Ub Manual 16
Point Of Origin Code Submitted Is Missing Or Is Not In
Accordance With Medicaid Policy. Rebill With Correct Source
00319 Of Admission Code. Refer To Ub Manual 16
Psychiatric And Hospital Visits Not Allowed On The Same Date

00320 Of Service B1
00323 Hospital And Office Visits Not Allowed Same Date Of Service B1
00324 Office And Hospital Visits Not Allowed Same Date Of Service B1
Procedure, Procedure/Modifier Combination Or Rate Invalid
00325 For This Date Of Service 16
Procedure, Procedure/Modifier Combination Or Rate Invalid
Multiple Panel Test Codes Billed On Same Day To Equivalent

00328 Panel Test Code 97
Miscellaneous Charges Not Allowed With Prolonged Services

00330 Or Critical Care B15
Eeg/Ecg/Ekg Recordings Included In Circadian Respiratory

00332 Pattern Recording 97
00334 Initial And Established Office Visit Included In Fee For Service 97
00337 Critical Care And Icu Follow-Up Not Allowed Same Day B15
00338 Biopsy Of Cervix Included In Colposcopy/Culdoscopy 97
00339 Icu Follow-Up And Critical Care Not Allowed Same Day B15
Dilation Of Cervical Canal/Dilation And Currettage Included In
Biopsy Of Cervix, Circumferential Cone With Or Without
00340 Dilation And Currettage 97
Colposcopy/Culdoscopy Includes Biopsy. Resubmit As An

00343 Adjustment 97
Colposcopy/Culdoscopy Includes Biopsy. Resubmit As An

00343 Adjustment 97
00344 Submit Claim Using Established Eye Exam Code 16
00345 Charges For Casting/Bracing Is Included In Surgery Fee 97
00346 Charges For Cast Included In Surgery Fee 97
Health Check Screen And Related Service Not Allowed Same

Day. Resubmit As An Adjustment With Documentation
00349 Supporting Related Services B15
Health Check Screen And Related Service Not Allowed Same

Day. Resubmit As An Adjustment With Documentation
00349 Supporting Related Services B15
00351 Prophylaxis With Fluoride Fee Includes Prophylaxis Charges 97
Chemonucleolysis And Laminectomy Cannot Be Billed Within
00352 One Year Of Each Other 119
Chemonucleolysis And Laminectomy Cannot Be Billed Within

00352 One Year Of Each Other 119
Prolonged Services And Critical Care Not Allowed With Daily

00355 Care Or Misc Charges B15
Maternity Charge Allowed Once Per Gestation Period, Submit
Claim With Records To Support Multiple Or Reoccurring
00357 Gestation. 119
Maternity Charge Allowed Once Per Gestation Period, Submit
Claim With Records To Support Multiple Or Reoccurring
00357 Gestation. 119
00358 Only One Nail Debridement Allowed Per 60 Day Period 119
Individual Components Recouped. Hematology Panel That

00359 Includes Components Already Paid 97
00360 Carbon Dioxide Determination Included In Fee For Service 97

Bitewings Already Billed Within 12 Calendar Months, Not A
00362 Part Of An Intraoral Complete Series (Including Bitewings) 119


00365 Office Visit And/Or Consultations Are Included In Eye Exam 97

Delivery (With Or Without Postpartum Care) Is Included In
00366 Total Ob Package 97
00367 Semen Analysis Included In Fee For Sterilization 97
Multiple Consultations Not Allowed Same Date Of Service,

00368 Same Provider Taxonomy Qualifier B15
Multiple Office Visits Not Allowed Same Date Of Service, Same

00369 Provider Taxonomy Qualifier B15
Multiple Hospital Visits Not Allowed Same Dos, Same Provider

00370 Taxonomy Qualifier B15
00371 Supplies Are Included In Fee For Surgery 97
00372 One Supply Allowed Per Date Of Service 119
00372 One Supply Allowed Per Date Of Service 119
Consults And Hospital Visits Not Allowed Same Dos, Same

00373 Provider Taxonomy Qualifier 96
Consults And Office Visits Not Allowed Same Date Of Service,

00375 Exploratory Laparotomy Included In Fee For Surgery 97
00376 Routine Labs Are Included In Dialysis Fees 97
00377 Routine Labs Are Included In Dialysis Fees 97

00380 Supplies Not Allowed With Health Check Fee B15
Health Check Reimbursement Not Allowed On Same Day Of

00381 Service As Supplies Paid Previously B15
Operative Records Received Have No Dates Of Service Or

Conflicting Dates Of Service, Correct Claim And/Or Records
00382 And Resubmit Both As An Adjustment 16


Salpingo-Oophorectomy Included In Hysterectomy Code,

00383 Resubmit As An Adjustment With Appropriate Medical Records 97


Circadian Respiratory Pattern Includes Eeg, Ecg, And Ekg

00384 Recordings. Resubmit As An Adjustment 97
00385 I&D Included In Appendectomy 97
Office Visit Or Consult Already Paid In History. Resubmit As A

00386 Adjustment 97
Daily And/Or Weekly Cobalt Therapy Cannot Be Billed Multiple

00387 Times On Same Date Of Service 97
Periodontal Scaling And Root Planing, Full Mouth Debridement
To Enable Comprehensive Periodontal Evaluation And
Diagnosis, And Perio- Dontal Maintenance Is Included In Fee
00388 For Periodontal Surgery 97
Hospital Visits And Consults Not Allowed Same Date Of

00390 Service, Same Provider Taxonomy Qualifier B1
Fetal Monitoring Denied, Reimbursement Has Been Made To

00391 Hospital 97
Delivery Of Placenta, External Cephalic Version, Or Special

00395 Miscellaneous Services Are Included In The Fee For Delivery 97
00396 Carbon Dioxide Determination Included In Fee For Service 97

Dilation And Curettage Included In Biopsy Of Cervix,
Circumferential Cone With Or Without D&C. Resubmit As An
00397 Adjustment 97
Dilation And Curettage Included In Biopsy Of Cervix,

Circumferential Cone With Or Without D&C. Resubmit As An
00397 Adjustment 97
Immunizations Covered Only In Health Check For Recipients

00398 Under 21 6
Office Visits And Consults Not Allowed Same Date Of Service,

Admission/Medical Visits/Observation Unit Not Allowed Same

00400 Date Of Service B15
Medical Visits/Observation Unit Not Allowed Same Date Of

00401 Service B15
Observation Unit/Medical Visits Not Allowed Same Date Of
00402 Service B15
Medical Visits/Admission Not Allowed Same Day As Initial

00403 Observation B15
Personal Care Service Not Allowed Same Day As Home Health

00404 Aide Services B15
Home Health Aide Services Not Allowed Same Day As

00405 Personal Care Service B15
Medical Visits/Epidural Follow-Up Not Allowed On The Same

Epidural Follow-Up/Medical Visits Not Allowed On The Same

00412 Blood Gases Included In Fee For Service 97
00413 Blood Gases Included In Fee For Service 97
Routine/Continuous Home Care/ Inpatient Respite

Care/General Inpatient Care Not Allowed Same Date Of
00414 Service B15
Routine Continuous Home Care/Inpatient Respite

Care/General Inpatient Care Not Allowed Same Date Of
00415 Service B15
Routine Home Care/General Respite Care/General Inpatient
Care Cannot Be Billed On Same Date Of Service As
00416 Continuous Home Care B15
Routine Home Care/Inpatient Respite Care/General Inpatient
Care Not Allowed Same Date Of Service As Continuous Home
00417 Care B1
General Inpatient Care Not Allowed Same Day As Routine
Home Care/Continuous Home Care/Inpatient Respite Care/
00418 Hospice- Long Term Care B1
Routine Home Care/Continous Home Care/General Inpatient

Care/Hospice-Long Term Care Not Allowed Same Day As
00419 Inpatient Respite Care B15
Routine Home Care/Continous Home Care/Inpatient Respite

Care/Hospice-Long Term Care Not Allowed Same Day As
00420 General Inpatient Care B15
Inpatient Respite Care Not Allowed Same Day As Routine

Home Care/Continous Home Care/General Inpatient
00421 Care/Hospice-Long Term Care B15
00422 Only One Routine Home Care Allowed Per Day 119
00422 Only One Routine Home Care Allowed Per Day 119
00423 Only One Inpatient General Care Allowed Per Day 119
00423 Only One Inpatient General Care Allowed Per Day 119
00426 Procedure Code Invalid For Billing Provider 204

Admission Type 2-Urgent Not Acceptable For Inpatient
00428 Psychiatric Admission 16
Admission Type 2-Urgent Not Acceptable For Inpatient
00428 Psychiatric Admission 16
Components Of Code 52285 Have Been Billed And Paid

00434 Separately, File Adjustment If Necessary 97
Combine Codes/Charges And Bill To The All Inclusive Code
00435 52285 16
Substance Abuse Intensive Outpatient Program(Saiop) Is Not
Allowed Same Date Of Service As Partial Hospitalization
00436 And/Or Day Treatment 96
The Date Associated With Occurrence Code Indicates This

00438 Claim Must Be Submitted To Primary Payer 22
The Date Associated With Occurrence Code Indicates This

00438 Claim Must Be Submitted To Primary Payer 22
Information On Value Code/Value Amount Is Missing Or

Incomplete. Rebill With Complete Value Code Data. Refer To
00439 Ub Manual 16
00439 Ub Manual 16
00439 Ub Manual 16
00441 Suspect Duplicate-Same Dos/Billed Amount, Institutional 97
00442 Outpatient Charges Are Included In Inpatient Reimbursement 97
Inpatient Claim Paid; Previously Paid Outpatient Claim Will Be

00443 Recouped 60
00445 Hit Services Not Allowed Same Day As Inpatient Services B1
Inpatient Services Paid; Previously Paid Hit Services Will Be

00448 Recouped 60
Hiv Case Management Denied Due To Inpatient Claim Paid
With Same Date Of Service. Case Management Fee Is
00449 Included In The Hospital Inpatient Per Diem B1
Hiv Case Management Denied Due To Inpatient Claim Paid
With Same Date Of Service. Case Management Fee Is
00449 Included In The Hospital Inpatient Per Diem 96
Less Severe Duplicate- Same Provider/4 Digit Procedure

00453 Match/Dos, Professional 97
Debridement Only Allowed When Billed On The Same Day As
00454 Surgical Cleansing Of Skin 107
Biopsy Of Skin Only Allowed When Billed On The Same Day As
00455 Biopsy Of Skin Lesion 107
Avulsions Of Nail Plate Only Allowed When Billed On The
00457 Same Day As Removal Of Nail 107
Less Severe Duplicate-Same Procedure Code,

00458 Professional/Dental 97
Exact Duplicate-Same Provider/Billed Amt/Dos/Procedure

00460 Code 97
Inpatient Claim Must Include Outpatient Charges Incurred
Within 24 Hrs Of Admission. Outpatient Charges Billed
Separately Have Been Denied Or Recouped. Correct &
00462 Resubmit Inpatient Claim 60
Tattooing Only Allowed When Billed On The Same Day As

00463 Correct Skin Color Defects 107
Outpatient Charges Within 24 Hrs Of Admission Not Paid
Separately. Add Charges To Inpatient Claim & Resubmit
Replacement Claim. If Multiple Encounter, Bill Others Not 24
00465 Hrs Of Admission, Separately 97
Full Thickness Graft, Each Additional 20 Sq Cm Must Bill With
00466 20 Sq Cm Or Less 107
00469 Suspect Duplicate- Overlapping Dates Of Service, Institutional 97
00470 Suspect Duplicate-Overlapping Dates Of Service, Institutional 97
Suspect Duplicate-Overlapping Dates Of Service, Same Billing

00471 Provider, Institutional 97
00472 Suspect Duplicate-Overlapping Dates Of Service, Institutional 97
00474 Suspect Duplicate-Overlapping Dates Of Service, Professional 97
00475 Suspect Duplicate-Exact Service Date, Professional 97

Suspect Duplicate-Same Procedure/Date Of Service,
00476 Professional 97
Suspect Duplicate-Overlapping Procedures/Date Of Service,

00478 Dental 97
Suspect Duplicate-Same Procedure/Date Of Service/Internal

00479 Modifier, Professional 97
Less Severe Duplicate- Same Provider/Procedure/Overlapping

00480 Dates Of Service, Professional 97
Less Severe Duplicate- Same Provider/Procedure/Revenue

00481 Code/Hour/Overlapping Date Of Service, Outpatient 97
Less Severe Duplicate- Same Provider/Overlapping Date Of

00482 Service, Institutional 97
Less Severe Duplicate-Same Provider/Overlapping Date Of

00484 Less Severe Duplicate-Same Provider/Date Of Service 22
00484 Less Severe Duplicate-Same Provider/Date Of Service 97
Less Severe Duplicate- Same Provider/Overlapping Date Of

00485 Service 97
Less Severe Duplicate- Same Provider/Date Of

00486 Service/Internal Modifier 97
Less Severe Duplicate-Same Provider/Date Of Service/Internal

00487 Modifier/3 Digit Procedure Match 97
00488 Less Severe Duplicate-Dental 97
Less Severe Duplicate-Same Provider/Procedure/Date Of

00489 Service/Internal Modifier, Instituitional 97
Duplicate Claim-Same Billing Provider Number/Generic Code

00490 Number/Date Of Service 16
Duplicate Claim-Same Billing Provider Number/Prescription

00491 Number/Date Of Service 16
Exact Duplicate-Same Provider/Billed Amount/Overlapping

00492 Date Of Service, Institutional 97
Exact Duplicate-Same Provider/Billed Amount/Date Of

Exact Duplicate-Same Provider/Procedure/Billed Amount/Date

00498 Of Service, Dental 97
00500 Routine Follow Up Care Included In Surgical Fee 97
00502 Cap Limitation Has Been Exceeded 96
00504 Bone Survey Allowed Once Annually For Dialysis Patients 119
00508 Bitewing X-Rays Allowed Once Within 12 Calendar Months 119

00512 Cap Limitation For Respite Care Has Been Exceeded 96
Inpatient Respite Care, Rc655 Not Allowed More Than 5

Consecutive Days. Split And Rebill All Subsequent Days Of
00513 Hospital Stay As Rc651 Routine Home Care B15
00515 Service Included In Health Check Package 97

Claim Denied. Service Not In Accordance With Rehab
00516 Guidelines B5
00519 Hepatitis B Surface Or Core Antibody Allowed Once Per Year 119
00520 Lab Test Allowed Once Every 90 Days For Dialysis Patients 119
00520 Lab Test Allowed Once Every 90 Days For Dialysis Patients 119
Supply Code Denied. Additional Payment Not Allowed Unless
Facility-Based Procedure Has Been Performed In Physician
00521 Office 16
Supply Code Denied. Additional Payment Not Allowed Unless
Facility-Based Procedure Has Been Performed In Physician
00521 Office 16
00527 Laboratory Services Included In Hospital Reimbursement 97
00529 Rebill Assistant Surgeon On Separate Claim 96
00530 Services Included In Initial Dialysis Training Fee 97
00531 Services Included In Monthly Professional Dialysis Fee 97
00532 Only One Ekg Allowed In 3 Months For Dialysis Patients 119
00532 Only One Ekg Allowed In 3 Months For Dialysis Patients 119
Only One Nerve Velocity Test Allowed In 3 Months For
00533 Dialysis 119
00534 Copay Previously Deducted For This Date Of Service 3
00535 Maximum Allowable Facility Fee Has Been Reached 45
00536 Total Surgical Time Must Be Indicated On Claim 152
00536 Total Surgical Time Must Be Indicated On Claim 152

Procedure Code Or Procedure/Modifier Code Combination Is
00537 Not Covered For This Date Of Service 16


Chemotherapy Administration Denied. Office Visit Or Consult
Included In Administration Fee Previously Paid To The Same
00544 Provider For This Date Of Service 97
Pdn Services Are Non-Covered When Recipient Is Receiving
00545 Inpatient Services 96
Chemo Administration Code Includes Surgical Procedure
Previously Paid To Same Provider For Same Date Of Service.
Refund Or Request Recoupment Of Paid Surgery Code For
00546 Reconsideration Of Chemo Administration Code 97
00551 Esrd Related Services Allowed Once Per Month 119
00552 Therapeutic Radiology Port Films Allowed Once Per Day 119
00552 Therapeutic Radiology Port Films Allowed Once Per Day 119
Timely Limit Exceeded. Resubmit As An Adjustment With
00553 Documentation Of Time 252
Timely Limit Exceeded. Resubmit As An Adjustment With
00553 Documentation Of Time 252
Daily And Monthly End Stage Renal Disease Related Services

00555 Not Allowed Within The Same Calendar Month 96
Daily And Monthly End Stage Renal Disease Related Services

00555 Not Allowed Within The Same Calendar Month 97
00561 Acellular Dtp Vaccine Allowed Once Per Date Of Service 119
00561 Acellular Dtp Vaccine Allowed Once Per Date Of Service 119
Service Is Included In The Chemotherapy Administration Code
Previously Paid To The Same Provider For This Date Of
00562 Service 97
Depo-Provera 150 Mg For Contraceptive Use Limited To One
00568 Per Date Of Service 119
Depo-Provera 150 Mg For Contraceptive Use Limited To One
00570 Percutaneous Transluminal Angioplasty Limit To Four Per Day 119

Percutaneous Transluminal Atherectomy Limited To Four Per
00571 Day 119
00571 Day 119

00571 Day 119

00571 Day 119
Claim Denied. Procedure Code Billed Is On The Medical

00585 Unlikely Event Table For The Ncci 236
Claim Denied. Procedure Code Billed Is On The Medical

00585 Unlikely Event Table For The Ncci 236
00586 Header Service End Date Is Outside Of Mce/Drg Date Range A8
Claims History Shows Medicaid Has Previously Paid For
Tonsillectomies For This Recipient. Resubmit Corrected Claim
Or File As An Adjustment With Operative Note And Path
00591 Report 252
00591 Report 252
00591 Report 252
00591 Report 252
00591 Report 252
00591 Report 252
Adenoidectomies For This Recipient. Resubmit Corrected
Claim Or File As An Adjustment With Operative Note And Path
00592 Report 252
00592 Report 252
00592 Report 252
00592 Report 252
00592 Report 252
00592 Report 252
Service Denied. Components Of This Blood Panel Have

00594 Already Been Paid For The Same Date Of Service 97
Service Denied. Test Is Included In A Related Panel Code

00595 Already Paid For The Same Date Of Service 97
00596 Billed Procedure Limited To One Per Date Of Service 119

Allow One Full Mouth Debridement To Enable Comprehensive

00600 Periodontal Evaluation And Diagnosis Every 364 Days 119
Allow One Full Mouth Debridement To Enable Comprehensive

00600 Periodontal Evaluation And Diagnosis Every 364 Days 119
Only Four Quadrants Of Periodontal Surgery Allowed Per
00601 Lifetime 149
00603 Allow One Oral Evaluation Within 6 Calendar Months 119
00603 Allow One Oral Evaluation Within 6 Calendar Months 119

Maximum Daily Units Exceeded For Service. Limit For Service
Is 8 Units Per Day (1 Unit = 1 Hour). Correct And Resubmit
00604 As A New Claim 119
Allow One Routine Dental Prophylaxis Within 6 Calendar

00605 Month 119
Allow One Routine Dental Prophylaxis Within 6 Calendar

00605 Month 119
00606 Two Periodontal Maintenance Procedures Allowed Per Year 119
00606 Two Periodontal Maintenance Procedures Allowed Per Year 119

Recommended Immunization Schedule Exceeded For This
Vaccine. Recipient Has Received Same Immunization Within
00608 300 Days Of Claim Date Of Service 119
Tooth Number Missing Or Invalid. Correct Detail And
00610 Resubmit Claim 16
Tooth Number Missing Or Invalid. Correct Detail And

Critical Care, First Hour Already Paid For This Date. Rebill
00612 Additional Time Using Cpt 99292 16
Critical Care, First Hour Already Paid For This Date. Rebill
00612 Additional Time Using Cpt 99292 16
00613 Ob Ultrasound Allowed Once Per Day, Same Provider 119
00613 Ob Ultrasound Allowed Once Per Day, Same Provider 119

Panorex Film Allowed Only Once Every Five Years Per State
00614 Limit 119
Panorex Film Allowed Only Once Every Five Years Per State
00614 Limit 119
00615 Extraction And Root Recovery Allowed Only Once Per Lifetime 149
Insertion Or Reinsertion Of Implantable Contraceptive
00617 Capsules (Norplant) Is Allowed Once Per Date Of Service 119
Insertion Or Reinsertion Of Implantable Contraceptive
00617 Capsules (Norplant) Is Allowed Once Per Date Of Service 119
Removal Of Implantable Contraceptive Capsule (Norplant) Is
00618 Allowed Once Per Date Of Service 119
Removal Of Implantable Contraceptive Capsule (Norplant) Is
00618 Allowed Once Per Date Of Service 119
Verify Source Of Prior Payment. If Filing For Additional

Payment From Medicaid, Submit Through Adjustment Or
00619 Replacement Claim 16
Verify Source Of Prior Payment. If Filing For Additional

Payment From Medicaid, Submit Through Adjustment Or
00619 Replacement Claim 16
Duplicate Procedure. Service Already Paid For A Different

00624 Date Of Service 97
00625 Allow Full Mouth Survey Once Every Five Years Per State Limit 119
00625 Allow Full Mouth Survey Once Every Five Years Per State Limit 119
00626 Exceeds Maximum Allowed For Intraoral Films 119

00626 Exceeds Maximum Allowed For Intraoral Films 119
00627 Only One Periapical Single First Film Allowed Per Day 119
00627 Only One Periapical Single First Film Allowed Per Day 119
00631 Critical Care Previously Paid For This Date Of Service 97

Only 2 Prosthetic Lens Procedures Allowed Without Prior
00633 Approval 119
00635 One Venipuncture For Specimen Collection Allowed Per Day 119
00635 One Venipuncture For Specimen Collection Allowed Per Day 119
00636 One Catheterization For Collection Allowed Per Day 119
00636 One Catheterization For Collection Allowed Per Day 119
00637 One Cataract Surgery Procedure Allowed Per Day 119
00637 One Cataract Surgery Procedure Allowed Per Day 119

Only 5 Hours Of Psych/Cns/Neuro-Cognitive/Mental/Speech
Testing Allowed Per Day. One Unit = 1 Hr. If Billing More
Than 5 Hours, Resubmit Claim With Documentation That
00645 Supports Amount Of Time Submitted On The Claim. B5
Tympanostomy Includes Myringotomy Procedure Previously

00646 Paid. Resubmit As An Adjustment 97
Myringotomy Included In Tympanostomy Code 69436

00647 Previously Paid 97
00648 Procedure Allowed Once Per Lifetime Without Prior Approval 149
Ventilation Assist Management Includes Cpap And/Or Cnp

00649 Which Has Previously Been Paid 97
Cpap/Cnp Included In Ventilation Assist Management Already
00650 Paid 97
Repair/Replacement Of Pacemaker Previously Paid For This

Services Included In Pacemaker Insertion Previously Paid On

00652 This Date Of Service 97
Private Duty Nursing Not Allowed Same Day As Hit Self

00653 Administered Drugs. Hit Payments Are Being Recouped B15
Temporary Closure Of Eyelids By Suture Included In Fee For

00654 Eye Surgery Same Day 97
Only One Health Check Screening Or Interperiodic Screen

00655 Allowed Per Date Of Service B15



00656 Only One Electroencephalogram Allowed Per Day 96
00656 Only One Electroencephalogram Allowed Per Day 96
Initial Supply Of Batteries Included In Dispensing Fee For New

00658 Hearing Aid/Aids 97
Home Infusion Therapy Self Administered Drugs Not Allowed
00659 Same Day As Private Duty Nursing B15
00660 Iv-Pole Not Allowed Same Day As Hit Self Administered Drugs B15
Influenza And Pneumococcal Vaccines For Recipients 21 Years

00665 And Older Must Be Billed With The Appropriate Diagnosis 16
00667 Newborn Assessment Limited To Once Per Lifetime 149

Medicaid Does Not Reimburse For Multiple Repeat
00678 Sterilizations 119
Verify Diagnosis And Procedure(S) And Rebill With Federal
Statement And Records If The Statement/Records Have Not
00679 Been Previously Submitted 11
Therapeutic Abortion Diagnosis Code Billed With Non-
Therapeutic Procedure Correct Diagnosis Or Procedure Code
00680 And Resubmit 11
Induced Abortion Procedure Code Must Be Billed With
00682 Appropriate Diagnosis Code Correct And Resubmit 11
Prior Approval Is Required For More Than 15 Consecutive
00686 Therapeutic Leave Days 197
Prior Approval Is Required For More Than 15 Consecutive
00686 Therapeutic Leave Days 197
Please Re-File With Medicare. Records Indicate That Someone
Other Than Medicaid Is Paying Medicare Part B Premiums For
00690 This Recipient For These Dates Of Service 22
Please Re-File With Medicare. Records Indicate That Someone
Other Than Medicaid Is Paying Medicare Part B Premiums For
00690 This Recipient For These Dates Of Service 22
00693 Only One Inpatient Respite Care Allowed Per Day 119
00693 Only One Inpatient Respite Care Allowed Per Day 119
Exceeds Daily Limit For Continuous Home Care, Rebill Using
00694 Rc651 119
00694 Rc651 119

00694 Rc651 119

00694 Rc651 119
00695 Only One Colectomy Allowed Per Day 119
00695 Only One Colectomy Allowed Per Day 119
00696 Only One Colonoscopy Allowed Per Day 119
00696 Only One Colonoscopy Allowed Per Day 119

One Unit Equals Multiple Determinations, Resubmit Billing
00698 Only One Unit 16
One Unit Equals Multiple Determinations, Resubmit Billing
00698 Only One Unit 16
00700 Use Established Office Visit Code 96
00700 Use Established Office Visit Code 96
Second Surgery Reduced 50% If Performed On The Same

00701 Day 59
00701 Day 59
Periodic Orthodontic Treatment Visit (As Part Of Contract)
00702 Allowed Once Per Calendar Month 119
Periodic Orthodontic Treatment Visit (As Part Of Contract)

00702 Allowed Once Per Calendar Month 119
00705 Exceeds Limitation Per Dme Guidelines 119

Admission History And Physical Allowed Once Per
Hospitalization. Transfers Within The Same Facility Do Not
Support The Billing Of Admission. Rebill Appropriate Level Cpt
00708 E/M Code 119
Admission History And Physical Allowed Once Per
Hospitalization. Transfers Within The Same Facility Do Not
Support The Billing Of Admission. Rebill Appropriate Level Cpt
00708 E/M Code 119
Exceeds Once Per Month Limitation For Transcutaneous
00709 Electrical Nerve Stimulation (Tens) Procedure 119
Only One Corneal Transplant Per Day If Surgery Is Performed

00710 On Both Eyes. Document And Resubmit As Adjustment 119
Only One Corneal Transplant Per Day If Surgery Is Performed

00710 On Both Eyes. Document And Resubmit As Adjustment 119
00711 Only One Epidural Follow-Up Allowed Per Day 119
00711 Only One Epidural Follow-Up Allowed Per Day 119
00715 Orginal Surgery Fee Includes Multiple Stage Retinal Repair 97
00716 Exceeds One Per Day Limitation 119
Sterilization Under Both General Anesthesia And Epidural

Anesthesia Not Allowed On The Same Day. Please File An
00720 Adjustment Request With Documentation For Exceptions B15

Anesthesia Not Allowed On The Same Day. Please File An
00720 Adjustment Request With Documentation For Exceptions B15
Each Additional Lesion Only Allowed When Billed On The
Same Day As Preoperative Placement Needle Localization
00722 Wire; Breast 107
00726 Cap Home Mobility Dollar Limitation Has Been Met 45
Dental Exam Not Allowed On The Same Date Of Service As

00730 Limited Oral Evaluation-Problem Focused B15
Gamma Globulin May Be Billed Only One Time Per Date Of
Service. If Billing Multiple Units Rebill Using The Appropriate
00732 Dose Specific Hcpc Code 119
Gamma Globulin May Be Billed Only One Time Per Date Of
Service. If Billing Multiple Units Rebill Using The Appropriate
00732 Dose Specific Hcpc Code 119
Hiv Case Management Daily Limit Has Exceeded The
00739 Maximum Of 96 Units Allowed Per Day 119
00741 Multiple Surgery For Ambulatory Surgical Centers Cutback 59
00741 Multiple Surgery For Ambulatory Surgical Centers Cutback 59
00743 Eye Surgery Only Allowed Once Per Year For Each Eye 119
Prior Claim For Case Management Has Been Paid For This
00749 Month 96
00749 Month 97
Therapeutic Leave Days Have Exceeded The Maximum Of 60
00750 Allowed For The Calendar Year 119
Therapeutic Leave Days Have Exceeded The Maximum Of 60

00750 Allowed For The Calendar Year 119
00752 Only Two Established Eye Exams Allowed Per Year 119
00752 Only Two Established Eye Exams Allowed Per Year 119
Claim Denied. Second Billing Of The Same Quadrant For

00753 Periodontal Scaling And Root Planing In 364 Days 97
Only 4 Quadrants Of Periodontal Scaling And Root Planing
00754 Allowed Every 364 Days 119

00754 Allowed Every 364 Days 119
00756 Only One Circumcision Allowed Per Lifetime 149
00757 Only 1 Therapeutic Apheresis Allowed Per Day 119
00757 Only 1 Therapeutic Apheresis Allowed Per Day 119
00758 Only 1 Dental Sealant Allowed Per Tooth 119
00759 Colposcopy Allowed Once Per Day 119
00759 Colposcopy Allowed Once Per Day 119

Ophthalmoscopy Angiographies Allowed Six Times Every 365
00761 Days 119
Ophthalmoscopy Angiographies Allowed Six Times Every 365

00761 Days 119
Medical Necessity Not Apparent; Submit Claim With Records
00762 Indicating Medical Necessity 197
Medical Necessity Not Apparent; Submit Claim With Records
00762 Indicating Medical Necessity 50
Cephalometric X-Ray And/Or Diagnostic Models Are Allowed
Once In A Lifetime In Conjunction With An Initial Orthodontic
00763 Workup 149
Comprehensive Orthodontic Treatment Of The Adolescent
00764 Dentition (Banding) Allowed Once Per Lifetime 149
00766 Medical Necessity For Multiple Non Stress Test Not Apparent 50
00768 Hearing Aid Batteries Allowed Six Times Per 365 Days 119
00770 Limit Exceeded For Periodic Orthodontic Treatment Visits 119
00771 Procedure Allowed Once In A Lifetime 149
00773 Exceeds Limit Per 365 Days 119
00773 Exceeds Limit Per 365 Days 119

Rc590 Allowed Once Per Day. If Submitting Adjustment,
00775 Attach Time Documentation 119
Rc590 Allowed Once Per Day. If Submitting Adjustment,
00775 Attach Time Documentation 119
Refractive Code Denied Due To A Medical Diagnosis Or
Medical Office Visit Paid In History With The Same Date Of
Service. If Necessary File An Adjustment To Correct The
00779 Diagnosis And Or Procedure Code 96
Refractive Code Denied Due To A Medical Diagnosis Or
Medical Office Visit Paid In History With The Same Date Of
Service. If Necessary File An Adjustment To Correct The
00779 Diagnosis And Or Procedure Code 96
00781 Only One Psychiatric Interview Allowed Per Six Months 119
00781 Only One Psychiatric Interview Allowed Per Six Months 119
00782 Only One Psychiatric Visit Allowed Per Day 119
00782 Only One Psychiatric Visit Allowed Per Day 119
Pap Test Only Allowed Once Per Year For The Same Provider
00783 Unless Diagnosis Or Symptoms Warrant Additional Tests 119
Facility Retraining Fees Limited To 15 Per Recipient'S Life
00784 Time 149
00786 Only Three Visual Field Exams Allowed Per Year 119
00786 Only Three Visual Field Exams Allowed Per Year 119
00787 Lupron Depot Allowed 16 Units Per 365 Days 119
00787 Lupron Depot Allowed 16 Units Per 365 Days 119
00788 Only One Therapeutic Abortion Allowed Per Month 119
00788 Only One Therapeutic Abortion Allowed Per Month 119
00789 Spinal Orthotics Allowed Once In 18 Months 119
00789 Spinal Orthotics Allowed Once In 18 Months 119
00790 Only Three Inhalers With Spacers Allowed Per Year 119
00790 Only Three Inhalers With Spacers Allowed Per Year 119
00796 Pentamidine Aerosol Therapy Limited To Once Every 4 Weeks 119
00796 Pentamidine Aerosol Therapy Limited To Once Every 4 Weeks 119

Allow 1 Capco Personal Emergency Response System Alert
00802 Per Calendar Month 119
Allow 1 Capco Personal Emergency Response System Alert

00805 Rebill Using Periodic Oral Examination Code 16
00805 Rebill Using Periodic Oral Examination Code 16

Medical Necessity For Multiple Fetal Cardiovascular
00807 Ultrasounds Not Apparent 50
00809 Only One Fetal Cardiovascular Ultrasound Allowed Per Day 119
00809 Only One Fetal Cardiovascular Ultrasound Allowed Per Day 119
Services Cannot Be Billed Spanning Multiple Calendar Months.
00817 Rebill With Dates Of Service Within One Month Only 16
Prior Approval Required. Provider Go To
00818 Www.Documentforsafety.Org Or Call 855 272 6576 197
00831 Dme Procedure Allowed Once In Two Years 119
00831 Dme Procedure Allowed Once In Two Years 119

Dme Equipment Allowed Once In Three Years. If Prior
Approval Was Obtained For This Piece Of Equipment For
Dates Of Service Prior To November 1, 1996, Please Resubmit
00832 As An Adjustment 119
Dme Equipment Allowed Once In Three Years. If Prior
Approval Was Obtained For This Piece Of Equipment For
Dates Of Service Prior To November 1, 1996, Please Resubmit
00832 As An Adjustment 119
00833 Dme Procedure Allowed Once In Five Years 119
00833 Dme Procedure Allowed Once In Five Years 119
Subsequent Billing Of Repair Code Has Been Paid At The

00835 Secondary Maximum Allowed Rate 59
Subsequent Billing Of Repair Code Has Been Paid At The

00835 Secondary Maximum Allowed Rate 59
00840 Exceeds Daily Limit For At-Risk Case Management (Adult) 119
00842 Dme Equipment Allowed Once In Three Years 119

00845 Dme Equipment Allowed Once In Five Years 119
00845 Dme Equipment Allowed Once In Five Years 119
00846 Dme Equipment Allowed Once In Two Years 119
00846 Dme Equipment Allowed Once In Two Years 119
Payment Reduced To Equal New Purchase Price. Medicaid Has

00849 Previously Paid For This Equipment Code 108

Medicaid Has Paid Maximum Allowable For This Equipment

00850 Code 108

00850 Code 108
00858 Dme Equipment Allowed Once Per Day 119

Personal Care Services Not Allowed Same Day As Cap In-

00870 Home Aide Level Ii And In-Home Aide Level Iii B15
Cap In-Home Aide Level Ii And In-Home Aide Level Iii Not
00871 Allowed Same Day As Personal Care Services B15
00872 I&D Included In Previously Paid Appendectomy 97
00873 Catheterization Included In Dilation 97
Multiple Er Visits Not Allowed Same Date Of Service, Same

Taxonomy Qualifier. File Adjustment If Visits Were Separate
00874 Occasion B15
00878 Episiotomy Included In Vaginal Delivery 97
Physician Charge Denied Same Date Of Service As Facility

00879 Billing B15
00881 Emg One Extremity Allowed Per Day 119
00881 Emg One Extremity Allowed Per Day 119
00882 Emg Two Extremities Allowed Per Day 119
00882 Emg Two Extremities Allowed Per Day 119
00883 Emg Three Extremities Allowed Once Per Day 119

00883 Emg Three Extremities Allowed Once Per Day 119
00884 Rebill Adjustment With Records Documenting Units B5
00884 Rebill Adjustment With Records Documenting Units B5
00886 Exceeds Limit Of Six Units Per Day For Reflex Study 119
00886 Exceeds Limit Of Six Units Per Day For Reflex Study 119

Medicare Covered Days Missing Or Invalid. Refile Claim With
00889 Medicare 16

00889 Medicare 16
00889 Medicare 16
00891 Self Administered Drugs Limited To Once Per Day 119
00891 Self Administered Drugs Limited To Once Per Day 119
Medical Necessity Not Apparent For Critical Care/Prolonged

00893 Services And Consults On The Same Day 50
Medical Necessity Not Apparent For Critical Care/Prolonged
00893 Services And Consults On The Same Day 50
00895 Exceeds Daily Limit For Termination Allowance 45
00895 Exceeds Daily Limit For Termination Allowance 45
Additional Procedure, Same Date Of Service, Paid At 50

00896 Percent Of Allowable Amount 59
Additional Procedure, Same Date Of Service, Paid At 50

00896 Percent Of Allowable Amount 59
00897 Tcd Included In Fee For Surgery 97
00899 Units Cutback. Maximum Number Of Units Per Day Exceeded 119
00901 No Adjustment Due 45
00905 Drug Not Covered Under Rebate Agreement 16
00906 Cervical Braces Allowed Once In 18 Months 119
00911 Denied. Cms Termination 16
Dispensing Fees For Accessories Are Included In The

00914 Dispensing Fee For A New Aid/Aids 97
Clia Identification Number Is Unknown To Nc Medicaid.
Contact Your State Clia Authority. Nc Providers Contact Nc
00920 Dfs, Clia, Po Box 29530 Raleigh Nc 27626-0530 16
Service Denied: The Dispensing Fee For Accessories That Is
Included In Dispensing Fee For New Hearing Aid(S) Has Been
00921 Paid For This Date Of Service 97
Consultation And Emergency Room Visit Not Allowed On

00923 Same Dos, Same Provider Taxonomy Qualifier B15
Emergency Room Visit And Consultation Not Allowed On

00924 Same Dos, Same Provider Taxonomy Qualifier B15
Admit Date And 'From' Date Of Service Not Consistent With
3Rd Digit/Frequency Code Of Bill Type. Enter Correct Bill
00925 Type, Admit Date Or 'From' Dos And Submit As A New Claim 16
Injection Of Antigen Is Included In The Fee For Allergenic
Immunotherapy With Provision Of Allergenic Extract Already
00928 Paid For This Date Of Service 97
Injection Of Antigen Has Already Been Paid For This Date Of

Service. Rebill Using Code For Provision Of Allergenic Extract
00929 Only 97
Any Combination Of Periodontal And Prophylaxis Not Allowed

00930 On Same Date Of Service B15
Patient Must Be Eligible On Banding Date And Banding Claim

Must Be Paid To Allow Payment Of Periodic Orthodontic
00931 Treatment Visit 96
Clia Certification Info Could Not Be Verified. Verify Clia
Number On Summary Page. Contact Your State Clia Authority-
N Providers Contact Nc Dfs Clia Po Box 29530 Raleigh Nc
00932 27626 16
00932 27626 16
00932 27626 16
J1055 Not Allowed On The Same Date Of Service As J1050 Or

00933 J1051 B15
J1050 Or J1051 Is Not Allowed On The Same Date Of Service

00934 As J1055 B15
Clia Cert Not Valid For Dos/Level. If You Have Only 1 Clia #,
Contact Agency That Issued Certification. If Multi Clia #, Send
00936 Copy Of Cert/Claim & Inquiry Form To Nctracks 16
00941 Prescription Number Required 16
00944 Professional Variance/Quantity 16
Fixation Of Femar Fracture Included In Hemiarthroplasty, Hip

00952 Partial 97
Individual Has Restricted Coverage - Medicaid Only Pays The
00953 Part B Premium 16
00955 Fqhc-Attending/Group Provider Number 16
Comprehensive Evaluation And Related Components Not

00956 Allowed On The Same Dos, Same Or Different Provider B15
Dialysis Treatment Allowed Once Per Day. If More Than One
Treatment Is Provided Submit An Adjustment With
00957 Documentation Showing Medical Necessity 119
Dialysis Treatment Allowed Once Per Day. If More Than One
Treatment Is Provided Submit An Adjustment With
00957 Documentation Showing Medical Necessity 119
Units Cut Back; Only One Unit Allowed Per Day. If Multiple
00958 Unrelated Tests Were Performed, File As An Adjustment 119
Units Cut Back; Only One Unit Allowed Per Day. If Multiple
00958 Unrelated Tests Were Performed, File As An Adjustment 119
Maximum Number Of Units Per Day Previously Paid For This
Maximum Number Of Units Per Day Previously Paid For This
Newborn Health Check Screen And Newborn Assessment Not

00961 Allowed On The Same Day B15
Dhs Immunizations Cannot Be Assigned A Family Planning
Category Of Service; No Family Planning Cos Exists For
00967 Required Financial Treatment 150
Periodontal Maintenance Procedures Are Allowed Only As

00971 Follow-Up To Periodontal Surgery 97
Periodontal Maintenance Procedures Are Allowed Only As

00971 Follow-Up To Periodontal Surgery 97
Over 3 Hours Of Unusual Physician Travel Must Be
00972 Documented. Please Resubmit Claim With Records 252
Over 3 Hours Of Unusual Physician Travel Must Be
00972 Documented. Please Resubmit Claim With Records 252
Dispensing Fee Was Cut Back (Same Drug In The Same
00983 Month) 16
Exceeds 4 Per 365 Day Limitation. Submit As An Adjustment

00993 Documenting The Medical Necessity For Additional Lens/Lense 119




Full Recoupment: Inpatient Charges Have Been Paid For
Some Of These Dates Of Service. Rebill For Covered Days
00997 Only. Correct And Resubmit As A New Claim 97
Claim Does Not Require Adjustment Processing. Resubmit
Claim With Corrections As A New Day Claim. If Pos, Reverse
00998 And Resubmit 96
Exceeds Cap-Mr/Dd Personal Emergency Response Monthly
01002 Limitation 119
Date Of Service Is More Than 30 Days Prior To Cap Effective

01003 Date 96
Cap Services Recouped To Pay Inpatient Stay Charges. Cap

01004 Services Are Not Allowed During Inpatient Stay 96


Cap Services Denied When Recipient Is Receiving Inpatient

01005 Services 96

01005 Services 96

01005 Services 96
Cap Limitation Of 2016 Hours Per Waiver Year Has Been
01006 Exceeded For Crisis Stabilization 119
Claim Denied. Procedure Included In Related Procedure

01009 Already Billed 97
Adult Care Home Personal Care Services Are Not Reimbursed

When Therapeutic Leave Has Been Paid For The Same
01013 Date(S) Of Service B15
Service Denied Or Cut Back. Exceeds 14 Consecutive Day

01014 Limit 119
01014 Limit 119
01014 Limit 119

01014 Limit 119
Initial Observation Has Already Been Paid For This Date Of

01017 Service 97
Observation Discharge Has Already Been Paid For This Date

01018 Of Service 97
Evaluation And Management Not Allowed Same Day As Nicu.

01019 Nicu Has Already Been Paid For This Date Of Service B15
Initial Hour Of Prolonged Services Allowed Once Per Date Of
01020 Service. Service Has Already Been Paid For This Date 119
Initial Hour Of Prolonged Services Allowed Once Per Date Of
01020 Service. Service Has Already Been Paid For This Date 119
Critical Care Not Allowed On Same Date Of Service As

Prolonged Service. Prolonged Service Already Paid For This
01021 Date B15
Prolonged Service Already Paid For This Date Of Service. No

01024 Additional Payment Allowed For Stand-By On Same Dos B15
Reimbursement For Related Procedure Is Being Recouped To

01026 Pay For Primary Procedure (52647 Or 52648) 97
Reimbursement For Therapeutic Leave Denied. Adult Care

01027 Home Pcs Has Been Paid For The Same Date(S) Of Service B15
Cap-Mr/Dd Supported Employment Services Not Allowed

Same Day As Prevocational Services Or Institutional Respite
01028 Care B15
Cap-Mr/Dd Institutional Respite Not Allowed On Same Day As
01029 Related Cap Services B15
Personal Care And Adult Care Home Not Allowed On Same

01030 Day As Cap-Mr/Dd Supported Living Services B15
Cap-Mr/Dd Supported Living Services Not Allowed On Same

01031 Day As Personal Care And Adult Care Home B15
Cap-Mr/Dd Supported Living Not Allowed Same Day As

01032 Related Cap Services B15
Related Cap-Mr/Dd Services Not On Same Day As Supported

01033 Living Services B15
Cap-Mr/Dd Crisis Stabilization Not Allowed On Same Date Of

01034 Service As Institutional Respite Care B15
Thank You For Reporting Vaccines. This Vaccine Is Provided

At No Charge Through The Vaccines For Children Program. No
01036 Payment Allowed 89
Thank You For Reporting Vaccines. This Vaccine Is Provided

At No Charge Through The Vaccines For Children Program. No
01036 Payment Allowed 89
Personal Care Services Not Allowed On Same Date Of Service

01040 As Adult Care Home Personal Care Service B15
Only One Case Management Allowed Per Day. Case
Management Billed Through Another Program Has Already
01042 Been Paid For This Date Of Service 96
Only One Case Management Allowed Per Day. Case
Management Billed Through Another Program Has Already
01042 Been Paid For This Date Of Service 97
Units Of Service Are Not Consistent With Dates Of Service.
01043 One Calendar Day Equals One Unit For This Hcpc Code 119
Units Of Service Are Not Consistent With Dates Of Service.
01043 One Calendar Day Equals One Unit For This Hcpc Code 119
Multiple Billings Of Same Or Similar Dme Supply/Equipment

01044 Not Allowed On The Same Date Of Service B15
At-Risk Case Management Not Allowed On Same Day As

01051 Related Case Management Services B15
At-Risk Case Management Services Are Noncovered When

01053 Recipient Is Receiving Inpatient Services 96


At-Risk Case Management Service Recouped. This Service Not

01054 Allowed When Recipient Is Receiving Inpatient Services 96


Er And Hospital Admission Not Allowed Same Dos/Same

01055 Provider
Er And Hospital Admission Not Allowed Same Dos/Same

01055 Provider
Er Services Recouped. Er Services And Hospital Admission Not

01056 Allowed Same Dos/Same Provider
Er Services Recouped. Er Services And Hospital Admission Not

01056 Allowed Same Dos/Same Provider
Valid Revenue Code Must Be Billed With A Valid Hcpc Code.
Hcpc Code Is Missing Or Invalid Or Hcpc Code Has Been Bille
01057 With Missing Or Invalid Revenue Code. Correct And Resubmit 16



The Only Well Child Exam Billable Through The Medicaid
01058 Program Is A Health Check Screen 16
The Only Well Child Exam Billable Through The Medicaid

01058 Program Is A Health Check Screen 16
Admit Hour/Time Of Pickup Is Missing Or Invalid. Please
01060 Correct And Resubmit As A New Claim 16
Only One Date Of Service Allowed Per Claim. Bill Each

01061 Ambulance Trip On A Separate Claim 16
Service Denied. The Procedure Billed Is Only Payable When
Billing And Rendering Providers Are Pregnancy Medical Home
01062 Providers A1
Cap In-Home Aide Service Not Allowed On Same Date Of

01066 Service As Adult Care Homes Services B15
Home Health Aide Service Not Allowed On Same Date Of

01067 Service As Adult Care Home Services B15
Component(S) Of Urinalysis Recouped. Urinalysis With Micro

Scopy-(Complete Service), Has Been Paid For This Date Of
01068 Service, Same Billing Provider B15
Component(S) Denied. Urinalysis With Microscopy-(Complete
Procedure) Has Already Been Paid For This Date Of Service,
01069 Same Billing Provider B15
Urinalysis Components Billed For The Same Date Of Service
Must Be Combined Under 81000. Please Submit Adjustment
01070 For Component(S) Already Paid 97


Renin Stimulation Panel Has Been Paid For This Date Of

01072 Service 97
Components Of Audiometry/Speech Recognition Recouped.

The Complete Service - Comprehensive Audiometry
Evaluation And Speech Recognition Has Already Been Paid
01074 This Day, Same Billing Provider B15
Component(S) Denied. Comprehensive Audiometry And

Speech Recognition, Which Is A Complete Procedure, Has
Already Bee Paid For This Date Of Service, Same Billing
01075 Provider B15
Audiometry Components Billed For The Same Date Of Service

Must Be Combined As 92557. Please Submit An Adjustment
01076 For Component 92556 That Already Paid B15
Audiometry Components Billed For The Same Date Of Service

Must Be Combined As 92557. Please Submit An Adjustment
01077 For Component 92553 That Already Paid B15
Detail Transportation Days Cannot Exceed Total Header Days

01079 For Domiciliary Care B5
Detail Transportation Days Cannot Exceed Total Header Days
01079 For Domiciliary Care B5
01080 Procedure Billed Exceeds One Per Day Limitation 119
Only One Spine Deformity Arthrodesis Can Be Billed Per
01083 Operative Episode, Per Date Of Service 119
Conflict In Procedures Billed. Anterior & Posterior Procedures
Billed For Same Date Of Service. Review, Correct, And
01084 Resubmit Or File An Adjustment With Records 96
Conflict In Procedures Billed. Anterior & Posterior Procedures
Billed For Same Date Of Service. Review, Correct, And
01084 Resubmit Or File An Adjustment With Records 96
Review Procedures Billed. Only One Instrumentation
Procedure Allowed Per Day.Correct And Resubmit As A New
01086 Claim 119
Cap-Mr/Dd Adult Day Health Or Developmental Day Care Not

01088 Allowed On Same Day As Institutional Respite B15
Cap-Mr/Dd Personal Care Service Not Allowed On Same Day

01089 As Institutional Respite B15
Claim Denied. Antepartum Package 59425 Has Already Been

01093 Paid For This Gestation Period 97
Stand-By Service Already Paid For This Date Of Service. No
Additional Payment Allowed For Prolonged Service On Same
Observation Service Already Paid For This Date Of Service. No
Additional Payment Allowed For Prolonged Service Same Date
01095 Of Service 97
Nicu Already Paid For This Date Of Service. No Additional

01096 Payment Allowed For Prolonged Service Same Date Of Service 97
Critical Care Has Already Paid For This Date Of Service. No
Additional Payment Allowed For Prolonged Service Same Date
01097 Of Service 97
Antepartum Package Has Already Been Paid For This

01098 Gestation Period 97
Nicu Not Allowed Same Day As Evaluation And Management

01099 Code. E/M Already Paid For This Date Of Service B15
Initial Viewing Of The X-Ray By The Er Physician Is Included
01102 In The Er Visit And Will Not Be Reimbursed Serarately 97
01103 Qty Outside Of Min And Max Limits 16
01104 Unacceptable Price/Unit. Check Quantity And Price 16
01104 Unacceptable Price/Unit. Check Quantity And Price 16
01105 Partial Dispensing Of Unbreakable Pack 16

Exceeds Limit Of Billings For Antepartum Package 4-6 Visits
01106 By Different Providers 119
01112 Related Services Not Allowed On Same Date Of Service B15
01123 Pos - Metric Decimal Quantity Missing Or Invalid 16
01124 Pos - Dur Alert Override Not Found 16
Component Of X-Ray (Either Technical Or Professional)

Denied. Same Procedure Code Has Already Been Reimbursed
01140 As Complete Procedure For This Date Of Service B15
X-Ray Billed As 'Complete' Denied. Technical Component Of

This Procedure Code Has Already Been Reimbursed For This
01141 Date. Rebill For Professional Component Only B15
X-Ray Billed As 'Complete' Denied. Professional Component O

This Procedure Code Has Already Been Reimbursed For This
01142 Date. Rebill For Technical Component Only B15
Cystourethroscopy With Meatotomy Not Allowed On Same
Day As Cysto. With Resection. Resubmit As An Adjustment
With Documentation Supporting Second Cystourethroscopy
01147 On Same Day B15
Cystourethroscopy With Meatotomy Not Allowed On Same

Day As Cysto. With Resection. Resubmit As An Adjustment
With Documentation Supporting Second Cystourethroscopy
01147 On Same Day B15
Cystourethroscopy With Resection Of Ureterocele Paid. Cysto
With Meatotomy Recouped. Resubmit As An Adjustment With
Documentation Supporting Second Cystourethroscopy On
01148 Same Day 97
Probing Of Nasolacrimal Duct With Or Without Irrigation Is

01151 Included In A More Comprehensive Procedure Already Paid 97
Components Denied. Rebill Using 92557 As Complete
01152 Procedure Versus Separate Components 92553 And 92556 16
Comprehensive Procedure For Probing Nasolacrimal Duct,
Which Includes Irrigation Paid. Separate Payment For
01153 Component Of Comprehensive Procedure Recouped 97
01154 Claim Denied Pending Rate Information From Dma 199
Delivery And/Or Postpartum Care Included In Total Ob

01157 Package 97
Antepartum Package Recouped. Total Ob Package Paid Which

01158 Includes Antepartum Care 97
Total Ob Package, Which Includes Antepartum Care, Has

01159 Already Been Paid For This Gestation Period 97
Postpartum Package Recouped. Total Ob Package Paid

01162 Includes Postpartum Care 97
Total Ob Package, Which Includes Postpartum Care, Has

01163 Already Been Paid For This Gestation Period 97
Transposition Of Ovaries Included In Abdominal
Hysterectomy. Resubmit As An Adjustment With Records If
01164 Ovaries Were Not Returned To Original Placement 97
Transposition Of Ovaries Included In Abdominal
Hysterectomy. Resubmit As An Adjustment With Records If
01164 Ovaries Were Not Returned To Original Placement 97
Abdominal Hysterectomy Includes The Transposition Of
Ovaries. Resubmit As An Adjustment With Records If Ovaries
01165 Were Not Returned To Original Placement 97
Abdominal Hysterectomy Includes The Transposition Of
Ovaries. Resubmit As An Adjustment With Records If Ovaries
01165 Were Not Returned To Original Placement 97
Superficial Hyperthermia Recouped. Medicaid Does Not Make

Separate Payment For Procedures That Are Components Of A
01166 More Comprehensive Service For The Same Date Of Service B15
Dme Allowed Once In Four Years. Resubmit As An Adjustment
If Prior Approval Was Obtained For This Piece Of Equipment
01167 For Dates Of Service Prior To November 1,1996 119
Dme Allowed Once In Four Years. Resubmit As An Adjustment
If Prior Approval Was Obtained For This Piece Of Equipment
01167 For Dates Of Service Prior To November 1,1996 119
01168 Arthrodesis, Hip Joint Included In Fusion Of Hip Joint 97
Superficial Hyperthermia Denied. Medicaid Does Not Make

Separate Payment For Procedures That Are Components Of A
01169 More Comprehensive Procedure B15
This Procedure Or Procedure/Modifier Combination Is Edited
For Units, Therefore Billing A Span Of Days Is Not Allowed.
01170 Please Bill Each Date Of Service On A Separate Detail 16
This Procedure Or Procedure/Modifier Combination Is Edited

For Units, Therefore Billing A Span Of Days Is Not Allowed.
01170 Please Bill Each Date Of Service On A Separate Detail 16
Diagnosis Requires Supporting Documentation. Resubmit As A
01171 Adjustment With Medical Records 96
Tenotomy For Multiple Tendons Can Not Be Billed Same Date

01172 Of Service As Single Tendons B15
Claim Denied. Superficial Hyperthermia Not Allowed On Same

01173 Date Of Service As Chemotherapy Administration B15
Thanks For Reporting Vaccine To Our Database. This Vaccine
Is Available At No Charge Through The Vaccines For Children
Program And Therefore Is Not Reimbursable Through
01174 Medicaid 89
Thanks For Reporting Vaccine To Our Database. This Vaccine
Is Available At No Charge Through The Vaccines For Children
Program And Therefore Is Not Reimbursable Through
01174 Medicaid 89
Dialysis Facility: This Revenue Code Must Be Billed With The
Appropriate 5 Digit Cpt Code. Correct Denied Detail And Refile
01175 As A New Day Claim 16
01176 This Drug Is Included In Monthly Dialysis Rate 97

Dialysis Facility: This Revenue Code Must Be Billed With A
Valid 5 Digit Hcpcs Drug Code. Correct Denied Detail And
01177 Refile As A New Day Claim 16
Procedure Code 57505 Recouped. Endocervical Curettage

01179 Included In Procedure Code 57454 97
Endocervical Curettage Included In Previously Paid Procedure

01180 Code 97
Insertion Of Vitrocert Is Covered Only For The Diagnosis Of
01184 Cytomegalovirus Retinitis (Cmv) 11
Only One Billing Of Chiropractic Manipulative Treatment
01185 Allowed Per Day 119
Medicaid Does Not Make Separate Payment For Professional

Or Technical Component Performed On The Same Date Of
01189 Service As The Complete Procedure B15
Complete Procedure Performed On The Same Date Of Service
As The Professional Or Technical Component Not Allowed.
01190 Component Recouped B15
Arthrotomy-Knee; With Sysnovial Biopsy Only Included In

01191 Joint Exploration, Biopsy Or Removal 97


Arthrotomy With Excision Of Semilunar Cartilage Included In

01194 Knee Excision Semilunar Cartilage 97


Physician Services And Visual Aids Cannot Be Processed On
The Same Claim. Resubmit Physician Services On A Separate
01197 Cms 1500 Claim 16
Physician Services And Visual Aids Cannot Be Processed On
The Same Claim. Resubmit Physician Services On A Separate
01197 Cms 1500 Claim 16
Related Lab Tests Included In Fee For Panel, Same Date Of

01199 Service 97
Panel Includes Fees For Related Lab Tests, Same Date Of

01200 Service 97
Patient Is Enrolled In A Hmo Plan. Delivery Charges Have
Been Made To Hmo. Facilities May Bill Fee For Service For
01201 Care Rendered On Out-Of-Plan Dates Of Service 24
Been Made To The Hmo. Facilities May Bill Fee For Service For
Been Made To The Hmo. Facilities May Bill Fee For Service For
Iv Sedation And General Anesthesia Not Allowed On Same

Arthrotomy With Synovectomy Knee Included In Arthrotomy

01205 Knee Anterior And Posterior 97
Discipline-Specific Diagnosis Code Is Not Allowed As A
01206 Principle Diagnosis 146
Discipline-Specific Diagnosis Code Is Not Allowed As A
01206 Principle Diagnosis 146
Rc651 And Rc652 Must Be Billed With Value Code 61 With
01207 Corresponding Msa Code 16
Rc651 And Rc652 Must Be Billed With Value Code 61 With
01207 Corresponding Msa Code 16
Purchase Of Supplies Related To Suction Equipment Not

01209 Allowed During The Same Month Equipment Is Rented B15
Service Recouped. Supplies Related To Suction Equipment

01210 Can Not Be Billed Within The Same Calendar Month 97



Topical Application Of Fluoride Not Allowed To Bill On The
01211 Same Date Of Service As Prophylaxis Application (Age 0-20) B15
Tenotomy, Single Tendon Can Not Be Billed Same Date Of

01212 Service As Multiple Tendons B15
Prophylaxis Application Of Fluoride Not Allowed To Bill On The

01213 Same Date Of Service As Topical Application (Age 0-20) B15
Transplant, Hamstring Tendon To Patella; Single Tendon Not

01215 Allowed On Same Day As Multiple Tendons B15
Reconstruction Of Dislocating Patella Not Allowed Same As

Extensor Realignment With Patellectomy And/Or Revision
01216 Removal Of Kneecap B15
Extensor Realignment Not Allowed Same Day As

01217 Reconstruction For Recurrent Dislocating Patella B15
Only One Catheter Or Reservoir/Pump Implantation Allowed
01218 Per Day 119
Arthroplasty, Femoral Condyles Not Allowed With Repair Of

01219 Knee Joint B15
Revision Of Total Knee Arthroplasty, With Or Without Allograft

01220 Not Allowed Same Day As One Component B15
Tenotomy, Percutaneous, Achilles Tendon Not Allowed Same

01221 Day As General Anesthesia B15
If Submitting A Dme Claim, Resubmit Claim Electronically With
An Invoice Attached. If Submitting An Unlisted Claim,
Resubmit Claim Electronically With A Special Report And
01224 Operative Notes And/Or Medical Records Attached. 133
Arthrotomy, Posterior Capsular Release, Ankle Not Allowed On

01225 The Same Day As Lengthening Or Shortening Of Tendon B15
Biopsy, Soft Tissue Of Leg Or Ankle Area Not Allowed Same

01226 Day As Superficial B15
Excision, Tumor, Leg Or Ankle Area Not Allowed Same Day As

01227 Excision Benign Tumor Deep Subfacial B15
Repair, Flexor Tendon, Leg; Primary, Without Graft, Not

01228 Allowed Same Day As Secondary With Or Without Graft B15
Repair, Extensor Tendon, Leg; Primary Without Graft Not
01229 Allowed Same Day As Secondary With Or Without Graft B15
Tenolysis, Flexor Or Extension Tendon Not Allowed Same Day

01230 As Multiple B15
Single Tendon Lengthening Or Shortening Not Allowed Same

01234 Day As Multiple B15
Superficial And Deep Transfer Or Transplant Of Single Tendon

01235 Not Allowed On The Same Date Of Service B15
01236 Allow One Application Of Fluoride Within Six Calendar Month 119
Repair, Secondary Disrupted Ligament, Ankle Not Allowed

01237 Same Day As Primary And Both Collateral Ligaments B15
Arthroplasty, Ankle; Revision Not Allowed Same Day As Repair

01238 Of Ankle B15
Arrest, Epiphyseal, Any Method Not Allowed Same Day As

01240 Repair Lower Leg Epiphyses B15
Incision And Drainage Below Fascia Not Allowed Same Day As
01241 Drainage Of Foot B15
Tenotomy, Percutaneous, Toe, Single Tendon Not Allowed

01242 Same Day As Multiple B15
Excision, Tumor, Foot Not Allowed Same Day As Benign

01243 Tumor Deep Subfascial Intramuscular B15
Fasciectomy, Plantar Fascia; Partial Not Allowed Same Day A

01244 Removal Of Foot Fascia B15
Single Or Two Segment Kyphectomy Not Allowed Same Date

01245 Of Service As Three Or More Segment Kyphectomy B15
Three Or More Segment Kyphectomy Not Allowed Same Date

01246 Of Service As Single Or Two Segment Kyphectomy B15
Ostectomy, Complete Excision Not Allowed Same Day As

01247 Partial Removal Metatarsal B15
Tenolysis, Extensor, Foot; Single Tendon Not Allowed Same

01249 Day As Multiple B15
Osteotomy, Tarsal Bones, Other Than Calcaneus Or Talus Not

01250 Allowed Same Day As Autograft B15
Transesophageal Echocardiography For Congenital Cardiac
Abnomalies Complete Procedure Includes Components For
01254 Probe Placement And/Or Image Acquisition B15
Components Of Transesophageal Echocardiography Are

Included In The Complete Procedure Already Paid For This
Osteotomy, With Or Without Lengthening, Other Than First

01258 Metatarsal, Not Allowed Same Day As Multiple B15
Reoperation, More Than 1 Month After Original Operation

01259 Must Bill With Primary Procedure 107

Complete Procedure Not Allowed The Same Date Of Service

As The Professional Or Technical Component. Professional Or
01261 Technical Component Recouped B15
Related Bypass Procedures Not Allowed To Bill Same Date Of

01262 Service B15


Chromatography; Single Analytes Not Allowed Same Date Of

01265 Service As Multiple Analytes B15

As The Professional Of Technical Component Not Allowed.
Very Long Chain Fatty Acids Not Allowed Same Date Of

01268 Service As Fatty Acids, Nonesterified B15


For The Same Tooth, Payment Is Limited To 1 Time Per
Surface, Per Episode Of Treatment. Connecting Surfaces Must
01271 Be Billed Under 1 Procedure Code 119


For Recipients With Medicare, Medicaid Will Only Reimburse

01274 For This Dme Item If Medicare Has Allowed Or Paid 22
Patient Monthly Liability Not On Eligibility File. Contact County
01275 Dss 16
Patient Monthly Liability Not On Eligibility File. Contact County

01275 Dss 16
Total Detail Primary Care Service And Therapeutic Leave Days
01278 Cannot Exceeds Total Header Pcs Days For Domiciliary Care 16






Complete Procedure Not Allowed On The Same Date Of

Service As The Professional Or Technical Component.

Component Recouped. Complete Procedure Not Allowed On

The Same Date Of Service As The Professional Or Technical
01283 Component B15
Outpatient Drug And Alcohol Rehab Services Are Only
01284 Contracted Through The Area Mental Health Program 185
Components Of Basic Metabolic Panel Recouped To Allow
01285 Reimbursement Of Panel Code B15
01286 This Lab Test Is Included In Fee For Basic Metabolic Panel 97
Component Of Electrolyte Panel Recouped To Allow

01287 Reimbursement Of Panel Code 97
01288 This Lab Test Is Included In Fee For Electrolyte Panel 97
Components Of Comprehensive Metabolic Panel Recouped To

01289 Allow Reimbursement For Panel Code 97
This Lab Test Is Included In The Fee For Comprehensive

01290 Metabolic Panel 97
Chemiluminescent Assay And Molecular Diagnostics Not

01291 Allowed Same Date Of Service As Hiv-1 Quantification B15
Related Lipo Protein Procedures Not Allowed Same Dos As

01292 Primary Procedure B15
Service Recouped. Hiv Quantification Includes Amplified Probe

01293 Technique 97
01294 Amplified Probe Technique Included In Hiv Quantification 97
Related Molecular Diagnostics Procedures Not Allowed Same

01295 Date Of Service As Primary Procedure B15
Related Patient Nucleic Acid Procedures Not Allowed Same
01297 Date Of Service As Primary Procedure B15
Immunization Update And Health Check Screen Not Allowed

01300 Same Day By Health Department B15
Simple Incision And Drainage Of Pilonidal Cyst Cannot Be

Billed Same Day As Complicated Incision And Drainage Of
01302 Pilonidal Cyst B15
Prostate Specific Antigen (Psa); Free Not Allowed Same Date

01303 Of Service As Total B15
Sugars; Single Qualitative Cannot Be Billed Same Date Of

01305 Service As Multiple Qualitative B15
Injection,Intralesional; Up To And Including Seven Lesions

01306 Cannot Be Billed Same Day For More Than Seven Lesions B15
01307 Provider Number Invalid For Cshs Code(S) Billed 16
01307 Provider Number Invalid For Cshs Code(S) Billed 16
Debridement Of Nail(S) By Any Method(S); One To Five

01308 Cannot Be Billed Same Day For More Than Six B15
Sugars; Single Quanitative Cannot Be Billed Same Date Of

01309 Service As Multiple Quanitative B15
Only One Simple Repair Code For Each Group Of Anatomic
01310 Site Is Allowed Per Date Of Service 119
Only One Simple Repair Code For Each Group Of Anatomic
01310 Site Is Allowed Per Date Of Service 119
Simple Pulmonary Stress Testing Not Allowed Same Date Of
01311 Service As Complex Testing B15
Treatment Of Simple Closure Not Allowed Same Day As With

01312 Packing B15
01313 First Treatment Date Is Invalid 16

Only One Intermediate Repair Code Allowed Per Date Of
01314 Service 119
Only One Intermediate Repair Code Allowed Per Date Of
01314 Service 119
Selective Catheter Placement, Additional 2Nd, 3Rd And

01315 Beyond Order Must Bill With Primary Procedure 107
Complex Repair, Trunk; 1.1Cm To 2.5Cm Not Allowed Same

01316 Day As 2.6Cm To 7.5Cm B15
Multiple Cannula Declotting Procedures Not Allowed On Same

01317 Date B15
Complex Repair Scalp Arms And Or Legs; 1.1Cm To 2.5Cm

01318 Not Allowed Same Day As 2.6Cm To 7.5Cm B15
Complex Repair 1.1Cm To 2.5Cm Not Allowed Same Date Of

01320 Service As Related Procedure B15
Complex Repair Of Over 2.6Cm To 7.5Cm Not Allowed Same

01321 Date Of Service As Related Procedure B15
Punch Graft For Hair Transplant Not Allowed Same Day Of
Service As Grafts For Hair Transplant Of More Than Fifteen
01325 Punch Grafts B15
Punch Graft For Hair Transplant Not Allowed Same Day Of

Service As Grafts For Hair Transplant From 1 To 15 Punch
01326 Grafts B15
Salabrasion Not Allowed Same Day Of Service If Less Than

01327 20Sq Cm B15
Salabrasion Not Allowed Same Day Of Service If Over 20Sq

01328 Cm B15
Complex Repair 1.0Cm Or Less Not Allowed Same Date Of


01332 Service As Related Procedures B15

Encounter: Provider Taxonomy Number Missing Or Invalid.

Refer To Appendix A. Choose The Appropriate Taxonomy For
01334 The Provider Performing The Service And Resubmit 16
Encounter: Provider Taxonomy Number Missing Or Invalid.

Refer To Appendix A. Choose The Appropriate Taxonomy For
01334 The Provider Performing The Service And Resubmit 16
Encounter: Mco/Hmo Provider Number Or Etin In Error;
01335 Please Correct And Resubmit 16
Cap Respite Not Allowed Same Date As Adult Care Homes' Pcs
01336 Or Therapeutic Leave B15
Periodic Services And/Or High Risk Intervention Services Not
Allowed Within The Same Calendar Month As Assertive
01341 Community Treatment Team Services 119
Periodic Services And/Or High Risk Intervention Services Not
Allowed Within The Same Calendar Month As Assertive
01341 Community Treatment Team Services 119
Assertive Community Treatment Team Services Not Allowed
Within The Same Calendar Month As Periodic Services And/Or
01342 High Risk Intervention Services 119
Assertive Community Treatment Team Services Not Allowed
Within The Same Calendar Month As Periodic Services And/Or
01342 High Risk Intervention Services 119
01345 Unit Limitation Exceeded For Diagnosis Billed 119
01345 Unit Limitation Exceeded For Diagnosis Billed 119
Excision, Each Additional Lesion Must Bill With Primary

01346 Procedure 107
Hysterectomy After Cesarean Delivery Must Bill With Primary

01347 Procedure 107
Simple Incision And Drainage Of Abcess Cannot Be Billed

Same Day As Complicated Or Multiple Incision And Drainage
01356 Of Abcess B15
Destruction Of Lesions By Any Method Second Through

Fourteen Not Allowed Same Date Of Service As Related
01361 Procedure B15
Destruction Of Lesions By Any Method Fifteen Or More Not

01362 Allowed Same Date Of Service As Related Procedure B15
Destruction Of Warts, Molluscum Contagiosm Or Millia By Any

Method Up To 14 Lesions Not Allowed Same Date Of Service
01364 As Related Procedure B15
Destruction Of Warts, Molluscum Contagiosum, Or Millia By
Any Method Of Fifteen Or More Lesions Not Allowed Same
01365 Date Of Service As Related Procedure B15
Excision Of Chest Wall Tumor Without Mediastinal

Lymphadenectomy Not Allowed Same Date Of Service As
01366 Related Procedure B15
Excision Of Chest Wall Tumor With Mediastinal

Lymphadenectomy Not Allowed Same Date Of Service As
01367 Related Procedures B15
01375 Fetal Nonstress Test Included In Fetal Biophysical Profile 97
Related Dme Procedures Are Not Allowed On The Same Date

01378 Of Service B15
Date Of Service Overlap: Refile Claim With Charges Broken
01380 Down On Each Line For Each Date Of Service 16
Date Of Service Overlap: Refile Claim With Charges Broken
01380 Down On Each Line For Each Date Of Service 16
Related Strabismus Surgery Must Be Billed With Primary

01384 Procedure 107
01386 Exceeds 50 Procedures Per Day Limitation 119
Related Strabismus Procedures Must Be Billed With Primary

01387 Procedure 107
Thoracic, Additional 2Nd, 3Rd And Beyond Order Must Bill

01388 With Primary Procedure 107
Drug Billed Is Not A Family Planning Drug. Correct And
01391 Resubmit As A New Day Claim 16
Drug Billed Is Not A Family Planning Drug. Correct And
Additional Hour For Work/ Hardening/Conditioning Must Be

01392 Billed With Primary Procedure 107
Preventive Medicine, Individual And Group Counseling Not
01398 Allowed More Than 10 Per Calendar Year 119
Preventive Medicine, Individual And Group Counseling Not

01398 Allowed More Than 10 Per Calendar Year 119
Detailed And Extensive Oral Evaluation Not Allowed Same

01401 Date Of Service As Dental Exam B15
Dental Exam Not Allowed On The Same Date Of Service As

01402 Detailed And Extensive Oral Evaluation B15
Only One Reduction Per Arch Allowed On The Same Date Of
01403 Service 119
Only One Reduction Per Arch Allowed On The Same Date Of
01403 Service 119
Private Insurance Payment Indicated On Claim. No Record Of
Tpl On File. Correct Claim Or Update Recipient Tpl Using Dm
01404 Form 2057 And Resubmit Claim 22
Private Insurance Payment Indicated On Claim. No Record Of
Tpl On File. Correct Claim Or Update Recipient Tpl Using Dm
01404 Form 2057 And Resubmit Claim 22
Large Volume Nebulizer Not Allowed Same Month As

01406 Compressor B15
Hcpc Code Not Appropriate With Non-Medicare Beneficiary.
Hcpc Code Not Appropriate With Non-Medicare Beneficiary.
Only Six Oral Evaluations And Flouride Varnish Applications
01412 Allowed Per Recipient'S Lifetime 149
Meniscectomy And/Or Arthrotomy Not Allowed On The Same

01415 Date Of Service As Arthroplasty B15
01416 Exceeds 20 Unit Per Year Limitation 119
01416 Exceeds 20 Unit Per Year Limitation 119

Diagnostic Arthroscopy Not Allowed On The Same Date Of
01417 Service As Surgical Arthroscopy B15
No Payment Allowed For Special Services Procedure When

E/M Service Is Not Paid For The Same Date Of Service, Same
01418 Provider B15
Surgical Arthroscopy (D7873, 29804) Not Allowed On The

01419 Same Date Of Service As Temporomandibular Joint B15
01420 Unit Cutback - Exceeds Max Units Allowed 119
Repair Of Maxillofacial Soft Or Hard Tissue Defects Not

Allowed On The Same Date Of Service As Related Dental
01421 Procedure B15
Immunization Administration Not Allowed Without Billing The
Appropriate Immunization Code. Refer To The Latest Health
01422 Check Billing Guide 96
Immunization Administration Not Allowed Without Billing The
Appropriate Immunization Code. Refer To The Latest Health
01422 Check Billing Guide 96
Detail Billed With Incorrect Or No Modifier. Correct Detail And

Resubmit As A New Day Claim. If Reimbursement Affected,
01432 Request A Full Recoupement And Resubmit Claim 4
Detail Billed With Incorrect Or No Modifier. Correct Detail And
Resubmit As A New Day Claim. If Reimbursement Affected,
01432 Request A Full Recoupement And Resubmit Claim 4
Related Dialysis Graft Procedures Not Allowed Same Date Of

01434 Service B15
Related Pelvic Exenteration Procedures Not Allowed Same

Related Vaginectomy Procedures Not Allowed Same Date Of

01436 Service B15
Thyroid Carcinoma Metastases Uptake Must Be Billed Same
01437 Date Of Service As Imaging Whole Body 107
Related Cardiac Blood Pool Imaging Must Be Billed Same Date

01438 Of Service As Primary Procedure 107
Amino Acids;Single Qualitative, Not Allowed Same Date Of

01439 Service As Multiple B15
2 To 5 Amino Acids Not Allowed Same Dos As 6 Or More

01441 Amino Acids B15
Specially Priced Claim Through Div. Of Medical Assistance: Bill
Type Must Be 111, 112, 113 Or 114. Correct The Bill Type
01443 And Resubmit Claim To Nctracks 16
Specially Priced Claim Through Div. Of Medical Assistance: Bill
Type Must Be 111, 112, 113 Or 114. Correct The Bill Type
01443 And Resubmit Claim To Nctracks 16
Stable Isotope Dilution; Single Analyte Not Allowed To Bill

01447 With Multiple B15
Radiologic Exam, Knee; Minimum Of 3 Views Not Allowed To
01451 Bill With Related Procedure B15
Radiologic Exam, Knee; Complete View Not Allowed To Bill

01452 With Related Procedure B15
Intravascular Ultrasound, Radiological Interpretation, Each

01453 Additional Vessel Must Be Billed With Primary Procedure 107
Transluminal Balloon Angioplasty, Each Additional Peripheral

01455 Artery Must Bill With Primary Procedure 107
Transluminal Artherectomy, Each Additional Peripheral Artery

Transluminal Artherectomy, Each Additional Visceral Artery

Liver Imaging Procedures Not Allowed To Bill With Same Date

Liver Imaging With Vascular Flow Not Allowed To Bill With

01459 Same Date Of Service B15
Cardiac Blood Pool Imaging, Gated Equilibrium Not Allowed

01460 To Bill With Multiple Studies B15
Performance Of The Test, Physician Supervision, Report And

01461 Interpretation Included In The Cardiac Stress Test 97
01462 Myocardial Perfusion Study Must Bill With Related Procedure 107
01463 Only One Special Services Visit Allowed Per Day 119
01463 Only One Special Services Visit Allowed Per Day 119
Amino Acids, Qualitative Not Allowed To Bill With Related
01464 Procedure B15
Chromatography, Quantitative,Column, Single Anlyte Not

01465 Allowed To Bill With Multiple B15
Immunoassay For Analyte Other Than Antibody Agent

01466 Antigen, Multiple Step Method Not Allowed To Bill With Single B15
Immunoassay For Analyte Other Than Infectious Agent For

01467 Single Step Method Not Allowed With Multiple Step Method B15
Chromatography, Quantitative, Column, Multiple Analytes Not

01468 Allowed Same Date Of Service As Single Analyte B15
Infectious Agent Analysis Not Allowed With Hiv Resistance

01469 Testing B15
01470 Molecular Diagnostics Not Allowed To Bill With Multiplex B15
Components Of Hiv Resistance Testing Recouped.

01471 Components Not Allowed Same Day As Hiv Resistance Testing B15
Iv Infusion For Therapy/Diagnosis Must Be Billed With Primary
01472 Procedure 107
01473 Use Of Vertical Electrodes Must Bill With Primary Procedure 107
Claim Denied. Transcatheter Placement Of An Intracoronary

01474 Stent, Each Additional Vessel Must Bill With Primary Procedure 107
Percutaneous Transluminal Coronary Balloon Angioplasty;
01475 Single Vessel Must Bill With Primary Procedure 107
Percutaneous Balloon Valvuloplasty; Aortic Valve Must Bill
Doppler Echocardiography, Pulsed Wave-Complete, Must Bill
01478 With Related Procedure 107
Doppler Echocardiography, Pulsed Wave-Follow Up, Must Bill
01479 With Related Procedure 107
Pulmonary Stress Testing-Simple, Not Allowed To Bill With

01480 Complex B15
Cardiac Stress Test Includes Performance Of The Test,

01481 Physician Supervision, Interpretation And Report 97
Intraoperative Neurophysiology Testing Per Hour, Must Be
01482 Billed With Primary Procedure 107
Doppler Color Flow Velocity Mapping Must Bill With Related
01483 Procedure 107
Electronic Analysis Of Implanted Neurostimulator Pulse
01487 Generated Must Bill With Primary Procedure 107
Intravascular Doppler Velocity Must Bill With Primary
01488 Procedure 107
Use Of Operating Microscope Not Allowed With Primary
01490 Procedure 107
Prolonged Physician Service In The Inpatient Setting Must Bill
Prolonged Physician Service In The Office Must Bill With
01492 Primary Procedure 107
Critical Care, Evaluation & Management Must Bill With Primary
01493 Procedure 107
01494 Payment Included In Multiple Tendons, Bilateral 97

Chemotherapy Administration, Intra-Arterial; Infusion Tech, 1
To 8 Hrs; Each Additional Hour Must Bill With Primary
01495 Procedure 107
Chemotherapy Administration, Intraveneous, Infusion Tech,
01496 Up To 1 Hour Must Bill With Primary Procedure 107
Each Additional Hour Of Physician Attendance Must Bill With
Strabismus Surgery; Repair Of Detached Extraocular Muscle
01499 Bill Medicare Part B Or Prescription Drug Plan 16

Medicaid Does Not Make Separate Payment For Procedures
That Are Components Of A More Comprehensive Service
01500 Already Paid For The Same Date Of Service B15
Components Denied. Rebill Using 81000 As The Complete

01502 Procedure, Versus Multiple Components Of Urinalysis B15
Cytopathology Definitive Hormonal Evaluation Related
01504 Procedure Codes Must Bill Same Date Of Service 107
Procedure Denied. Bronchoplasty Procedure Only Allowed
When Billed In Addition To Primary Surgery Procedure.
01506 Review Claim, Correct And Resubmit As A New Claim 107
01507 Multiple Osteotomy Of Metatarsals Not Allowed On Same Date B15
01508 Multiple Arthrodesis Procedures Not Allowed On Same Date B15
Multiple Related Arthrodesis Procedures Not Allowed On Same

01509 Date B15
01510 Multiple Capsulodesis Procedures Not Allowed On Same Date B15
01511 Tenotomy, Multiple, 1 Leg Included In Bilateral 97
01512 Medicaid Has Paid The Maximum Allowable For Procedure 119
Separate Reimbursement Not Allowed When Other Services

01514 Are Paid On The Same Date Of Service B15
01515 Bypass Graft, Composite Must Bill With Primary Procedure 107
Foreskin Manipulation Included In Related Procedure Same
Removal Of Vitreous Included In Extracapsular Cataract

01517 Procedure Same Dos B15
01518 Enterolysis Included In Intestinal Procedures Same Dos B15
Component Of Procedure (Either Technical Or Professional

Denied Because Same Procedure Code Has Already Been
Reimbursed As A Complete Procedure For This Date Of
01519 Service B15
Technical Component Of This Procedure Has Already Been

Reimbursed For This Date. Rebill For Professional Component
01520 Only B15
Professional Component Of This Procedure Code Has Already

Been Reimbursed For This Date. Rebill For Technical
01521 Component Only B15
No Payment For Add-On (Zzz) Code Allowed If 'Primary' Code
In Series Is Not Paid For The Same Date Of Service, Same
01522 Provider 97
01522 Provider 97
01522 Provider 97
01523 Provider 97
01523 Provider 97
01524 Provider 97
01524 Provider 97
Reimbursement For Monthly Rental Of Dme Includes Payment

01528 For Related Supplies 97
Payment For Supplies Recouped To Allow Reimbursement For

01529 Monthly Rental Of Related Dme 97
01530 Provider 97
01530 Provider 97
01531 Provider 97
01531 Provider 97
01537 Units Cutback To Allow A Maximum Of 14 Units Per Day 119

Graft Procedure Only Allowed When Billed In Addition To
01538 Spinal Operative Session, Same Date Of Service 107
01541 E/M Visit Not Allowed Same Date Of Service As Clinic Visit B15
01542 Clinic Visit Not Allowed Same Date Of Service As E/M Visit B15
01543 Only 14 Units Allowed Per Date Of Service 119
01543 Only 14 Units Allowed Per Date Of Service 119
01548 Exceeds Unmanaged Mental Health Visit Limitation 119

Recipient Must Have Received Erythropotein Therapy On The
Same Date Of Service Or Within 3 Months Prior To The Date
01549 Of Service Of Ferrlecit Or Iron Sucrose B5
01550 Dme Equipment Allowed Twice Per Year 119

Only 8 Psychiatric Outpatient Visits Allowed Without Prior
01551 Approval 119
Only 8 Psychiatric Outpatient Visits Allowed Without Prior

01551 Approval 119
01552 Dme Equipment Allowed Twice Per Three Years 119
01553 Refer To 1998 Cpt For Hiv Viral Load Codes And Refile 16
Service Recouped. Nursing Home/Ach Service Not Allowed

01554 During Inpatient Stay 97
01555 Dme Equipment Allowed Twice In Two Years 119
Miscellaneous Charges Not Allowed With Prolonged Services

01565 Or Critical Care B15
Alcohol/Drug Intensive Outpatient Services Not Allowed
01567 During Inpatient Stay B15
Personal Care Service Not Allowed The Same Day As High

01569 Risk Intervention-Ri Facility B15
01570 Recoup Pcs When Hri-Ri Is Paid B15
01572 Units Cutback. Units Billed Exceed Maximum Units Allowed 119
Case Management Paid To Dmh. Recouped To Allow Payment

For Case Management To Cap Provider For The Same Date Of
01573 Service B15
Adjustment Of Immediate Dentures Not Allowed Until Six

01574 Months After Receipt Of Denture Per State Limit 119
01574 Months After Receipt Of Denture Per State Limit 119
01575 Inpatient Services Billed Same Day, Pdn Not Allowed B15
Canal And Pulpotomy Procedures Not Allowed For The Same

01577 Tooth, Same Date Of Service 97
Pulpotomy Procedure Included In Reimbursement For Root

01578 Canal 97
01579 Months After Receipt Of Dentures Per State Limit 119
01579 Months After Receipt Of Dentures Per State Limit 119
Hospice And Pdn Not Allowed The Same Day. Contact Hospice
Responsible For Patient. Refile Claim Only For Date(S) Of
01581 Service Not Covered By Hospice Benefit B9
Hospice And Pdn Not Allowed The Same Day. Contact Hospice
Responsible For Patient. Refile Claim Only For Date(S) Of
01581 Service Not Covered By Hospice Benefit 96
Pdn Recouped-Hospice Patient. Contact Hospice Responsible

For Patient. Refile Claim Only For Date(S) Of Service Not
01583 Covered By Hospice Benefit B15
01584 Cap Procedure Allowed Once Per Day 119
01584 Cap Procedure Allowed Once Per Day 119

Only One X-Ray Procedure Allowed For This Provider Within A
6 Month Period. Resubmit As An Adjustment With
01585 Documentation To Support Necessity 119
01586 1 Repair Of Laceration Of Palate Allowed Per Date Of Service 119

Claim Denied. Treatment Has Been Rendered By Another
01588 Provider For This Date Of Service B20
01589 Only One Incision/Excision Allowed Per Date Of Service 119
01589 Only One Incision/Excision Allowed Per Date Of Service 119
Service Denied. Exceeds The Maximum Units Allowed Per

01593 Month 119
01593 Month 119

01593 Month 119
01593 Month 119
The Procedure/Modifier Combination Billed Requires An

01594 Additional Modifier 16
The Procedure/Modifier Combination Billed Requires An

01594 Additional Modifier 16
01596 Recipient Not Eligible For Cap Services 177

01598 Allowed When Recipient Is Receiving Related Services B15
Cap Respite Care Services Recouped. This Service Not
Allowed When Recipient Is Receiving Adult Care Homes Pcs
01599 Or Therapeutic Leave 96
01600 Recipient Disability Code Invalid - Header Level
Payment Is Included In The Allowance For Another Service Or

01603 Procedure 97
Synagis Max 25-Day Qty Rules Exceeded. Synagis Rules Allow
No More Than One 50Mg Vial And No More Than 250Mg Total
01604 In Any 25-Day Period 16
Service Denied. Recipient Eligible For Only Emergency

01605 Services 96
Services. Please Resubmit As An Adjustment With Supporting
01606 Documentation If An Emergency Situation Existed 96

Services. Please Resubmit As An Adjustment With Supporting
01606 Documentation If An Emergency Situation Existed 96
Recipient Eligible For Emergency Services Only. Place Non-
Emergency Charges (I.E., Steri) In Non-Covered Column &
01608 Note Change In Remarks Field 96
Family Planning Procedure Code Requires Family Planning
01610 Diagnosis. Please Correct And Resubmit 11
Service Has Already Been Paid To Another Provider For Same
01611 Dos B20
Service Has Already Been Paid To Another Provider For Same

01611 Dos B20
Exceeds Maximum Allowed For A Primary Posterior Composite
01614 On A Single Tooth 119
01615 Claim Denied. Neonatal Drg Has Invalid Diagnosis 167
01615 Claim Denied. Neonatal Drg Has Invalid Diagnosis 167

The Procedure Billed Requires A Modifier 26 To Establish The
Professional Component Was Billed. Correct Your Claim And
01616 Resubmit 4
The Procedure Billed Requires A Modifier 26 To Establish The

Professional Component Was Billed. Correct Your Claim And
01616 Resubmit 4
The Rendering Provider Number Cannot Be Used As A Billing
Provider Number. Add The Correct Billing Provider Number An
The Lt Or Rt Modifier Must Be On The Same Detail Line As
The Nu Modifier. Add The Appropriate Modifier And Resubmit
01618 The Claim 4
The Lt Or Rt Modifier Must Be On The Same Detail Line As

The Nu Modifier. Add The Appropriate Modifier And Resubmit
01618 The Claim 4
The Lt Or Rt Modifier Must Be Billed With Procedure Code
01619 Billed. Add The Appropriate Modifier And Resubmit The Claim 4
The Lt Or Rt Modifier Must Be Billed With Procedure Code

01619 Billed. Add The Appropriate Modifier And Resubmit The Claim 4
Certified Rendering Provider Number Is Required When Billing
This Procedure Code. Resubmit With Appropriate Rendering
01620 Number 16
Certified Rendering Provider Number Is Required When Billing
This Procedure Code. Resubmit With Appropriate Rendering
01620 Number 16
Invalid Drg Grouping Due To Incorrect/Insufficient Coding.
01621 Include Weight Of Newborn On Claim And Resubmit 16
Invalid Drg Grouping Due To Incorrect/Insufficient Coding.
01621 Include Weight Of Newborn On Claim And Resubmit 16
Intra-Nasal/Oral Administration Requires The Appropriate
01622 Intra-Nasal/Oral Immunization Procedure 16
Intra-Nasal/Oral Administration Requires The Appropriate
01622 Intra-Nasal/Oral Immunization Procedure 16
First Intra-Nasal/Oral Immunization Administration And First
Injectable Immunization Administration Not Allowed On The
01623 Same Day 96
Incorrect Immunization Administration Code Combination
Billed. This Combination Cannot Be Billed On The Same Date
01624 Of Service. See Billing Guidelines 96
01625 Provider 97
01625 Provider 97
01626 Provider 97
01626 Provider 97
01627 Provider 97
01627 Provider 97
01631 Gastric Restrictive Procedures Limited To One Per Lifetime 35

Physical Therapy Re-Evaluation Not Allowed Same Day As
01632 Physical Therapy Evaluation B15
Physical Therapy Evaluation Not Allowed Same Date Of

01633 Service As Physical Therapy Re-Evaluation B15
Component (Technical Or Professional) Denied. Complete
01634 Procedure Has Been Reimbursed Within 2 Years B13
Professional Component Has Already Been Reimbursed Within
01635 2 Years. Re-Bill For Technical Component Only B13
Technical Component Has Already Been Reimbursed Within 2
01636 Years. Re-Bill For Professional Component Only B13
Payment Has Been Reduced To The Same Total

Reimbursement As The Three Surface Resin-Based Composite
01638 Restoration For Posterior Tooth B10

Reimbursement As The Three Surface Resin-Based Composite
01638 Restoration For Posterior Tooth B10
For Dos On & After 01-01-2009, Procedure Requires A
Secondary Modifier Of Hp, Hn, Ho, Ub, U8, U7, U6 Or U5.
01639 Refer To The February 2009 Nc Medicaid Bulletin For Details 4


For Dos On & After 01-01-2009, Modifiers Hp, Hn, Ho, Ub, U8
U7, U6 Or U5 Must Be Billed In The Secondary Position. Refer
01640 To The February 2009 Nc Medicaid Bulletin For Details 4
01641 Unit Cutback. Exceeds Maximum Units Allowed Per Month 119
Crossover Percentage Payments Are Not Allowed For This

01642 Provider Taxonomy 170
Cap-Mr/Dd Respite Care; Facility & Institutional Not Allowed

The Primary Or Secondary Diagnosis Code Billed Does Not
Meet The Medicaid Billing Requirements For This Provider
01647 Taxonomy Qualifier 12
Invalid Or Missing First Treatment Date. Resubmit Claim With
01648 Valid First Treatment Date 16
Component Procedure Not Allowed Same Day As

01651 Comprehensive Procedure B15
01652 Care Plan Oversight Already Paid For This Calendar Month 97
Care Plan Oversight For Home Health Recipient Already Paid

01653 For This Calendar Month 97
Care Plan Oversight For Hospice Recipient Already Paid For

01654 This Calendar Month 97
Comprehensive Procedure Paid. Component Procedures Will

01655 Be Recouped B15
Payment For Care Plan Oversight Is Included In Dialysis
01656 Composite Rate Already Paid For This Calendar Month 97

01656 Composite Rate Already Paid For This Calendar Month 97

01657 Composite Rate Billed Separately For Same Calendar Month 97

01657 Composite Rate Billed Separately For Same Calendar Month 97
16 Psychiatric Outpatient Visits Allowed Without Prior
01658 Approval 119
01659 Claim Denied. Procedure Code Must Bill With Fp Modifier 4
01660 No Rate On File 204
01661 No Other Procedure Allowed To Be Billed With T1015 16
01662 Only One Rendering Taxonomy Allowed 16
01663 Month 97
01664 Service Denied. Drug Allows 1200 Units Per Calendar Month 119
Secondary Thrombectomy Code Must Be Billed With A Primary
01665 Procedure 97

01665 Procedure 97

01665 Procedure 97

01665 Procedure 97

01665 Procedure 97

01665 Procedure 97
Dermagraft Limited To 4 Applications Totaling 150.00 Sq. Cm
01666 Per Day 119
01666 Per Day 119

01666 Per Day 119

01666 Per Day 119
Only 8 Applications Or 300 Sq. Cm. Of Dermagraft Allowed
01667 Every 12 Weeks 119
Only 8 Applications Or 300 Sq. Cm. Of Dermagraft Allowed

01667 Every 12 Weeks 119
01672 Dme Allowed Once In Four Years For Ages 21-115 119
Required Dme Local Code And/Or Prior Approval Number Is
Missing Or Invalid. Verify Dme Local Code And/Or Prior
01673 Approval Number And Resubmit As A New Claim. 96
01674 Diagnosis Billed Is Not Allowed As Primary Diagnosis 16

Drug Is Limited To 240 Units Per Calendar Month. Units Have
01675 Cutback To Allowable Units For This Timeframe 119
Units Cutback. Exceeds The Maximum Units Allowed Per

01676 Calendar Month 119



01677 Service Denied. Exceeds Allowed Units Per Calendar Month 119
Related Aneurysm Procedures Not Allowed On The Same Date

01679 Provider Denied For False Claims Act 16
01679 Provider Denied For False Claims Act 16
01680 Service Eligible For The Affordable Care Act Enhanced Rate 96
Related Laminotomy Procedures Not Allowed On Same Date

01682 Vaccine Procedure Only Allowed 2 Per Lifetime 149

Diabetes Self Management Training Services, Individual Or
Group Sessions Not Allowed More Than 20 Units Per Calendar
01683 Year 119
01683 Year 119
01683 Year 119
01683 Year 119
01684 Unit(S) Cutback. Exceeds Maximum Units Per Calendar Year 119
The Procedure Submitted Requires A Modifier To Identify
Number Of Patients. Please Resubmit Claim With The
01685 Appropriate Modifier 4


Diabetes Self Management Outpatient Service Not Allowed
01686 Same Day As Physician Service 96
Physician Service Not Allowed Same Day As Diabetes Self
01687 Management Outpatient Service 96
01688 Payment Included In Asc Reimbursement On First Detail Line 45

Condition Code Indicating Medicare Override Is Not Allowed
01689 When Medicare Payment Is Also Indicated On Claim 16
Related Mri Procedures Not Allowed By The Same Rendering
01690 Provider B15
01696 Mammography Screening Limited To One Per 5 Years 119
Service Is Not Consistent With Or Not Covered For This

01699 Diagnosis Or Service Does Not Match Diagnosis 16
Product/Services Not Covered For Special Assistance
01700 Recipients In An Institution For Mental Disease. 16
Nemt Services Require Nemt Prior Approval. Please Request
01701 Prior Approval From Local Dss Office 197
Nemt Services Denied. Approved Amount Exhausted On Nemt
01702 Pa. 119
Recipient Eligibility Indicates Medicare Part C / No Part C
01703 Present
01704 Medicare Part C Paid, No Part C Eligibility Indicated
01705 Prior Approval Required For Capch, Capda, Capco Recipients.
01705 Prior Approval Required For Capch, Capda, Capco Recipients.

Non-Physician Counseling Immunization Administration
Procedure Not Allowed Same Day As Physician Counseling
01706 Immunization Administration Procedure 96
Procedure Recouped. Administration With Non-Physician
01707 Counseling Not Allowed Same Day As Physician Counseling 96
01708 Medicare Code Editor - Mce - Age Is Invalid 6
01709 Medicare Code Editor - Mce - Gender Code Is Invalid 119

No Medicare On File. Contact The Buy-In Unit Toll Free 888-

01710 245-0179 22
Portable Gaseous Oxygen System; Home Compressor
Including Containers Not Allowed During Same Period As
01711 Other Related Systems/Units 96
Other Related Systems/Units Not Allowed When Portable
Gaseous Oxygen System; Home Compressor Including
01712 Containers Is Paid In History 96
01714 Mfp Claim Date Of Service Prior To Mfp Transition Date 96
Ambulance\Transportation Claims Must Be Submitted On The
Institutional Claim Form. Please Resubmit Claim Using The
837I Transaction Or Institutional Claim Submission Page On
01715 The Nctracks Provider Portal 16
Ambulance\Transportation Claims Must Be Submitted On The
Institutional Claim Form. Please Resubmit Claim Using The
837I Transaction Or Institutional Claim Submission Page On
01715 The Nctracks Provider Portal 16
01716 Only One Early Refill Per Year For Lost Rx Allowed 16
01717 Reversal Not Processed 16

Cbsa Code Missing, Invalid Or Does Not Match Zip Code Of
The Location Where Service Was Provided. Correct Claim And
01718 Refile Or Contact Nctracks. 16
The Hospice Revenue Code Billed Must Be Billed With A Value
01719 Code Of 61 And Corresponding Cbsa Code 16
The Hospice Revenue Code Billed Must Be Billed With A Value
01719 Code Of 61 And Corresponding Cbsa Code 16
01721 Related Mri Procedure Not Allowed On Same Date Of Service B15
01722 Pharmacy Pa Required 16
01723 Drug Not On Pdl. Pharmacy Pa Required 16
Secondary Thrombectomy Not Allowed Same Day As Primary

01724 Procedure 97
01724 Procedure 97

01724 Procedure 97

01724 Procedure 97
Related Mammography Screenings Not Allowed On The Same



01726 Reimbursement As The Intraoral Complete Series B10

01726 Reimbursement As The Intraoral Complete Series B10
Value Code Requirements Not Met. Dos Span Code
Requirements. Split Claim By Dos & Bill Msa Code(S) For Dos
Prior To 01/01/2009 And Cbsa Code(S) For Dos On Or After
01727 01/01/2009 16
Value Code Requirements Not Met. Dos Span Code
Requirements. Split Claim By Dos & Bill Msa Code(S) For Dos
Prior To 01/01/2009 And Cbsa Code(S) For Dos On Or After
01727 01/01/2009 16
01728 Must Use Preferred Vendor-Roche 16
01728 Must Use Preferred Vendor-Roche 16
Oral Evaluation Must Be Billed With Topical Fluoride Varnish

01729 Application 107
01731 Epsdt Monthly Personal Care Units Have Been Exceeded 119
Billing Provider Not Allowed To Submit Claims For This

01732 Procedure Code 8
Medicaid Does Not Cover Ndcs That Are Not Covered By Part
01734 B 16
Prior Claim For Cap Case Management Has Been Paid For This
01735 Month Under A Different Cap Program 96
01736 Claim Paid $0.00 Due To No Cost Sharting Amount 16

Procedure/Product Denied. Product Requires Use Of Preferred
01737 Vendor-Prodigy 204
Procedure/Product Denied. Product Requires Use Of Preferred
Original Transaction For Rebill/Reversal Not Posted As An

01738 Ncpdp Transaction 16
Pharmacy Prior Approval And Non-Preferred Drug Override

01739 Needed For Drug Category 16
Only One Emergency Fill Of A Controlled Substance Allowed

01742 Per Year For Each Year Of The Lock-In Period. 16
Reimbursement For Restorative Procedure Code Includes All

01743 Necessary Bases And Liners 97
Safty Doc Required. Prescriber Must Call Nctracks 866-246-
01744 8505 197
Mfp Service For The Pre-Transition Period Is Submitted Prior

01745 To Mfp Transition Date 96
Related Radiology Procedures Not Allowed On The Same Date
Primary Or Principal Diagnosis Not Allowed. Please Verify And

01748 Enter The Correct Diagnosis Code And Submit As A New Claim 146
Primary Or Principal Diagnosis Not Allowed. Please Verify And

01748 Enter The Correct Diagnosis Code And Submit As A New Claim 146
Related Fetal Biophysical Profile Procedures Not Allowed On

01749 The Same Date Of Service B15
Fluoride Varnish Application Must Be Billed With Related
01750 Procedure Codes On The Same Claim 107
Related Prostate Specific Antigen (Psa) Procedures Not

01751 Allowed On The Same Date Of Service B15
Repeat Billing Of The Same Quadrant For Periodontal Scaling

01752 And Root Planing Not Allowed In This Time Frame 97
Vitamin, Unspecified Not On Same Date Of Service As Vitamin

01753 A Or K B15
Diagnosis Not Covered. Please Verify And Enter The Correct
01754 Diagnosis Code And Submit As A New Claim 167
Diagnosis Not Covered. Please Verify And Enter The Correct
Drug/Implant Must Be Billed With The Appropriate

01755 Administration Code B15
Diagnosis Non-Specific. Please Verify And Enter The Correct
Diagnosis Non-Specific. Please Verify And Enter The Correct
This Procedure Included In A More Comprehensive

01758 Audiometry Procedure Billed On Same Date Of Service 97
Procedure Recouped To Allow Reimbursement Of More
01759 Comprehensive Procedure 97
01760 Missing Medicare Line Other Payer Information 276
Related Cap Service Not Allowed On Same Day As Cap-Mr/Dd

01761 Institutional Respite B15
Cap-Mr/Dd Habilitation Service Not Allowed On Same Date As

01762 Adult Day Health B15
Cap-Mr/Dd Group Respite And Institutional Respite Are Not

01764 Allowed On The Same Date Of Service B15
01765 Cap Dollar Limitation Has Been Exceeded For This Service 45
Units Cutback To Maximum Allowable Amount. Limitation Has
Been Reached. Submit Adjustment With Necessary
01767 Documentation 119
01768 Fee Adjusted To Maximum Allowable Amount. Limitation Met 45
No Additional Payment Made For Hearing And/Or Vision

01769 Service. Payment Is Included In Health Check Reimbursement 97
01773 Only One Hri Level Iv Residential Procedure Allowed Per Day 119
01773 Only One Hri Level Iv Residential Procedure Allowed Per Day 119
01774 Services Included In Health Check Package 97
01775 Only One Hri Level Iii Residential Procedure Allowed Per Day 119
01775 Only One Hri Level Iii Residential Procedure Allowed Per Day 119
Related Immunization Procedures Not Allowed On The Same

01776 Day B15
Immunization Update And Health Check Screen Not Allowed

01778 On The Same Day B15
01780 Therapeutic Leave Quarterly Limit Exceeded 119
The Rx Clarification Code Specified Is Not Valid For The

Recipient And Drug. Only Long-Term Care Recipients Are
01781 Valid For This Override 16
The Rx Clarification Code Specified Is Not Valid For The

Recipient And Drug. Only Long-Term Care Recipients Are
01781 Valid For This Override 16
Service Denied. An Ultrasound Has Already Been Paid For This

Please Resubmit As An Adjustment With Medical Records

01786 Supporting Units Billed 16
Please Resubmit As An Adjustment With Medical Records
01786 Supporting Units Billed 16
One Follow-Up Ultrasound Allowed Per Day. If More Than One
Fetus, Please Resubmit Procedure Code With Appropriate
01788 Modifier And Diagnosis To Support Additional Unit(S) 119
One Follow-Up Ultrasound Allowed Per Day. If More Than One

Fetus, Please Resubmit Procedure Code With Appropriate
01788 Modifier And Diagnosis To Support Additional Unit(S) 119
01789 One Ob Transvaginal Ultrasound Allowed Per Date Of Service 119
01789 One Ob Transvaginal Ultrasound Allowed Per Date Of Service 119

Claim Denied. Maximum Submitted Units For Revenue Codes
01790 For Outpatient Specialized Therapy Is One
Provider Suspended Due To Not Completing Required Re-

01791 Verification 16
Provider Suspended Due To Not Completing Required Re-

01791 Verification 16
Dme Supplies/Equipment Are Included In The Nursing Facility

01792 Per Diem Package. 96
No Payment Allowed If "Primary" Code Is Not Paid In The

01793 Past 365 Day History 97
Two Quadrant Periodontal Scaling And Root Planing Allowed
Per Date Of Service Unless Treatment Is Rendered In Hospital
01794 Or Ambulatory Surgical Center 119
Two Quadrant Periodontal Scaling And Root Planing Allowed
Per Date Of Service Unless Treatment Is Rendered In Hospital
01794 Or Ambulatory Surgical Center 119
Previously Paid Technical Component Recouped, Complete

01795 Procedure Paid 45
Beneficiary_X001A_S Eligibility Is Limited To Inpatient
01796 Hospital Stay Services 16
Beneficiary'S Eligibility Is Limited To Inpatient Hospital Stay
01797 Services 16
Beneficiary'S Eligibility Is Limited To Inpatient Hospital Stay
01797 Services 16
Recipient Is Not Eligible For Medicaid Claims Payment Due To
01799 Current Living Arrangment 16
The Procedure/Diagnosis Billed Indicates A Family Planning
Service And Requires Modifier Fp To Be Appended To The
01800 Procedure 96
01801 Claim Denied. Service Provider Id Qualifier Is Not 01 16
01801 Claim Denied. Service Provider Id Qualifier Is Not 01 16
01802 Service Provider Id Is Invalid 16
01802 Service Provider Id Is Invalid 16

Service No Longer Covered By Medicaid For Recipients Who
01803 Are Also Enrolled With Medicare 22
Claim Denied For Recipient 21 Years Of Age Or Older With
01805 Invalid Diagnosis 9
Claim Denied For Recipient 21 Years Of Age Or Older With
01805 Invalid Diagnosis 9
Invalid Conditon Code Billed, Verify And Resubmit With A

01806 Valid Condition Code 16
Claim Denied. Prior Authorization For Outpatient Specialized
01807 Therapy Services Is Missing Or Exhausted. 197
Missing Or Invalid Ub Information Or Code. Check Patient
Status, Condition, Value, Or Occurrence, Code, Or Other
01808 Claim Information, Correct And Resubmit If Applicable 16
Missing Or Invalid Ub Information Or Code. Check Patient
Status, Condition, Value, Or Occurrence, Code, Or Other
01808 Claim Information, Correct And Resubmit If Applicable 16
Reimbursement For This Service Has Been Denied Due To The

01811 Lack Of Proper Service Endorsement Or Medicaid Participation 242
Fee For Service Claim Submited With Encounter Etin: Please
01812 Correct And Resubmit
Claim Denied. Recipient_X001A_S Eligibility And/Or Claim 197
01813 Indicate
RECIPIENT
IS SUBJECT
TO OTHER
HEALTH
CARE
COVERAGE Claim/Serv
. A1 ice denied.
01814 Claim Denied For Non Covered Diagnosis For Nchc Recipient 167
01815 Per Diem Reimbursement Based On Eligible Days Only 4

Room And Board Is Not Allowed On The Same Claim As
01816 Therapeutic Leave. Separate Services And Re-Bill 16
Second Approach Procedure Reduced 50% Of Allowed

01817 Amount If Performed On The Same Day 59
Second Approach Procedure Reduced 50% Of Allowed

01817 Amount If Performed On The Same Day 59
Second Repair/Reconstruction Code For Skull Base Surgery
Reduced 50% Of Allowed Amount If Performed On The Same
01818 Day 59
Second Repair/Reconstruction Code For Skull Base Surgery

Reduced 50% Of Allowed Amount If Performed On The Same
01818 Day 59
Second Definitive Procedure Code Reduced 50% Of Allowable

01819 If Performed On The Same Day 59
Second Definitive Procedure Code Reduced 50% Of Allowable
01819 If Performed On The Same Day 59
01820 Only One Vagotomy Allowed Per Day 119
01820 Only One Vagotomy Allowed Per Day 119
01821 Only One Gastrectomy Allowed Per Day 119
01821 Only One Gastrectomy Allowed Per Day 119
Medicaid Has Paid The Maximum Allowable For This

01822 Equipment Code 108

Payment Reduced To Equal The Purchased New Price For
Each Unit Allowed. Medicaid Has Previously Paid For This
01825 Paid By Drg 16
Specialized Therapy Providers May Only Render Provider Type

01827 Specific Therapy Services. 8
Repair Codes Billed In Conjunction With A Space Maintainer
01829 Are Paid At The Secondary Maximum Allowed Rate 119
Carolina Access Ii Enhanced Care Management Fee Is

01830 Reimbursed Only Through System Generated Claims 22
Carolina Access Ii Enhanced Care Management Fee Is

01830 Reimbursed Only Through System Generated Claims 22
Recipients Covered Under The Medicaid For Pregnant Women
Program (Mpw) Are Not Eligible For Orthodontic Services As
01832 Described In Dma Clinical Coverage Policy 4B. 96
Case Management Not Allowed Same Date Of Service As Case
01833 Management Provided By The Cap Program 96
Ndc Missing. The Procedure/Product Billed Requires A Valid
01838 Ndc. Preferred Vendor-Prodigy 16
Ndc Missing. The Procedure/Product Billed Requires A Valid
01838 Ndc. Preferred Vendor-Prodigy 16
Invalid Ndc Submitted. Resubmit With Valid Ndc Preferred
Invalid Ndc Submitted. Resubmit With Valid Ndc Preferred
01840 Claim Denied.Invalid Gc3 Match For Modifier Sc 16
01840 Claim Denied.Invalid Gc3 Match For Modifier Sc 16

Claim Denied. The Ndc Submitted Product Is Not For A
01841 Product From The Preferred Diabetic Supply Vendor. 175
Claim Denied. The Ndc Submitted Product Is Not For A
01841 Product From The Preferred Diabetic Supply Vendor. 175
The Otc Product Is Not Covered On Outpatient Pharmacy
01842 Claims A1
Medicaid Denied Based On Claim Adjustment Reason

01843 Assigned By Prior Payer 276
Timely Filing Limit Extended Due To State Corrective Action
01844 Of Selected Edit 16
Home Health Service Recouped. Pdn Service Paid For This
Claim Denied. Exceeds The Allowable 100 Medicaid Units Per

01847 84 Day Period 119
01847 84 Day Period 119

01847 84 Day Period 119
01847 84 Day Period 119
Continuous Home Care Services (Revenue Code 0235) Must
01848 Be Billed With Supporting Nursing Care Procedure 16
Continuous Home Care Services (Revenue Code 0235) Must
01848 Be Billed With Supporting Nursing Care Procedure 16
Continuous Home Care Services (Revenue Code 0235) Cannot
Be Performed By Licensed Practical Nurse (Lpn) Procedure
01849 Code G0300. 16
Only Two Psych Visits Allowed Per Day For Provisionally
01851 Licensed Services 119
Continuous Home Care Services (Revenue Code 0235) Can
Only Be Billed For The Date Of Service Within The Recipients
01852 Last Seven Days Of Life. 204
01853 Units Cutback To Allow The Maximum Of 2 Units Per Day 119
Only Be Billed On Claims With A Patient Status Of Hospice
01854 Expired 204
Hospice Claims Must Bill Using A Hospice Specific Patient
01855 Status Code When The Patient Has Expired 16
The Billing, Attending Or Rendering Provider Is Currently
Enrolled As An Ordering, Prescribing And Referring (Opr) Only
01856 Provider. 16
The Billing, Attending Or Rendering Provider Is Currently
Enrolled As An Ordering, Prescribing And Referring (Opr) Only
01856 Provider. 16
Medical Lactation Consultation Procedure Code Modifier

01857 Missing. Refer To Clinical Coverage Policy 1-I 16
Discharge Date Must Equal Recipient Date Of Death When
01858 Billing A Patient Status Code Indicating Expired. 16
Discharge Date Must Equal Recipient Date Of Death When
01858 Billing A Patient Status Code Indicating Expired. 16
Ocular Photodynamic Therapy Must Be Billed With

01860 Verteporfin, Verteporfin Must Be Also Billed With Opt B15
Exceeds 10 Treatments Of Ocular Photodynamic Therapy Per
01861 Year 119
Add On Code For Concurrent Eye Must Be Billed With Primary

01862 Code For Ocular Photodynamic Therapy 97
Add On Code For Concurrent Eye Must Be Billed With Primary

01862 Code For Ocular Photodynamic Therapy 97
Intravenous Infusion Service Not Allowed When Ocular

01863 Photodynamic Therapy Is Paid B15
Intravenous Infusion Service Not Allowed When Ocular

01863 Photodynamic Therapy Is Paid B15
Dollar Amount Cutback To Maximum Allowable For This

01865 Service For This Period Of Time 45
Physician Stand-By Service Exceeds 2 Hour Limit. If
Necessary, Correct Denied Detail And Resubmit As A New
01866 Claim 119
Nicu Codes Allowed Once Per Day. Nicu Already Paid For This
Nicu Codes Allowed Once Per Day. Nicu Already Paid For This
Prolonged Services Exceeds 3 Hour Maximum Allowed Per
Day For All Providers. If Necessary, Correct The Number In
01868 Unit Field And Resubmit As A New Claim 119
Prolonged Services Exceeds 3 Hour Maximum Allowed Per
Day For All Providers. If Necessary, Correct The Number In
01868 Unit Field And Resubmit As A New Claim 119
01869 Only One Esophagectomy Procedure Allowed Per Day 119

01869 Only One Esophagectomy Procedure Allowed Per Day 119
Exceeds Maximum Number Of Physical Therapy Modalities,
01870 (6) Allowed Per Day 119



1 Ambulance Base Can Be Billed For Same Dos, Same
Hour/Time. Correct All Units/Details On Claim And Resubmit.
Multi Ple Respondents,Single Transport, If There Are Any
01871 Exception, File Adjustment With Records B5
1 Ambulance Base Can Be Billed For Same Dos, Same
Hour/Time. Correct All Units/Details On Claim And Resubmit.
Multi Ple Respondents,Single Transport, If There Are Any
01871 Exception, File Adjustment With Records B5
Alcohol/Drug Intensive Outpatient Services Not Allowed

01872 During Inpatient Stay B15
Only One Ambulance Miles And/Or Base Can Be Billed For The
Same Dos, Same Hour/Time Of Pick Up. File An Adjustment
With Records For Multiple Respondents, Single Transport
01874 Exceptions B5
Units Cut Back. Please Resubmit As An Adjustment With

01882 Anesthesia Records To Support Additional Units 59


Service Denied. Neuraxial Labor Anesthesia/Analgesia Is
01886 Limited To One Unit Of Service 119
Service Denied. Neuraxial Labor Anesthesia/Analgesia Is
01886 Limited To One Unit Of Service 119
Combine Charges And Rebill Using Major Anesthesia Code.
Indicate Total Time (Units) In Column G. File Adjusment Of
01887 Previously Paid Claim If Necessary 97
01888 One Anesthesia Procedure Allowed Per Same Date Of Service 119
01888 One Anesthesia Procedure Allowed Per Same Date Of Service 96
01893 Related Therapeutic Parental Drugs Not Allowed Same Day B15
Claim Denied Because It Is Subject To Transfer Of Asset

01895 Penalties 45
01898 Units Cutback. Maximum Number Of Units Per Year Exceeded 119
01901 Dme Fixed Armrest Limited To One Per Date Of Service 119
01902 Dme Leg Straps Limited To One Per Date Of Service 119
01903 Dme Battery Limited To Two Per Date Of Service 119
01905 Dme Tires Limited To Two Per Date Of Service 119

Dme Rear Wheel Assembly Limited To Two Per Date Of
01906 Service 119
01906 Service 119

01906 Service 119

01906 Service 119
01907 Dme Handrims Limited To Two Per Date Of Service 119
01908 Dme Footplates Limited To Two Per Date Of Service 119

01909 Dme Back Insert Limited To One Per Date Of Service 119
01910 Dme Rear Wheel Tire Tubes Limited To Two Per Day 119
01911 Dme Caster Tires Limited To Two Per Date Of Service 119
01912 Dme Battery Charger Limited To One Per Date Of Service 119
01913 Dme Footrests Limited To Two Per Date Of Service 119

Dme Front Caster Assembly Limited To Two Per Date Of
01914 Service 119
01914 Service 119

01914 Service 119

01914 Service 119
01915 Dme Armrests Limited To One Pair Per Date Of Service 119
01916 Dme Equipment Allowed Twice In 2 Yrs For Ages 00-20 119
01916 Dme Equipment Allowed Twice In 2 Yrs For Ages 00-20 119
Dme Equipment Allowed Twice In Three Years For Ages 21-
01917 115 119
Dme Equipment Allowed Twice In Three Years For Ages 21-

01917 115 119
Health Check Screening And Original Core Visit Not Allowed
01918 Same Day. Original Core Visit Denied 96
Dme Equipment Allowed Once In Three Years For Ages 21-
01919 115 119
Dme Equipment Allowed Once In Three Years For Ages 21-

01919 115 119
Personal Care Not Allowed Same Day As Cap-Mr/Dd

01920 Supported Living B15
Personal Care Services Not Allowed On Same Day As Adult

01921 Care Home Personal Care Service B15
Personal Care Services Not Allowed Same Day As Cap In-

01922 Home Aide B15
Personal Care Services Not Allowed Same Day As Cap

01923 Attendant Care Services B15
01924 Personal Care Services Not Allowed Same Day As Hospice B15
01925 Related Services Not Allowed On Same Date Of Service B15
Personal Care Service Recouped. Pcs Not Allowed Same Day

01926 As Home Health Aide Service B15
Private Duty Nursing Not Allowed Same Day As High Risk
01927 Residential Intervention B15
Private Duty Nursing Recouped If Billed The Same Date Of

01928 Service As High Risk Residential Intervention Services B15
01930 Service Billed Is Not Valid For The Recipient'S Age 96
01930 Service Billed Is Not Valid For The Recipient'S Age 96

Original Core Visit Recouped. Original Core Visit Not Allowed
01938 Same Day As Health Check Screening 96
Terminated Drug/Discontinued Product/Service Id Number
01942 (Product Expired) 16
Service Denied, Home Health Nursing Services Not On The
01946 Same Date Of Service As Private Duty Nursing 96



01949 Incorrect Combination Of Hcpcs Codes B5

01950 Code 108

01950 Code 108

01951 Code 108

01951 Code 108


01954 Recipient Claim Covered Under Hospice 16
Duplicate Service Denied. If Multiple Details For The Same

Procedure Were Billed, Combine Units On A Single Detail And
01956 Resubmit As A New Claim 18
Duplicate Service Denied. If Multiple Details For The Same

Procedure Were Billed, Combine Units On A Single Detail And
01956 Resubmit As A New Claim 97
01962 Service Denied. Exceeds Maximum Units Allowed Per Day 119
Service Is Not Consistent With Or Not Covered For This

01964 Diagnosis Or Description Of Service Does Not Match Diagnosis 16
01965 Service Denied. Drug Allows 100 Units Per Day 119
01967 Multiple Procedure/Modifiers Not Allowed Same Day 96

Fitting Of Contact Lens Must Be Billed With Appropriate
01968 Contact Lens Code 16
Repairs Of Aac Device Cannot Exceed $500 Per Recipient

01969 Annually 119

01969 Annually 119

01969 Annually 119

01969 Annually 119
01970 Only One Telemedicine Occurrence Allowed Per Day 119

01971 Only Three Telemedicine Occurrences Allowed Per Day 119
01971 Only Three Telemedicine Occurrences Allowed Per Day 119
01972 Only One Telehealth Site Service Allowed Per Day 119
Service Denied. Vaginal Delivery Included With Postpartum

01973 Care 97

01973 Care 97

01973 Care 97

01973 Care 97
Aac Device, Software, Upgrades, Mounting System,
Accessories And Repairs For One Recipient Not To Exceed
01974 $9,500 For A Two-Year Period 119


Qualifying Circumstance Procedure Requires Related
01975 Anesthesia Procedure To Be Paid In History 107
The Zip Code Applied In Your Service Location Field Is Missing
Or Invalid. Zip Code Must Be Entered And Compatible With
01976 The Cbsa Code Applied To Your Claim 16
01977 Crna Required To Bill With Appropriate Modifier 4
01977 Crna Required To Bill With Appropriate Modifier 4
01978 Service Recouped. Crna Required To Bill Appropriate Modifier B15

Dme Equipment Accessory Allowed Once Every 182 Days,
01979 Ages 000-020 119
Dme Equipment Accessory Allowed Once Every 182 Days,

01979 Ages 000-020 119
01980 Dme Equipment Allowed 3 Units Per 2 Years 119
Related Splenectomy Procedures Not Allowed Same Date Of

01981 Service B15
Service Recouped. Splenectomy Previously Paid As Complete

01982 Procedure 97

Serviced Denied. Postpartum Care Included With Vaginal
01984 Delivery 97

01984 Delivery 97

01984 Delivery 97

01984 Delivery 97
01985 Service Denied.Procedure Unit Limitation Exceeded 96
01986 Claim Pended For Alternate Benefit Plan Processing B11
01986 Claim Pended For Alternate Benefit Plan Processing 22
01987 Claim Forwarded To Next Dhhs Payer 107
01988 Recycle, Jre Problem 133

01988 Recycle, Jre Problem
Ach-Pcs Not Allowed To Bill Revenue Code 0183 (Therapeutic
01989 Leave) For Dates Of Service Beginning 07/01/05 16
Ach-Pcs Not Allowed To Bill Revenue Code 0183 (Therapeutic

01989 Leave) For Dates Of Service Beginning 07/01/05 16
01990 Superpend Tpl Recovery Claim 119

Complete X-Ray Procedure Denied. Technical Component Of
This Procedure Has Been Reimbursed Within A Year. Rebill
01991 For Professional Component Only 119
Complete X-Ray Procedure Denied. Professional Component
Of This Procedure Already Reimbursed Within A Year. Rebill
01992 For Technical Component Only 119
Claim Line Denied Per Provider Request To Nctracks To Adjust
01993 Original Claim 97
01994 Invalid Claim Separation Parameter Found 133
01995 Pended For Mass Adjustment/Void 133
01995 Pended For Mass Adjustment/Void 133
01996 Claim Pended Awaiting Additional Processing 133

Dental Radiograph Procedure Limited To Six Per Five Year
01997 Period 119
01997 Period 119
01997 Period 119
01997 Period 119
Duplicate Claim, Same Date Of Service, Admit Hour, And Ndc

01998 Number 97
Duplicate Claim, Same Date Of Service, Admit Hour, And Ndc

01998 Number 97
02000 Procedure Limited To One Per Lifetime 35

02002 Claim Denied By Prior Fiscal Agent
02013 Hysterectomy Consent Form Guidelines Not Met. 16

Infusion For Therapy Or Diagnosis Not Allowed Same Date Of
02015 Service As Prolonged Service B15
Prolonged Service Not Allowed Same Date Of Service As

02016 Infusion For Therapy Or Diagnosis B15
Iv Infusion For Therapy Or Diagnosis, Up To One Hour
02017 Allowed Only Once Per Day 119
Iv Infusion For Therapy Or Diagnosis, Up To One Hour
02017 Allowed Only Once Per Day 119
Fetal Monitoring Recouped; Reimbursement Has Been Made

02019 To Hospital 97
02020 Incision To Appendix Allowed Only Once Per Date Of Service 119
02020 Incision To Appendix Allowed Only Once Per Date Of Service 119
Nicu And Prolonged Services Not Allowed On The Same Date

Of Service. Prolonged Service Has Already Paid For This Date
Observation And Prolonged Service Not Allowed On The Same

Date Of Service. Prolonged Service Already Paid For This Date
State Assigned Diagnosis Code For Health Department Use
02027 Only. Correct And Resubmit As A New Day Claim 12
02028 Orchiectomy Allowed Once Per Date Of Service 119
02028 Orchiectomy Allowed Once Per Date Of Service 119
Service Recouped. Orchiectomy Previously Paid For The Same

Daily Management Of Epidural Denied, Not Allowed Same Day
02032 As Epidural Procedure 96
Daily Management Of Epidural Recouped, Not Allowed Same
02034 Day As Epidural Procedure 96
Rental And Purchase Of Cap-Mr/Dd Augmentative
Communication Devices Not Allowed On Same Date Of
02035 Service B15


Procedure Not Allowed On The Same Date Of Service As An

02040 Extraction For The Same Tooth B15
Procedure Not Allowed On The Same Date Of Service As An

02040 Extraction For The Same Tooth B15
02044 Management Fee Already Paid For This Quarter
02058 Related Diagnostic Ultrasounds Not Allowed Same Day B15
02058 Related Diagnostic Ultrasounds Not Allowed Same Day 16
02062 Related Fetal Non-Stress Test Not Allowed Same Day B15
Immunization Administration And Therapeutic Injections Not

02066 Allowed Same Day As Evaluation And Management B15
Immunization Administration And Therapeutic Injections Not
02066 Allowed Same Day As Evaluation And Management 96
02068 Related Immunization Procedures Not Allowed Same Day B15
02071 Related Contraceptive Procedures Not Allowed Same Day B15
Service Denied. Exceeds Maximum 8 Units Allowed Per 365

02072 Days 119
02072 Days 119
Only One Annual Exam Allowed Per 365 Days For Recipients
02074 19 Years Of Age And Older 119
02080 Related Testing Procedures Not Allowed Same Day B15
02091 Procedures Exceeds Three Units Per 365 Days Limitation B15
Hcpcs Code Allowed Only Once Per Day, By Same Or
02096 Different Provider 119
Only Three Hcpcs Units Of Provenge Allowed Per Lifetime Of

02097 Recipient, Administered By Same Or Different Provider 119



Related Vaccines, Tetanus And Diptheria Toxoids, Are Not

02098 Allowed On The Same Date Of Service 96
Related Vaccines, Tetanus And Diptheria Toxoids, Are Not
Effective 10/01/2011 The Medical Eye Exam Code Billed Is
Not Allowed When The Only Diagnosis Code(S) On The Claim
02099 Indicate The Service Was Performed For Refraction 16
Incorrect Hysterectomy Consent Statement On File For
02101 Service Date. Submit Form For Consent Prior To Surgery. 16
Incorrect Hysterectomy Consent Statement On File For
02101 Service Date. Submit Form For Consent Prior To Surgery. 16
Claim Pended Due To Billing Or Rendering Provider Expired

02104 Credentials B7
Claim Pended Due To Billing Or Rendering Provider Expired

02104 Credentials B7
Medical Records In Support Of Procedure Are Required.
02105 However, A Valid Consent Form Is On File. 16
Medical Records In Support Of Procedure Are Required.
02105 However, A Valid Consent Form Is On File. 16
Multiple Details With Modifier 55 Appended Must Have The

02106 Same Date Of Service. Please Correct And Resubmit 16
02107 Crossover Claims Not Allowed For Provider Taxonomy 170
Limitation For This Capmr Service For This Waiver Year, Has
02112 Been Exceeded B5
Molecular Diagnostics And Hiv 1&2 Quantification Procedures

02115 Limited To 1 Unit/Year 119



Infectious Agent Phenotype Analysis Procedure Limited To 9
02116 Units Per Day 119
Infectious Agent Phenotype Analysis Procedure Limited To 9
02117 Nuclear/Molecular Diagnostic Procedures Limited To 2/Year 119

Sodium Fluoride Diagnostic Procedure Must Bill With A Pet
02118 Imaging Procedure 16


Regadenoson Must Bill With Cardiovascular Imaging Or Stress
02119 Test Procedures 16

Infectious Agent Phenotype Analysis Procedure Limited To
02120 One Unit Per Day 119
Service Recouped. Similar Incision To Appendix Previously

02124 Paid Same Date Of Service 97
Service Recouped. Similar Incision To Appendix Previously

02124 Paid Same Date Of Service 97
Drainage Of Lymphocele To Peritoneal Cavity Allowed Once
Drainage Of Lymphocele To Peritoneal Cavity Allowed Once
Service Recouped. Drainage Of Lymphocele To Peritoneal

02131 Cavity Previously Paid Same Date Of Service 97
02132 Renal Incision Allowed Only Once Per Date Of Service 119
02132 Renal Incision Allowed Only Once Per Date Of Service 119
Service Recouped. Renal Incision Previously Paid Under

02133 Similar Procedure For Same Date Of Service 97
02134 Only One Enterolysis Procedure Allowed Per Date Of Service 119
02134 Only One Enterolysis Procedure Allowed Per Date Of Service 119
Service Recouped. Only One Enterolysis Procedure Per Date

02135 Of Service 96
02135 Of Service 96
02135 Of Service 96

02135 Of Service 96
One Transperineal Or Abdominal Closure Of Rectovaginal
02140 Fistula Allowed Per Date Of Service 119
One Transperineal Or Abdominal Closure Of Rectovaginal
02140 Fistula Allowed Per Date Of Service 119
Service Recouped. Transperineal Approach Previously Paid

02141 Under Abdominal Approach To Closure Of Rectovaginal Fistula 97
Radical Trachelectomy Not Allowed On The Same Date Of

02142 Service As Total Abdominal Hysterectomy B15
Total Abdominal Hysterectomy Not Allowed Same Date Of

02143 Service As Radical Trachelectomy B15
Catheterization And Contrast Material Introduction Included In

02144 Hysterosonography 97
Service Recouped. Catheterization And Contrast Material

02145 Introduction Previously Paid Under Hysterosonography 97
Recipient Enrolled In Medicare And Another Third Party
Insurance. Rebill Totaling Insurance Amounts In Proper Field
02148 And Attach Both Vouchers 16

Single Kidney Imaging Study Not Allowed Same Date Of

02150 Service As Multiple Studies B15
Service Recouped. Single Kidney Imaging Study Previously

02151 Paid As Multiple Studies Procedure 97
Kidney Imaging Without Pharmacological Intervention Not
02152 Allowed Same Date Of Service As Imaging With Intervention B15
Service Recouped. Kidney Imaging Without Pharmacological

02153 Intervention Previously Paid Under Imaging With Intervention 97
Service Recouped. Kidney Imaging Without Pharmacological

02153 Intervention Previously Paid Under Imaging With Intervention 97
Cd4 Count Not Allowed Same Date Of Service As Similar Tcell

02154 Procedure B15
Service Recouped. Cd4 Count Previously Paid Same Date Of

02155 Service As Similar Tcell Procedure 97
Procedures Including Similar Evaluation And Management
02156 Services Allowed Once Per Date Of Service 119
Denial For Action Resason Codes 25 And 44 (Provier Number
02158 Suspended By Financial) 16
Denial For Action Resason Codes 25 And 44 (Provier Number
02158 Suspended By Financial) 16
Rural Health Clinic Or Federally Qualified Health Center Visit

02160 Not Allowed Same Day As General Clinic Visit B15
General Clinic Visit Not Allowed Same Day As Rural Health

02161 Clinic Or Federally Qualified Health Center Visit B15
General Clinic Visit Not Allowed Same Day As Medicare Detail

02162 For Crossover Processing B15
Medicare Detail For Crossover Processing Not Allowed Same

02163 Day As General Clinic Visit B15
02164 Office Visit Not Allowed Same Day As General Clinic Visit B15
02165 General Clinic Visit Not Allowed Same Day As Office Visit B15
02166 Multiple Office Visits Not Allowed For Crossover Processing B15
02167 Multiple Clinic Visits Not Allowed For Crossover Processing B15
Office Visit Not Allowed To Bill With Clinic Visit And Federally
02170 Qualified Health Center Core Services B15
Clinic Visit And Federally Qualified Health Center Core Services

02171 Not Allowed To Bill Wit Office Visit B15
02174 General Clinic Visit Not Allowed Same Day As Office Visit B15
02175 Office Visit Not Allowed Same Day As General Clinic B15
Medicare Payment Indicated For This Claim. Medicare Does
Not Cover Procedures With Ep Modifier. Rebill Health Check
Services Separately From Procedures Related To Medicare
02176 Payment 16
02178 Ncpdp Origin Code Is Invalid 16

02178 Ncpdp Origin Code Is Invalid 16
Diagnosis Billed Is Not Valid For The Service Rendered For
02179 The Recipient'S Age Or Sex 16


Billed Procedure Included In Similar Heart Catheterization

02180 Procedure 97
Service Recouped. Heart Catheterization Previously Paid As

02181 Similar Procedure 97
Maximal Voluntary Ventilation Included In Similar Pulmonary

02182 Procedure 97
Service Recouped. Maximal Voluntary Ventilation Previously

02183 Paid As Related Pulmonary Procedure 97
Related Service Recouped. Billed Procedure Previously Paid

02184 Under Sleep Study On Same Date Of Service 97
02185 Billed Procedure Included In Sleep Study 97
02186 Cpap Ventilation Included In Sleep Staging Procedure 97
Related Service Recouped. Cpap Ventilation Previously Paid As

02187 Sleep Staging Procedure On The Same Date Of Service 97
Related Service Recouped. Cpap Ventilation Previously Paid As

02187 Sleep Staging Procedure On The Same Date Of Service 97
02188 Component Tests Included In Polysomnography 97
Recoup Related Procedure. Polysomnography Includes

02189 Component Tests 97




Single Extremity Electromyography Not Same Date Of Service

02190 As Multiple Extremities B15
Related Service Recouped. Single Extremity Procedure

02191 Included Under Multiple Extremity On Same Date Of Service 97
Related Service Recouped. Single Extremity Procedure

02191 Included Under Multiple Extremity On Same Date Of Service 97
One Discharge Management Service Allowed Per Date Of
02192 Service 119
One Discharge Management Service Allowed Per Date Of
02192 Service 119
Related Service Recouped. Physician Standby Service
Included Under Attendance At Delivery On The Same Date Of
02193 Service 97
Related Service Recouped. Physician Standby Service
Included Under Attendance At Delivery On The Same Date Of
02193 Service 97
Physician Standby Not Allowed Same Date Of Service As

02194 Attendance At Delivery B15
Intestinal Resection With Anastomosis Allowed Once Per Date
02196 Of Service 119
Intestinal Resection With Anastomosis Allowed Once Per Date
Related Service Recouped. Intestinal Resection With
Anastomosis Previously Paid As Similar Procedure On The
02197 Same Date Of Service 97
Esophagogastric Fundoplasty Allowed Once Per Date Of
02198 Service 119
Esophagogastric Fundoplasty Allowed Once Per Date Of
02198 Service 119
Related Service Recouped. Esophagogastric Fundoplasty
Previously Paid As Similar Procedure On The Same Date Of
02199 Service 97
Prior Authorization Missing Or Does Not Match The Approved
02201 High Tech Imaging Prior Authorization In System. 252
The Revenue Code Billed Requires Procedure Code To Be
02208 Attached 252
The Revenue Code Billed Requires Procedure Code To Be
02208 Attached 252
Money Follows The Person (Mfp) - Transition Services Cutback

02218 To The Maximum Allowable Dollar Limitation Per Year 119
Money Follows The Person (Mfp) - Transition Coordination

02219 Services Per Year Dollar Limitation Has Been Exceeded 45
Provider Must Respond To The Early Refill Alert In Order For

02220 The Claim To Process 16
02221 An Invalid Icd Diagnosis Code Was Submitted On The Claim 16

02223 The Recipient'S Age 16

02223 The Recipient'S Age 16
Claim Recouped. Adult Care Home/Special Care Unit-
02224 Alzheimer Not Allowed Same Day As Hospice Services 96
Claim Recouped. Adult Care Home/Special Care Unit-
02224 Alzheimer Not Allowed Same Day As Hospice Services 96
There Is Not An Approved Fl-2 For The Billed Nf Level Of Care
02229 For The Date Of Service 197
02231 Bill Medicare Part B Carrier 22
Case Management Services Should Be Billed Through Cap-

02240 Mr/Dd Area Programs 15
02264 Testopel Is Limited To 6 Units Per 3 Months 119
Units Cutback. Maximum Number Of Units Per 3 Months

02265 Exceeded 119
02265 Exceeded 119

02265 Exceeded 119
02265 Exceeded 119
Drug Is Limited To 240 Units Per Calendar Month. Units For
02275 This Timeframe Have Been Exceeded 119
Claim Denied. Adult Care Home/Special Care Unit-Alzheimer
02280 Not Allowed Same Day As Hospice 96
Claim Denied. Adult Care Home/Special Care Unit-Alzheimer
02280 Not Allowed Same Day As Hospice 96
Recipient In Pace Program For All Inclusive Care Of Elderly
Recipient'S Card Indicates Pace Provider Responsible For
02281 Care. Fee For Service Care Not Covered Outside Of Pace 16
02282 All Over The Counter Drugs Are In Compound 16

Primary Diagnosis On Claim Does Not Match Prior
02285 Authorization, Other Diagnosis Match Pa
At Least One Icd Diagnosis Used On The Claim Must Match A
02286 Diagnosis Specified On The Authorization Request 15
Procedure Code(S) Are Limited To The Approved Procedure
02287 Codes On The Pa 15
Hearing Aid Battery Supply Is Limited To A Maximum Of $35

02288 Per Claim 45
Claim Service Date Must Be Within The Service Date Range
02290 Approved On The Pa 15
Claims For Specialized Therapies Must Include The Discipline-
Specific Icd Diagnosis Codes And Match The Diagnosis Code
02291 On The Pa 11
Patients Third Party Insurance Requires Authorization From

Cdsa For Payment Without Submitting Third Party Insurance
02292 Eob 133
02293 Diagnosis Specified On The Prior Authorization Request 16
The Procedure Codes On The Claim Must Match The
02295 Procedure Codes On The Pa 15
One Of The Discipline-Specific Diagnosis Codes On The Claim
02296 Must Match One Of The Diagnosis Codes On The Pa 16
Claims Must Include The Discipline-Specific Icd Diagnosis
Codes Comparable To The Specialized Therapy On The Prior
02297 Authorization 15
02299 Provider Not Enrolled In Health Plan Assigned To Claim Line 239
02301 Referring Provider Not On File 16
02301 Referring Provider Not On File 16
02302 Billing Provider Inactive Or Terminated B7
02303 Location Of Service Invalid For Billing Provider 16
02304 Ordering/Referring Provider Is Deceased On Dates Of Service 183
02305 Servicing Provider Deceased On Dates Of Service B7
02306 Referring Provider Not In Active Status At Time Of Service 183
02307 Prescribing Provider Not In Active Status At Time Of Service 184
Attending/Servicing Provider Not In Active Status For Date Of

02308 Service B7
02309 Procedure Code Not On File For Dates Of Service 204
Procedure Code Is Not Covered Or Not On File For Dates Of

02310 Service 204
02311 Revenue Code Is Not Valid 96
02311 Revenue Code Is Not Valid 96
02312 Revenue Code Is Not Covered For Dates Of Service 204
02313 Procedure Code Invalid For Rendering Provider Taxonomy 8

02314 Local Procedure Codes Cannot Be Submitted 96
Outpatient Hospital Claim Require Hcpcs Code To Be Billed
02315 With Revenue Code 16
Candida, Gardnerella And Trichomonas Are All Included In

02324 The Same Fee 97
Service Denied. Product No Longer Provided By Medicaid.
Resubmit With Preferred Vendor-Prodigy. Refer To
02340 Http://Www.Ncdiabetes.Org For Override Instructions 204
Service Denied. Product No Longer Provided By Medicaid.
Resubmit With Preferred Vendor-Prodigy. Refer To
02340 Http://Www.Ncdiabetes.Org For Override Instructions 204
02348 Date Prescribed Is After Date Of Service 16

Claim Denied. Case Management Service With Modifier
02351 Indicating Assessment Units, Exceeds Annual Limit 119
Claim Denied. Case Management Service With Modifier
02351 Indicating Assessment Units, Exceeds Annual Limit 119
Conflicting Abortion Or Sterilization Code On Form For
02369 Newborn 16
02375 Allow One Oral Evaluation Every 60 Days 119

Personal Care Services For Same Recipient, Same Date Of
Service Not Allowed By Both Adult Care Home And Pcs
Providers. Service Is Paid To Another Provider For This Date
02379 96
02379 96
02379 96
02379 96
02400 Ambulance Claims Require An Origin Destination Modifier 4

More Than One Ambulance Modifier Was Submitted On Same
Claim Line. If There Were Multiple Individual Trips On The
Same Day Resubmit As Separate Claim Lines With
02401 Documentation For Reconsideration Of Payment 16
Ordering Provider Invalid Or Not Active On Dates Of Service.
This Claim \ Line Will Pend For 90 Days In Order To Give The
Provider Time To Enroll With Medicaid. After 90 Days The
02420 Claim \ Line Will Deny. 16
Ordering Provider Invalid Or Not Active On Dates Of Service.
Referring Provider Invalid Or Not Active On Dates Of Service.
Referring Provider Invalid Or Not Active On Dates Of Service.
Detail Reviewed By Pharmacy Department. Ndc Units
Incorrect. Ndc Units Must Correspond To Submitted Hcpcs
02424 Procedure Units. Verify And Resubmit Correct Ndc Units 16
Service Facilty Provider Invalid Or Not Active On Dates Of
Service. This Claim \ Line Will Pend For 90 Days In Order To
Give The Provider Time To Enroll With Medicaid. After 90
02425 Days The Claim \ Line Will Deny. 16
Supervising Provider Invalid Or Not Active On Dates Of
Supervising Provider Invalid Or Not Active On Dates Of
Operating Provider Invalid Or Not Active On Dates Of Service.
Operating Provider Invalid Or Not Active On Dates Of Service.
Other Operating Provider Invalid Or Not Active On Dates Of
Other Operating Provider Invalid Or Not Active On Dates Of
Assistant Surgeon Provider Invalid Or Not Active On Dates Of
Assistant Surgeon Provider Invalid Or Not Active On Dates Of
Attending Provider Missing, Invalid, Or Not Active On Dates Of
Attending Provider Missing, Invalid, Or Not Active On Dates Of
Prtf Hospital Stay Requires Attending Provider To Bill
02436 Psychiatric Specialty 16
Service Facilty Provider Invalid Or Not Active On Dates Of
02438 Ordering Provider Is Required For This Service 16
02439 Ordering Provider Npi Must Be Enrolled As Individual Provider 16
02440 Referring Provider Is Required For This Service 16
02441 Referring Provider Npi Must Be Enrolled As Individual Provider 16
02442 Operating Provider Is Required For This Service 16
02447 Durable Medical Equipment Allowed 8 Per Year 119
02450 Durable Medical Equipment Allowed 1 Per Month 119
02452 Durable Medical Equipment Allowed 2 Per Day 119
02453 Durable Medical Equipment Allowed 2 In Three Years 119
02454 Durable Medical Equipment Allowed 2 Per Calendar Month 119
02456 Durable Medical Equipment Allowed 4 Per Calendar Month 119

02467 Dme Allowed 720 Per Month 119

Cost Share Is Not Applicable For The Claim Filing Indicator
Selected. Please Submit A Claim Filing Indicator Applicable To
Insurance Policies With Cost Share Information Or Remove
02470 The Invalid Cost Share Amounts. 16
Service Denied. Exceeds The Limitation Of Units Allowed Per
02476 State Fiscal Year 119
Units Cutback. Exceeds The Allowable 8 Units Per Day




This Drug Contra-Indicated For Disease/Diagnosis On File For

02485 This Recipient 16
This Drug Has Adverse Interactions With Other Drugs On File

02486 For This Recipient 16
Drug Dosage Dispensed Exceeds Maximum Units (High Dose

02487 Alert) 16
02488 Drug Billed Has A Duplication Of Ingredients With Prior Claim 16
Drug Dosage Dispensed Less Than Minimum Units (Low Dose

02489 Alert) 16
Drug Dispensed Has A Dur Pediatric Precaution Or Geriatric

02490 Precaution 16
Drug Dispensed Has A Dur Pregnancy Precaution Or Lactation

02491 Precaution 16
02492 Drug Dispensed Is A Therapeutic Duplication Of Prior Claim 16
02493 Drug Dispensed Is An Early Refill (Overuse Alert) 16
02494 Drug Dispensed Is A Late Refill (Underuse Alert) 16
Procedure Not Allowed Without Modifier Fp For This Age

02547 Recipient 6
No Hcpc Code Is Required To Be Submitted On The Claim For

02563 The Specific Revenue Code 199
Service And/Or Place Of Service Not Covered Under The Famil
02600 Planning Waiver 5
Service And/Or Place Of Service Not Covered Under The Famil
02600 Planning Waiver 5
02601 Procedure Not Covered Under The Family Planning Waiver 16
02602 Invalid Or Missing First Annual Exam Date. 16

Lab Procedure Date Of Service Not Within Allowed Time
02603 Frame Of Annual Exam Date 16
Lab Procedure Date Of Service Not Within Allowed Time
02603 Frame Of Annual Exam Date 16
Diagnosis Missing Or Not Covered Under The Family Planning
02604 Waiver 16
02604 Waiver 16
02604 Waiver 16
02604 Waiver 16
02604 Waiver 16
02604 Waiver 16
The Diagnosis Billed Is Not Allowed For The Combination Of
Qualifying Circumstance Procedure And Anesthesia Service
02606 Billed On This Claim 11
Service Recouped. Bypass Graft Not Allowed Same Day As

02607 Bypass Graft With Endovascular Repair 97


Claim Denied. Family Planning Procedure Code Must Be
02609 Present On Family Planning Claim 16
All Unauthorized Units Have Been Exhausted. Prior Approval

02610 Is Now Required 96
02613 Exceeds The Maximum Limit Of 30 Units Per Calendar Year 119
02614 Exceeds The Maximum Limit Of 480 Units Per Calendar Year 119
Service Denied. Units Have Been Exceeded Per 30 Days When

02621 Billed In An Inpatient Setting 119
Service Denied. Units Have Been Exceeded Per 30 Days When
02621 Billed In An Inpatient Setting 119
Service Denied. Maximum Units Allowed Per Day Have Been

02622 Exceeded 119
Service Denied. Maximum Units Allowed Per Day Have Been
02622 Exceeded 119
Service Denied. Intranasal/ Oral Vaccine Administration
02623 Procedure Allowed One Per Day 119
Service Denied. Intranasal/ Oral Vaccine Administration
02623 Procedure Allowed One Per Day 119
Units Cutback. Maximum Units Allowed Per Day Have Been
02638 Exceeded 119
Units Cutback. Maximum Units Allowed Per Day Have Been
02638 Exceeded 119
Units Cutback. Exceeds The Maximum Units Allowed Per 30
02639 Days When Billed In An Inpatient Setting 119
Implanon Required To Be Billed With Insertion/Removal Of
02640 Implant 96
Implanon Required To Be Billed With Insertion/Removal Of

02640 Implant 96
02641 Boniva Limited To 3 Units Allowed Per 90 Days 119
02641 Boniva Limited To 3 Units Allowed Per 90 Days 119
02642 Orencia Limited To 300 Units Per Calendar Month 119
02642 Orencia Limited To 300 Units Per Calendar Month 119

Service Denied. This Administration Of Provenge Does Not
Meet The Approved Medicaid Guidelines In Relation To The
Recipient'S Previous Payment History Associated W/The Drug
02653 119
02671 Icd Version Invalid For Date Of Service 16
02671 Icd Version Invalid For Date Of Service 16
02672 Service Denied. J Code + Ndc/Gcn Combination Is Not Valid. 96
Service Denied. Ndc/Gcn + Icd Diagnosis Combination Is Not

02673 Valid. 96
Fqhc Providers Must Submit Place Of Service 50 And Rhc
Providers Must Submit Place Of Service 72 When Billing
Procedure T1015. Resubmit Claim With Correct Place Of
02689 Service. 5
Procedure/Service Exceeds Limitation (S) For Waiver
02700 Recipient 119
Bypass Graft With Endovascular Repair Not Same Day As

02706 Other Bypass Graft 97

Surgical Pathology Must Be Billed Within 10 Days Of

02719 Sterilization For Mafd Recipients B15
Semen Analysis Must Be Billed Within 90 Days Of Sterilization

02720 For Mafd Recipients B15
Action Reason Code Indicates Provider Address On File Is
02721 Incorrect 133
Service Denied. Echocardiography Procedure Is Not Allowed
On Same Date Of Service When Billed In Conjunction With
02725 Doppler Echocardiography Procedure 97
Service Denied. Doppler Echocardiography Procedure Is Not
Allowed On Same Date Of Service When Billed In Conjunction
02726 With Echocardiography 97
Procedure/Modifier Combination Not Allowed Same Day When
02750 Billed By Dme Provider And Paid To Cap Provider 96


Dme Service Recouped. Not Allowed Same Day As Service

02751 Rendered For Cap Provider 96


Claim Denied. Only One Epogen Administration Allowed Per
02864 Day. Service Has Previously Billed For This Date Of Service 96
Claim Denied. Only One Epogen Administration Allowed Per
02864 Day. Service Has Previously Billed For This Date Of Service 96
Reimbursement For Base Endoscopy Is Included In Rate For

02892 Related Endoscopy Procedure Performed Same Day 97
Base Endoscopy Procedure Is Not Allowed When Related

02893 Endoscopy Procedure Is Performed On The Same Day B15
Multiple Scopy Procedures Performed On The Same Day Are
Reimbursed According To Pricing Calculations Set Forth By
02896 Medicaid Guidelines 59

02896 Medicaid Guidelines 59
02899 Rc452 Not Allowed Without Corresponding Rc451 16
02901 Denied Due To Inactive Eft Status A1
The Claim Pregnancy Indictor Must Be Numeric Value And It

02906 Must Be One Of The Following: 0, 1 Or 2 16
The Claim Other-Coverage-Code Field Must Be A Numeric

Value, And It Must Be 00 - 08 For Ncpdp Format 5.1 Or 00 -
02907 04 Or 08 For Ncpdp Format D.0 16
02908 Maximum Days Supply Or Daily Dosage Have Been Exceeded 16
02908 Maximum Days Supply Or Daily Dosage Have Been Exceeded 16
02913 Pos - Processor Control Number Not Certified To Submit Claim 16
Pos - Invalid Quantity. Correct Quantity To Numeric Value And

02914 Resubmit 16
02915 Dispense As Written Value Invalid. Correct And Resubmit 16
Pos - Ucc Amount Must Be Numeric And Greater Than Zero.

Pos - Ucc Amount Must Be Numeric And Greater Than Zero.

Pos - Invalid Value For Compound Code. Correct And

02918 Resubmit 16
02920 Pos - Level Of Service Invalid. Correct And Resubmit 16

02921 Pos-Unit Dose Indicator Invalid. Correct And Resubmit 16
Pos -Prescription Date Invalid. Correct And Resubmit In

02922 Ccyymmdd Format 16
Pos - Other Payer Amount Invalid (Data Must Be Numeric).

02925 Pos - Dur Conflict Code Invalid. Correct And Resubmit 16
Pos - Missing Or Invalid Professional Code. Correct And

02926 Resubmit 16
02927 Pos - Dur Outcome Code Invalid. Correct And Resubmit 16
02929 Point-Of-Sale Agreement Not On File 16
02931 Pos - Days Supply Must Be Numeric And Greater Than Zero 16
02931 Pos - Days Supply Must Be Numeric And Greater Than Zero 16
Prescriber Npi Not Active. Contact Prescriber And Refile With

02951 Correct Npi 16
Reimbursement Was Made On Previously Paid Detail. Payment
Is Determined By # Of Automated Tests Billed. Payment And
02954 # Of Units Are Reflected On 1St Detail 97
02960 Missing Or Invalid Compound Ingredient Ndc 16

Missing Or Invalid Prescription Number Qualifier. Only A Value
02962 Of '1' Is Accepted 16
Missing Or Invalid Product Id Qualifier, Only A Ndc Qualifier

02963 Code Of '03' Is Accepted 16
02964 Missing Or Invalid Prior Authorization Type Code 16
02965 Partial Fill/Completion Transactions Are Not Supported 16
Missing Or Invalid Prescriber Id Qualifier. The Valid Qualifier

02966 Is 12 16
Only A Value Of 1, 2 Or 3 Can Be Submitted For Coordination

02967 Of Benefits/Other Payments Count 16
Invalid Other Payer Coverage Type. 01, 02, 03, 98 Or 99 Are

02968 The Only Valid Types Accepted 16
Invalid Other Payer Amount Count. Other Payer Amount

02969 Count Must Be A Numeric Value Between 1 And 9 16
Missing Or Invalid Other Payer Amount Paid Qualifier. Must Be

02970 01 Through 08, 98, 99 Or Blank 16
02976 Missing Or Invalid Compound Ingredient Quantity 16

Missing Or Invalid Compound Product Id Qualifier, Only A Ndc
02977 Qualifier Code Of '3' Is Accepted 16
02978 Missing Or Invalid Compound Ingredient Cost 16
Actual Compound Ingredient Does Not Match Ingredient

02979 Count Submitted On Claim 16
Compound Ingredient Count Must Be Greater Than '0' And

02981 Less Than '26' 16
Compound Ingredient Count Must Be Greater Than '0' And

02981 Less Than '26' 16
02985 Daw - Prescriber Invalid With Family Planning Waiver 16
02987 Depo Provera Can Only Be Dispensed Every 77 Days 16
02987 Depo Provera Can Only Be Dispensed Every 77 Days 16
Anesthesia Services Must Be Appended With Modifiers Aa, Ad

02988 Qk, Qx, Qy, Or Qz 4
Resubmit Claim With Appropriate Directed Anesthesia
Modifier,Or Submit With Documentation Of Separate
02989 Operative Sessions 4
Resubmit Claim With Appropriate Directed Anesthesia

Modifier,Or Submit With Documentation Of Separate
02989 Operative Sessions 4
02992 Tpl Amounts Should Not Include Medicare Payment 22
02992 Tpl Amounts Should Not Include Medicare Payment 22
02999 Rc599 And Rc679 Not Allowed On Same Date Of Service 96

Revenue Code And/Or Hcpcs Code Is Missing And/Or Is An
03001 Invalid Combination. Correct And Resubmit As A New Claim. 16
Patient Facility Id Is Missing, Invalid, Or Unresolved. Verify
Patient Facility Id And Resubmit As New Claim Or Contact
03007 Nctracks If Id Is Correct 16
Add-On Code Must Be Billed With A Paid Primary Procedure

03011 For Reimbursement 97
Add-On Code Must Be Billed With A Paid Primary Procedure

03011 For Reimbursement 97
Add-On Code Must Be Billed With A Paid 'Primary' Procedure

03012 In Series For Reimbursement 97





Simple And Complex Repair For Resection Of Diaphragm Not

03015 Allowed On Same Date Of Service B15
Only One Appendectomy Procedure Allowed Per Recipient
03016 Lifetime 119
03017 Only One Laparoscopy Procedure Allowed Per Date Of Service 119
03017 Only One Laparoscopy Procedure Allowed Per Date Of Service 119
Multiple Initial Inguinal Hernia Repair Procedures Not Allowed

03018 On The Same Date Of Service B15
Multiple Recurrent Inguinal Hernia Repair Procedures Not

03019 Allowed On Same Date Of Service B15
Multiple Procedures Related To Renal Cysts Not Allowed On

Related Pyeloplasty Procedures Not Allowed On Same Date Of

03021 Service B15
Related Donor Nephrectomy Procedure Not Allowed On Same

Related Nephrectomy Procedures Not Allowed On Same Date

Related Nephroureterectomy Procedure Not Allowed On Same

Related Ureterolithotomy Pprocedure Not Allowed On Same

Related Sling Operation For Stress Incontinence Not Allowed
03026 On Same Date Of Service B15
Related Orchiopexy Procedure Not Allowed On Same Date Of

03027 Service B15
Related Male Genital Procedure Not Allowed On Same Date Of

03028 Service B15
Related Spermatic Procedure Not Allowed On Same Date Of

03029 Service B15
Related Male Genital Procedure Not Allowed On Same Date Of

03030 Service B15
Related Vaginal Hysterectomy Procedure Not Allowed On

Related Cranial Neurostimulator Procedure Not Allowed On



Cervical Or Thoracic Injection Limited To 18 Per Date Of
03034 Service 119
03034 Service 119

03034 Service 119
03034 Service 119


03036 Lumbar Or Sacral Injection Limited To 5 Per Date Of Service 119






03042 Procedure Limited To 18 Per Date Of Service 119

Related Lab Panel Code Already Billed For Same Date Of
03043 Service B15
Components Of Renal Function Panel Recouped To Allow

Components Of Renal Function Panel Included In

03045 Reimbursemen Of Panel Code 97
Related Cardioversion Procedure Not Allowed On Same Date

Internal And External Cardioversion Procedure Not Allowed O

Related Cardiac Recorder Procedure Not Allowed On Same

Component Of This Procedure Denied. This Procedure Already
Reimbursed As A Complete Procedure On The Same Date Of
03049 Service 97
Complete Procedure Denied. Technical Component Of This

03050 Procedure Already Reimbursed For The Same Date Of Service 97
Complete Procedure Denied. Professional Component Of This

03051 Procedure Already Reimbursed For The Same Date Of Service 97
Components Of Hepatic Function Panel Recouped To Allow

Components Of Hepatic Function Panel Included In

Procedure Must Be Billed With The Required E&M Or

Administration Procedure Code, By The Same Attending
03066 Provider B15


Levulan Kerastick, 1 Stick Equals 1 Unit. Medicaid Allows 2
03073 Units Within 8 Weeks 119


Levulan Kerastick Not Allowed Unless Procedure 96567 Is
03074 Paid. Please Bill J7308 With Procedure 96567 16
Levulan Kerastick Not Allowed Unless Procedure 96567 Is

03074 Paid. Please Bill J7308 With Procedure 96567 16
Adult Care Home Transition Procedure Not Allowed On The
Same Date Of Service As Personal Care Services Already Paid
03079 To The Same Or Different Provider 96
Personal Care Service Procedure Not Allowed On The Same
Date Of Service As Adult Care Home Transition Procedure
03080 Already Paid To The Same Or Different Provider 96
03085 Units Cutback. Procedure Limitation Exceeded Per Day B5

Molecular Diagnosis Add On Must Be Billed With Primary
03087 Procedure 16
Molecular Diagnosis Add On Must Be Billed With Primary
03087 Procedure 16
Auditory Pre-Lingual Hearing Loss Not Allowed With Post-
03088 Lingual Hearing Loss Procedure 16
The Taxonomy Code For The Rendering Provider Is Missing

03100 Or Invalid 16
The Taxonomy Code For The Rendering Provider Is Missing
03100 Or Invalid 16
The Taxonomy Code For The Attending Provider Is Missing Or
03101 Invalid 16

03101 Invalid 16
03101 Invalid 16
The Taxonomy Code For The Billing Provider Is Missing Or

03102 Invalid 16
The Taxonomy Code For The Billing Provider Is Missing Or
03102 Invalid 16
The National Provider Identifier Submitted Is Not Found On
03103 The Provider File 16
The National Provider Identifier Submitted Is Not Found On

03103 The Provider File 16
The National Provider Identifier Submitted For The Prescribing
03105 Provider Is Missing Or Invalid 16

03105 Provider Is Missing Or Invalid 16
Provider Cannot Be The Same As The Pharmacy'S National
03106 Provider Identifier 16
Provider Cannot Be The Same As The Pharmacy'S National
03106 Provider Identifier 16
Claim Should Contain Npi Only Without The Medicaid Provider
03107 Number As Provider Is Not Atypical 16
Claim Should Contain Npi Only Without The Medicaid Provider

03107 Number As Provider Is Not Atypical 16
03108 Exceeds Number Of Units Allowed Per 84 Days 119

Units Cutback. Number Of Units Allowed Per 84 Days
03109 Exceeded 119
Supply Of Injectable Contrast Material For Use In
Echocardigraphy, Requires Echocardiography Procedure On
03112 The Same Day 16
03113 Provider Ineligible On Service Date-Under Review B7
Provider Doesn'T Have Qualifiying Conditions To Get A Valid

03114 Qualifier
Type Of Bill Submitted Is Not Valid. Correct And Resubmit As
03115 A New Day Claim 16
Type Of Bill Submitted Is Not Valid. Correct And Resubmit As
03115 A New Day Claim 16
03116 Revenue Code Is Nubc Reserved 16
03116 Revenue Code Is Nubc Reserved 16
03118 Procedure Limited To 230 Units Per Calendar Month 119

High Tech Image And Ultrasound, Same Revenue Code Or
03119 Procedure Code Not Allowed Same Day 96
Previously Billed Procedure. Surgery Performed During Follow
Up Of Another Surgery Requires A Modifier. If Current Claim
Is Original Procedure, Request Recoupment Of Paid Detail
03120 And Resubmit With Modifier 97
Units Cutback, Exceeds The Allowable 230 Units Per Calendar
03121 Month 119
Units Cutback, Exceeds The Allowable 230 Units Per Calendar
03121 Month 119
03122 Maximum Units Per Year For This Procedure Have Been Paid 119
Mental Health/Substance Abuse Targeted Case Management
Not Allowed With Related Behavioral Health Services
03125 Procedures For The Same Calendar Week 96
Behavorial Health Services Not Allowed With Other Related
03126 Procedures For Same Calendar Week 96


Add-On Code Not Allowed Unless Primary Procedure Paid In
History For Same Date Of Service, By The Same Or Different
03134 Provider 97
Add-On Code Not Allowed Unless Primary Procedure Paid In
History For Same Date Of Service, By The Same Or Different
03140 Wrong Pharmacy For Controlled Substance B7
03141 Wrong Prescriber For Controlled Substance 184

Only One Ach Transition Payment Procedure Allowed Per
Same Date Of Service By The Same Or Different Provider
03150 119
03162 Drug Limited To 1800 Units Per Calendar Month 119
03162 Drug Limited To 1800 Units Per Calendar Month 119

Behavioral Health Service Not Allowed On Same Date Of
Service As Related Service Performed By Same Rendering
03163 Provider 96
Behavioral Health Hcpcs Code Not Allowed On Same Date Of
Service As Related Cpt Code Paid To The Same Rendering
03164 Provider 96
Cpt Code Not Allowed Same Date Of Service As Related
Behavioral Health Hcpcs Code Paid For Same Date Of Service
03170 To Same Rendering Provider 96
03183 Rc450 Not Allowed Same Day, Same Hour As Rc451 Or Rc452 B15
Rc451 And Rc452 Not Allowed Same Day, Same Hour As

03184 Rc450 B15
03195 Claim Denied. Essure Follow Up Guidelines Not Met A1
03195 Claim Denied. Essure Follow Up Guidelines Not Met 119

Procedure/Modifier Combination With This Diagnosis Is
03196 Allowed Only Once Per Lifetime 149
Procedure/Modifier Combination With This Diagnosis Is

03196 Allowed Only Once Per Lifetime 149
Other Sterilization Procedure Is Not Allowed When Essure
03197 Procedure Is Paid In History For This Recipient 119
This Hri-Rh Not Authorized To Receive Hri Payment For This

03235 Recipient For Dates Of Service Billed 15
This Recipient Not Authorized On The Dates Of Service Billed

03236 For High Risk Intervention Coverage 15
The Level Of High Risk Intervention Coverage Billed Is Not

03237 Authorized For This Recipient 15
This Hospice Provider Is Not Authorized To Receive Hospice

03239 Payment For This Recipient On Date Of Service 185
Nctracks Has Not Been Notifed Of Hospice Election For This

Nctracks Has Not Been Notified Of Hospice Election For This

03241 Recipient 15
Therapeutic, Prophylactic Or Diagnostic Injection Must Be
Billed With The Primary Procedure Code By The Same
03269 Provider 97
Billed With A Related Radiopharmaceutical Code By The Same
03270 Provider 97
03295 Encounter Provider Not Enrolled For This Taxonomy 16
03296 Encounter Provider Number Invalid For Date Of Service 16
03297 Encounter Provider Number Not On File 16
Recipient Not Enrolled With This Hmo Provider For This Date
03298 Of Service
Procedure Cutback. Limited To 1 Per Instance Of Breast
03300 Cancer 119
03300 Cancer 119

03300 Cancer 119

03300 Cancer 119
Delivery Of Placenta, External Cephalic Version Or Special
Miscellaneous Services Included In Fee For Delivery. Services
03325 Recouped 97
Delivery Of Placenta, External Cephalic Version Or Special
Miscellaneous Services Included In Fee For Delivery. Services
03325 Recouped 97
School Based Health Center'S Sponsoring Provider Is Not
03332 Eligible. Please Contact Dwch For More Information 185
Claim Denied. Respiratory Therapy In A School Setting
03392 Limited To 2 Dates Of Service Per Recipient Every 365 Days 119
03395 Procedure Code Allowed Once Per Gestational Period 96

Pmh Initial Assessment And Pmh Post Partum Assessment,
03398 Not Allowed Same Day 96
Original Claim Is Not In A Paid Status. Adjustment/Void

03405 Cannot Be Processed 16


Ach Providers Must Use Diagnosis Code V60.6 When Billing
Type Of Bill 893 Or 897. Verify And Resubmit Correct
03409 Diagnosis Code As A New Day Claim 12
Provider Taxonomy Cannot Bill Enhanced Benefit Services On
03410 Or After Date Of Service March 20, 2006 96
03412 Or After Date Of Service July 1, 2006 96
03413 And After Date Of Service October 1, 2006 96
Incorrect Number Of Units Billed For This Service. Please
03414 Correct And Resubmit With Corrected Units 16
Community Support Not Allowed Same Calendar Week As
03425 Mental Health/Substance Abuse Tcm 96


Service Denied. Dme Equipment Not To Exceed Three Units
03437 In Three Years, Ages 000-115 119
Service Denied. Dme Equipment Not To Exceed Three Units

03437 In Three Years, Ages 000-115 119
Units Cutback. Dme Equipment Not To Exceed Three Units In
03438 Three Years, Ages 000-115 119
Units Cutback. Dme Equipment Not To Exceed Three Units In

03438 Three Years, Ages 000-115 119
Acute Lower Level Of Service Met Before Average Length Of
03470 Stay
Acute Lower Level Of Service Met Before Average Length Of
03471 Stay
Procedure Billed Only Allowed 2 Evaluations/Assessments Per
03472 Year 119
Skilled Nursing Services Limited To Two Visits Per 30 Day
03473 Period 119
Skilled Nursing Visit Charge Limited To One Visit Per Calender
03474 Week 119
Skilled Nursing Visit Charge Limited To One Visit Per Calender
03475 Month 119
03476 An Event Code May Only Bill One Unit A Day 119
03500 Claim Line Cutback To Maximum Allowed By Pa 198
03501 Claim Line Cutback To Zero Units. Pa Exhausted. 96

Units Billed For Epogen Procedure For The Calendar Month
Have Been Exceeded. Adjustment Request Including Medical
03505 Records Is Required For Consideration Of Additional Units 119
Epogen Services Are Limited To 13 Occurrences Per Calendar
Month. Adjustment Request Including Medical Records Is
03506 Required For Review Of Additional Occurrences 119
Units Billed For Epogen Procedure Have Been Cutback To The
03507 Maximum Allowable Units 119
Units Billed For Epogen Procedure Have Been Cutback To The
03508 Maximum Allowable Units 119
Epogen Procedures Are Specific To Units Billed. Correct Claim
If Necessary To Combine Units Under One Appropriate
03509 Procedure And File As An Adjustment 16
Epogen Procedures Are Specific To Units Billed. Correct Claim
If Necessary To Combine Units Under One Appropriate
03509 Procedure And File As An Adjustment 16
Units Billed For Epogen Procedure For Calendar Month Have
Been Exceeded. An Adjustment Request Including Medical
03510 Records Is Required For Consideration Of Additional Units 119
Service Rendered In Facility This Date Of Service. Physician
03511 Charge Not Allowed B20
Service Rendered In Facility This Date Of Service. Physician
03511 Charge Not Allowed B20
03522 Rendering Provider Not Eligible During Dates Of Service B7
03523 Rendering Provider Not On File 16
03537 Family Planning Indicator Invalid Or Missing 16
03542 Procedure Billed Limited To Two Per Day 119
03542 Procedure Billed Limited To Two Per Day 119
03552 All Asc Dental Procedures Must Bill The Same Modifier 16
03562 Missing Or Invalid Ndc Code, Or Not On File, For Compound 16
03575 Drg Code Not On Pricing File A8

Drug Therapy Procedure(S) Not Allowed Unless Billed In
03585 Addition To Hit Nursing Service Procedure 16
Drug Therapy Procedure(S) Not Allowed Unless Billed In
03585 Addition To Hit Nursing Service Procedure 16
03602 Principal Diagnosis Code Is Missing 16

03603 Accident Code Is Not Valid - Header 16
Attending/Rendering Provider Is Required. Please Refer To
The September 2016 Special Medicaid Bulletin 42 Cfr 455.410
03605 And 455.440 Part 1. 16
03606 Zero Units Submitted 16
Resubmit An 837 Transaction With The Medicare Data

03608 Elements Populated. 16
03609 Invalid Encounter Control Number - Encounter Only 16
03611 Encounter Claim - Procedure Code Is Missing 16
03611 Encounter Claim - Procedure Code Is Missing 16
03612 Principal Procedure Is Missing 16
03612 Principal Procedure Is Missing 16
03613 Missing Primary Diagnosis Code 16
03613 Missing Primary Diagnosis Code 16
03615 Invalid Oral Cavity Code 16
03615 Invalid Oral Cavity Code 16
03618 Invalid Submitted Units 16

Community Support Recouped, Not Allowed Same Calendar
03626 Week As Mh/Sa Tcm 119


03628 Billing Provider Id Is Required 16
03628 Billing Provider Id Is Required 16
03629 Missing Or Invalid Present On Admission Code 16
03629 Missing Or Invalid Present On Admission Code 16
03630 Invalid Emergency Code 16
03636 Other Insurance Payment Amount Is Invalid 16
03641 Admitting Diagnosis Code Missing 16
03642 Principle Procedure Code Date Invalid 16
03644 Discharge Hours Invalid 16
03652 Discharge Date Prior To Admission Date 16
03653 Beginning Date Of Service Is Prior To The Admission Date 16
03657 Service End Date Prior To The Stay Deny Date 16
03660 Stay Deny Effective Date Prior To Admission Date 16
03663 Admit Number Missing 16

Patient Still In Hospital But Discharge Date Or Hour Present
03665 On Claim 16
03666 Patient Has Been Discharged, But Date And Hour Are Missing 16
Patient Born In Hospital - Year Of Birth Differs From
03667 Admission Year 16
03668 Admission Code Invalid When Epsdt Is Found 16
Conflicting Accident Code Found On Claim For Newborn
03670 Recipeint 16
03671 Disability Code On Institutional Claim For Newborn 16
03672 Family Planning Indicator Found On Newborn Claim 16
03673 Invalid Alternate Care Date 16
03674 Therapeutic Leave Days Not On Separate Line 16

Hospital Leave Days Not On Separate Line For Institutional
03675 Claim 16
03677 No Primiary Diagnosis Info For Status Admission Or Discharge 16
03679 Medicare Coinsurance Days Incorrect 16
03680 Error In Calculation Of Non Covered Days 16
03681 Invalid Tpl Amount 16
03682 Occurence Span Date Is Invalid 16
03683 Medicare Payment Is Required 16
03685 Invalid Or Missing Recipient Date Of Birth 16
03685 Invalid Or Missing Recipient Date Of Birth 16
03686 The Adjustment/Void Field Is Incomplete 16
03689 Undefined Claim Type 16
Epidermal Autograft Must Be Billed With Primary Procedure

03700 Code 97
Epidermal Autograft Must Be Billed With Primary Procedure
03700 Code 97
Epidermal Autograft, Face, Scalp, Eyelids, Mouth, Neck, Ears,

03701 Orbits Must Be Billed With Primary Procedure Code 97
Epidermal Autograft, Face, Scalp, Eyelids, Mouth, Neck, Ears,

03701 Orbits Must Be Billed With Primary Procedure Code 97
Dermal Autograft, Trunk, Arms, Each Additional Must Be Billed

03702 With Primary Procedure Code 97
Dermal Autograft, Trunk, Arms, Each Additional Must Be Billed

Dermal Autograft, Each Additional Must Be Billed With Primary

Dermal Autograft, Each Additional Must Be Billed With Primary

Tissue Cultured Epidermal Autograft, Each Additional Must Be

03704 Billed With Primary Procedure Code 97







03708 Add-On Code Must Be Billed With Primary Procedure. 97

Allograft Skin For Temporary Wound Closure, Each Additional

03711 Must Be Billed With Primary Procedure Code 97
Allograft Skin For Temporary Wound Closure, Each Additional

03711 Must Be Billed With Primary Procedure Code 97

Xenograft Skin (Dermal), For Temporary Wound Closure, Each

03717 Additional Must Be Billed With Primary Procedure Code 97
Xenograft Skin (Dermal), For Temporary Wound Closure, Each

03717 Additional Must Be Billed With Primary Procedure Code 97
Acellular Xenograft Implant, Each Additional Must Be Billed

Acellular Xenograft Implant, Each Additional Must Be Billed

Incision And Drainage, Open, Of Deep Abscess Not Allowed

03719 Same Date Of Service As Related Procedures 97


Services Recouped. Incision And Drainage, Open, Of Deep
Abscess Not Allowed Same Date Of Service As Related
03720 Procedures 96
03720 Procedures 96
03720 Procedures 96
Resection Of Apical Lung Tumor Not Allowed Same Date Of

03724 Service As Related Procedures 97


Services Recouped. Resection Of Apical Lung Tumor Not
03725 Allowed Same Date Of Service As Related Procedures B5
Anastomosis, Cavopulmonary, Second Superior Vena Cava,
03728 Must Be Billed With Primary Procedure Code. 97
Anastomosis, Cavopulmonary, Second Superior Vena Cava,

03728 Must Be Billed With Primary Procedure Code. 97
Anastomosis, Cavopulmonary, Second Superior Vena Cava

03729 Not Allowed Same Date Of Service As Related Procedures 97


Services Recouped. Anastomosis, Cavopulmonary, Second
Superior Vena Cava Not Allowed Same Date Of Service As
03730 Related Procedures 97
Repair Of Pulmonary Artery Arborization Anomalies Not

03738 Allowed Same Date Of Service As Related Procedures 97


Services Recouped. Repair Of Pulmonary Artery Arborization
Anomalies Not Allowed Same Date Of Service As Related
03739 Procedures 96
03739 Procedures 96
03739 Procedures 96


03741 Procedures 96
03741 Procedures 96
03741 Procedures 96
Contrast Injection(S) For Radiologic Evaluation Not Allowed



Services Recouped. Contrast Injection(S) For Radiologic
Evaluation Not Allowed Same Date Of Service As Related
03743 Procedures 96
03743 Procedures 96
03743 Procedures 96
Primary Percutaneous Transluminal Mechanical
Thrombectomy Not Allowed Same Date Of Service As Related
03744 Procedures 97
03744 Procedures 97
03744 Procedures 97
Services Recouped. Primary Percutaneous Transluminal
Mechanical Thrombectomy Not Allowed Same Date Of Service
03745 As Related Procedures 96
03746 Related Codes Not Allowed Same Date Of Service 97
03746 Related Codes Not Allowed Same Date Of Service

Services Recouped. Related Codes Not Allowed Same Date Of
03747 Service 96
03747 Service 96
03747 Service 96
Primary Percutaneous Transluminal Must Be Billed With

03748 Primary Procedure Code 97
Primary Percutaneous Transluminal Must Be Billed With

03748 Primary Procedure Code 97
Ligation, Division, And Stripping, Short Or Long Saphenous

03749 Not Allowed Same Date Of Service 97


Services Recouped. Ligation, Division, And Stripping, Short Or

03750 Long Saphenous Not Allowed Same Date Of Service 97


Service Denied. Immunization Administration Not Allowed

Same Date Of Service As Core Clinic Visit By Same Or
Service Denied. Immunization Administration Not Allowed
Same Date Of Service As Core Clinic Visit By Same Or
Laparascopy, Surgical Must Be Billed With Primary Procedure

03753 Code 97
Laparascopy, Surgical Must Be Billed With Primary Procedure

03753 Code 97
Immunization Administration Has Been Recouped, Service

Not Allowed Same Day As Core Clinic Visit By Same Or
Immunization Administration Has Been Recouped, Service

Not Allowed Same Day As Core Clinic Visit By Same Or
Tissue Cultured Allogeneic Skin Substitute Not Allowed Same



Services Recouped. Tissue Cultured Allogeneic Skin Substitute



Anorectal Exam, Surgical, Requiring Anesthesia Not Allowed



Services Recouped. Anorectal Exam, Surgical, Requiring
Anesthesia Not Allowed Same Date Of Service As Related
03758 Procedures 96
03758 Procedures 96
03758 Procedures 96
Removal And Replacement Of Internally Dwelling Ureteral Not

03759 Allowed Same Date Of Service As Related Procedures. 97


Services Recouped. Removal And Replacement Of Internally
Dwelling Urteral Not Allowed Same Date Of Service As
Endometrial Sampling Must Be Billed With Primary Procedure

03761 Code 97
Endometrial Sampling Must Be Billed With Primary Procedure

03761 Code 97
Chemotherapy Administration Must Be Billed With Primary

Chemotherapy Administration Must Be Billed With Primary

Intravenous Infusion, Hydration Must Be Billed With Primary

Intravenous Infusion, Hydration Must Be Billed With Primary

Intravenous Infusion For Therapy Must Be Billed With Primary







Intravenous Infusion Therapies Not Allowed Same Date Of

03770 Service 97

03770 Service 97

03770 Service 97

03771 Service 97

03771 Service 97

03771 Service 97
3D Rendering With Interpretation Not Allowed Same Date Of

03772 Service With Related Services 97




Stereoscopic X-Ray Guidance Not Allowed Same Date Of






Evaluation Of Auditory Rehabilitation Status Must Be Billed

Evaluation Of Auditory Rehabilitation Status Must Be Billed

Electrical Stimulation Must Be Billed With Primary Procedure

03777 Code 97
Electrical Stimulation Must Be Billed With Primary Procedure

03777 Code 97
Electrical Stimulation Not Allowed Same Date Of Service With

03778 Related Services 97


Services Recouped. Electrical Stimulation Not Allowed Same
03779 Date Of Service With Related Services. 96
Electrical Stimulation Not Allowed Same Date Of Service As



03781 Date Of Service As Related Services 96
Billing Of Services With Modifier Lm Is Limited To One Per
03782 Day 119
Billing Of Services With Modifier Lm Is Limited To One Per
03782 Day 119
03783 Billing Of Services With Modifier Ri Is Limited To One Per Day 119
03783 Billing Of Services With Modifier Ri Is Limited To One Per Day 119
Mfp Pre-Transition Case Management Service Units Limitation
03784 Has Been Exceeded For The 60 Days Period 119
Mfp Pre-Transition Case Management Service Has Been
Cutback To The Maximum Units Allowed For The 60 Days
03785 Period 119
Mfp Pre-Transition Case Management Service Has Been
Cutback To The Maximum Units Allowed For The 60 Days
03785 Period 119
Only Six Stainless Steel Crowns Allowed On Same Date Of
03800 Service 119

03800 Service 119

03800 Service 119
03800 Service 119
03801 Only Six Pulpotomies Allowed On Same Date Of Service 119
03802 Placement Of Prosthesis Requires Endovascular Repair 97
Transposition With Carotid Artery Repair Not Allowed Same

03804 Day As Other Transposition 97


03809 Descending Thoracic Aorta Requires Endovascular Repair 97
03810 Placement Of Prosthesis Requires Endovascular Repair 97
Placement Of Distal Extension Prosthesis Requires

03811 Endovascular Repair 97
03812 Service Denied. Hospice Services Limited To One Unit Per Day 119
03813 Units Cutback. Hospice Services Limited To One Unit Per Day 119
Placement Of Distal Prosthesis After Endovascular Repair Not

03814 Allowed With Related Repair Procedure 97


Related Repair Procedure Not Allowed With Placement Of

03815 Distal Prosthesis After Endovascular Repair 97


Only One Mco Capitated Payment Allowed Per Calendar
03997 Month 119
Add-On Code Not Allowed Without Primary Procedure Paid In
History For The Same Date Of Service, Same Or Different
03998 Provider 97
Add-On Code Not Allowed Without Primary Procedure Paid In
History For The Same Date Of Service, Same Or Different
03998 Provider 97
04006 Dialysis Training Sessions Limited To 25 Per Lifetime 149
04007 Completion Of Dialysis Training Fee Allowed Once Per Lifetime 149
General Anesthesia Limited To 22 Units On Same Date Of
04008 Service 119
04009 Iv Sedation Limited To 22 Units On Same Date Of Service 119

04010 Equipment 45
Tracheostomy Care Kit Limited To 90 Units Per Month For
04011 Ages (00-20) 119

04011 Ages (00-20) 119
04012 Ages (21-99) 119

04012 Ages (21-99) 119
Waiver Specialized Supply-Cutback To The Maximum Of

04014 $600.00 Allowed Per Sfy 45
Cutback To The Maximum Of $1500.00 Allowed Per Sfy For

04016 Cap/Mobility 45
Payment Of The Appropriate Postpartum Service To This
Billing Provider Is Required To Meet Medicaid Guidelines For
04018 Reimbursement Of This Code 96
Refractive Code Denied Due To Medical Diagnosis/Medical
Office Visit Paid In History With The Same Date Of Service. If
Necessary File Adjustment To Correct Diagnosis/Procedure
04019 Code 96
04025 Related Enhanced Benefit Services Not Allowed On Same Day 96

04027 Exceeds Once Per Calendar Month Limitation 119
04027 Exceeds Once Per Calendar Month Limitation 119

Removal And Reinsertion Of Implantable Contraceptive
04029 Capsule (Norplant) Is Allowed Once Per Day 119

04030 Day 59

04030 Day 59
04031 Radiation Treatment Delivery Limited To 3 Per Day 119

Only Two Radiation Management Services Allowed In A 7 Day
04035 Period 119
Only Two Radiation Management Services Allowed In A 7 Day

04035 Period 119
Weekly Radiation Therapy Management Limited To 5 In A
04036 Four Week Period 119
Weekly Radiation Therapy Management Limited To 5 In A

04036 Four Week Period 119
Purchase/Rental/Repair Of Augmentative Devices Allowed
04038 Once Per Day 119
Purchase/Rental/Repair Of Augmentative Devices Allowed
04038 Once Per Day 119
Radiation Treatment Management For Cranial Lesions Not
04042 Allowed Same Day As Stereotactic Radiosurgery Services 96
Service Recouped. Stereotactic Radiosurgery Services Not
Allowed Same Day As Radiation Treatment Management For
04043 Cranial Lesions 96
Radiation Treatment Management For Extracranial Lesions
04044 Not Same Day As Stereotactic Radiosurgery Services 96
04045 Extracranial Lesions 96
04046 Radiation Management Is Limited To Twice In A 7 Day Period 96
04046 Radiation Management Is Limited To Twice In A 7 Day Period 96

Intranasal And H1N1 Vaccine Not Allowed On The Same Date
04049 Of Service 96
04049 Of Service 96
04049 Of Service 96
04049 Of Service 96
Sleep Study Procedure Not Allowed On The Same Date Of

Service As A Related Procedure Already Paid For This Date
04061 96
Sleep Study Procedure Not Allowed On The Same Date Of

Service As A Related Procedure Already Paid For This Date
04061 96
Related Procedure Not Allowed The Same Date Of Service As
04062 Sleep Study Already Paid For This Date 96



Procedure Billed With This Modifier Only Allows Two Units.
04086 Units Have Been Exceeded For This Date Of Service 119
Related Vaccines Are Not Allowed On The Same Date Of

04091 Service 96
04091 Service 96

04091 Service 96
04091 Service 96
04095 Only One Sleep Study Procedure Per Date Of Service 119
04095 Only One Sleep Study Procedure Per Date Of Service 119
One Multiple Extremity Electromyography Procedure Per Date
One Multiple Extremity Electromyography Procedure Per Date
04097 One Home Visit Allowed Per Date Of Service 119
04097 One Home Visit Allowed Per Date Of Service 119

Providers Billing For Dates Of Service After June 1, 2004, Must
Bill Only The Applicable National Codes And/Or Corresponding
04100 Revenue Codes. 16
You Are Attempting To Adjust A Claim That Is Either Not

Found On Our File Or Is Not Found On Our File As Previously
04102 Paid 16
04102 Paid 16
04102 Paid 16

04102 Paid 16
You Are Attempting To Void A Claim That Is Either Not Found

04103 On Our File Or Is Not Found On Our File As Previously Paid 16


The Number Of Ach Facilty Beds Is Not Listed On The Provide

04104 File For Provider Taxonomy 16
The Number Of Ach Facilty Beds Is Not Listed On The Provide

04104 File For Provider Taxonomy 16
Quantities In Excess Of The Adult Dosages Recommended By
The Food And Drug Administration (Fda) For Atypical
04110 Antipsychotics. B5
The Food And Drug Administration (Fda) For Atypical
04110 Antipsychotics. 188
Suspect Duplicate, Same Procedure Code/Rendering Provider

04116 And Overlapping Dos 97
04120 Units Cutback. Maximum Number Of Units Exceeded 119
04124 Rental Cost Exceeds Purchase Price For 1 Year, Ages 021-115 108
04124 Rental Cost Exceeds Purchase Price For 1 Year, Ages 021-115 108

04125 The Food And Drug Administration (Fda) For Antidepressants. B5
04125 The Food And Drug Administration (Fda) For Antidepressants. 188
The Food And Drug Administration (Fda) For Add/Adhd
04140 Medications. B5
The Food And Drug Administration (Fda) For Add/Adhd
04140 Medications. 188
Delivery Only Or Related Abdominal Surgery Not Allowed
Same Day As Delivery With Postpartum Care By Same
04152 Rendering Provider 16
Delivery With Postpartum Care Performed This Day By Same
Rendering Provider. Delivery Only Or Related Abdominal
04153 Surgery Recouped 16
04200 Allow One Topical Fluoride Varnish Application Every 60 Days 96

Incision Procedure Is A Component Of Surgical Procedure
Already Paid For This Date Of Service. No Payment Allowed
04201 For Current Procedure 97


Surgical Procedure Does Not Allow Separate Incision

04202 Component On Same Day. Component Recouped 97



Quantities In Excess Of The Pediatric Dosages Recommended
By The Food And Drug Administration (Fda) For Behavioral
04207 Health Meds. B5
By The Food And Drug Administration (Fda) For Behavioral
04207 Health Meds. 188

Thromboendarterectomy And Harvest Of Upper Extremity
04219 Vein Are Not Allowed On The Same Date Of Service 96


Related Bypass Procedures Not Allowed On The Same Date Of
04221 Service 96

04221 Service 96
04221 Service 96

04221 Service 96
Claim Denied. Ultrasound Of Transplanted Kidney Not Allowed
04229 Same Day As Visceral And Penile Vascular Studies 96


Claim Recouped. Ultrasound Of Transplanted Kidney Not
04230 Allowed Same Day As Visceral And Penile Vascular Studies 96


Claim Denied. Ultrasonic Guidance, Intraoperative Not
04231 Allowed Same Day As Laparoscopy 96


Claim Recouped. Ultrasonic Guidance, Intraoperative Not



Related Fluoroscopic Guidance Procedures Not Allowed On
04233 The Same Date Of Service 96


Claim Recouped. Related Fluoroscopic Guidance Procedures
04234 Not Allowed On The Same Date Of Service 96


Claim Denied. Fluoroscopic Guidance For Needle Placement
04235 Not Allowed Same Day As Radiological Examination 96


Claim Recouped. Fluoroscopic Guidance For Needle Placement



Claim Denied. Fluoroscopic Guidance Not Allowed Same Day
04237 As Surgical Or Radiological Procedures 96


Claim Recouped. Fluoroscopic Guidance Not Allowed Same
04238 Day As Surgical Or Radiological Procedures 96


04239 As Myelography Procedures 96


04240 Unexpected Grouper Return Code 133

Claim Denied. Computerized Tomography Guidance Not
04241 Allowed Same Day As Related Procedure 96

Claim Recouped. Computerized Tomography Guidance

04242 Previously Paid 97
Claim Denied. Laparoscopy/Hysteroscopy Not Allowed Same
04243 Day As Related Surgery 96


Claim Recouped. Laparoscopy/Hysteroscopy Not Allowed

04244 Same Day As Related Surgery 97



Claim Denied. Abdominal Laparoscopy Not Allowed Same Day
04245 As Laparoscopy/Hysteroscopy 96

Claim Recouped. Abdominal Laparoscopy Not Allowed Same

04246 Day As Laparoscopy/Hysteroscopy 97



Claim Denied. Surgical Laparoscopy Not Allowed Same Day As
04247 Laparoscopy With Radical Hysterectomy 96


Claim Recouped. Surgical Laparoscopy Not Allowed Same Day

04248 As Laparoscopy With Radical Hysterectomy 97



Claim Denied. Related Surgical Procedures Not Allowed Same
04249 Day As Resection (Tumor Debulking) 96

04251 Never Event - Paid 0.00 233
04252 Invalid Bill Type. 5
04252 Invalid Bill Type. 5
04253 Never Event Diagnosis And Bill Type Mismatch. 5
04254 Poa Indicator Is Missing Or Invalid For Drg A8

Drg - Other Diagnosis Code 10 Is Invalid Or Requires Further
04255 Subdivision. Correct And Resubmit Claim 16
Drg - Other Diagnosis Code Found In 11 Through 17 Is
Invalid Or Requires Further Subdivision. Correct And Resubmit
04256 Claim 16
Drg - Other Diagnosis Code Found In 18 Through 25 Is
Invalid Or Requires Further Subdivision. Correct And Resubmit
04257 Claim 16
Claim Denied. Physician Supervision Of Patients Under Care
Of Home Health Not Allowed Within 30 Days Of Pediatric
04258 Home Apnea Monitoring Event 119
Claim Recouped. Physician Supervision Of Patients Under Care
Of Home Health Not Allowed Within 30 Days Of Pediatric
04259 Home Apnea Monitoring Event 119
Procedure/Modifier Limited To 2 Units Per Day. If Additional
Units Were Provided Rebill As Adjustment With Medical
04263 Records 119

04263 Records 119
04263 Records 119
04263 Records 119

04263 Records 119
04263 Records 119
Procedure Limited To 1 Unit Without Modifier. If Multiple Units

04264 Were Provided, Resubmit Claim With Appropriate Modifiers 96
04265 Exceeds 3 Units Per Day Limitation 96

04267 Exceeds 4 Units Per 31 Day Limitation 119
Orthotic Or Prosthetic Equipment Allowed Once Every 18

04269 Months For Ages 000 - 005. Units Cutback To Allowed Amount 119

04269 Months For Ages 000 - 005. Units Cutback To Allowed Amount 119
Related Cardiovascular Surgeries Not Allowed Same Date Of

04270 Service 97

04270 Service 97

04270 Service 97

04270 Service 97
04271 Units Cutback. Exceeds Maximum Units Allowed Per Day 119
04272 Inhalation Treatment, First Hour Once Per Day B5

Related Pulmonary Procedures Not Allowed Same Date Of
04273 Service 96

04273 Service 96
04273 Service 96

04273 Service 96
04274 Service 96

04274 Service 96
04274 Service 96

04274 Service 96
Catheterization Not Allowed Same Day As Comprehensive

04275 Surgical Procedure 97


Comprehensive Surgical Procedure Not Allowed Same Day As

04276 Related Catheterization. Catheterization Recouped 97



Delayed Creation Of Exit Site Not Allowed Same Day As
04277 Insertion Of Intraperitoneal Cannula Or Catheter 96


Insertion Procedure Not Allowed Same Day As Related

04278 Procedure. Delayed Creation Of Exit Site Procedure Recouped 96



Related Treatment Procedure Not Allowed Same Day As
04279 Stereotactic Radiation Treatments 96

Stereotactic Radiation Treatment Not Allowed Same Day As
04280 Related Treatment Procedure 96


Radiation Management Not Allowed Same Date Of Service As
04281 Radiation Therapy 96


Radiation Therapy Not Allowed Same Date Of Service As

04282 Radiation Management 97



Cardiovascular Graft Procedure Not Allowed Same Day As
04285 Related Cardiovascular Surgery Procedure 97





Cardiovascular Surgery Procedure Not Allowed Same Day As

04286 Related Cardiovascular Graft. Graft Procedure Recouped 97





Insertion Procedure Not Allowed Same Date Of Service As
04288 Repair Procedure 96


Repair Procedure Not Allowed Same Date Of Service As
04289 Related Insertion Procedure. Insertion Procedure Recouped 96


Component Of Surgical Incision/Closure Procedure Not
Allowed On Same Date Of Service As A Related Closure
04290 Procedure 97
04290 Procedure 97

04290 Procedure 97
04290 Procedure 97
04290 Procedure 97

04290 Procedure 97
Related Closure Procedure Not Allowed Same Day As
Component Incision/Closure Procedure. Component
04291 Incision/Closure Procedure Recouped 97


Surgical Procedure Not Allowed Same Day As Separate Scopy

04292 Procedure 97

04292 Procedure 97

04292 Procedure 97

04292 Procedure 97

04292 Procedure 97

04292 Procedure 97
Separate Scopy Procedure Not Allowed Same Day As Surgical

04293 Procedure 97

04293 Procedure 97

04293 Procedure 97

04293 Procedure 97

04293 Procedure 97
04293 Procedure 97
04294 Repair Procedures Not Allowed Same Day As Excision Of Skin 96
04295 Excision Of Skin Not Allowed Same Day As Repair Procedures 96
04296 Corneal Topography Not Allowed Same Day As Keratoplasty 96

Corneal Topography Recouped. Service Not Allowed Same
04297 Day As Keratoplasty 96

04300 Dme Iou Limited Per Calendar Month 119
04300 Dme Iou Limited Per Calendar Month 119
04301 Denied - Dme Iou Limited Per 6 Calendar Months 119
04301 Denied - Dme Iou Limited Per 6 Calendar Months 119
04302 Dme Iou Limited Ounces Per Calendar Month 119
04302 Dme Iou Limited Ounces Per Calendar Month 119
04303 Denied - Dme Iou Limited Ounces Per 6 Calendar Months 119
04303 Denied - Dme Iou Limited Ounces Per 6 Calendar Months 119
04304 Dme Iou Limited Tablets Per Calendar Month 119
04304 Dme Iou Limited Tablets Per Calendar Month 119
04305 Dme Iou Limitation Of 150 Per 6 Calendar Months Exceeded 119
04306 Dme Iou Limitation Of 2 Per Calendar Month Exceeded 119

Dme Incontinence Ostomy Urinary (Iou) Supply Limitation Of

04318 1 Box Of 50 Per Calendar Month Exceeded 119
04318 1 Box Of 50 Per Calendar Month Exceeded 119
04319 2 Per 6 Calendar Months Exceeded 119
04319 2 Per 6 Calendar Months Exceeded 119

04320 4 Ounces Per Calendar Month Exceeded 119
04320 4 Ounces Per Calendar Month Exceeded 119
Dme Inconience Ostomy Urinary (Iou) Supply Limitation Of 16

04321 Ounces Per Calendar Month Exceeded 119
Dme Inconience Ostomy Urinary (Iou) Supply Limitation Of 16
04321 Ounces Per Calendar Month Exceeded 119
04323 Dme Iou Limitation Of One Per Calendar Month Exceeded 119
04323 Dme Iou Limitation Of One Per Calendar Month Exceeded 119
Dme Iou Limitation Of 2 Ounces Per Calendar Month

04324 Exceeded 119
Dme Iou Limitation Of 2 Ounces Per Calendar Month
04324 Exceeded 119
Dme Iou Limitation Of 1 (16 Oz) Per Calendar Month

04325 Exceeded 119
Dme Iou Limitation Of 1 (16 Oz) Per Calendar Month
04325 Exceeded 119
Dme Iou Limitation Of 100 Tablets Per Calendar Month

04326 Exceeded 119
Dme Iou Limitation Of 100 Tablets Per Calendar Month
04326 Exceeded 119
Dme Iou Limitation Of 16 Ounces Per 6 Calendar Months

04327 Exceeded 119
Dme Iou Limitation Of 16 Ounces Per 6 Calendar Months
04327 Exceeded 119
04365 Service Denied. Exceeds 1 Per 365 Day Limitation 119

04366 Units Cutback To Allow 1 Unit Per 365 Days 119

04368 28 Days 119

04368 28 Days 119
04368 28 Days 119
04369 Units Cutback To The Maximum Units Allowed 119
04369 Units Cutback To The Maximum Units Allowed 119


Orthotic Or Prosthetic Equipment Allowed Six Per Year For

04371 Ages 000-002. Units Cutback To Allowed Amount 119

04371 Ages 000-002. Units Cutback To Allowed Amount 119
04372 Drug Units Cutback To The Allowable 85 Units Per 28 Days 119
Drug Units Cutback To The Allowable 210 Units Per Calendar

04373 Month 119
04373 Month 119
04373 Month 119

04373 Month 119

04373 Month 119

04373 Month 119

04373 Month 119
04373 Month 119
04373 Month 119
Personal Care Services Not Allowed On Same Or Overlapping
04416 Dos As Inpatient Or Nursing Home Stay B15
Duplicate Claim Submission - Different Billing Provider

04417 Number, Same Gcn, Patient, And Date Of Service 16
04418 Dme Procedure Allowed Once Per Year 119
Exact Duplicate-Same Procedure/Rendering Provider And

04420 Overlapping Dos, Professional 97
Suspect Duplicate-Overlapping Dos, Same Procedure/Blank

04423 Modifiers Spaces. Professional 97
Suspect Duplicate-Overlapping Dos, Same Procedure/Anesthia

04424 Modifiers. Professional 97
Suspect Duplicate-Overlapping Dos, Same

04425 Procedure/Assistant Surgeon Modifiers. Professional 97
Suspect Duplicate-Overlapping Dos, Same Procedure/Primary

04426 Service Modifiers. Professional 97
Suspect Duplicate- Overlapping Dos, Same

04427 Procedure/Ambulance Modifiers. Professional 97

04428 Procedure/Professional And Technical Modifiers. Professional 97

04429 Procedure/Ambulatory Surgery Center Modifier. Professional 97
Suspect Duplicate- Overlapping Dos, Same Procedure/Durable

Medical Equipment Or Home Insusion Therapy Modifiers.
04430 Professional 97
Suspect Duplicate- Overlapping Dos, Same Procedures/
04431 Related Eye Modifiers. Professional 97
Suspect Duplicate- Overlapping Dos, Same Procedure/

04432 Related Finger Modifiers. Professional 97
Suspect Duplicate- Overlapping Dos, Same Procedure/

04433 Related Toe Modifiers. Professional 97
Suspect Duplicate- Overlapping Dos, Same Procedure/Bilateral

04434 Procedure Modifiers. Professional 97
04437 Hospital Region 40 Not Allowed With Amb Serv Region 10 B15
Suspect Duplicate- Overlapping Dos, Same Procedure,

04439 Different Modfiers. Professional 97

04440 Different Modifiers. Professional 97

Suspect Duplicate-Overlapping Dos, Same Procedure,



Service Not Allowed While Recipient Is Enrolled In A High Risk
04445 Intervention-Residental Hospital B15
Service Not Allowed While Recipient Is Enrolled In A High Risk

04445 Intervention-Residental Hospital B15
Service Recouped. Recipient Is Enrolled In A High Risk

Intervention-Residential Hospital On The Same Date Of
04446 Service B15
Service Recouped. Recipient Is Enrolled In A High Risk

Intervention-Residential Hospital On The Same Date Of
04446 Service B15
Claim Denied. Exact Duplicate Of Previously Paid Claim With

04450 The Same Medicare Tcn 97
Personal Care Services Are Not Allowed When Recipient Is

04465 Receiving Inpatient Services 96
Service Recouped. Personal Care Service Not Allowed When

Orthotic Or Prosthetic Equipment Allowed Once Per Three

04470 Years For Ages 006 - 115. Units Cutback To Allowed Amount 119
Orthotic Or Prosthetic Equipment Allowed Once Per Three

04473 Anesthesia Procedure Allowed Once Per Day 119

04476 Invalid Number Of Services For Modifier Billed On Claim 4
04476 Invalid Number Of Services For Modifier Billed On Claim 4
04477 Osteotomy Procedure Allowed One Occurrence Per Day 119
04477 Osteotomy Procedure Allowed One Occurrence Per Day 119
04478 Osteotomy And Exploration Of Spine Not Same Day 96

Exploration And Osteotomy Of Spine Not Allowed On Same
04479 Day 96

04479 Day 96
04479 Day 96

04479 Day 96
04480 Add-On Procedure Must Be Billed With Primary Procedure 97
04480 Add-On Procedure Must Be Billed With Primary Procedure 97
04481 Tenotomy Not Allowed Same Day As Debridement 96

04482 Debridement Not Allowed Same Day As Tenotomy 96
04483 Related Hip Procedure Not Allowed Same Day 96
04485 Related Repair Codes Not Allowed Same Day 96
04487 Related Fracture Procedures Not Allowed Same Day 96

Biceps Tenodesis Not Allowed Same Day As Related
04489 Arthroscop Procedure 96


Related Arthroscopy Procedures Not Allowed Same Day As
04490 Biceps Tenodesis 96


04491 Thoracentesis Not Allowed Same Day As Related Procedure 96

Related Procedure Not Allowed Same Day As Thoracentesis.
04492 Thoracentesis Recouped 96
Related Procedure Not Allowed Same Day As Thoracentesis.
04492 Thoracentesis Recouped 96
Insertion Of Catheter Not Allowed Same Day As Related
04493 Procedure 96

04493 Procedure 96
04493 Procedure 96

04493 Procedure 96
Related Procedure Not Allowed Same Day As Insertion Of
04494 Catheter 96
Related Procedure Not Allowed Same Day As Insertion Of
04494 Catheter 96
04495 Thoracostomy Not Allowed Same Day As Excision 96

04496 Excision Procedure Not Allowed Same Day As Thoracostomy 96
04497 Ablation Must Be Billed With Related Cardiac Procedure 97
04498 Related Surgical Procedure Not Allowed Same Day 96
04499 Units Cutback. Exceeds 10 Units Per 270 Days 119
04499 Units Cutback. Exceeds 10 Units Per 270 Days 119
04501 Aorta Graft Not Allowed Same Day As Related Procedure 96

04502 Related Procedure Not Allowed Same Day As Aorta Graft 96
04503 Transcatheter Must Be Billed With Related Repair Procedure 96

Bypass Graft Procedure Not Allowed Same Day As Related
04504 Procedure 96

04504 Procedure 96
04504 Procedure 96

04504 Procedure 96
04505 Related Procedure Not Allowed Same Day As Bypass Graft 96

Excision Of Tumors Not Allowed Same Day As Related

Related Surgical Procedure Not Allowed Same Day As Excision
04507 Of Tumors 96

04507 Of Tumors 96
04507 Of Tumors 96

04507 Of Tumors 96
Gastric Tube Placement Not Allowed Same Day As Related
04510 Insertion Procedure 96


Insertion Procedure Not Allowed Same Day As Gastric Tube
04511 Placement. Gastric Tube Placement Recouped 96


Mechanical Removal Or Contrast Injection Not Allowed Same
04512 Day As Replacement Procedure 96


04513 Replacement Procedure Not Allowed Same Day 96

Mechanical Removal Not Allowed Same Day As Insertion
04514 Contrast 96

04514 Contrast 96
04514 Contrast 96

04514 Contrast 96
Contrast Injection Not Allowed Same Day As Mechanical
04515 Removal 96

04515 Removal 96
04515 Removal 96

04515 Removal 96
04517 Additional Augmentation Requires Initial Procedure

Anesthesia Assistant Services Not Allowed Same Day As
04520 Related Anesthesia Procedure 96


Related Anesthesia Services Not Allowed Same Day As
04521 Anesthesia Assistant Services 96



Anesthesia Stand By Not Allowed On The Same Day As An
04522 Anesthesia Procedure 96



Anesthesia Procedure Not Allowed Same Day As Anesthesia
04523 Stand By Procedure 96


04524 Only 1 Hour Of Anesthesia Stand By Allowed Per Day 119
04525 Billing Locator Code Cannot Be Derived 16
04526 Rendering Locator Code Cannot Be Derived 16
04527 Attending Locator Code Cannot Be Derived 16

Unable To Determine Rndr Prov Loc Cd Based On Submtd
Addr. Loc Cd Set Based On Rndr Prov Taxon Only. Contact
The Rndr Prov And Ask Them To Complete A Managed Chg
Request Adding The Svc Fac On This Claim As An Active Svc
04528 Loc. 5
Billing Address Submitted On The Claim Does Not Match The
04529 Address On File 16
Billing Address Submitted On The Claim Does Not Match The
04529 Address On File 16
04531 Billing Provider Taxonomy Is Invalid For Service Location 16
04532 Rendering Provider Taxonomy Is Invalid For Service Location 16
04533 Claim Pended Awaiting Address Validation 16
04533 Claim Pended Awaiting Address Validation 16
04560 No Budget Or Budget Information On File 133
04561 Funding For Applicable Payer Not Found 133
04562 System Error From Financial System 133
04566 Line Previously Paid By Another Dhhs Payer 22

The Food And Drug Administration (Fda) For Behavioral
04610 Health Meds. B5
The Food And Drug Administration (Fda) For Behavioral
04610 Health Meds. 188
Subcutaneous Infusion Add-On Code Must Be Billed With

Subcutaneous Infusion Add-On Code Must Be Billed With

04613 Only One Initial Infusion Allowed Per Day 119
04613 Only One Initial Infusion Allowed Per Day 119
04614 Only One Additional Pump Set-Up Allowed Per Day 119
04614 Only One Additional Pump Set-Up Allowed Per Day 119
Lab Procedure Not Allowed Same Day As Related Lab
04615 Procedure 96

04615 Procedure 96
04615 Procedure 96

04615 Procedure 96
04615 Procedure 96

04615 Procedure 96
Lab Procedure Recouped, Not Allowed Same Day As Related

04616 Lab Procedure 97





Service Denied. Basic Metabolic Panel Not Allowed Same Day
04617 As Comprehensive Panel 96


Basic Metabolic Panel Recouped To Allowed Reimbursement

04618 Of Comprehensive Panel Code 97





Service Denied. Basic Metabolic Panel Includes Procedure As

04619 A Component Of The Panel 97
Service Denied. Basic Metabolic Panel Includes Procedure As

04619 A Component Of The Panel 97
Component Of Basic Metabolic Panel Recouped To Allow

Component Of Basic Metabolic Panel Recouped To Allow

Service Denied. Related Procedure Not Allowed Same Day As
04621 Cardiac Mri Procedure 96



Service Recouped. Cardiac Mri Procedure And Related

04622 Procedure Not Allowed Same Day 97





Service Denied. Related Cardiac Procedures Not Allowed
04623 Same Day 96

04623 Same Day 96
04623 Same Day 96
04623 Same Day 96
04623 Same Day 96

04623 Same Day 96
Service Denied. Nasolacrimal Duct Probe Procedure Not



04625 Nasolacrimal Duct Probe Procedure 96



Service Denied. Laser Procedure Of Prostate Not Same Day As
04626 Related Procedure 96


04627 Laser Procedure Of Prostate 96



Service Denied. Laparoscopic Hysterectomy Not Allowed
04628 Same Day As Abdominal Hysterectomy 96


Service Denied. Abdominal Hysterectomy Not Allowed Same
04629 Day As Laparoscopic Hysterectomy 96



Service Denied. Related Surgical Procedure Not Allowed Same



Service Recouped. Laparoscopic Hysterectomy And Related

04631 Surgical Procedure Not Allowed Same Date Of Service 97




Service Denied. Paravaginal Defect Repair Not Allowed Same
04634 Day As Related Surgical Procedure 96



04635 Day As Paravaginal Defect Repair 96


Service Denied. Related Procedure Included In Laser
04636 Procedure Of Prostate Complete 96



Service Recouped. Laser Procedure Of Prostate Includes






Moderate Sedation Service Not Allowed On Same Date Of
04638 Service As Related Procedures When Performed In An Office 96


Related Procedure Not Allowed On Same Date Of Service As
04639 Moderate Sedation Services When Performed In An Office 96



Service As Related Procedures When Performed By Same



Moderate Sedation Services When Performed By Same



04642 Service As Related Sedation Procedures 96



Related Sedation Procedure Not Allowed On Same Date Of
04643 Service As Moderate Sedation Services 96


Tcm/Dd Procedure Not Allowed Same Calendar Week As

04647 Other Treatment, Service Already Rendered By Other Provider 96
Other Treatment/Service Procedure Not Allowed When

04648 Tcm/Dd Is Rendered Same Calendar Week By Other Provider 96
Service Denied. Procedure Code/Modifier Combination Not

Allowed For Place Of Service Billed If 60 Days Have Expire
04649 From When Tcm/Dd Service Was Rendered 96
04701 Missing Billing Taxonomy Code 16
04707 Related Cause Is Auto Accident And Accident Date Is Missing 16
04708 Invalid Epsdt Indicator 16
04709 Invalid Category Of Benfit Other Payer Paid Date 16
04710 Missing Billing Indicator 16
04712 Invalid Billing Provider Taxonomy 16
Duplicate Pharmacy Claim-Same Date Of Service, Ndc,

04770 Prescription Number, And Fill Number 16
Orthotic Or Prosthetic Equipment Allowed Once Per Two
Orthotic Or Prosthetic Equipment Allowed Once Per Two

Service Denied. Differing Hyaluronan Injections Not Allowed
04780 On The Same Day 96



04789 Papilloma Virus Vaccine Allowed Once Per Day 119
04789 Papilloma Virus Vaccine Allowed Once Per Day 119
04790 Papilloma Virus Vaccine Allowed Three Per Lifetime 149
04791 Vaccine Allowed Only Three Times Per Lifetime 149
H0040 Not Allowed Same Date Of Service With Other

04798 Enhanced Benefit Services B15

Service Denied. Maximum Allowed Units Per Waiver Year For
04799 This Capmr Service Billed Have Been Exceeded 119
The Maximum Allowed Monetary Limitation Per Waiver Year
04800 For The Cap/Ch Service Billed Has Been Exceeded 119
The Maximum Allowed Monetary Limitation For The Cap/Ch
Service Billed Has Been Exceeded For The Allowed 5 Year
04801 Period 119
The Maximum Allowed Unit Limitation Per Year Waiver For
04802 Cap/Ch Service Billed Has Been Exceeded 119
Maximum Allowed Units Per Day For Cap/Ch Services Billed
04803 Has Been Exceeded 119
Maximum Allowed Units Per Day For Cap/Ch Services Billed
04803 Has Been Exceeded 119
Maximum Allowed Number Of Occurrences Per Waiver Year
04804 For Cap/Ch Service Billed Has Been Exceeded 119
Only One Occurrence Allowed For Cap/Ch Service Per
04805 Recipient'S Lifetime 119
Only One Occurrence Allowed For Cap/Ch Service Per

04805 Recipient'S Lifetime 119
04806 Cap/Ch Service Not Allowed Same Day As Hospice Service 96
04806 Cap/Ch Service Not Allowed Same Day As Hospice Service 96
Service Denied. Unit Limitation Has Been Exceeded For This

04807 Service 119
Service Denied. Unit Limitation Has Been Exceeded For This
04807 Service 119
Cap/Ch Service Recouped. Cap/Ch Service Not Allowed Same

04808 Day As Hospice Service 97
04832 Fuzeon Can Only Be Dispensed Once Per Month 16

Service Denied. Diagnosis Does Not Support Units Billed. If
Units Are Correct, Review For Appropriate Diagnosis, Correct
04839 And Resubmit As A New Day Claim 16
Transportation Of Portable X-Ray Equipment Is Limited To 2
04840 Trips Per Day 119
Transportation Of Portable X-Ray Equipment Is Limited To 2
04840 Trips Per Day 119
04841 Months For Ages 000-020 119
04841 Months For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed 3 Per Foot Each
04842 Year For Ages 000-020 119
04842 Year For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allow 4 Every 6 Months For
04843 Ages 000-020 119
Orthotic Or Prosthetic Equipment Allow 4 Every 6 Months For
04843 Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Once In Three
04844 Years For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Once In Three
04844 Years For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Four Per Year For
04845 Ages 000-020 119
04845 Ages 000-020 119
04846 Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Twelve Per Year For
04847 Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed One Per Two Years
04848 For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Twice In One Year
04849 For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Once Per Year For
04850 Ages 000-020 119
04851 Year For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Twice Every 6
04852 Months For Ages 000-020 119
Orthotic Or Prosthetic Equipment Allowed Once Every Two
04853 Years For Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Once Every Six
04854 Months For Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Once Per Five Years
04855 For Ages 021-115 119
04856 Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Once Every Three
04857 Years For Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Two Per Year For
04858 Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Once Per Year For
04859 Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Two Every Six
04860 Months For Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Two Per Foot Each
04861 Year For Ages 021-115 119
04862 Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Three Per Foot
04863 Each Year For Ages 021-115 119
Orthotic Or Prosthetic Equipment Allowed Twelve Per Year For
04864 Ages 021-115 119
Orthotic And Prosthetic Equipment Allowed Two Per Limb
04865 Every 6 Months For Ages 000-020 119
04868 Every 3 Years For Ages 021-115 119
Orthotic And Prosthetic Equipment Allowed Four Per Limb
04869 Every 6 Months For Ages 000-020 119
Orthotic And Prosthetic Equipment Allowed Four Per Limb
04870 Every 3 Years For Ages 021-115 119
04871 Every Year For Ages 000-020 119
04872 Every Year For Ages 021-115 119
04877 Surgical Procedures Limited To 60 Per Day 119
04878 Surgical Procedures Limited To 20 Per Day 119
04879 Units Cutback. Exceeds Maximum Units Per Day 119

Money Follows The Person (Mfp) Service Not Allowed Same
04950 Day As Inpatient Claim 96
Inpatient And Money Follows The Person (Mfp) Services Not
04951 Allowed On Same Day 96
04961 Units Cutback To The Amount Allowed Per Calendar Week 119
Units Cutback To The Amount Allowed Per Calendar Week
04963 Without Prior Approval 119
Related Eye Treatment Procedure Codes Cannot Be Billed On
04965 The Same Claim By The Same Provider 96
Units Exceeded The Maximum Allowable Amount Limit.Claim
Pended For Review.Resubmit Claim With Corrected Units
04966 Within Allowable Limit 119
Units Exceeded The Maximum Allowable Amount Limit.Claim
Pended For Review.Resubmit Claim With Corrected Units
04966 Within Allowable Limit 119
Units Cutback. Only One Procedure Or Procedure/Modifier

05003 Combination Allowed Per Day 119

05007 Service Denied. Exceeds Maximum Units Allowed Per Week 119
05008 Units Cutback To The Maximum Units Allowed Per Week 119
Service Denied. Only One Procedure Or Procedure/Modifier


05017 Day 119
The Maximum Allowed Monetary Limitation Per Waiver Year

05020 For This Capmr/Dd Service Has Been Exceeded 45
Service Denied. In Home Care (Ihc) Services Not Allowed

05065 Same Day As Hospice 96
Service Recouped. In Home Care (Ihc) Service Not Allowed
05066 Same Day As Hospice 96

05067 Same Day As High Risk Intervention (Hri)-Ri Facility 96
05068 Same Day As High Risk Intervention (Hri) 96

05069 Sameday As Home Health Services 96
05070 Same Day As Home Health Service 96

05071 Same Day As Adult Care Home Personal Care Services (Pcs) 96
05072 Same Day As Adult Care Home Personal Care Services (Pcs) 96
05078 Ihca Limited To 320 Units Per Calendar Month 119

05079 Same Day As Cap Services 96
05080 Same Day As Cap Services 96
Service Denied. Drug Limited To Maximum Allowed Units Per
05101 Override Request For Timely Filing Is Missing Documentation 16
05102 Manual Review Of Attached Documentation For Timely Filing 16

Injection For Non-Esrd Use Not Allowed Same Date Of Service
05103 As Injection For Esrd Use 96
Injection For Esrd Use Not Allowed Same Date Of Service As
05104 Injection For Non-Esrd Use 96
Drug Limited To Maximum Allowed Units Per Calendar Month.

05105 Units Cutback To Allowed Amount 119


Service Denied. Drug Limited To 1000 Units Per Calendar

05108 Month 119

05108 Month 119

05108 Month 119

05108 Month 119
Drug Limited To 1000 Units Per Calendar Month. Units

05109 Cutback To Allowed Amount 119


Provider Enrollment Indicator Signifies Provider Must Be

05110 Enrolled In Appropriate Population Group 16








The Prescriber Denial Clarification Field On The Input Claim

05122 Was Invalid. Valid Values Are '00' Thru '07' 16
Multiple National Miscellaneous Procedure Codes Not Allowed
05124 On One Claim 16
Diagnostic Procedure Allowed Once Per Day Unless Billed With
05201 Appropriate Modifiers 119
05202 Repeat Diagnostic Procedure Allowed Twice Per Day 119

Service Represented By This Procedure Code/Modifier

05203 Combination Is Not Covered As Billed. 96
Service Represented By This Procedure Code/Modifier
05203 Combination Is Not Covered As Billed. 96
Procedure/Service Cannot Be Verified As Being Performed

Following Review Of Medical Records/Operating Notes
05205 Provided 251
Procedure/Service Cannot Be Verified As Being Performed
Following Review Of Medical Records/Operating Notes
05205 Provided 251
Modifier Cc Is For Internal Use Only: To Be Applied Only By

The Payer. Remove Modifier Cc And Resubmit Either As A
05211 New Day Claim Or An Adjustment 16
Billing Of Procedures With Modifier 55 And Different

05216 Postoperative Periods Is Not Allowed On The Same Claim. 96
05221 Provider 97
05221 Provider 97
05222 Provider 97
05222 Provider 97
05223 Provider 97
05223 Provider 97
05224 Provider 97
05224 Provider 97
05225 Provider 97
05225 Provider 97
05226 Provider 97
05226 Provider 97
05227 Provider 97
05227 Provider 97
05228 Provider 97
05228 Provider 97
05229 Provider 97
05229 Provider 97
05230 Provider 97
05230 Provider 97
Only One Surgical Code Per Day Is Allowed As The Primary
Procedure. Another Code Has Already Been Billed As Primary
For This Date Of Service. Correct Detail By Appending
05232 Modifier 51 To Claim And Rebill 119
05234 Procedure Is Included In Open Cholecystectomy 97
05238 Service Included In Ob Package 97

Ob Package Code Has Been Billed. Previously Billed Related
05239 Services Are Not Allowed 119

05241 Services Are Not Allowed B15

05243 Services Are Not Allowed B15
05291 Infant Toddler Claim With Tpl Money Pend For Manual Review
05308 Prior Authorized Units Exceeded 16
05308 Prior Authorized Units Exceeded 198
05312 Prior Authorized Dollars Exceeded 198
05328 Units Cutback. Exceeds Maximum Units Allowed Per Month 119
05329 Units Cutback. Exceeds Maximum Units Allowed Per 60 Days 119
05356 Units Cutback. Exceeds Maximum Units Allowed Per 6 Months 119
Units Cutback. Exceeds The Maximum 100 Medicaid Units
05363 Allowed Per 84 Day Limitation 119


Units Cutback. Exceeds The Maximum 600 Units Allowed Per

05364 90 Day Limitation 119


Procedure Code Covers Both Axillae. Units Cutback To The
05365 Allowable One Unit Per Day 119


Dme Incontinence Supply Limited To 192 Units Per Calendar
05377 Month 119
05378 Month 119
Exact Duplicate-Same Rend Prov/Pcode/Internal

05400 Modifier/Dos/Mod/Bill Amt/Different Tcn 97
Exact Duplicate-Same Rend Prov/Pcode/Internal

05400 Modifier/Dos/Mod/Bill Amt/Different Tcn 97
Duplicate-Same Rend Prov/Pcode/Internal

05401 Modifier/Dos/Related Modifier 97
Duplicate-Same Rend Prov/Pcode/Internal
05401 Modifier/Dos/Related Modifier 97
05402 Duplicate-Same Rend Prov/Pcode/Im/Dos/Related Modifiers 97
05402 Duplicate-Same Rend Prov/Pcode/Im/Dos/Related Modifiers 97
Duplicate-Same Pcode/Internal Modifier/Overlapping

05403 Dos/Related Modifiers 97
Duplicate-Same Pcode/Internal Modifier/Overlapping

05403 Dos/Related Modifiers 97
Severe Duplicate-Same Rendering Prov/Pcode/Internal

05404 Modifier/Dos/Modifier 97
Severe Duplicate-Same Rendering Prov/Pcode/Internal

05404 Modifier/Dos/Modifier 97
Exact Duplicate-Same Pcode/Internal

05405 Modifier/Dos/Modifier/Bill Amount/Rend Provider/Tcn 97
Exact Duplicate-Same Pcode/Internal

05405 Modifier/Dos/Modifier/Bill Amount/Rend Provider/Tcn 97
05406 Suspect Duplicate-Same Procedure/Date Of Service/Modifier 97
Severe Duplicate-Same Pcode/Overlapping Dos, Modifier Vs

05407 Modifier 97
Severe Duplicate-Same Pcode/Overlapping Dos, Modifier Vs

05407 Modifier 97
Severe Duplicate-Same Pcode/Internal

05410 Modifier/Modifier/Dos/Tcn 97
Severe Duplicate-Same Pcode/Internal
05410 Modifier/Modifier/Dos/Tcn 97
Tpl Not Submitted On Claim. Please Resubmit With Tpl Claim
05415 Line Details.
Immunization Administration Or Therapeutic Injection

Recouped, Not Allowed With E/M On Same Date Of Service,
05428 Same Billing Provider 96
05500 Follow Up Care Included In Global Surgical Package 97
Service Recouped. Follow-Up Is Included In Global Surgery

05521 Package 97

05553 Month 119
05553 Month 119

05553 Month 119

05553 Month 119
05553 Month 119

05553 Month 119
05554 Service Denied. Drug Limited To 50 Units Per Calendar Month 119
05555 Month 119
05555 Month 119

05555 Month 119

05555 Month 119
05555 Month 119

05555 Month 119

05556 Month 119
05556 Month 119

05556 Month 119

05556 Month 119
05556 Month 119

05556 Month 119
05557 Dme Exceeds Limitation Of $2000.00 Per Calendar Month 119
Supply Of Injectable Contrast Material Requires Appropriate

05560 Procedure On The Same Day B15
Drug Limited To 228 Units Per Calendar Month. Units Cutback

05563 To Allowed Amount 119






05596 Lidoderm Allows One Box On Original Fills 119

Related Endoscopy Procedure Must Be Billed With Primary
05700 Procedure
Related Endoscopy Procedure Must Be Billed With Primary

05700 Procedure
05701 Related Laparoscopy Codes Not Allowed On Same Day 96


Related Surgical Procedure Has Previously Paid For This Date
Related Surgical Procedure Has Previously Paid For This Date
05703 Related Biopsy Incision Procedures Not Allowed On Same Day 96

Service Recouped. Related Biopsy Incision Procedures Not On
05704 Same Day. 96
05704 Same Day. 96
05704 Same Day. 96
05704 Same Day. 96
05704 Same Day. 96
05704 Same Day. 96
05705 Related Surgical Procedures Not Allowed Same Day 96

Arthroplasty Procedure Not Allowed Same Day As
05706 Microsurgery 96
05707 Related Autograft Procedures Not Allowed Same Day 96
05708 Autograft Not Allowed Same Day As Arthroscopy 96
05709 Arthroscopy Not Allowed Same Day As Autograft 96
05710 Arthroscopy Not Allowed Same Day As Related Procedure 96
05711 Related Procedure Not Allowed Same Day As Arthroscopy 96

Bypass Graft Not Allowed Same Day As Related Vein
05712 Procedure. 96
05712 Procedure. 96
05712 Procedure. 96
05712 Procedure. 96
Related Vein Procedure Not Allowed Same Day As Bypass
05713 Graft 96
05713 Graft 96
05713 Graft 96
05713 Graft 96
Bypass Graft Of Vein Not Allowed Same Day As Repair
05714 Procedure 96
05714 Procedure 96
05714 Procedure 96
05714 Procedure 96
Repair Procedure Of Vein Not Allowed Same Day As Bypass
05715 Graft 96
05715 Graft 96
05715 Graft 96
05715 Graft 96
Bypass Graft Not Allowed Same Day As Related Surgical
05716 Procedure 96
05716 Procedure 96
05716 Procedure 96
05716 Procedure 96
Related Surgical Procedure Not Allowed Same Day As Bypass
05717 Procedure 96
05717 Procedure 96
05717 Procedure 96
05717 Procedure 96
Programming Device Evaluation Not Allowed Same Day As
05718 Peri-Procedural Device Evaluation 96
Peri-Procedural Device Evaluation Not Allowed Same Day As
05719 Programming Device Evaluation 96
Cardiography Procedure Not Allowed Same Day As
05720 Cardiovascular Device Monitoring 96
Cardiovascular Device Monitoring Not Allowed Same Day As
05721 Cardiography Procedure 96
05722 Related Cardiography Evaluation Not Allowed On Same Day 96
05723 Related Implantable Devices Not Allowed On Same Day 96
05724 Related Procedures Not Allowed Same Day 96

05725 Device Evaluation Limited To Once Per 90 Days 119
05726 Device Evaluation Limited To One Per Day 119
Related Echocardiograph Procedure Requires Primary

05727 Procedure 16
Related Echocardiograph Procedure Requires Primary

05727 Procedure 16
05728 Allograft Not Allowed Same Day As Related Arthroscopy 96
05729 Related Arthroscopy Not Allowed Same Day As Allograft 96
Technical Component Of Evaluation Already Paid Within 90

05730 Days 119
Professional Component Of Evaluation Already Paid Within 90

05731 Days 119
05802 Prtf Age Must Be Less Than 21 At Time Of Admission 9
05809 Procedure Code Pricing Date Invalid For Dates Of Service

Units Cutback. Exceeds Maximum Units Allowed Per Calendar
05810 Year Without Prior Approval 119


Pricing For Procedure Code Modifier Combintion Record Is

05811 Missing Or Invalid
05812 Pricing Factor Code Segment Missing Or Invalid
Secondary Factor Code X Percentage Segment Date Missing

05814 Or Invalid
Secondary Pricing Factor Code Y Post-Op Segment Date

05815 Missing Or Invalid
Evaluation & Management Already Paid For This Date Of
Service By Same Rendering Provider. File Adjustment With
05858 Medical Documentation To Support Medical Necessity 96
Recoup Evaluation And Management, Not Allowed Same Day
As Normal Newborn Care Received By A Different Rendering
05859 Provider 97
05859 Provider 97
05859 Provider 97
05859 Provider 97
Only One Neonatal Or Pediatric Initial Day Critical Care
05860 Service Allowed Within A 10 Day Period Per Hospitalization 119
Daily Care And Normal Newborn Care Cannot Be Billed On

The Same Date Of Service With The Same Attending
Daily Care And Normal Newborn Care Cannot Be Billed On

The Same Date Of Service With The Same Attending
Recoup Daily Care. Daily Care Cannot Be Billed On Same Date
Of Service As Normal Newborn Care For The Same Attending
Inpatient Consult And Normal Newborn Care Same Attending

05863 Taxonomy Qualifier Cannot Be Billed Same Date Of Service 96
Inpatient Consult And Normal Newborn Care Same Attending

05863 Taxonomy Qualifier Cannot Be Billed Same Date Of Service 96
Inpatient Consult Recouped. Inpatient Consult Cannot Be
Billed On Same Day As Normal Newborn Care, Same
05864 Attending Taxonomy Qualifier 96
Initial Normal Newborn Care Not Allowed Same Date Of

05865 Service As Neonatal Or Pediatric Critical Care 96
Initial Normal Newborn Care Not Allowed Same Date Of

05865 Service As Neonatal Or Pediatric Critical Care 96
Neonatal Or Pediatric Critical Care Services Not Allowed Same

05866 Date Of Service As Initial Normal Newborn Care 96
Neonatal Or Pediatric Critical Care Services Not Allowed Same

05866 Date Of Service As Initial Normal Newborn Care 96
Hospital Care/Discharge Management Not Allowed Same Day

05867 As Initial Normal Newborn Care 96
Hospital Care/Discharge Management Not Allowed Same Day

05867 As Initial Normal Newborn Care 96
Hospital Care/Discharge Management Recouped, Not Allowed

05868 Same Day As Initial Normal Newborn Care 97


Daily Management Or Inpatient Consult And
Neonatal/Pediatric Critical Care Services With Same Rendering
Provider Taxonomy Qualifier, Not Allowed Same Date Of
05869 Service B15
Daily Management Or Inpatient Consult And

Neonatal/Pediatric Critical Care Services With Same Rendering
Provider Taxonomy Qualifier, Not Allowed Same Date Of
05869 Service B15
Only One Neonatal Or Pediatric Critical Care Global Code Is
05871 Allowed Per Date Of Service 119
Neonatal/Pediatric Critical Care Add On Code Must Be Billed

05872 With The Primary Critical Care Code 97
Neonatal/Pediatric Critical Care Add On Code Must Be Billed

05872 With The Primary Critical Care Code 97
Neonatal/Pediatric Critical Care Add-On Code Units Exceed

05873 The Allowable Maximum Of 4 Units Per Date Of Service 119

Units Cutback. Neonatal/Pediatric Critical Care Add-On Code

05874 Exceed The Allowable 4 Units Per Date Of Service 119


Related Delivery And Birthing Codes Not Allowed On The
Service Already Included In Neonatal/Pediatric Critical Care

05876 Global Code 97
Service Already Included In Neonatal/Pediatric Critical Care

05876 Global Code 97
Procedure Recouped. Rendered Same Day As Neonatal
Critical Care. Covered In Payment Of Neonatal Critical Care
05877 Global Code. 97
Related E/M Code Billed By A Different Attending Is Not
Normal Newborn Care Not Allowed Same Date Of Service As

05882 Initial Hospital Care 96
Normal Newborn Care Not Allowed Same Date Of Service As

05882 Initial Hospital Care 96
Initial Hospital Care Not Allowed Same Date Of Service As

05883 Normal Newborn Care 96
Initial Hospital Care Not Allowed Same Date Of Service As

05883 Normal Newborn Care 96
Only One Normal Newborn Care Or Pediatric Critical Care

05884 Service Allowed Per Date Of Service 96
Only One Normal Newborn Care Or Pediatric Critical Care

05884 Service Allowed Per Date Of Service 96
Normal Newborn Care Not Allowed Same Day As Neonatal

05885 Critical Care 96
Normal Newborn Care Not Allowed Same Day As Neonatal

05885 Critical Care 96
Normal Newborn Care Not Allowed Same Day As Hospital

05886 Discharge Management 96
Normal Newborn Care Not Allowed Same Day As Hospital

05886 Discharge Management 96
Hospital Discharge Management Not Allowed The Same Date

05887 As Normal Newborn Care 96
Hospital Discharge Management Not Allowed The Same Date

05887 As Normal Newborn Care 96
Repositioning Procedure Not Allowed Same Day As Related
05888 Procedure 96
05888 Procedure 96
05888 Procedure 96
05888 Procedure 96
Related Procedures Not Allowed Same Day As Repositioning
05889 Procedure 96
05889 Procedure 96
05889 Procedure 96
05889 Procedure 96
Alcohol/Substance Abuse Screening And Intervention Not
Related Behavior Intervention Counseling Codes Not Allowed
05891 On The Same Date Of Service. 96
Concurrent Infusion Add On Code Must Be Billed With Primary

05892 Procedure 97

05892 Procedure 97

05892 Procedure 97

05892 Procedure 97
Diagnostic Aspiration Not Allowed On Same Date Of Service
05893 As Related Diagnostic Procedures. 96
Related Diagnostic Procedure Not Allowed On Same Date Of
05894 Service As Diagnostic Aspiration Procedure 96
Related Radiosurgery Procedure Not Allowed Same Date Of
05895 Service 96
05895 Service 96
05895 Service 96
05895 Service 96
05895 Service 96
05895 Service 96
Related Stereotactic Services Not Allowed On The Same Date
05896 Of Service 96
05896 Of Service 96
05896 Of Service 96
05896 Of Service 96
05896 Of Service 96
05896 Of Service 96
Recoup Stereotactic Service, Not Allowed Same Day As
05897 Related 96
05897 Related 96
05897 Related 96
05897 Related 96
05897 Related 96
05897 Related 96
Related Injection Procedures Not Allowed On Same Date Of
05898 Service 96
05898 Service 96
05898 Service 96
05898 Service 96
05898 Service 96
05898 Service 96
05899 Radiosurgery Add-On Code Must Be Billed With Primary 97
05899 Radiosurgery Add-On Code Must Be Billed With Primary 97
Spinal Stereotactic Radiosurgery Add-On Code Must Be Billed

05900 With Primary Procedure. 97
Spinal Stereotactic Radiosurgery Add-On Code Must Be Billed

05900 With Primary Procedure. 97
Service Denied. Pdn Iou Medical Supplies Limited To One Unit

05901 Per Month 119

05901 Per Month 119

05901 Per Month 119

05901 Per Month 119
Service Denied. Pdn Iou Medical Supplies Limited To Two

05902 Units Per Month 119



Service Denied. Pdn Iou Medical Supplies Limited To Three



Service Denied. Pdn Iou Medical Supplies Limited To Four




Service Denied. Pdn Iou Medical Supplies Limited To Six Units

05905 Per Month 119

05905 Per Month 119

05905 Per Month 119

05905 Per Month 119
Service Denied. Pdn Iou Medical Supplies Limited To 10 Units

05906 Per Month 119

05906 Per Month 119

05906 Per Month 119

05906 Per Month 119
05907 Per Month 119

05907 Per Month 119

05907 Per Month 119

05907 Per Month 119

05908 Per Month 119

05908 Per Month 119

05908 Per Month 119

05908 Per Month 119

05909 Per Month 119

05909 Per Month 119

05909 Per Month 119

05909 Per Month 119

05910 Per Month 119

05910 Per Month 119

05910 Per Month 119

05910 Per Month 119
05911 Per Month 119

05911 Per Month 119

05911 Per Month 119

05911 Per Month 119

05912 Per Month 119

05912 Per Month 119

05912 Per Month 119

05912 Per Month 119

05913 Per Month 119

05913 Per Month 119

05913 Per Month 119

05913 Per Month 119

05914 Per Month 119

05914 Per Month 119

05914 Per Month 119

05914 Per Month 119
05915 Per Month 119

05915 Per Month 119

05915 Per Month 119

05915 Per Month 119

05916 Per Month 119

05916 Per Month 119

05916 Per Month 119

05916 Per Month 119

05917 Per Month 119

05917 Per Month 119

05917 Per Month 119

05917 Per Month 119

05918 Per Month 119

05918 Per Month 119

05918 Per Month 119

05918 Per Month 119
Service Denied. Exceeds Maximum Limitation For Pdn Iou
05919 Medical Supplies 119



Service Denied. Pdn Iou Medical Supplies Limited To 200




Pdn Iou Medical Supplies Limited To One Unit Per Month.



Pdn Iou Medical Supplies Limited To Two Units Per Month.



Pdn Iou Medical Supplies Limited To Three Units Per Month.


Pdn Iou Medical Supplies Limited To Four Units Per Month.



Pdn Iou Medical Supplies Limited To Six Per Month. Units



Pdn Iou Medical Supplies Limited To 10 Units Per Month. Units





































Exceeds Maximum Limitation For Pdn Iou Medical Supplies.



Pdn Iou Medical Supplies Limited To 200 Units Per Month.



05941 Per Six Months. 119


Service Denied. Unlisted Home Visit Service Limited To Four

05942 Per 85 Days 119
05942 Per 85 Days 119

05942 Per 85 Days 119

05942 Per 85 Days 119
Pdn Iou Medical Supplies Limited To One Unit Per Six Months.

05944 Units Per Six Months 119






Pdn Iou Medical Supplies Limited To Three Units Per Six

05946 Months. Units Cutback To Allowed Amount 119





Unlisted Home Visit Service Limited To Four Per 85 Days.


Injection Allowed 4 Units Per Day, Same Or Different
05951 Provider. Cutback Units To Allowed Amount 119
Injection Allowed 4 Units Per Day, Same Or Different
05951 Provider. Cutback Units To Allowed Amount 119
Service Denied. Injection Allowed 4 Units Per Day, Same Or
05952 Different Provider 96
Service Denied. Injection Allowed 4 Units Per Day, Same Or
Private Duty Nursing Services, Any Combination, May Not
05953 Exceed 96 Units Per Day 119
05955 Detail Priced According To Multiple Surgery Guidelines 59
05955 Detail Priced According To Multiple Surgery Guidelines 59

05957 Month 119
Units Cutback To The Maximum Units Allowed Per Calendar

05959 Month 119
05961 Exceeds Units Allowed Per Calendar Week 119

Mental Health/Substance Abuse Service Not Allowed On Same
05962 Day As Related Service(S) 96
Exceeds Units Allowed Per Calendar Week Without Prior
05963 Approval 119

05963 Approval 119
05963 Approval 119

05963 Approval 119
05964 Exceeds Unit Limitation Per Calendar Year 119
05965 Exceeds Unit Limitation Per Calendar Week 119
05966 Exceeds The Maximum Units Allowed Per Day 119
05967 Exceeds The Maximum Units Allowed Per Calendar Month 119
05968 Units Cutback To The Maximum Units Allowed Per Day 119
Service Denied. Orthotic Or Prosthetic Equipment Allowed

05969 Once Every 18 Months For Ages 000 - 005 119
05969 Once Every 18 Months For Ages 000 - 005 119

05970 Once Per Three Years For Ages 006 - 115 119

05970 Once Per Three Years For Ages 006 - 115 119
Service Denied. Orthotic Or Prosthetic Equipment Allowed Six

05971 Per Year For Ages 000-002 119
Service Denied. Orthotic Or Prosthetic Equipment Allowed Six

05971 Per Year For Ages 000-002 119

05972 Once Per Two Years For Ages 003-115 119

05972 Once Per Two Years For Ages 003-115 119
05976 Service Denied. Injection Allowed 2 Units Per Day 119

Units Cutback To Allowed Amount. Injection Allowed 2 Units
05986 Per Day 119
05987 Per Day 119
05988 Per Day 119
05990 Drug Limited To Six Month Supply Per 12 Months 16
05991 Drug Limited To 102 Days Per 12 Months 16

05992 Sedative Hypnotics Only Allowed 15 Per Calender Month 16
05993 Drug Limited To 12 Per Month 16
05994 Drug Limited To 1 Canister Per 60 Days 16
05995 Drug Limited To 50 Grams Per 60 Days 16
06002 Cardiac Rehab Services Are Limited To 1 Per Day 119
Service Denied. Cardiac Rehab Services Have Exceeded The

06003 36 Unit Within 90 Day Limit 119



06004 Unit Cutback. Exceeds The Allowable Units Per Day Limitation 119

06005 Month 119
06005 Month 119
06006 Exceeds Calendar Month Limitation 119
06009 Service Exceeds The 16 Units Per Date Of Service Limitation 119
Service Units Cutback To The Allowable 16 Unit Limitation Per


06012 Anesthesia Not Allowed On The Same Day B15
Cochlear Device Implantation Requires Prior Approval For

06015 Second Procedure 197
Cochlear Device Implantation Requires Prior Approval For

06015 Second Procedure 197

06035 Exceeds 6 Units Per 270 Days Limitation 119
06035 Exceeds 6 Units Per 270 Days Limitation 119

Drug Limited To 11,300 Units Per Treatment Day, Units
06057 Cutback To Maximum Allowed 96
Drug Limited To 132,000 Units Per Calendar Month, Units
06058 Cutback To Maximum Allowed 96
Procedure Allowed Once Per Day Unless Billed With

Procedure Allowed Once Per Day Unless Billed With
This Repeat Procedure Modifier Combination Allowed Once
06075 Per Day 119
This Repeat Procedure Modifier Combination Allowed Once
06075 Per Day 119

06083 Allowed Every 2 Years 119
Transition Service Dollar Limitation Per Lifetime Of The

06088 Capda Waiver Has Been Exceeded 119
Participant Goods And Services Maximum Dollar Limitation

06089 Has Been Met By The Same Or Different Provider 119
06090 Procedure Billed Exceeds Maximum Units Allowed Per Day 119
06091 Units Cutback. Exceeds Maximum Units Allowed Per Day
Procedure Billed Exceeds Maximum Units Allowed Per


06093 Month 119
06093 Month 119

06093 Month
06096 Exceeds Maximum Units Allowed Per 90 Days 119
Service Recouped. Related Procedure Not Allowed Same
06107 Calendar Week As Tcm/Dd Rendered By Another Provider 96
The Maximum Dollar Limitation Per The 5 Year Waiver Period

Of This Cap Service Has Been Exceeded By The Same Or

Units Cutback. Exceeds The Allowable 6 Units Per 270 Days

Units Cutback. Exceeds The Allowable 6 Units Per 270 Days
Units Cutback To Allowed Amount. Vaccine Limited To One
06171 Per Day 96
06301 Premium Payment Amount Error. Claim Pended For Review 133
06337 Procedure Code Missing Or Invalid 16

06337 Procedure Code Missing Or Invalid 16
06339 Revenue Code Is Invalid For This Type Bill 16
06339 Revenue Code Is Invalid For This Type Bill 16

06666 Dummy Edit To Populate Text Table
Services Denied Because They Are Covered By The Behavorial

06702 Health Lme Mco 24
Services Denied Because They Are Covered By The Behavorial
06702 Health Lme Mco 24
Encounter: Patient Not Covered Under Plan During Date(S) Of

06996 Service 96
07000 Units Cutback. Only One Unit Allowed Per Day 119
07000 Units Cutback. Only One Unit Allowed Per Day 119
Units Cutback. Maximum Number Of Units Per Day(S)

07002 Exceeded 119
07002 Exceeded 119
07002 Exceeded 119

07002 Exceeded 119

07002 Exceeded 119

07002 Exceeded 119
07003 Exceeds Maximum Units Allowed Per Day(S) 119

Units Cutback. Maximum Number Of Units Per Week(S)

07004 Exceeded 119
07004 Exceeded 119

07004 Exceeded 119

07004 Exceeded 119
07005 Exceeds Maximum Units Allowed Per Week 119
Units Cutback. Maximum Number Of Units Per Month(S)

07006 Exceeded 119
07006 Exceeded 119

07006 Exceeded 119

07006 Exceeded 119
07007 Exceeds Maximum Units Allowed Per Month(S) 119

07009 Exceeds Maximum Units Allowed Per Year 119
07011 Exceeds Maximum Units Allowed Per Lifetime 149
07013 Exceeds Maximum Units Allowed Per Fiscal Year 119
07015 Exceeds Maximum Units Allowed Per Calendar Year 119
07023 Taxonomy Invalid For Claim Provider Form 8
07023 Taxonomy Invalid For Claim Provider Form 8
07024 Exceeds Established Eye Exam Limit Of Two Times Per Year 119
The Rendering Provider Is Not Affiliated With Your Provider
Group. Contact The Rendering Provider And Ask Them To
Complete A Managed Change Request Adding Your Provider
Group Npi On The Affiliated Provider Page Within The Next
07025 Four Weeks To Prevent Claims Being Denied 96
07026 Service Covered By Hmo Provider 24
07026 Service Covered By Hmo Provider 24

Exceeds Limit Of One Routine Eye Exam And/Or Refraction
Per Year For Recipients Under Age 21. Additional Routine Eye
Exam Services Require Prior Approval Before Service Is
07050 Rendered 119
07057 Drug Limited To 11,300 Units Per Treatment Day 96
07058 Drug Limited To 132,000 Units Per Calendar Month 96
07059 Dme Allowed 6 Units Per Calendar Month 119
07062 Dispense Brand Name Drug. Generic Drug Is Non-Preferred 16
07062 Dispense Brand Name Drug. Generic Drug Is Non-Preferred 16

Claim Denied. Case Management Units Billed Exceeds Annual
07074 Allowable Limit 119
Service Denied. Unit Limitation For Defibrillator Has Been
07075 Exceeded For The Allowed 91 Day Period 119
The Maximum Dollar Amount Allowed For This Service Per

Waiver Year By The Same Or Different Provider Has Been
07082 Exceeded 45
Dilation Included In Related Laparoscopy Procedure

07100 Performed The Same Day 97
Dilation Included In Related Laparoscopy Procedure

07100 Performed The Same Day 97
Service Recouped. Dilation Included In Related Laparoscopy

07101 Procedure Performed The Same Day 97
Service Recouped. Dilation Included In Related Laparoscopy

07101 Procedure Performed The Same Day 97
Pricing Rate Record Required For Payer And Attending
07102 Provider 16
Add-On Procedure For Cystometrogram Must Be Billed With A

07103 Paid Primary Procedure For Reimbursement B15
Add-On Procedure For Cystometrogram Must Be Billed With A
07103 Paid Primary Procedure For Reimbursement B15
07104 Exceeds Maximum Units Allowed Per Day 96
07105 Exceeds Maximum Units Allowed Per Month 96

Strapping Below The Knee Or Compression Already Paid For
This Date Of Service. File Adjustment With Supporting
07107 Documentation For Reconsideration If Neccessary 97
Strapping Below The Knee Or Compression Already Paid For
This Date Of Service. File Adjustment With Supporting
07107 Documentation For Reconsideration If Neccessary 97
By The Food And Drug Administration (Fda) For Atypical
07110 Antipsychotics. B5
By The Food And Drug Administration (Fda) For Atypical
07110 Antipsychotics. 188
By The Food And Drug Administration (Fda) For
07125 Antidepressants. B5
By The Food And Drug Administration (Fda) For
07125 Antidepressants. 188
By The Food And Drug Administration (Fda) For Add/Adhd
07140 Medications. B5
By The Food And Drug Administration (Fda) For Add/Adhd
07140 Medications. 188
Tissue Transfer, Specified Site Not Allowed When Tissue
Transfer "Any Area" Billed Same Date Of Service. File
07151 Adjustment Supporting Different Areas 96
Related Cardiovascular Surgery Already Paid For This Date Of
07153 Service B13
07157 Related Angiography Service Previously Paid For This Date B13
Service Recouped. Ultrasound Guidance Is Included In The
Related Surgical Procedure Performed On The Same Date Of
07160 Service 97
Service Recouped. Ultrasound Guidance Is Included In The
07160 Service 97
Service Denied. Ultrasound Guidance Is Included In The
07161 Service 97
Service Denied. Ultrasound Guidance Is Included In The
07161 Service 97
Vestibular Function Test With Recording Already Paid For This
Add-On Code Not Allowed, Primary Procedure Must Be Paid In
History For Same Date Of Service By The Same Rendering
07300 Provider 97
Ophthalmic Diagnostic Imaging Denied, Not Allowed On The
Same Day As Related Ophthalmic Diagnostic Imaging
07306 Performed By The Same Or Different Provider 96
Add On Code Not Allowed, Primary Procedure Must Be Paid In
History For Same Date Of Service, By The Same Rendering
07308 Provider 97
Related Endovascular Codes Not Allowed Same Date Of

07309 Service, Same Rendering Provider 97
Only One Revascularization Procedure Allowed Per Day.

07310 Related Procedure Already Paid For This Date Of Service 97
Exceeds Maximum Units Allowed Per Day, By Same Rendering

07311 Provider 119
Arthroscopy Surgery Codes Not Allowed Same Date Of Service

07312 As Arthroscopy Diagnostic Codes, Same Billing Provider 96
Arthroscopic Diagnostic Codes Not Allowed Same Date Of

07313 Service As Arthroscopic Surgical Codes, Same Billing Provider 96
Add On Code Not Allowed, Primary Procedure Must Be Paid In
History For Same Date Of Service By The Same Rendering
07325 Provider 97
Surgical Procedure Denied. Related Surgical Procedures Not
07326 Allowed On The Same Day 96
07328 Related Procedures Not Allowed On The Same Day. 96
Procedure Recouped, Related Procedures Not Allowed On The
07329 Same Day 96
Surgical Procedure Denied. Related Surgical Procedures Not
07330 Allowed On The Same Day 96
Surgical Procedure Recouped. Related Surgical Procedures
07333 Not Allowed On The Same Day 96
Procedure Denied. Related Procedures Not Allowed On The
07336 Same Day 96
Procedure Recouped. Related Procedures Not Allowed On The
07337 Same Day, By The Same Rendering Provider 96
Procedure Denied. Related Procedures Not Allowed On The
07338 Same Day 96
Procedure Recouped. Related Procedures Not Allowed On The
07339 Same Day 96
Catheterization Procedure Not Allowed Same Date Of Service
07341 As Related Catheterization Procedure 96
Injection Procedure Not Allowed Same Date Of Service As
07344 Catheterization Procedure 96
Left Catheterization Procedure Must Be Billed With Related
07345 Primary Catheterization Procedure 107
Pharmacological Agent Administration Must Be Billed With
Physiological Exercise Study Must Be Billed With
Injection Procedure Must Be Billed With Catheterization
07348 Procedure 107
07349 Dilution Studies Must Be Billed With Catheterization Procedure 107

Catheterization Procedure Recouped When Related
07351 Catheterization Procedure Paid On Same Date Of Service 96
Injection Procedure Recouped. Catheterization Procedure
07354 Already Paid On Same Date Of Service 96
Service Denied. Exceeds Maximum Units Allowed Per Calendar

07356 Month 119
07357 Units Cutback To The Maximum Units Allowed Per Day 119
07358 Units Cutback To The Maximum Units Allowed Per Month 119
Combination Abdomen/Pelvis Ct Not Allowed Same Day As
07360 Standalone Abdomen/Pelvis Ct 96
Standalone Abdomen/Pelvis Ct Not Allowed Same Day As
07361 Combination Abdomen/Pelvis Ct 96
07362 Related Heart Ct Procedures Not Allowed Same Day 97

Complete Ultrasound Of Extremeties Not Allowed Same Day
07363 As Limited Ultrasound Of Extremeties 96
Additional Immunization Administration Requires Primary

07364 Administration To Be Paid First, Same Rendering Provider B15
Health Check Immunization Administrations Limited To 14
07366 Immunization Administrations Limited To 9 Units Per Day 119

E/M Service Denied. Another E/M Procedure Previously Paid
07367 For This Date Of Service, Same Rendering Provider 96
Ophthalmoscopy Not Allowed Same Day As E/M Of The Eye,
07369 Same Rendering Provider 96
Ophthalmoscopy Recouped. Procedure Not Allowed Same Day
07370 As E/M Of The Eye, Same Rendering Provider 96
Add-On Code Not Allowed, Primary Procedure Code Must Be
Paid In History For The Same Date Of Service, By The Same
Manipulation Not Allowed Without Injection Paid In History,

07401 Same Billing Provider B15
Related Strapping Of Lower Extremity Not Allowed Same Day,

07402 Same Billing Provider 96
Manual Therapy Not Allowed Same Day As Application Of

07403 Compression System, Same Billing Provider 96
Related Application Of Compression System And Therapy Not

07404 Allowed Same Day, Same Billing Provider 96
Thoracotomy Not Allowed Same Day As Removal Of Lung,
07405 Same Or Different Provider 96
07406 Removal Of Lung Not Allowed Same Day As Thoracotomy 96
07407 Thoracotomy Limited To Once Per Day 119
07407 Thoracotomy Limited To Once Per Day 119
07408 Thoracoscopy Not Allowed Same Day As Lung Removal 96
07409 Lung Removal Not Allowed Same Day As Thoracoscopy 96

Thoracoscopy Not Allowed Same Day As Lung Volume
07410 Reduction, Same Rendering/Billing Provider 96
Thoracoscopy Not Allowed Same Day As Lung Volume

07410 Reduction, Same Rendering/Billing Provider 96
Lung Volume Reduction Not Allowed Same Day As
07411 Thoracoscopy, Same Rendering/Billing Provider 96
Lung Volume Reduction Not Allowed Same Day As

07411 Thoracoscopy, Same Rendering/Billing Provider 96
Resection Of Thymus Not Allowed Same Day As Thymectomy,
07412 Same Rendering/Billing Provider 96
Resection Of Thymus Not Allowed Same Day As Thymectomy,

07412 Same Rendering/Billing Provider 96
Open Thymectomy Not Allowed Same Day As Resection Of
07413 Thymus, Same Rendering/Billing Provider 96
Open Thymectomy Not Allowed Same Day As Resection Of

07413 Thymus, Same Rendering/Billing Provider 96
Related Lymphadenectomy Not Allowed Same Day, Same
07414 Rendering/Billing Provider 96
Related Lymphadenectomy Not Allowed Same Day, Same
07414 Rendering/Billing Provider 96
Service Recouped. Related Lymphadenectomies Not Allowed
07415 Same Day, Same Rendering/Billing Provider 96
Service Recouped. Related Lymphadenectomies Not Allowed

07415 Same Day, Same Rendering/Billing Provider 96
Insertion And Removal Of Pacemaker Not Allowed Same Day,
Insertion And Removal Of Pacemaker Not Allowed Same Day,

Removal Of Pacemaker Not Allowed Same Day As Upgrade Of
07417 Pacemaker, Same Billing Provider 96
Removal Of Pacemaker Not Allowed Same Day As Upgrade Of

Upgrade Of Pacemaker Not Allowed Same Day As Removal Of
Upgrade Of Pacemaker Not Allowed Same Day As Removal Of

Insertion Of Pulse Generator Not Allowed Same Day As
07419 Removal Of Pulse Generator, Same Billing Provider 96
Insertion Of Pulse Generator Not Allowed Same Day As

07419 Removal Of Pulse Generator, Same Billing Provider 96
Removal Of Pulse Generator Not Allowed Same Day As
07420 Insertion Of Pulse Generator, Same Billing Provider 96
Removal Of Pulse Generator Not Allowed Same Day As

07420 Insertion Of Pulse Generator, Same Billing Provider 96
07421 Catheter Placement Of Kidneys Limited To Once Per Day 119
07421 Catheter Placement Of Kidneys Limited To Once Per Day 119

Repositioning Of Filter Not Allowed Same Day As Insertion Of
07422 Intravascular Vena Cava Filter, Same Billing Provider 96
Repositioning Of Filter Not Allowed Same Day As Insertion Of
07422 Intravascular Vena Cava Filter, Same Billing Provider 96
Service Recouped. Repositioning Of Filter Not Allowed Same
Day As Insertion Of Intravascular Vena Cava Filter, Same
07423 Billing Provider 96
Service Recouped. Repositioning Of Filter Not Allowed Same

Day As Insertion Of Intravascular Vena Cava Filter, Same
07423 Billing Provider 96
Removal Of Intravascular Vena Cava Filter Not Allowed Same
07424 Day As Removal Of Transcatheter Filter 96
Removal Of Intravascular Vena Cava Filter Not Allowed Same

07424 Day As Removal Of Transcatheter Filter 96
Removal Of Transcatheter Filter Not Allowed Same Day As
07425 Removal Of Intravascular Vena Cava Filter 96
Removal Of Transcatheter Filter Not Allowed Same Day As

07425 Removal Of Intravascular Vena Cava Filter 96
Application Of Skin Substitute Not Allowed Same Date Of

07451 Service As Related Procedure, Same Billing Provider 96
Removal Of Devitalized Tissue Not Same Day As Application

07452 Of Skin Substitute, Same Billing Provider 96
Removal Of Devitalized Tissue Not Same Day As Application

07452 Of Skin Substitute, Same Billing Provider 96
07455 Billing/Rendering Providers 97
07455 Billing/Rendering Providers 97
Removal Of Devitalized Tissue Recouped, Not Allowed Same

07456 Day As Skin Substitute, Same Billing Provider 96
07457 Service As Related Procedure, Same Rendering Provider 96

07457 Service As Related Procedure, Same Rendering Provider 96
Application Of Skin Substitute Procedure Recouped, Only One

07458 Of This Series Allowed Per Day, Same Rendering Provider 97
Surgical Procedure Not Allowed On Same Date Of Service As
07476 Related Radiological Procedure 96



Radiology Procedure Not Allowed On Same Date Of Service As
07477 Related Surgical Procedure 96



Related Abdominal Paracentesis Procedures Not Allowed On


Implantation Procedure Not Allowed On Same Date Of Service
07479 As Related Medical Maintenance Procedure 96



Medical Maintenance Procedure Not Allowed On Same Date
07480 Of Service As Related Implantation Procedure 96



Related Implantation Procedures Not Allowed On Same Date
07481 Of Service 96

07481 Of Service 96

07481 Of Service 96

07481 Of Service 96
Related Tomography And Fluoroscopic Procedures Not
07482 Allowed On Same Date Of Service 96


Related Hepatobiliary Procedures Not Allowed On Same Date
07483 Of Service 96

07483 Of Service 96

07483 Of Service 96

07483 Of Service 96
Only One Pulmonary Imaging Procedure Allowed Per Date Of
07484 Service 119
Only One Pulmonary Imaging Procedure Allowed Per Date Of
07484 Service 119
Pulmonary Imaging Not Allowed Same Day As Related
07485 Myocardial Imaging 96



Myocardial Imaging Not Allowed Same Day As Related
07486 Pulmonary Imaging 96


Related Contact Lens Fitting Procedures Not Allowed Same
07487 Date Of Service By The Same Billing Provider 96



Related Pulmonary Services Not Allowed Same Date Of
07488 Service 96

07488 Service 96

07488 Service 96

07488 Service 96
Related Electromyography Procedures Not Allowed Same Date
07490 Of Service 96

07490 Of Service 96

07490 Of Service 96

07490 Of Service 96
Electromyography Procedures Limited To 4 Per Date Of
07491 Service By The Same Rendering Provider 119
Electromyography Procedures Limited To 4 Per Date Of
07491 Service By The Same Rendering Provider 119
Related Nerve Conduction Studies Limited To 1 Unit Per Date
Related Nerve Conduction Studies Limited To 1 Unit Per Date
Procedure Not Allowed When Performed On Same Date Of
Service As Arthordesis By The Same Or Different Provider
07493 96

07493 96
07493 96

07493 96
Arthrodesis Performed On The Same Date Of Service Includes

The Previously Paid Procedure, By Same Or Different
07494 Provider Previously Paid Proceudre Recouped 96
Arthrodesis Performed On The Same Date Of Service Includes

The Previously Paid Procedure, By Same Or Different
07494 Provider Previously Paid Proceudre Recouped 96
Shoulder Procedure Not Allowed Same Day As Revision Of

Shoulder By Same Attending Provider. If Services Performed
07495 Bilaterally, Submit An Adjustment With Operative Notes 96



Revision Of Shoulder Does Not Allow For Related Shoulder
Procedure Same Day, Same Attending Provider. Related
07496 Procedure Recouped 96
Revision Of Shoulder Does Not Allow For Related Shoulder
Revision Of Shoulder Procedure Already Paid For This Date Of

Service, By Same Or Different Provider. If Procedure Were
07497 Performed Bilaterally, Submit With Appropriate Modifier 96
Revision Of Shoulder Procedure Already Paid For This Date Of

Service, By Same Or Different Provider. If Procedure Were
07497 Performed Bilaterally, Submit With Appropriate Modifier 96
Elbow Procedure Not Allowed Same Day As Revision Of Elbow
By Same Attending Provider. If Services Performed
Bilaterally, Submit As An Adjustment With Operative Notes
07498 96
07498 96
07498 96
07498 96
Revision Of Elbow Does Not Allow For Related Elbow
Revision Of Elbow Does Not Allow For Related Elbow
Revision Of Elbow Procedure Already Paid For This Date Of
Service, By The Same Or Different Provider. If Procedure
Were Performed Bilaterally, Submit With Appropriate Modifier
07500 96
Revision Of Elbow Procedure Already Paid For This Date Of
Service, By The Same Or Different Provider. If Procedure
Were Performed Bilaterally, Submit With Appropriate Modifier
07500 96
Thoracentesis Or Pleural Drainage Procedure On Same Date
Of Service As Related Procedure Not Allowed By Same Or
07501 Different Provider. Related Procedure Recouped 96
Thoracentesis Or Pleural Drainage Procedure On Same Date
Of Service As Related Procedure Not Allowed By Same Or
07501 Different Provider. Related Procedure Recouped 96
Treatment Planning Not Allowed On Same Date Of Service As
Radiation Therapy Procedure By Same Or Different Provider
07502 96

07502 96
07502 96

07502 96
Radiation Therapy Performed On Same Date Of Service As
Treatment Planning By Same Or Different Provider Not
07503 Allowed Treatment Planning Procedure Recouped 96
Radiation Therapy Performed On Same Date Of Service As
Treatment Planning By Same Or Different Provider Not
07503 Allowed Treatment Planning Procedure Recouped 96
Catheterization Is Included In Tavr/Tavi Procedure Performed

07504 Same Date Of Service By Same Or Different Provider 96
Catheterization Is Included In Tavr/Tavi Procedure Performed

07504 Same Date Of Service By Same Or Different Provider 96

07505 Paid In History For The Same Date Of Service 97
Tavr/Tavi Included In Catheterization Procedure Performed

07506 On Same Date Of Service, Same Or Different Provider 97
Tavr/Tavi Included In Catheterization Procedure Performed

07506 On Same Date Of Service, Same Or Different Provider 97
Repositioning Of Device Is Included In The Insertion Surgery
Performed On The Same Date Of Service By Same Or
Repositioning Of Device Is Included In The Insertion Surgery
Performed On The Same Date Of Service By Same Or
Insertion Procedure On Same Day As Repositioning Of Device
By Same Or Different Provider Not Allowed. Repositioning
Insertion Procedure On Same Day As Repositioning Of Device
By Same Or Different Provider Not Allowed. Repositioning
Only One Transcatheter Therapy Allowed Per Day, Same Or
Transplantation Of Donor Marrow Not Allowed Same Date Of
Service As Related Procedure, Same Or Different Provider
07510 96

07510 96
07510 96

07510 96
Non-Selective Catheter Placement Included In Selective
Catheter Placement, Same Date Of Service, Same Attending
Non-Selective Catheter Placement Included In Selective
Catheter Placement, Same Date Of Service, Same Attending
Exceeds Maximum Units Allowed Per Day, Same Attending

Selective Catheter Placement Performed On Same Day As
Non- Selective Placement By Same Attending Provider Not
07513 Allowed. Non-Selective Procedure Recouped 96
Selective Catheter Placement Performed On Same Day As
Non- Selective Placement By Same Attending Provider Not
07513 Allowed. Non-Selective Procedure Recouped 96
Thoracentesis/Pleural Drainage Procedure Performed Same

Day As Related Radiological Procedure By Same Or Different
07514 Provider Not Allowed. Radiological Procedure Recouped 96
Thoracentesis/Pleural Drainage Procedure Performed Same

Day As Related Radiological Procedure By Same Or Different
07514 Provider Not Allowed. Radiological Procedure Recouped 96
Tavr/Tavi Service Does Not Indicate Service Was Performed

07520 By Two Surgeons As Required 96
Related Behavioral Health Codes Not Allowed Same Dos,
07596 Same Attending 96


Related Behavioral Health Codes Exceed Daily Limitation

07597 96
Behavioral Health Not Allowed Same Day As E/M, Same
07598 Attending Provider 96



E/M Not Allowed Same Day As Behavioral Health, Same



Prolonged Service Not Allowed Same Day As Psychotherapy,
07601 Same Attending Provider 96


Psychotherapy Not Allowed On The Same Day As Prolonged
Service By Same Or Different Provider. Prolonged Service
07602 Recouped 96
Psychotherapy Not Allowed On The Same Day As Prolonged
Service By Same Or Different Provider. Prolonged Service
07602 Recouped 96
Crisis Management Unit Limit Exceeded Per Calendar Year,

Crisis Management Not Allowed Same Day As Related

07604 Behavioral Health Procedure, Same Attending Provider 96



Behavioral Health Procedure Not Allowed Same Day As Crisis
07605 Management, Same Attending Provider 96



Additional Crisis Daily Unit Limit Exceeded, Same Attending

Comprehensive Code Includes Related Procedure, Same Or
07607 Different Provider. Component Procedure Recouped 97
07608 Or Different Provider 97
Allergy Testing Daily Unit Limit Exceeded, Same Or Different

Sleep Monitoring Daily Unit Limit Exceeded, Same Or

Nerve Conduction Study Limited By Cpt Description. Rebill

07611 Using Correct Code 96
Nerve Conduction Not Allowed Same Day As Nerve Studies,



07613 Nerve Studies Not Same Day As Nerve Conduction 96

Related Function Test Already Paid For This Date Of Service,
07614 Same Or Different Provider 96


Continuous Monitoring Of Multiple Patients Or Outside The
Operating Room Has Already Been Paid To This Provider For
07616 This Date Of Service 96


Billed In History For The Same Date Of Service, By The Same
Combination Of Billed Modifiers Is Invalid. Please Review And

07701 Resubmit With Correct Billing Combination 16
Medicaid Does Not Accept One Or More Of The Billed Modifier

Please Correct The Modifier Information And Resubmit. Refer
07702 To Your Modifier Manual For Assistance If Necessary. 16
Provider Taxonomy Is Not Allowed To Bill The Modifier

07704 Submitted. Correct And Resubmit Denied Detail If Necessary 16
Postoperative Dates Billed Are Not Within The Postop Period

07705 For The Billed Procedure. Please Correct And Resubmit 16
Invalid Date Information (Month, Day, Year) Included As The

07706 Postoperative From And To Dates. Please Correct & Resubmit. 16
Postoperative Dates Begin The Day Following Surgery. Please

07707 Correct Postoperative Dates And Resubmit. 16
Postoperative Dates Billed Are Not Within The Postop Period
07708 For The Billed Procedure. Please Correct And Resubmit. 16
Cardiovascular Therapeutic Services Are Not Allowed Unless

07709 Billed With The Appropriate Modifier. 4
Procedure Must Be Rendered By An Approved Anesthesia
07710 Provider In Order To Receive Reimbursement From Medicaid 185
07711 One Single Vessel Service Allowed Per Day 119
07711 One Single Vessel Service Allowed Per Day 119
07713 Billing Of Services With Modifier Lc Is Limited To One Per Day 119
07713 Billing Of Services With Modifier Lc Is Limited To One Per Day 119
07714 Billing Of Services With Modifier Ld Is Limited To One Per Day 119
07714 Billing Of Services With Modifier Ld Is Limited To One Per Day 119
07715 Billing Of Services With Modifier Rc Is Limited To One Per Day 119
07715 Billing Of Services With Modifier Rc Is Limited To One Per Day 119
Medicaid Only Allows For One Unit Of Other Diagnostic
Services To Be Paid Per Day. The Maximum Number Of Units
07716 Have Been Paid For This Date Of Service 119
Medicaid Only Allows For One Unit Of Other Diagnostic
Services To Be Paid Per Day. The Maximum Number Of Units
07716 Have Been Paid For This Date Of Service 119
This Procedure Code Requires A Modifier That Signifies The
Category Of Class Findings To Be Appended In Order For
Medicaid To Consider Payment. Review And Resubmit New
07717 Claim 96
This Procedure Code Requires A Modifier That Signifies The
Category Of Class Findings To Be Appended In Order For
Medicaid To Consider Payment. Review And Resubmit New
07717 Claim 96
Coronary Intervention Service Is Not Consistent With/Or Not

07718 Covered For This Diagnosis. 11
E&M Services Recouped. Evaluation And Management Service
Is Included In The Anesthesia Global Package Billed Same
07719 Day 97
Endoscopy Codes From Related Groups Billed With The Same
Date Of Service Must Be Submitted On A Single Claim. A Code
07720 From This Group Has Previously Been Paid For This Dos 16
Billing For Services Not Allowed Without Appropriate

07721 Ambulatory Surgery Center Modifier. 16
Overlapping Postoperative Dates Are Not Allowed During The

Follow-Up Period For A Single Procedure. Please Correct Billed
07723 Postop Dates B15
Diagnosis Does Not Support Billing Of Debridement Of Nails

07724 Per Medicaid Guidelines 11
Medicaid Requires Documentation For Procedures Appended
With Modifier 66 When Billing Over 3 Units Of
Service.Resubmit As An Adjustment With Records Indicating
07726 All Surgeons Involved For This Dos 16
Once In A Lifetime Procedure Has Been Previously Completed.
07727 Subsequent Billings Are Not Allowed 149
Evaluation And Management Service Is Included In The

07728 Anesthesia Global Package 97
Diagnosis Billed Does Not Meet Medicaid Guidelines For Paring

07729 And Cutting Of Lesions Or Trimming Of Nondystrophic Nails 11
07730 Only One Discontinued Surgical Procedure Is Allowed Per Day 119
Evaluation And Management Included In Global Package,

07733 Same Day 97
Evaluation And Management Included In Global Package,

07734 Same Day 97
07735 E/M Included In Global Surgical Package, Pre-Op 97
07736 E/M Included In Global Surgical Package Pre-Op 97
E/M And Major Surgical Procedure Not Allowed For The Same
E/M And Major Surgical Procedure Not Allowed For The Same
Decision For Surgery Has Already Been Paid For This Episode
07739 Of Care 97
07740 Service Is Included In Global Surgery Package 97
07741 Service Is Included In Global Surgery Package 97
E/M Service Is Included In Reimbursement For Ventilation

07742 Management On The Same Day 97
E/M Services Recouped. E/M Service Is Included In
Reimbursement For Ventilation Management On The Same
07743 Day 97
Unit(S) Cutback. Procedure Exceeds One Unit Per Day
Unit(S) Cutback. Procedure Exceeds One Unit Per Day
07748 Exceeds One Procedure Per Month Limitation 119

07748 Exceeds One Procedure Per Month Limitation 119
07749 Exceeds One Procedure Per 60 Day Limitation 119

Procedure Billed Exceeds One Procedure Per 225 Day
Procedure Billed Exceeds One Procedure Per 225 Day

07752 Exceeds Two Procedures Per Day Limitation 119
07753 Monitored Anesthesia Not Supported By Diagnosis 11
07755 Exceeds Three Procedures Per Day Limitation 119
07757 Exceeds Four Procedures Per Day Limitation 119

07758 Exceeds Five Procedures Per Day Limitation 119
07759 Exceeds Six Procedures Per Day Limitation 119
07760 Exceeds Eight Procedures Per Day Limitation 119
07761 Exceeds Nine Procedures Per Day Limitation 119
07762 Exceeds Ten Procedures Per Day Limitation 119


07769 Exceeds 3 Procedure Per Day Limitation 119

07773 Exceeds Seven Procedures Per Day Limitation 119
07776 Exceeds One Procedure Per Six Months Limitation 119
07777 Exceeds One Procedure Per 14 Days Limitation 119

Once In A Lifetime Procedure Has Been Previously Billed As
Unilateral. Subsequent Complete And Same Location Services
07781 Are Not Allowed 149
Once In A Lifetime Procedure Has Been Previously Billed As
Unilateral. Subsequent Complete And Same Location Services
07782 Are Not Allowed 149
This Surgical Procedure Previously Paid At Maximum Allowed
For Primary Surgeon. If Appropriate, Rebill As Assistant Or
07783 File As An Adjustment With Documentation Of Multi-Surgeons 97
This Surgical Procedure Previously Paid At Maximum Allowed

For Primary Surgeon. If Appropriate, Rebill As Assistant Or
07783 File As An Adjustment With Documentation Of Multi-Surgeons 97
This Procedure Code Has Been Billed As Primary Surgeon On

A Separate Claim. If Appropriate, Rebill As Assistant Or File As
07784 An Adjustment With Documentation Of Multi-Surgeons 97
This Procedure Code Has Been Billed As Primary Surgeon On

A Separate Claim. If Appropriate, Rebill As Assistant Or File As
07784 An Adjustment With Documentation Of Multi-Surgeons 97
07785 Service Has Previously Been Paid As Assistant Surgeon 97
Service Has Been Billed As A Co-Surgery Or A Team Surgery

Procedure. Medicaid Does Not Allow An Assistant Surgeon
07786 When The Procedure Is Performed By Team Or Co-Surgeons B15
Service Has Previously Been Paid As Team Or Co-Surgery.

Medicaid Does Not Allow An Assistant Surgeon When The
07787 Procedure Was Performed By A Team Or Co-Surgeons B15
Claim Has Same Procedure On Multiple Details With

Modifier(S) Appended, Indicating More Than One Surgeon.
07788 Medicaid Only Allows One Rendering Provider Per Claim 16
07789 This Surgery Has Previously Been Submitted As Team Surgery 97
07790 This Surgery Has Previously Been Submitted As A Co-Surgery 97
The Modifier Billed Indicates This Procedure Was Conducted

07791 As Co-Surgery Already Involving Two Surgeons 16
Duplicate Billing - Same Procedure/Provider/Date Of Service,
07792 Same Or Related Modifier(S) 97
Complete Procedure Has Been Previously Billed. Additional

07793 Services In The Global Period Are Not Allowed B15
Part Of The Global Package For This Service Has Previously

07794 Been Billed. Additional Complete Service Is Not Allowed B15
07796 Exceeds One Per Lifetime Limitation 149
07797 Exceeds Two Per Lifetime Limitation 149
07798 E/M Included In Global Surgical Package Pre-Op 97







Related Endoscopy Procedure Performed Same Day. Refer To
07808 Ma 1999 Bulletin For Listing Of Base And Related Codes 97










07818 Related Endoscopy Procedure Performed Same Day. 97




07822 Related Endoscopy Procedure Performed Same Day. 97



























Multiple Endoscopy Procedures Performed On The Same Day
Are Reimbursed According To Endoscopy Pricing Calculations
07860 Set Forth By Medicaid Guidelines 96
07860 Set Forth By Medicaid Guidelines 96

07861 Set Forth By Medicaid Guidelines B15









07871 Medicaid Guidelines B15













Base Procedure Billed Is Discontinued. Related Procedures Are

Not Allowed On The Same Date Of Service As The Base That
07890 Has Been Discontinued B15
Base Procedure Billed Is Discontinued. Related Procedures Are

Not Allowed On The Same Date Of Service As The Base That
07890 Has Been Discontinued B15
Related Procedures Are Not Allowed On The Same Date Of

07891 Service As The Base Procedure That Has Been Discontinued B15
Related Procedures Are Not Allowed On The Same Date Of

07891 Service As The Base Procedure That Has Been Discontinued B15
Service Or Procedure Is Included In The Anesthesia Global

07900 Package 97
07901 Procedure Or Service Included In Anesthesia Global Package 97

07905 Provider 97
07905 Provider 97
No Payment For Add-On (Zzz) Code Allowed If In Series Is

07906 Not Paid For The Same Date Of Service, Same Provider 97
No Payment For Add-On (Zzz) Code Allowed If In Series Is

07906 Not Paid For The Same Date Of Service, Same Provider 97
07907 Provider 97
07907 Provider 97
07908 Provider 97
07908 Provider 97
07910 Provider 97
07910 Provider 97
07911 Provider 97
07911 Provider 97
07912 Provider 97
07912 Provider 97
07913 Provider 97
07913 Provider 97
07914 Provider 97
07914 Provider 97
07915 Provider 97
07915 Provider 97
07916 Provider 97
07916 Provider 97
07919 Provider 97
07919 Provider 97
07920 Provider 97
07920 Provider 97
07921 Provider 97
07921 Provider 97
No Payment Allowed If Primary Procedure Is Not Paid For The

No Payment Allowed If Primary Procedure Is Not Paid For The

07923 Provider 97
07923 Provider 97
07924 Provider 97
07924 Provider 97
07925 Provider 97
07925 Provider 97
07926 Provider 97
07926 Provider 97
07927 Provider 97
07927 Provider 97
07928 Provider 97
07928 Provider 97
07929 Provider 97
07929 Provider 97
07930 Provider 97
07930 Provider 97
07931 Provider 97
07931 Provider 97
07932 Provider 97
07932 Provider 97
07933 Provider 97
07933 Provider 97
07934 Provider 97
07934 Provider 97
07935 Provider 97
07935 Provider 97
07936 Provider 97
07936 Provider 97
07937 Provider 97
07937 Provider 97
07938 Provider 97
07938 Provider 97
07939 Provider 97
07939 Provider 97
07940 Provider 97
07940 Provider 97
07941 Provider 97
07941 Provider 97
07942 Provider 97
07942 Provider 97
07943 Provider 97
07943 Provider 97
07945 Provider 97
07945 Provider 97
07946 Provider 97
07946 Provider 97
07947 Provider 97
07947 Provider 97
07948 Provider 97
07948 Provider 97
07949 Provider 97
07949 Provider 97
07950 Provider 97
07950 Provider 97
07952 Provider 97
07952 Provider 97
07953 Provider 97
07953 Provider 97
07954 Provider 97
07954 Provider 97
07955 Provider 97
07955 Provider 97
07956 Provider 97
07956 Provider 97
07957 Provider 97
07957 Provider 97
07958 Provider 97
07958 Provider 97
07959 Provider 97
07959 Provider 97
07960 Provider 97
07960 Provider 97
07961 Provider 97
07961 Provider 97
07963 Provider 97
07963 Provider 97
07964 Provider 97
07964 Provider 97
07965 Provider 97
07965 Provider 97
07966 Provider 97
07966 Provider 97
07967 Provider 97
07967 Provider 97
07968 Provider 97
07968 Provider 97
07969 Provider 97
07969 Provider 97
07970 Provider 97
07970 Provider 97
07971 Provider 97
07971 Provider 97
07972 Provider 97
07972 Provider 97
07973 Provider 97
07973 Provider 97
07975 Provider 97
07975 Provider 97
07976 Provider 97
07976 Provider 97
07977 Provider 97
07977 Provider 97
07978 Provider 97
07978 Provider 97
07979 Provider 97
07979 Provider 97
07980 Provider 97
07980 Provider 97
07981 Provider 97
07981 Provider 97
07982 Provider 97
07982 Provider 97
07983 Provider 97
07983 Provider 97
07984 Provider 97
07984 Provider 97
07985 Provider 97
07985 Provider 97
07986 Provider 97
07986 Provider 97
07987 Provider 97
07987 Provider 97
07988 Provider 97
07988 Provider 97
07989 Provider 97
07989 Provider 97
07990 Provider 97
07990 Provider 97
07991 Provider 97
07991 Provider 97
07992 Provider 97
07992 Provider 97
07993 Provider 97
07993 Provider 97
07994 Provider 97
07994 Provider 97

07996 For This Dos. Correct Detail By Appending -51 And Rebill 119



Evaluation And Management Service Not Allowed Within The

07998 Postoperative Period Of The Related Surgical Procedure 97
Surgical Procedure'S Postoperative Period Includes Follow-Up

07999 Evaluation And Management Service 97
Money Follows The Person (Mfp) Dollar Limitation Has Been

08009 Exceeded For This Service 45
Non-Telemedicine Service Not Allowed Same Day As A
08010 Related Telemedicine Service 96


Telemedicine Service Not Allowed Same Day As A Related
08011 Non- Telemedicine Service 96

Separate Evaluation And Management Procedure Not Allowed
08012 Same Day As A Telemedicine Service 96




Telemedicine Service Not Allowed Same Day As A Separate
08013 Evaluation And Management Procedure 96




Standby Service Not Allowed Same Day As A Telemedicine
08014 Procedure 96

08014 Procedure 96
08014 Procedure 96

08014 Procedure 96
Telemedicine Service Not Allowed Same Day As A Standby
08015 Service 96

08015 Service 96
08015 Service 96

08015 Service 96
08016 New Patient Eye Exam One Per 3 Year Limit Exceeded 119
08016 New Patient Eye Exam One Per 3 Year Limit Exceeded 119
Money Follows The Person (Mfp) - Assistive Technology Dollar

08019 Limitation Per Recipient Lifetime Has Been Exceeded 45
Procedure Is Only Covered For Money Follows The Person
08020 Recipient 16
Service Denied. Moderate Sedation And Anesthesia
08021 Procedures Not Allowed Same Date Of Service 96



Service Denied. Moderate Sedation Services Not Allowed On

08022 The Same Date Of Service As Anesthesia Related Procedures 97








Anesthesia Related Procedure Not Allowed On The Same Date

08023 Of Service As Moderate Sedation Services 97







Service Denied. Moderate Sedation Is Included In A Service
Already Paid To The Provider In History. Reference Cpt
08024 Appendix G. 97


Moderate Sedation Recouped To Allow Payment Of Service
Which Includes Sedation For Same Date Of Service. Reference
08025 Cpt Appendix G 97


Moderate Sedation Add-On Code Must Be Billed With A Paid
08026 Primary Procedure For Reimbursement. 107
Service Denied. Evaluation And Management Service And
Moderate Sedation Not Allowed Same Date Of Service.
08027 Provider Has Been Paid For Moderate Sedation This Date 96



Service Denied. Moderate Sedation Not Allowed Same Date Of
Service As Evaluation And Management Services. Moderate
08028 Sedation Already Paid To Provider For This Date 96


Claim Denied. Inpatient Place Of Service Being Billed And
08029 Recipient Is Not Enrolled In Money Follows The Person (Mfp) 96
Money Follows The Person(Mfp)/Programs Of All-Inclusive

Care For The Elderly (Pace) Dollar Limitation Has Been
08030 Exceeded For This Service 45
08031 Procedure Is Limited To 36 Per Year 119
08032 Unit Cutback. Procedure Limited To 36 Per Year 119
Dollar Limitation For Capmr Modification Procedures Billed Has

08033 Been Exceeded This Waiver Period 45
Mfp-Transition Year Stability Resource(Tysr) "Demonstration"
Service Provided Has Exceeded The Approved Maximum
08036 Dollar Limitation Per 365 Days 96
Service Provided Has Exceeded The Approved Maximum
08036 Dollar Limitation Per 365 Days 96
Service By Same Or Different Provider Has Been Cutback To
The Approved Maximum Dollar Limitation Allowed Per 365
08037 Days 96
Exceeds Maximum Allowed For A Permanent Posterior

08039 Composite On A Single Tooth 45
Reimbursement As The Four Surface Resin-Based Composite
08050 Restoration For A Permanent Posterior Tooth 45
Reimbursement As The Four Surface Resin-Based Composite
08050 Restoration For A Permanent Posterior Tooth 45
Service Denied. Procedure Billed Exceeds The Allowed Units
08051 Per Day 119
Service Denied. Procedure Billed Exceeds The Allowed Units
08054 Service Denied. Exceeds The Allowed Units Per Year 119
Reimbursement As The Four Or More Surfaces Amalgam
08060 Restoration 45
Reimbursement As The Four Or More Surfaces Amalgam
08060 Restoration 45
Exceeds Maximum Allowed For A Posterior Amalgam On A

08069 Single Tooth 45
Capmr Yearly Dollar Limtation Exceeded Procedure This

08073 Waiver Year 45
Billed Amount For This Capmr Procedure Exceeds The Dollar

Limitation Allowed For The Waiver Year. Payment Has Been
08074 Reduced/Cutback To The Allowed Limit 45
08080 The Allowable 8 Units Per Day Limitation Has Been Exceeded 119
08080 The Allowable 8 Units Per Day Limitation Has Been Exceeded 119
Service Denied. Exceeds Allowed Units Within 26 Days By The
Covered Days And Patient Status Are Inconsistent With Bill

08103 Type. Correct Your Bill Type Or Patient Status And Resubmit 16
Health Check Immunization Administration Procedures Limited
08104 To 10 Units Per Day 119
Allowed Days For Lower Level Of Care In Acute Facility Has
08105 Been Exceeded 119
Therapeutic Leave Not Reimbursable To This Provider Type

08107 When Billing Lower Level Of Care (Lloc) 185
Dollar Amount Cutback To The Allowable Maximum For Money

08109 Follows The Person Waiver Year 45

Follows The Person Assistive Technology Per Recipients
08110 Lifetime 45

Follows The Person Assistive Technology Per Recipients
08110 Lifetime 45

08111 Follows The Person Waiver Per Recipient'S Lifetime 45

08111 Follows The Person Waiver Per Recipient'S Lifetime 45
Allowed Units For This Dme Procedure Code With Modifier Sc
08112 Have Been Exceeded For This Recipient'S Age 119
Allowed Units For This Dme Procedure Code With Modifier Sc
08115 Have Been Exceeded 119
Service Not Allowed Greater Than 60 Days For Mfp/Pace

08131 Transitioning Recipient B1
08171 Vaccine Limited To One Per Day 96
Coordination Fees And Management Fees Are Reimbursed

08173 Through System Generated Claims Only 22
Coordination Fees And Management Fees Are Reimbursed

08173 Through System Generated Claims Only 22
Sick Visit Codes May Not Be Billed On The Same Claim Form
08174 With Health Check Screening Services 96
All Other Dates Of Service Must Be Billed On A Separate Claim
08175 Form From Health Check Screening Dates Of Service 16
Procedure Exceeds Limit Of One Unit Per 365 Days For The
Only One Unit Of The Related Imaging Procedures Is Allowed
Per 365 Days With Diagnosis Billed For The Same Or Different
Only Two Units Of The Related Imaging Procedures In Any
Combination Allowed Per 365 Days With This Diagnosis For
08204 The Same Or Different Provider 119
08301 Units Cutback To The Maximum Allowed Units Per Day 119
08301 Units Cutback To The Maximum Allowed Units Per Day 119
Units Cutback To The Maximum Allowed Units Per Calendar

08311 Month 119
Units Cutback To The Maximum Allowed Units Per Calendar
08311 Month 119
08328 Attending Provider Not Eligible On Service Date(S) B7

Hospice Patient. Contact Hospice Responsible For Patient'S
Care. Refile Claim Only For Date(S) Of Service Not Covered By
08400 Hospice Benefit 16
Care. Refile Claim Only For Date(S) Of Service Not Covered By
08400 Hospice Benefit 16
Care. Refile Claim With Medicare For Date(S) Of Service Not
08401 Covered By Hospice Benefit B9
Units Cutback To Maximum Units Allowed Per Calendar Month
08498 For This Dme Iou Code 119
Units Exceed Maximum Allowed Amount Per Calendar Month
08499 For This Dme Iou Code 119
Dmh Inpatient Stay Most Be Billed On The Institutional Claim
08510 Form (837I) For Admit Dates On Or After 07/01/2016 16
Dmh Inpatient Stay Most Be Billed On The Institutional Claim

08510 Form (837I) For Admit Dates On Or After 07/01/2016 16
Inpatient Stays Require An Accommodation Revenue Code
08511 With Accompanying Yp Code 16

08512 Dmh Inpatient Payment Made On First Accommodation Detail 16
08513 Dmh Invalid Claim Type 16
08513 Dmh Invalid Claim Type 16
08518 Dmh Filing Time Expired 29
08519 Rendering Provider Deceased 183
08521 Rendering Provider Suspended B7
08522 Rendering Provider Cancelled B7

08523 Rendering Provider On Review B7
08532 Billing Provider Ineligible B7

Service Facility Location Cannot Be An Rendering Provider
Identified As An Individual. Please Verify Your Facility
08533 Location And Resubmit Your Claim B7
Service Facility Location Is Not A Valid Iprs Rendering
Provider, Or The Npi Submitted Could Not Be Mapped To One
08534 Sfl. B7
08536 Invalid Rendering Provider 185
08536 Invalid Rendering Provider 8
08537 Invalid Provider Taxonomy 8
08537 Invalid Provider Taxonomy 8

Inpt-Hospital And/Or 3-Way Contract Yp820/Yp821 Claim
08557 Denied. Client Has Medicaid And Dmh Coverage 22
Lme Unauthorized To Refer This Alternative Service. Please

Submit The Lme Alternative Service Request Form To Dmh
08560 For Approval. 185
Dos Is Outside Approved Authorization Period For This
Alternative Service. Please Contact Dmh For Possible Re-
08561 Approval. 15
Service Exceeds The Allowable Of One Occurrence Within An
08564 Eligibility Period 198
Service Exceeds The Allowable Of Two Occurrences Per Pop
08565 Group Within A Fiscal Year 198
08566 Service Exceeds The Allowable Of Four Units Per Day 198
08580 Referring Provider Missing 16

08586 Single Stream Funding Claim 198
08587 County Funds Claim 96

Targeted Case Management For Mental/Substance And
08594 Community Support Not Allowed In The Same Calendar Week 96


Receipient Covered By Piedmont Benefit Plan Not Eligible For

08596 Dmh 24
Receipient Covered By Piedmont Benefit Plan Not Eligible For
08596 Dmh 24
08597 Units Cutback To Whole Number 16
08597 Units Cutback To Whole Number 16
08598 Assigned Benefit Plan Does Not Match The Payer Id Assigned 109
The Benefit Plan Is Not Matching Provider Or Recipient

08599 Eligibility Or The Service Covered B5
30 Residential Level Iv Treatment Received, Prior Approval Is

08620 Required For Additional Service 198
30 Residential Level Iv Treatment Received, Prior Approval Is
60 Residential Level Iii Treatment Received, Prior Approval Is

60 Residential Level Iii Treatment Received, Prior Approval Is
60 Residential Level Ii Treatment Received, Prior Approval Is

60 Residential Level Ii Treatment Received, Prior Approval Is
Claim Denied. Maximum Allowed Occurrences Processed And
08628 Paid For Asdwi 119
Claim Denied. Maximum Allowed 26 Occurrences Processed

08645 And Paid, Prior Approval Is Required For Additional Service 198
Claim Denied. Maximum Allowed 26 Occurrences Processed
08645 And Paid, Prior Approval Is Required For Additional Service 198
Claim Denied. Maximum Allowed Occurrences Processed And
08648 Paid For Csdwi 119
Claim Denied. Maximum Allowed 26 Occurrences Have
Processed And Paid, Prior Approval Is Required For Additional
08649 Service 198
Claim Denied. Maximum Allowed 26 Occurrences Have
Processed And Paid, Prior Approval Is Required For Additional
08649 Service 198
Related Enhance Benefit Services Not Allowed On The Same
08652 Date Of Service As H0040, H2022, H2033, Or H2015:Ht 35
Related Enhance Benefit Services Not Allowed On The Same
08652 Date Of Service As H0040, H2022, H2033, Or H2015:Ht 35
Claim Denied. Service Billed Over The Maximum Allowed
08653 Amount 35
Only 16 Units Allowed Per Day Without Prior Approval. Prior
Approval Is Needed Or Units Need To Be Correct And
Service Denied. Unit Limitation Has Been Exceeded For The

08663 Services Payable With Diagnosis Code 119
Service Denied. Unit Limitation Has Been Exceeded For The

08663 Services Payable With Diagnosis Code 119
Service Denied. Limitation Has Been Exceeded For The Fiscal
08664 Year 119
Service Denied. Maximum Allowed Has Been Exceeded For
08665 The Quarter 119
Per Legislative Mandate This Medicaid Claim Must Be Filed

08700 Electronically For Adjudication 16
Per Legislative Mandate This Medicaid Claim Must Be Filed

08700 Electronically For Adjudication 16
Override Limit Exceeded - Prescriber Call Nctracks 866-246-

08703 8505 A1
08705 Follow-Up Care Is Included In Radiation Management 97
Services Recouped. Radiation Management Paid In Follow- Up

08706 Care 97
08707 Iv/Irrigation Fluids Are Limited To 499.99Ml 197
Claim Submitted Indicates Medicare Payment. The Sum Of

Coinsurance And Deductible Amounts Must Be Placed In The
08827 Estimated Amount Due Field Locator 55. 148
Service Denied. Only One Unit Per Calender Week Allowed For
08907 Mental Health/Substance Abuse Targeted Case Management 119
Maximum Allowed Units Per Day Have Been Exceeded For
Behavioral Health Services By Same Or Different Provider
08908 119
Maximum Allowed Units Per Day Have Been Exceeded For
Behavioral Health Services By Same Or Different Provider
08908 119
Service Denied. Exceeds Maximum Allowed For Specialized
08911 Therapy Evaluations Per Calendar Year 119
08952 Recipient Age Invalid Or Needs Prior Approval 6
08953 Procedure Code H0040 Must Be Billed With One Unit 222
Claim Denied. Provider Was Not Endorsed/Licensed/Certified

08988 On Date Of Service. B7
First Ndc Invalid. Verify And Enter The Correct Ndc And
08990 Submit As A New Claim 16
First Ndc Invalid. Verify And Enter The Correct Ndc And
Tenth Ndc Invalid. Verify And Enter The Correct Ndc And
Tenth Ndc Invalid. Verify And Enter The Correct Ndc And
09000 Dme Armrests Limited To Two Per Date Of Service 119
Units Cutback. Maximum Number Of Units Has Been

09007 Exceeded Fo This Service 119


09011 Ndc Was Terminated For The Detail Date Of Service Billed 16
09039 Only One Nurse In-Home Visit Allowed Per Date Of Service 119
09039 Only One Nurse In-Home Visit Allowed Per Date Of Service 119
Revenue Code Requires Hcpcs: Q4055 For Dos 9/1/05-

12/31/05, J0886 For Dos 01/01/2006-3/31/2007 & Q4081 For
09040 Dos 04/01/2007 Forward. 16
12/31/05, J0886 For Dos 01/01/2006-3/31/2007 & Q4081 For
09040 Dos 04/01/2007 Forward. 16
12/31/05, J0886 For Dos 01/01/2006-3/31/2007 & Q4081 For
09040 Dos 04/01/2007 Forward. 16
Revenue Code Requires Value Code 68 In Addition To Value
Code 48 Or 49. Correct/Add Necessary Value Code(S) And
09042 Disenfranchised Resident Is Not Eligible For Ach/Pcs Coverage 15

Code Limited To Addition Of Antibiotics And Steroids Through
09053 Existing Iv Line 107
Technical Component Performed By The Facility. Rebill As
09054 Interpretation Only 96
Technical Component Performed By The Facility. Rebill As
09054 Interpretation Only 96
09061 Edit Limit Exceeded 16
09062 Claim Denied. Exceeds Maximum Units Allowed Per Day 119
09062 Claim Denied. Exceeds Maximum Units Allowed Per Day 119
Intraoral Periapical Film Not Allowed Same Date Of Service As

09070 Intraoral Complete Series, Same Provider B15
Intraoral Complete Series Not Allowed Same Date Of Service

09071 As Intraoral Periapical Film, Same Provider B15
Enhanced Service Not Allowed Same Day As Other Enhanced
09074 Mental Health Service 96
09075 Exceeds The Maximum 4 Units Allowed Per Calendar Month 119
09076 Exceeds The Maximum Unit(S) Per Date Of Service 119

Units Cutback To Allow The Maximum Of 4 Units Per Calendar

09077 Month 119
09077 Month 119

09077 Month 119
09077 Month 119
Enhanced Benefit Service Not Allowed Same Day As Other
09078 Enhanced Mental Health Service 96
Enhanced Benefit Service Not Allowed Same Date Of Service
09079 With Other Periodic Mental Health Service 96
Enhanced Benefit Service Not Allowed Same Day As Inpatient
09080 Service Paid To A Mental Health/Psychiatric Facility 96
Enhanced Service Not Allowed Same Day As Psych Resident
09083 Treatment Facility Service 96
Enhanced Service Not Allowed Same Date Of Service As
09084 Inpatient Hospital Service 96
Claim Submitted More Than Two Years After The Drug
09085 Obsolete Date. Claim Is Denied 16

Units Cutback To Allow The Maximum Of 480 Units Per

09086 Calendar Year 119



The Drug Class Of The Tenth Submitted Ndc Must Match The
09097 Drug Class Of The Submitted Hcpcs Drug Code 16
The Drug Class Of The Tenth Submitted Ndc Must Match The
09097 Drug Class Of The Submitted Hcpcs Drug Code 16
There Is Not A Valid Consent/Statement On File. Resubmit A
09105 Valid Consent/Statement 252
There Is Not A Valid Consent/Statement On File. Resubmit A
09105 Valid Consent/Statement 252
09108 Units Cutback To Allow The Maximum Of 1 Unit Per Day 119
Submit Meters With Bin #610415. For Assistance Call 1-877-

09111 906-8969 16
09112 Diabetic Supply Limit Exceeded 16
09115 Prescriber Must Complete Adverse Event Report 16
09117 Recipient Has Lock-In Record For Claim Dos 16
09117 Recipient Has Lock-In Record For Claim Dos 16

Claim Denied. Procedure Limited To One Occurrence Per 84
09133 Day Period 119


Claim Denied. Exceeds Maximum Units Allowed Per 90 Day


Procedure Code Covers Both Axillae, Only One Unit Can Be
09145 Approved 119
09145 Approved 119
09145 Approved 119
09145 Approved 119
Claim Denied. Evaluation And Management Procedure Not

09147 Allowed Same Date Of Service As Administration Procedure 97





Evaluation And Management Recouped. E&M Procedure And
09148 Administration Procedure Not Allowed Same Date Of Service 97



Procedure Must Be Billed With The Required Evaluation And

09149 Management Or Administration Procedure Code B15
Procedure Must Be Billed With The Required Evaluation And

09149 Management Or Administration Procedure Code B15
Administration Procedure Code Must Be Billed With Botulinum

09150 Toxin A B15
One Refraction Allowed Per Two Years For Recipients Age 21
09170 And Older 119
Only One Refraction Allowed Per Year For Recipients Under
09171 Age 21 119
Diagnosis Code Is Missing Or Invalid For Lab Code. Refile

09180 With The Correct Diagnosis Code 11
Service Denied. Maximum Units Allowed Per Week Have Been
09182 Exceeded 119
Service Denied. Maximum Units Allowed Per Week Have Been

09182 Exceeded 119
Product Requires Insulin/Byetta Script Fill Within The Past 90
09184 Days 16
Product Requires Insulin/Byetta Script Fill Within The Past 90

09184 Days 16
Drg - Inpatient Stay Requires Accommodation Revenue Code.
09200 Correct And Resubmit Claim 16
Drg - Admission Date And Discharge Date The Same On

09201 Inpatient Claim. Resubmit As Outpatient Services 16
Drg - Admission Hour Is Invalid (Not 00 Through 23). Correct
09202 And Resubmit Claim 16
Drg - Patient Status Is Not Valid With 3Rd Digit Frequency Of
Type Of Bill. Correct Patient Status Or Bill Type And Resubmit
09205 Claim 16
09205 Claim 16
09205 Claim 16
09205 Claim 16
09205 Claim 16
09205 Claim 16
Drg - Interim Claims Must Reflect Span Of Dates Over Sixty

Days To Be Accepted For Reimbursement By Medicaid.
Drg - Admitting Diagnosis (Fl 76) Is Required. Correct And

Drg - Admitting Diagnosis (Fl 76) Is Required. Correct And

Drg - Principal Diagnosis (Fl 67) Is Required Correct And

Drg - Principal Diagnosis (Fl 67) Is Required Correct And

Admitting Diagnosis Code Is Invalid Or Requires Further
09209 Subdivision. Correct And Resubmit 146
Drg - Principal Diagnosis Code (Fl 67) Is Invalid Or Requires
09210 Further Subdivision. Correct And Resubmit Claim. 146
Drg - Principal Diagnosis Code (Fl 67) Is Invalid Or Requires

09210 Further Subdivision. Correct And Resubmit Claim. 146
Drg - Other Diagnosis Code 3 Is Invalid Or Requires Furthe
Drg - Principle Dx (Fl 67) Invalid For Recipient Sex. If Mi And
Dx Are Correct, Submit Claim To Dma Claims Analysis Uni See
09219 Billing Guidelines 10
Drg - Principle Dx (Fl 67) Invalid For Recipient Sex. If Mi And
Dx Are Correct, Submit Claim To Dma Claims Analysis Uni See
09219 Billing Guidelines 10
Drg - Other Dx Code 2 Invalid For Recipient Sex. If Mid And
Dx Are Correct, Submit Claim To Dma Claims Analysis Unit,
Dx Are Correct, Submit Claim To Dma Claims Analysis Unit
09237 Drg - Admitting Diagnosis Not Allowed For Type Of Admission 11
Drg - Principal Diagnosis Code (Fl 67) Is The Manifestation Of

An Underlying Disease Or Condition. Correct Principal D Code
09238 To The Underlying Condition And Resubmit Claim 16
Drg - Principal Diagnosis Code (Fl 67) Is The Manifestation Of

An Underlying Disease Or Condition. Correct Principal D Code
09238 To The Underlying Condition And Resubmit Claim 16
Drg - Principal Diagnosis (Fl 67) Cannot Be 'E' Code. Correct

Principal Dx To Condition, Illness, Or Injury Requiring
09239 Admission And Resubmit Claim 16
Drg - Principal Diagnosis (Fl 67) Cannot Be 'E' Code. Correct

Principal Dx To Condition, Illness, Or Injury Requiring
09239 Admission And Resubmit Claim 16
Drg - Principal Diagnosis Code (Fl 67) Unacceptable For

Admission To Acute Care Hospital. Correct And Resubmit
09240 Claim 16
Drg - Principal Diagnosis Code (Fl 67) Unacceptable For

Admission To Acute Care Hospital. Correct And Resubmit
09240 Claim 16
Drg - Principal Diagnosis (Fl 67) Unacceptable For Admission
09241 Without Additional Diagnosis. Correct And Resubmit Claim 16
Drg - Principal Diagnosis (Fl 67) Unacceptable For Admission

09241 Without Additional Diagnosis. Correct And Resubmit Claim 16
Drg - Other Diagnosis 2 Is Duplicate Of Principal Diagnosis

Drg - Principal Procedure Code Is Invalid Or Requires Further

Drg - Other Procedure Code 2 Is Invalid Or Requires Further



Drg - Other Procedure Code 6-25 Is Invalid Or Requires
09248 Further Subdivision. Correct And Resubmit Claim 16

Drg-Principle Procedure Invalid For Recipient Sex. If Rid And

Procedure Are Correct, Submit Claim To Dma Claims Analysis
09249 Unit, See Billing Guidelines 7
Drg-Principle Procedure Invalid For Recipient Sex. If Rid And

Procedure Are Correct, Submit Claim To Dma Claims Analysis
Drg-Other Procedure 2 Invalid For Recipient Sex. If Mid And

Icd Px Are Correct, Submit Claim To Dma Claims Analysis






































Drg - Bilateral Procedure 2: Please Attach Operative Record
09263 And Submit Claim As An Adjustment 252











Drg-Bilateral Procedure 6: Please Attached Operative Record



Drg - Admission Hour And Discharge Hour Are Invalid (Not 00
09269 Through 23). Correct And Resubmit Claim 16
Payment Included In Drg Reimbursement On First
09271 Accommodatio Detail 45



No Drg Rcc Code Segment On File For Provider Number For

09273 Claim Dates Of Service 16
Drg - Claim Is Ungroupable. Principal Diagnosis (Fl-67) Is
Invalid As Discharge Diagnosis. Review Claim To Assure
09275 Validity Of Data; Modify And Resubmit A8
Drg - Claim Is Ungroupable. Principal Diagnosis (Fl-67) Is
Invalid As Discharge Diagnosis. Review Claim To Assure
09275 Validity Of Data; Modify And Resubmit A8
Units Cutback To Allowed Amount. Drug Limited To 210 Units



Provider Must Rebill After Dates Of Service Have Met The 60

09291 Day Interval 16
09293 Drg - Most Current Services Already Received B13
09294 Drg Recoupment 45
09294 Drg Recoupment 45

This Revenue Code Must Be Billed With A Valid 5 Digit Hcpcs
09300 Code. Correct Denied Detail And Refile As A New Day Claim 16
Only One Sexually Transmitted Infection Treatment Allowed
09491 Per Calendar Year For Family Planning Waiver Recipients 16
Only One Sexually Transmitted Infection Treatment Allowed

09491 Per Calendar Year For Family Planning Waiver Recipients 16
Ndc Drug Class (Gc3) Must Match Gc3 Of Procedure Code
09506 Billed 16
Service Denied. Based On The Tenth Ndc Information
Provided A More Specific Hcpcs Drug Code Must Be Billed
Instead Of The Miscellaneous Code Used. Correct And
09519 Resubmit 189
09519 Resubmit 189
09519 Resubmit 189
09519 Resubmit 189
Adult Care Home Services Are Not Allowed When Client Is In-
Patient (Acute Or Ltc Facility). Correct And Resubmit For
09612 Service Dates Client Was Not Hospitalized 16
09618 One Evaluation Allowed Per Calendar Year 119
Detail Has Been Combined Per The Link Prescription Number

09701 For Processing As A Compound Drug 96
Detail Has Been Combined Per The Link Prescription Number

09701 For Processing As A Compound Drug 96
Dos And/Or Hcpcs/Revenue Codes Billed Do Not Match For
Compound Drug As Indicated By The Link Prescription
09702 Number 16
Dos And/Or Hcpcs/Revenue Codes Billed Do Not Match For

Compound Drug As Indicated By The Link Prescription
09702 Number 16
Occupational Therapy Re-Evaluation Not Allowed Same Day

09703 As Occupational Therapy Evaluation B15
Occupational Therapy Evaluation Not Allowed Same Day As

09704 Occupational Therapy Re-Evaluation B15
Exceeds Maximum Allowed Of 10 Ndcs Per Revenue

Code/Hcpcs For Compound Drugs. Review Claim And
09705 Resubmit 16
Exceeds Maximum Allowed Of 10 Ndcs Per Revenue

Code/Hcpcs For Compound Drugs. Review Claim And
09705 Resubmit 16
Claim Denied. Follow-Up Care Is Included In Radiation

09800 Management 97
Medicare Claim Denied As Duplicate, Resubmit With Medicare

09803 Eomb That Shows Payment For Dates Of Service Listed 97
Service Recouped. Radiation Management Paid Included

09810 Follow-Up Care 97
Invalid Coordination Of Benefits Other Payer Id Qualifier.
09820 Valid Qualifiers Are: 01 Through 04, 09, 99 Or Blank 16
Invalid Coordination Of Benefits Reject Count. Must Be 01
09821 Through 05 16
Paid Detail Indicates Visit Has Not Exceeded The Legislative
Limit But Counts Towards The Limit; Denied Detail Indicates
09825 Legislative Visit Limit Has Been Exceeded. 119
Paid Detail Indicates Visit Has Not Exceeded The Legislative
Limit But Counts Towards The Limit; Denied Detail Indicates
09825 Legislative Visit Limit Has Been Exceeded. 119
Units Cutback To Allowed Amount. Drug Limited To 1800
09862 Units Per Calendar Month 119


Only One Influenza Procedure Allowed Per Same Date Of
09865 Service 119
Only Two Units Of Influenza Procedures Allowed Within 240

09872 Days 119
Only Two Units Of Influenza Procedures Allowed Within 240
09872 Days 119
Claim Denied. A Meningococcal Vaccine Has Already Been

09874 Paid To A Provider For This Date Of Service B15
Been Made To The Hmo. Physicians May Bill Fee For Service
09905 For Care Rendered On Out-Of-Plan Dates Of Service 24
Been Made To The Hmo. Physicians May Bill Fee For Service
09906 For Care Rendered On Out-Of-Plan Dates Of Service 24
09940 Tenth Ndc Is Desi (Less-Than-Effective) 175
09940 Tenth Ndc Is Desi (Less-Than-Effective) 175

Tenth Ndc Is Non-Covered Either By Dma Policy Or Cms
09951 Mandated 175
Tenth Ndc Is Non-Covered Either By Dma Policy Or Cms

09951 Mandated 175
09952 Ndc Is Desi (Less-Than-Effective) A1
09952 Ndc Is Desi (Less-Than-Effective) A1
09952 Ndc Is Desi (Less-Than-Effective) 16

09952 Ndc Is Desi (Less-Than-Effective) 16
Over The Counter Drugs (Except Insulin) Are Not Paid For
09972 Long Term Care (Snf Only) Recipients 175
Over The Counter Drugs (Except Insulin) Are Not Paid For
09972 Long Term Care (Snf Only) Recipients 175
Levulan Kerastick 1 Stick Equals 1 Unit. Medicaid Allows 2
09973 Units Within 8 Weeks. Units Cutback To Maximum Allowable 119


Ndc Missing. Verify And Enter The Correct Ndc And Submit A
09992 New Claim 16
Ndc Missing. Verify And Enter The Correct Ndc And Submit A
09992 New Claim 16
$9,500 For A Two-Year Period -> Line Reimbursed Amount
29979 Cutback So That Total Reimbursed Is $9500. 119
49270 Ncci Edit B5
49270 Ncci Edit B5

49280 Ncci Outpatient Hospital Services Edit B5
49280 Ncci Outpatient Hospital Services Edit B5
49480 Medical/Pharmacy Dupe, Same Ndc Or Gcn Cd 97
Early Refill Due To Vacation, Restricted To One Event (5 Day

50310 Span) Per 365 Days A1
Month -> Line Reimbursed Units Cutback So That Total Units
52599 Reimbursed Is 192. 119
Month -> Line Reimbursed Units Cutback So That Total Units
52609 Reimbursed Is 200. 119
53140 Presumptive Drug Testing Limited To 24 Per State Fiscal Year 119
53300 Definitive Drug Testing Limited To 24 Per State Fiscal Year 119
Procedure Code T2025 For Capda And Capco Is Limited To

$800 Per Fiscal Year. Line Reimbursed Amount Cutback So
53779 That Total Reimbursed Is $800
Home Health Pa Required For T1999 With Accumulated

Services Greater Than $250 Within The Sfy. Please Request
55100 Home Health Pa 197
Exceeds $1500 Maximum Limitation Allowed Per State Fiscal

55110 Year 119
Exceeds $1500 Maximum Limitation Allowed Per State Fiscal
Year. Line Reimbursed Amount Cutback So That Total
55119 Reimbursed Is $1500
Image-Guided Procedure Not Allowed To Bill On Same Dos As

55120 Similar Image-Guided Procedures 97
Breast Biopsies Not Allowed To Bill On Same Dos As Related

55130 Procedures 97
Primary Procedure Must Be Paid In History For Add-On
55140 Procedure To Be Paid On The Same Dos 107
Primary Procedure Must Be Paid In History For Add-On
55140 Procedure To Be Paid On The Same Dos 107
Removal Of Shoulder Prosthesis Not Allowed To Be Billed On
55220 Same Dos As Revision Of Shoulder Arthroplasty 97
Endovascular Repair Of Visceral Aorta Not Allowed To Be

55240 Billed On Same Dos As Related Procedures 97
Endovascular Repair Of Visceral Aorta And Infrarenal
Abdominal Aorta Not Allowed To Be Billed On Same Dos As
Vascular Embolization Or Occlusion Not Allowed To Be Billed

55280 On Same Dos As Related Procedures. 97
Only One Esophagoscopy, Rigid, Transoral, Allowed To Be

55300 Billed On Same Dos 97
Esophagoscopy, Flexible, Transnasal, Not Allowed To Be Billed

55330 On Same Dos As Related Procedures 97
Esophagoscopy, Flexible, Transoral, With Endomucosal
Resection Not Allowed To Be Billed On Same Dos As Related
55350 Procedures 97
Esophagoscopy, Flexible, Transoral, With Placement Of
Endoscopic Stint Not Allowed To Be Billed On Same Dos As
Esophagoscopy, Flexible, Transoral, With Ablation Not Allowed

55390 To Be Billed On Same Dos As Related Procedures 97
Esophagogastroduodenoscopy, Flexible, Transoral, With
Ultrasound Guided Injection Not Allowed To Be Billed On
55410 Same Dos As Related Procedures 97
Endoscopic Mucosal Resection Not Allowed To Be Billed On
55420 Same Dos As Related Procedures 97
Placement Of Stent Not Allowed To Be Billed On Same Dos As
Ablation Not Allowed To Be Billed On Same Dos As Related
55440 Procedures 97
Ercp With Removal Of Foreign Body Or Stent Not Allowed To

55450 Be Billed On Same Dos As Related Procedures 97
Inage Guided Fluid Collection Drainage By Catheter Not

55470 Allowed To Be Billed On Same Dos As Related Procedures 97
Chemodenervation Of Neck Muscle Not Allowed To Be Billed

55480 On Same Dos As Related Procedures 97
Chemodenervation Of Trunk Muscle(S) Allowed To Be Billed
55510 Only Once Per Session On The Same Dos 97
Percutaneous Transcatheter Closure Of Patent Ductus
Arteriosus Not Allowed To Be Billed On The Same Dos As
No More Than A Total Of Six Screenings Per 365 Days Are
55750 Allowed For Mafd Recipients 119
Hiv/Sti Screenings Must Be Performed With An Annual Exam
55760 Paid In History 119
55770 Procedure Codes 63050 & 63051 Cannot Be Billed Same Day B15
55770 Procedure Codes 63050 & 63051 Cannot Be Billed Same Day B15
Procedure Codes 63050 & 63051 Cannot Be Billed Same Day

As Procedure Codes 22600 22614 22840-22842 63001 63015
55780 63045 63048 63295 B15
Procedure Codes 63050 & 63051 Cannot Be Billed Same Day

As Procedure Codes 22600 22614 22840-22842 63001 63015
55780 63045 63048 63295 B15
Radium Ra 223 Dichloride Allowed 1 Treatment Every 4
55880 Weeks 119
Radium Ra 223 Dichloride Allowed 1 Treatment Every 4

55880 Weeks 119
55940 Maximum Unit Limit Exceeded For 365 Day Period 119
Podiatry Services For Mpw Recipients Require Prior
55950 Authorization After Initial Visit 119
Chiropractic Services For Mpw Recipients Require Prior
55960 Authorization After Initial Visit 119
56040 Max Units Exceeded Per Day For Procedure J9354 119
56050 Max Units Exceeded Per Calendar Month For Procedure J9354 119
Epinephrine Auto Injectors Are Limited To 6 Per Rolling 180
56060 Days. A1
Hetlioz Daily Dose Can Not Exceed 1.00. Quantity Can Not
56070 Exceed 34 Per Claim. 16
Procedure Code S5165 For Capda And Capco Is Limited To

56130 $10,000 Per Waiver Lifetime 119
Procedure Code S5165 For Capda And Capco Is Limited To

$10,000 Per Waiver Lifetime. Line Reimbursed Amount
56139 Cutback So That Total Reimbursed Is $10,000

56140 $2500 Per Waiver Lifetime 119

$2500 Per Waiver Lifetime. Line Reimbursed Amount Cutback
56149 So That Total Reimbursed Is $2500

56150 $3000 Per Waiver Lifetime 119

$3000 Per Waiver Lifetime. Line Reimbursed Amount Cutback
56159 So That Total Reimbursed Is $3000
Us Guidance Recouped/Denied; Included In Procedure On

56180 Us Guidance Denied; Included In 20604 Same Date Of Service B15

Injection Recouped/Denied; Included In Comprehensive
56190 Procedure 96
Imaging Guidance Recouped/Denied; Included In
Insertion, Programming, Interrogation, Ep Eval

56230 Recouped/Denied; Included In Comprehensive Procedure B15
Programming, Interrogation Recouped/Denied; Included In

Lead Placement Recouped/Denied; New Leads Not Placed In

56270 33240, 33262; Incl. In 33270 B15
Programming And Interrogation Incl. In Repositioning; Not

56290 Required In Lead Removal B15
56330 Ecmo Daily Management Not Same Dos As Initiation B15
Peripheral Cannula(E) Insertion/Repositioning Not Same Dos

56350 As Endovascular Prosthesis Procedure B15
56370 Component Procedure Not Same Dos As Comprehensive B15
56390 Ecmo Initiation Not Same Dos As Repositioning B15

Ecmo Cannula(E) Removal Not Same Dos As Endovascular
56410 Prosthesis Procedure Or Vessel Repair B15
Creation Of Graft Conduit For Ecmo Not Same Dos As

56450 Endovascular Prosthesis Procedure B15
56470 Add On Code Must Be Billed With Primary Procedure 97
56640 Injection Not Same Dos As Bleeding Control For Same Lesion 96
57000 Only 1 Myelography Procedure Dos B15
57010 Only One Dxa Scan Per Dos B15
Stereotactic Radiation Treatment Delivery Not Same Dos As

57040 Imrt B15
57060 Primary Code Must Be In History On Same Dos 97
Only One Immunohistochemistry/Immunocytochemistry

57070 Methodology Allowed Per Day B15
Each Code Set Is Mutually Exclusive And Cannot Be Reported
57100 In Conjunction With One Another 119
Program Includes Interrogation; Do Not Report Implantable

57130 Defibrillator Same Dos As Subq Device Services B15
Program And Interrogation Incl. In Insert/Repositioning; Not
57150 Required With Removal B15
Programming And Eval Include Interrogation; Do Not Report

57170 With Interrogation Of Transvenous System Same Dos B15
57210 Ep Eval Included In Subq Device Insertion On Same Dos B15
57450 Only One Code May Be Billed Per Dos B15
Procedure Code May Only Be Billed Once Per Day, Regardless

57600 Of How Many Tests Are Performed B15
57610 Services May Only Be Billed Once Per Session B15
57620 Services May Only Be Billed Once Per Session, Per Breast B15
Program (Mpw) Are Not Eligible For Dental Services After The
Delivery Date. Dental Claims Paid In History Are Recouped.
57700 Refer To Dma Clinical Coverage Dental Policy 4A 96
Program (Mpw) Are Not Eligible For Dental Services After The
Delivery Date. Refer To Dma Clinical Coverage Dental Policy
57710 4A 96
Missing Or Insufficient Documentation To Support Payment Of
An Ambulance Service Billed With Same Date Of Service As A
57740 Paid Ambulance Service 16
Annual Exam Or Postpartum Code Must Be Paid In History
57750 Within 365 Days B15
Claim Denied. Duplicate Outpatient Specialized Therapy

57760 Services For Dos. 97
Lifetime Maximum Allowed Amount Has Been Paid For This

57770 Item 45
Payment Has Been Cutback To Lifetime Maximum Allowed

57779 Amount For This Item 45
57780 Ym120 Limited To 300 Units Per 30 Days 119

Ym120 Limited To 300 Units Per 30 Days _X001A_ Line
Reimbursed Units Cutback So That Total Units Reimbursed Is
57789 300 119
Documentation To Demonstrate Distinct Procedure Performed

57850 Is Required. B15
Allow One Interim Caries Arresting Medicament Application

58450 Every 6 Months 119
Inpatient Stay Only Allowd Once Per Date Of Service Per

58470 Recipient 97
58490 Recipient Has No Paid Claims Within 12 Months 16

Presumptive Drug Screening Limited To 20 Per State Fiscal
58520 Year 119
Confirmatory Drug Testing Not Allowed In Absence Of An

58530 Unanticipated Presumptive Test. B15
58540 Validity Testing Included In Urine Drug Screen 97
58580 Documentation Of Unanticipated Or Positive Test Required 16

Hcpcs Codes May Not Be Billed With Cpt Codes For Urine
58590 Drug Testing 97
Concomitant Use By An Adult Of Three Or More Atypical
58610 Antipsychotics Will Be Denied. A1
Concomitant Use By An Adult Of Two Or More
58620 Antidepressants Will Be Denied. A1
Concomitant Use By An Adult Of Two Or More
58630 Antidepressants Will Be Denied. A1
Concomitant Use By An Adult Of Two Or More Anxiolytics Will
58640 Be Denied. A1
Concomitant Use By A Child Of Three Or More Atypical
58650 Antipsychotics Will Be Denied. A1
Concomitant Use By A Child Of Two Or More Antidepressants
58660 Will Be Denied. A1
Concomitant Use By A Child Of Two Or More Antidepressants
58670 Will Be Denied. A1
Concomitant Use By A Child Of Two Or More Anxiolytics Will
58680 Be Denied. A1
Transferring Physician Must Bill Day Of Transfer As Critical
58690 Care Time, Not Nicu 119
High Dose Pa Is Required When Daily Dose Exceeds 120Mg
59060 Morphine Equivalency 188
It Has Been Determined That The Tier 1 Rate Amount Paid To
You For Hospice Routine Home Care Was An
Overpayment.The Claim Has Been Recouped.Please Resubmit
59070 The Claim To Receive Proper Payment. 16

59080 Only Bill A Maximum Of 16 Units Per Date Of Service. 119
59090 Only One Continuous Home Care Service Allowed Per Day. 119
Lactation Services Limited To 6 Units Per Date Of Service Per
Beneficiary. One Unit = 15 Minutes, Same Or Different
59100 Provider 119
Claim Line Denied. Lactation Services Limited To 36 Units Per

59110 Beneficiary Lifetime, Same Or Different Provider 119
Claim Line Paid. Service Applies Toward Lactation Services
Limitation Of 36 Units Per Beneficiary Lifetime, Same Or
Claim Line Denied. Initial Lactation Assessment Session
59120 Allowed Once Per Beneficiary 119
Claim Line Paid. Service Applies Towards Limitation Of Initial

59125 Lactation Assessment Session Allowed Once Per Beneficiary 119
Non-Surgical Sialolithotomy Not Allowed Same Day As

59150 Surgical Sialolithotomy 97
Procedure Code 1354 Allowed Once Per Tooth In 6 Calendar

59170 Months. 119
Procedure Code D1354 Allowed 4 Times Per Tooth In A

59180 Lifetime. 119
Maximum Of 4 Teeth Is Allowed Per Day For Procedure Code

59190 D1354. 119
Amount Cutback So That Proc Code D1354 Pays At 100% For

59199 The 1St Tooth And 50% For Additional Teeth. 119
HIPAA
GROUP
HIPAA ADJUSTMENT REASON CODE DESCRIPTION CODE
Claim/service lacks information which is needed for
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
Patient has not met the required eligibility requirements. CO

Information requested from the patient/insured/responsible
party was not provided or was insufficient/incomplete. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangement. CO
adjudication. CO
The time limit for filing has expired. CO
The diagnosis is inconsistent with the patient's age. CO
The benefit for this service is included in the

payment/allowance for another service/procedure that has
already been adjudicated. CO
Precertification/authorization/notification absent. CO
An attachment/other documentation is required to adjudicate
this claim/service. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
Diagnosis was invalid for the date(s) of service reported. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
These are non-covered services because this is not deemed a
'medical necessity' by the payer. CO
Billing date predates service date. CO

Benefit maximum for this time period or occurrence has been
reached. CO
reached. CO
Rent/purchase guidelines were not met. CO

Coverage/program guidelines were not met or were
exceeded. CO
Procedure/service was partially or fully furnished by another
provider. CO

This care may be covered by another payer per coordination

of benefits. CO

of benefits. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
Payment is denied when performed/billed by this type of
provider. CO

adjudication. CO

adjudication. CO
Lifetime benefit maximum has been reached for this
service/benefit category. CO

adjudication. CO
Claim spans eligible and ineligible periods of coverage. Rebill
separate claims. CO
separate claims. CO

The date of death precedes the date of service. CO

adjudication. CO

adjudication. CO

adjudication. CO



adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

Monthly Medicaid patient liability amount. CO

adjudication. CO


adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
The prescribing/ordering provider is not eligible to

prescribe/order the service billed. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
Non-covered charge(s). CO
adjudication. CO
adjudication. CO

adjudication. CO
The procedure code is inconsistent with the modifier used or

a required modifier is missing. CO
adjudication. CO

adjudication. CO
The disposition of the claim/service is pending further review. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
The diagnosis is inconsistent with the procedure. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
This service/procedure requires that a qualifying
service/procedure be received and covered. The qualifying
other service/procedure has not been received/adjudicated.
Note: Refer to the 835 Healthcare Policy Identification
Segment, if present. CO
Precertification/authorization exceeded. CO
adjudication. CO

adjudication. CO
adjudication. CO


adjudication. CO
adjudication. CO
This service/equipment/drug is not covered under the

patient_x001A_s current benefit plan CO

reached. CO
reached. CO
reached. CO
reached. CO

of benefits. CO
Services not provided by network/primary care providers. CO
Referral absent or exceeded. CO
Referral absent or exceeded. CO

adjudication. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO

reached. CO
Non-covered visits. CO

reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO


adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
exceeded. CO
exceeded. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO




exceeded. CO

The procedure/revenue code is inconsistent with the patient's

age. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO
adjudication. CO
adjudication. CO

of benefits. CO

of benefits. CO

adjudication. CO

adjudication. CO

adjudication. CO

Charges for outpatient services are not covered when
performed within a period of time prior to or after inpatient
services. CO
services. CO

The related or qualifying claim/service was not identified on
this claim. CO
this claim. CO
this claim. CO



services. CO

this claim. CO

this claim. CO












of benefits. CO






adjudication. CO

adjudication. CO



reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
exceeded. CO
reached. CO
reached. CO

reached. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO
Co-payment Amount CO

Payer deems the information submitted does not support this
length of service. CO
length of service. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
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. CO
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. CO
Ungroupable DRG. CO











reached. CO
reached. CO
Non-covered charge(s).

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

exceeded. CO

exceeded. CO

exceeded. CO


adjudication. CO
reached. CO
of benefits. CO

of benefits. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
adjudication. CO
adjudication. CO
Processed based on multiple or concurrent procedure rules.
(For example multiple surgery or diagnostic imaging,
concurrent anesthesia.) CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
this claim. CO


reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO
adjudication. CO
reached. CO
reached. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

exceeded. CO
exceeded. CO
reached. CO
reached. CO
reached. CO
reached. CO
adjudication. CO

adjudication. CO
adjudication. CO
reached. CO
reached. CO





reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO


adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

level of service. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
Professional fees removed from charges. CO

reached. CO
reached. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
Claim/Service denied. CO



exceeded. CO
exceeded. CO
reached. CO
reached. CO

reached. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
reached. CO
adjudication. CO

adjudication. CO

adjudication. CO
Revenue code and Procedure code do not match. CO


reached. CO

reached. CO

adjudication. CO

adjudication. CO


adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

reached. CO

adjudication. CO

adjudication. CO
Charges are covered under a capitation agreement/managed

care plan. CO
care plan. CO

care plan. CO

care plan. CO

care plan. CO

adjudication. CO
adjudication. CO


reached. CO




reached. CO

reached. CO

reached. CO

reached. CO

this claim. CO

reached. CO

of benefits. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
The rendering provider is not eligible to perform the service
billed. CO





adjudication. CO
adjudication. CO
reached. CO
reached. CO
adjudication. CO
reached. CO
reached. CO

this claim. CO

adjudication. CO

adjudication. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

this claim. CO

this claim. CO
adjudication. CO
adjudication. CO

this claim. CO
reached. CO
reached. CO

this claim. CO

this claim. CO
adjudication. CO
adjudication. CO

this claim. CO
reached. CO

reached. CO
reached. CO
reached. CO

of benefits. CO

of benefits. CO
adjudication. CO
adjudication. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

this claim. CO

this claim. CO

adjudication. CO

adjudication. CO

this claim. CO

this claim. CO

this claim. CO

this claim. CO
this claim. CO
reached. CO
reached. CO
this claim. CO
this claim. CO

this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO


this claim. CO
this claim. CO
this claim. CO
this claim. CO

adjudication. CO
this claim. CO

this claim. CO
reached. CO

this claim. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
this claim. CO
reached. CO
reached. CO
reached. CO

exceeded. CO

exceeded. CO

exceeded. CO

exceeded. CO
reached. CO
reached. CO

reached. CO
reached. CO
adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
Patient is enrolled in a Hospice. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
provider. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

adjudication. CO

adjudication. CO



adjudication. CO

adjudication. CO
adjudication. CO

provider. CO

provider. CO
reached. CO
This (these) diagnosis(es) is (are) not covered. CO



adjudication. CO




adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
Lifetime benefit maximum has been reached. CO

Previously paid. Payment for this claim/service may have been
provided in a previous payment. CO
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. CO
procedure/test. CO







reached. CO

reached. CO
reached. CO

reached. CO

provider. CO
The diagnosis is inconsistent with the provider type. CO

adjudication. CO
reached. CO




adjudication. CO

adjudication. CO

reached. CO
reached. CO

reached. CO
reached. CO


reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

adjudication. CO

adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO






adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO

adjudication. CO
adjudication. CO
reached. CO
CO
CO

age. CO
reached. CO

gender. CO

of benefits. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO
procedure/test. CO
procedure/test. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

this claim. CO
reached. CO

reached. CO
reached. CO

reached. CO
The procedure code is inconsistent with the provider

type/specialty (taxonomy). CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

this claim. CO


Services denied by the prior payer(s) are not covered by this

payer CO


reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
reached. CO

reached. CO
reached. CO
reached. CO
CO

adjudication. CO

adjudication. CO

reached. CO

reached. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
Treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
of benefits. CO

adjudication. CO
adjudication. CO


adjudication. CO

adjudication. CO
CONTRACT
UAL
OBLIGATIO
CO NS

adjudication. CO


reached. CO
reached. CO
reached. CO
reached. CO


adjudication. CO

reached. CO

of benefits. CO

of benefits. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
Prescription is incomplete. CO
Services denied by the prior payer(s) are not covered by this

payer CO
adjudication. CO

reached. CO
reached. CO

reached. CO
reached. CO
adjudication. CO
adjudication. CO
adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO


reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
reached. CO


reached. CO


reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

exceeded. CO

exceeded. CO

exceeded. CO
reached. CO
reached. CO
reached. CO


reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO
exceeded. CO



adjudication. CO
Exact duplicate claim/service CO


reached. CO
reached. CO
reached. CO

adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
this claim. CO
adjudication. CO

adjudication. CO

adjudication. CO


reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
The claim/service has been transferred to the proper

payer/processor for processing. Claim/service not covered by
this payer/processor. CO

of benefits. CO
this claim. CO
The disposition of the claim/service is pending further review. OA

adjudication. CO

adjudication. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO


adjudication. CO
adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO



adjudication. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
adjudication. CO
adjudication. CO
adjudication. CO
This provider was not certified/eligible to be paid for this

procedure/service on this date of service. CO

adjudication. CO
adjudication. CO

adjudication. CO

provider. CO

exceeded. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
reached. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO










reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO


adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

of benefits. CO
The authorization number is missing, invalid, or does not

apply to the billed services or provider. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO


adjudication. CO
adjudication. CO

separate claims. CO
adjudication. CO
adjudication. CO


adjudication. CO
The referring provider is not eligible to refer the service billed. CO






adjudication. CO



adjudication. CO
reached. CO
reached. CO
adjudication. CO
reached. CO

reached. CO

reached. CO

reached. CO


adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

age. CO
Revenue code and Procedure code do not match. CO

The procedure code/bill type is inconsistent with the place of
service. CO
service. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
adjudication. CO
adjudication. CO

service. CO
reached. CO


adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO




of benefits. CO

of benefits. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO

adjudication. CO
exceeded. CO
exceeded. CO
exceeded. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

reached. CO
reached. CO

adjudication. CO


adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO



reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO




billed. CO



adjudication. CO

adjudication. CO
adjudication. CO

reached. CO
reached. CO

reached. CO

reached. CO
billed. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

reached. CO
provider. CO
provider. CO

adjudication. CO
adjudication. CO
reached. CO
reached. CO

adjudication. CO
adjudication. CO
Ungroupable DRG. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
exceeded. CO
exceeded. CO
exceeded. CO
CO


reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO


reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

exceeded. CO
This product/procedure is only covered when used according

to FDA recommendations. CO


reached. CO
reached. CO

reached. CO
reached. CO

exceeded. CO

exceeded. CO


adjudication. CO

adjudication. CO





exceeded. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO








Services/charges related to the treatment of a hospital-

acquired condition or preventable medical error. CO
Services/charges related to the treatment of a hospital-

acquired condition or preventable medical error. CO


service. CO
service. CO
service. CO
Ungroupable DRG. CO
adjudication. CO

adjudication. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO



reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
exceeded. CO

exceeded. CO
exceeded. CO




















reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

adjudication. CO
reached. CO




















reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

service. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

of benefits. CO

exceeded. CO

reached. CO
reached. CO
reached. CO
reached. CO




















adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
adjudication. CO

adjudication. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO


reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO
adjudication. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
The attachment/other documentation content received did

not contain the content required to process this claim or
service. CO
The attachment/other documentation content received did
not contain the content required to process this claim or
service. CO

adjudication. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

adjudication. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO








reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

care plan. CO
care plan. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
care plan. CO
care plan. CO

reached. CO
reached. CO
adjudication. CO
adjudication. CO
reached. CO
reached. CO

adjudication. CO

exceeded. CO


exceeded. CO


exceeded. CO


reached. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
this claim. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

billed. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO







adjudication. CO

adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO









this claim. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO




reached. CO
reached. CO
reached. CO





reached. CO
reached. CO
reached. CO

adjudication. CO
reached. CO
reached. CO

billed. CO





reached. CO
reached. CO

of benefits. CO

of benefits. CO
adjudication. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO


adjudication. CO

adjudication. CO
Patient is enrolled in a Hospice. CO

reached. CO
reached. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
'Not otherwise classified' or 'unlisted' procedure code
(CPT/HCPCS) was billed when there is a specific procedure
code for this procedure/service CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO


adjudication. CO
adjudication. CO
The time limit for filing has expired. CO






billed. CO



of benefits. CO

billed. CO

adjudication. CO

care plan. CO
care plan. CO
adjudication. CO
adjudication. CO
Claim/service not covered by this payer/contractor. You must

send the claim/service to the correct payer/contractor. CO

exceeded. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO
Information from another provider was not provided or was

insufficient/incomplete. CO



reached. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

age. CO
Exceeds the contracted maximum number of hours/days/units

by this provider for this period. This is not patient specific. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
adjudication. CO
reached. CO
reached. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

this claim. CO

adjudication. CO
reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
adjudication. CO
adjudication. CO

adjudication. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO
adjudication. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO
reached. CO
reached. CO
reached. CO
reached. CO





reached. CO
reached. CO

reached. CO

reached. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

The diagnosis is inconsistent with the patient's gender. CO


adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO
gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO

gender. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

adjudication. CO

adjudication. CO






















adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO




adjudication. CO
Ungroupable DRG. CO
Ungroupable DRG. CO

reached. CO
reached. CO

reached. CO

reached. CO

adjudication. CO

adjudication. CO
adjudication. CO
adjudication. CO
adjudication. CO
reached. CO
reached. CO
adjudication. CO

adjudication. CO
adjudication. CO





adjudication. CO
reached. CO
adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO

adjudication. CO
adjudication. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO

reached. CO
reached. CO

care plan. CO

care plan. CO

adjudication. CO
adjudication. CO
reached. CO

reached. CO
reached. CO

reached. CO
adjudication. CO
adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO
exceeded. CO

exceeded. CO
exceeded. CO

exceeded. CO


reached. CO

reached. CO
reached. CO
reached. CO

reached. CO

this claim. CO
this claim. CO
reached. CO
reached. CO
reached. CO

reached. CO

reached. CO
reached. CO
reached. CO

reached. CO
reached. CO

adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

adjudication. CO


reached. CO

reached. CO

reached. CO
adjudication. CO
reached.
Segment, if present.
already been adjudicated.
adjudication.
already been adjudicated.
reached. CO
reached. CO
reached. CO
reached. CO

adjudication. CO

reached. CO

reached. CO

reached. CO

reached. CO

reached. CO
reached. CO

reached. CO


reached. CO

reached. CO

reached. CO

reached. CO
HIPAA
HIPAA GROUP CODE REMARK
DESCRIPTION CODE
N63
Contractual Obligations
N257
N257
M119
M119
MA130
MA130
MA66
MA66
MA66
M76
M76
M76
M76
M76
N255
N255
N257
N257
N521
N521
N10
N182
N517
M86
N3
N3
MA30
MA30
MA66
MA66
MA66
M50
M50
M51
M51
M76
M76
M76
M76
M76
M76
MA04
MA30
MA30
MA30
M50
M50
M50
M51
M51
M77
M77
M77
M54
M52
M52
M52
N173
N173
N173
N3
N3
N3
N3
N29
N29
N3
N3
N3
N3
M53
M53
N180
M86
M86
N130
M86
MA04
MA04
MA31
MA31
MA31
N34
N34
N255
N95
M53
N345
N587
M76
M86
N1
M52
MA04
MA04
N381
N381
M52
M52
MA61
MA61
N10
N58
N58
N29
N29
N29
MA31
N58
MA30
MA43
MA43
MA43
N574
N3
N3
N3
N3
M2
M51
M51
MA04
N519
M54
N318
N187
N75
N75
N37
N37
M50
MA36
M20
M20
M50
M50
N20
N351
M86
N56
N56
N56
N20
M80
M80
N1
M80
N1
N20
M54
M54
N20
N3
N187
M86
M86
N362
N362
M80
M80
N30
N30
MA04
M76
MA04
MA04
MA04
N20
N20
M86
M86
M86
N20
M86
M86
M80
M80
M80
M80
N188
N188
N225
N225
MA66
M80
N1
MA42
MA42
MA66
N301
M80
N20
M80
M80
N20
M80
N20
M80
M80
N1
MA66
M80
M80
M80
M80
M51
N20
M80
M86
N357
N20
M86
N435
M86
M80
M80
M86
M86
N130
N130
M80
M80
M80
N20
N20
N20
M80
M86
M86
M80
N20
M80
M80
M80
N20
M86
MA130
MA130
MA130
M80
M80
M80
M80
M80
M86
M86
M80
M86
M80
M80
M80
N1
N20
N20
N20
N20
N20
N20
N20
N20
N20
M80
M80
N20
N20
N20
N20
N20
N20
M86
M86
M86
M86
N381
MA41
MA41
M80
MA66
N20
MA04
MA04
M49
M49
M49
M86
M80
M2
M86
M86
M86
M2
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
MA04
M86
M86
M86
M86
M86
M86
N257
N257
M86
M86
M86
M80
N381
N381
N640
N640
M90
M90
M90
N381
N381
N381
N381
N640
N640
N381
N381
N640
N640
M80
M90
M86
N357
M77
N56
M80
N61
M80
M80
M86
N357
M86
N381
N301
N301
N56
N56
N56
N56
M80
M2
M80
M86
M86
M86
N29
N29
M86
M86
M86
M86
M80
M86
M86
M86
M86
N357
N357
M86
M86
N357
N357
M29
M29
M29
M30
M30
M30
M29
M29
M29
M30
M30
M30
M80
M80
M86
M86
M86
M86
N357
N381
N381
N357
N357
N362
N362
N381
N381
M86
N357
M86
N37
N37
MA66
MA66
M86
M86
M86
N357
N587
M86
M86
M86
M86
MA130
MA130
M86
M86
N357
M86
N362
M86
M86
M86
N362
M86
M86
M86
M86
M86
M86
N640
N640
N640
M80
M80
N587
M80
M80
M80
M80
N20
M80
M80
M80
M86
M86
M86
M86
M80
N20
N20
M76
N587
N657
N657
N657
N657
N657
N657
N657
M86
M86
M86
M86
N357
N357
M86
M86
M86
M86
M53
M53
M13
M13
M86
N357
M86
M86
N357
M86
M86
M86
M86
M86
M80
M86
M86
N1
N20
N381
N20
M86
M86
M86
M86
N362
N362
N381
N381
N640
N640
M90
M86
M86
M86
N357
M86
N357
M86
M86
N357
N587
M86
M86
M86
M86
M86
N357
N180
N587
N587
N180
M86
N362
N587
M86
N357
M86
M86
M13
M13
M86
N357
M86
M86
M90
N587
M86
N357
N357
N362
M86
N357
M86
N357
M86
N357
M86
N357
M86
N357
MA66
MA66
N180
M86
M86
MA31
MA31
M53
M53
N54
M86
N357
M86
N357
M86
M86
N357
N357
M86
N357
M86
N357
M86
M86
N357
M86
N357
M86
N357
M7
N130
M7
N130
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N20
N20
M80
M80
M80
M80
N205
M86
M86
M86
M86
M86
M86
N1
N640
M86
M86
M86
M86
N4
N4
N4
M86
M86
N180
N180
N381
N381
M80
N362
N362
N362
N381
N381
N381
M119
M86
N257
M80
MA120
MA120
MA120
M80
N20
N20
MA30
MA30
MA31
MA31
M86
M86
N20
N30
MA120
MA120
MA120
N20
N20
MA120
M119
M119
M119
M123
M123
M80
N257
N20
M86
M86
M86
M86
M80
M80
N20
M80
N130
N29
N29
N57
M86
M86
M86
N435
N435
N435
M86
N59
M86
N30
M2
N20
N30
M2
N20
N30
M86
N20
N20
N362
N362
N381
N381
M86
M86
N20
M86
M86
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
M86
M86
M86
M86
N20
N20
M2
N20
N30
M2
N20
N30
M2
N20
M2
N20
M20
M20
M50
M50
MA66
MA66
N46
M53
N381
N20
N20
N20
N20
M80
N1
M80
N1
M86
N20
N20
N20
N20
N640
N640
M86
M86
M86
M86
M86
N20
N20
M86
M86
M86
M80
M80
M86
N20
M80
MA130
M53
M79
N378
N20
M53
MA130
N20
N20
N20
M51
N20
M86
M80
N56
M80
N657
M80
M80
M80
M80
M80
M80
M80
M80
M80
N20
M80
N20
M53
M53
N163
N20
N20
M51
M51
N50
N50
M80
M20
M20
N50
N50
M80
M80
N657
M86
N20
N20
M80
N20
N20
M80
N20
N20
N61
N61
M80
M80
N20
M80
M76
M76
M49
M49
M80
N357
N357
N381
N381
N20
N20
N20
N20
N20
N20
M86
N20
N20
N20
N225
N29
N225
N225
N29
N29
N20
N20
N20
N20
N20
N20
N20
N20
M86
M86
N381
N381
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N188
N20
N20
MA04
N58
N58
M52
M52
M53
M53
M59
M59
N20
N20
N20
N20
N20
M80
M80
M80
M80
M80
N20
N20
M80
M80
N20
N20
N20
N20
N20
N20
N20
N77
N77
N20
N20
M86
M86
N20
N20
MA31
M86
M86
N20
M80
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
MA130
MA130
N77
N20
M86
N357
M86
N357
N362
N362
N20
N20
N20
N20
N20
N20
N20
M80
N20
N63
N63
M86
M86
N56
N56
M86
N357
N20
N20
M86
M86
MA04
N155
M80
M56
M56
N587
N20
N357
N362
N20
N20
N20
N362
N362
N362
N381
N381
N381
N20
N381
N381
N519
N20
N20
N20
N20
N20
MA30
MA30
N20
N20
N20
N20
N20
N20
M80
M86
M86
N20
N20
N20
N20
N20
N20
N20
N20
N20
M80
M80
MA04
N20
N20
N20
N20
N20
N20
M80
N362
N20
N20
N20
N20
N20
N20
N20
N122
N161
N19
N122
N19
N122
N19
M80
M86
N122
N19
N122
N19
N362
N362
N362
N381
N381
N381
N20
N20
N362
N362
M86
N584
N584
N640
N640
M86
M86
N357
M86
MA66
M2
M86
N20
N20
N20
N20
N362
N362
N381
N381
N20
M86
M86
N20
M80
M80
M86
M86
N143
N20
M86
M86
M86
M86
M86
N357
N357
N357
M86
M86
M86
M86
M86
M86
M86
M86
N362
N362
MA130
MA130
N20
N20
M76
M80
M53
M53
M53
N30
N30
N30
N30
M86
N517
N517
N253
N288
N290
M51
N349
M86
N56
N122
N19
N122
N19
N122
N19
N587
N20
N20
M16
M16
N657
N657
M16
M16
N657
N657
M86
M86
N362
N362
N95
N20
N657
MA122
N20
M86
M86
M86
N20
M80
M80
M80
M80
M86
M51
N448
M51
N288
M86
M86
M86
N362
N362
M80
M80
M80
N19
N19
N19
M86
M86
N357
N357
M86
N357
M86
N225
N225
N29
N29
MA66
MA66
MA66
M76
M76
M76
M86
M86
N362
N362
N381
N381
M86
N357
N362
N20
MA130
MA130
N442
N20
N587
M86
M86
N357
N357
M86
M86
N357
N357
N517
N517
N657
N657
M80
M80
N20
N20
M80
M80
N20
N20
M50
M50
M50
N381
N381
N381
M44
N20
M86
M86
N362
N362
M76
MA134
N54
M86
N54
N54
M86
M86
N129
M86
M86
MA04
M80
M80
M86
M86
N20
N20
M80
M80
M86
M86
N20
N20
N30
N34
N34
MA130
N152
M49
M49
M49
M49
M49
N20
N54
N54
M80
M80
N20
N20
M80
M80
N20
N20
M49
M49
MA130
MA130
M86
M86
N362
N362
N381
N54
N20
N54
M16
M16
MA130
N54
MA130
N381
N54
N30
N20
M76
M76
N20
N20
M86
N20
M51
M76
M76
M80
M80
MA04
N20
N20
N20
N381
M86
M86
N362
N362
N362
N362
N381
N381
N381
M80
M86
M86
M80
M86
M86
N20
N20
M86
MA130
MA130
M86
MA130
M53
M86
M86
M86
M86
M53
M143
M143
M2
N19
M86
M86
MA125
M2
M2
M77
M77
M2
M2
M77
M77
M77
M77
MA134
N428
N277
N277
N277
N277
N196
N657
N657
M44
M44
N657
N657
N54
MA30
MA30
M16
Alert: Patient
eligible to
apply for other
coverage
which may be
N196 primary.
M76
N517
N61
M86
M86
M86
M86
M7
M7
N130
N130
M76
N318
N381
M86
N185
N185
N30
N20
M119
M119
M119
M119
M119
M119
M16
M16
N182
M80
M86
M86
N362
N362
M20
M20
N56
M86
M86
N362
N362
N362
N362
N362
N381
N381
N381
MA43
N55
N55
M51
M86
N122
N19
N20
N20
N381
M86
M86
M86
M86
M86
M86
M86
N357
N357
N357
N640
N640
N20
N640
M53
M86
N122
N122
N122
M86
M86
N20
N59
N362
N362
N381
N381
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
N357
M86
N357
M80
M80
N130
N130
N20
N20
M86
N357
N20
N20
N20
N20
N20
N20
N20
N20
N20
N129
N130
M80
M80
N130
N130
N20
N20
M119
M80
M80
M86
M86
N20
N20
M7
N130
M7
N130
M7
M7
M76
M86
M86
N362
N362
N362
M76
M86
M86
N362
N362
M80
M80
M80
M86
M86
M86
N20
N20
N20
M51
N171
N171
N435
N435
M80
M80
N20
N20
N357
N357
M80
M80
M86
M86
M80
M80
M86
M86
N171
N171
N435
N435
M49
M49
M49
MA130
MA130
N20
M86
M86
M86
N357
N20
M80
M86
N357
M80
M80
M86
M86
M86
M86
M86
N362
N362
N362
N185
N185
N185
Other Adjustments
MA66
N301
M86
M86
N357
N357
N381
N381
N185
N357
N357
N381
N381
N357
N357
N381
N381
N185
N185
N185
N185
N185
M86
M86
N362
N362
N20
N20
N117
N3
N3
N3
N3
N20
N20
M86
M86
M80
M86
M86
N20
N20
N657
M86
M86
M80
M86
M80
N20
N20
N674
N20
N20
N20
N20
N20
N20
N20
N20
N20
N362
N362
M90
N20
N20
M86
M86
M86
N362
N362
N20
N20
M67
N3
N3
N3
N3
MA130
N95
N381
M86
M86
N362
N362
M86
M86
N362
N362
M86
M86
N362
N362
M86
N362
M86
M86
N362
N362
MA66
MA66
M51
M51
MA66
MA66
M51
M51
M86
M86
N362
N362
N20
N20
M86
M86
N20
M86
M86
N20
M86
M86
N20
N20
N381
N381
M86
M86
M80
N20
N20
M80
M80
MA92
MA92
MA92
N20
M80
M80
M80
M80
N20
N20
M86
N258
N258
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N63
MA130
MA130
MA39
MA39
M76
M76
M80
N20
M80
N20
N20
M80
M80
N20
N20
N19
N19
N20
N20
N381
N381
N19
N19
N20
N20
N381
N381
N20
N20
N20
M86
M86
N20
N20
M80
M86
M86
M86
M86
M86
N20
N175
M51
M51
M86
M139
MA130
MA66
MA66
M76
M76
N175
M76
M76
M80
N20
M86
M86
N362
N362
M86
M86
N357
N357
M86
M80
N20
N521
M76
MA63
N54
N381
N657
MA63
N54
N286
N286
MA115
N253
M50
M50
N95
N59
M51
M80
M16
M16
N57
M86
N362
M44
M86
M86
N357
N357
M86
M86
N357
N357
N519
N20
M86
M86
M86
M86
M119
M119
M53
M53
M70
M70
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N265
N265
N262
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N58
M86
N362
N362
N362
N381
N381
N381
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
N657
M77
M77
M51
N326
N301
N301
M76
M76
M76
N314
N314
N314
N657
M80
M80
M80
M51
N362
N362
N362
M86
M86
M86
M86
M86
M86
N362
N362
N362
N161
N161
M86
N362
M86
N362
M86
M76
M76
N180
N180
M77
M86
M80
M80
M80
M51
M51
N185
M80
M80
M86
M86
N20
N20
M80
M80
M86
M86
N20
N20
M86
M86
N20
N20
M80
M86
N20
M86
M86
M86
N20
N161
N24
MA130
MA130
MA130
M53
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
N51
MA130
MA130
MA130
M86
MA130
MA130
MA130
MA130
M53
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
M123
N20
N357
MA04
MA04
N20
MA130
MA134
MA134
N253
N253
N122
N19
N122
N19
N122
N19
N122
N19
N20
N117
M86
M86
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N122
N19
M86
M86
N357
N357
N122
N19
M86
M86
N357
N357
N122
N19
N122
N19
N122
N19
M86
M86
N357
N357
N20
M80
M80
N20
N20
N20
M80
M80
M80
M80
M80
M51
M51
N674
N674
M86
M86
N362
N362
N161
N161
N20
N20
N640
N640
N640
M51
M51
M51
M51
M51
N288
N288
M86
N251
N251
N255
N255
N280
N280
N31
N31
N280
N280
N280
N280
N362
N362
N161
MA30
MA30
M50
M50
M86
M86
N362
N362
M86
M86
N20
N20
M80
N362
N362
N362
M80
M80
N357
N357
M80
M80
N357
N357
N122
N19
M86
M86
M86
M80
M80
M80
N20
N20
M16
M16
N587
N587
M86
M86
M86
M86
M86
N362
N362
N19
N19
N255
N77
N77
M86
M86
N357
N357
M15
N19
M86
M86
N20
MA130
MA130
N152
N152
N657
N351
N351
N95
N95
N351
N351
N95
N95
N351
N351
N95
N95
N142
M86
M86
N357
N357
M86
N357
M86
N357
M86
M86
M86
M86
M86
N54
N54
N54
N362
M86
M86
M86
M86
M50
M50
M86
N290
N554
M86
M86
MA130
M119
N657
M51
N161
MA63
M76
N290
M53
M47
M51
M51
MA66
MA66
MA63
MA63
N346
N346
M53
M86
M86
N357
N357
N257
N257
N434
N434
MA130
MA65
N303
N317
N318
M52
N299
N299
M47
N50
N50
N340
M44
M45
M44
M44
N300
N63
N63
M76
MA34
MA33
N300
N329
N329
N152
MA130
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
N122
N19
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
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M80
M80
M86
M86
M86
M86
M86
M86
N19
M80
N19
M80
M80
N362
M80
M80
N19
M80
M86
M80
M86
M80
M86
M80
M86
M80
M86
M86
M80
M80
M86
M86
N362
N357
M80
M80
M80
M80
M80
M86
M86
M80
M80
M80
N122
N19
N674
M86
M86
M86
M86
M86
N362
N362
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N20
N20
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N20
N20
M86
M86
M86
M86
M86
M86
N357
N122
N19
N20
M86
N357
N20
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
M86
M86
M80
M80
N357
N357
N20
N20
M80
M80
N357
N357
N20
N20
M86
M86
M80
M80
N357
N357
N20
N20
M86
M86
N20
N59
M80
M80
N357
N357
N20
N20
N20
N20
N122
N20
N20
N20
N20
N20
N20
N362
M80
M80
N357
N357
N20
N20
N362
N20
N20
N20
N20
N130
M80
M80
N357
N357
N362
M80
M80
N357
N357
M80
M80
N357
N357
M80
M80
N357
N357
N20
N20
N362
M80
M80
N357
N357
M80
M80
N357
N357
N362
N20
N122
N362
N362
N362
M80
M80
N357
N357
M80
M80
N357
N357
M80
M80
N357
N357
M80
M80
N357
N357
N122
MA130
MA130
MA130
MA130
MA130
MA130
MA130
N657
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
MA130
N180
N657
M80
MA130
MA130
M86
N657
MA66
MA66
MA66
N29
N29
N29
N587
M80
N657
M86
M80
M80
M80
M80
N20
N20
M86
M80
M80
M80
M80
M86
M86
M86
N357
M86
N357
M86
N357
M86
N357
M86
M86
N357
N357
N657
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
M86
N357
N357
M86
N357
M86
N357
N587
N587
M86
M86
M86
M86
M86
N20
M80
MA130
MA130
M86
M80
M80
N587
N587
N122
N19
M80
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N59
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
M51
N20
M51
N20
M80
M80
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
N122
N19
M86
M86
M86
M86
M80
M80
M139
M80
M80
N20
N20
M80
M80
N20
N20
M80
M80
N20
N20
N358
N358
M80
M80
N20
N20
N358
N358
M80
M80
N20
N20
M80
M80
N20
N20
M86
M86
M86
M86
M86
M86
M139
M51
M80
M80
M86
M86
N20
N20
M80
M80
M80
M86
M86
M86
N20
N20
N20
M80
M80
M80
M86
M86
M86
N20
N20
N20
M80
M80
M80
N20
N20
N20
M86
M86
M86
N20
N20
N20
M80
M80
M86
M86
N20
N20
M80
M80
N20
N20
N428
M139
M86
M86
N362
N362
M86
M86
N362
N362
N381
N59
N59
N59
N381
N2
N381
M86
M86
M86
N2
N381
N381
N381
N381
M86
M86
M86
MA130
N362
N362
M139
M139
N381
M139
N381
M86
M86
M16
N362
N185
N185
N61
N61
M86
M86
M86
N362
N362
N362
N362
MA66
N303
N143
N362
N362
MA52
MA52
M51
M51
M51
M51
M50
M50
N381
N381
M50
M50
N381
N381
MA05
MA05
N253
N288
N95
N54
N54
N54
N286
Contractual Obligations N70
N193
N357
N357
N357
M53
M53
N185
N30
N54
N54
N54
N54
N54
N54
M86
M86
N362
N362
N362
N362
N362
N362
N362
MA130
MA130
N30
M80
M80
N54
MA07
MA07
MA07
M86
M86
N362
N362
M86
M86
M86
N129
N640
N185
M119
N142
M119
N142
M86
M86
N357
N357
N362
N362
N381
N381
M119
M86
M86
M20
M20
M20
M49
N194
N20
MA130
M86
M86
N20
N20
M80
M80
N20
N20
M86
M86
N362
N362
M86
M86
N362
N362
M86
M86
N362
N362
M80
M80
N20
N20
M80
M80
N20
N20
M80
M80
N20
N20
M80
M80
N20
N20
M80
M80
N20
N20
M80
M80
N20
N20
N61
N61
N182
N182
N182
N362
N362
N362
N381
N381
N381
MA130
MA130
N3
N3
N362
N362
N362
N381
N381
N381
MA130
M53
MA130
N256
N77
M86
M86
N357
N357
M86
M86
N362
N362
M16
M16
N362
N362
M80
M80
M86
M86
N20
N20
M80
M80
N20
N20
M51
N19
M51
M86
M86
N657
M86
M86
M16
M16
MA130
MA130
N46
MA30
MA30
MA30
MA43
MA43
MA43
MA130
MA130
MA130
MA130
MA130
MA65
MA65
MA65
MA63
MA63
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
M64
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
N657
MA130
MA130
MA130
MA130
MA130
MA130
MA130
MA130
M64
M64
M64
MA66
MA66
MA66
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
M67
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M64
M64
M64
M76
M76
M76
M29
M29
M29
N1
N1
N1
M29
M29
M29
N1
N1
N1
M29
M29
M29
N1
N1
N1
M29
M29
M29
N1
N1
N1
M29
M29
M29
N1
N1
N1
N317
N46
N46
N46
N50
N50
N50
M50
M50
M50
N381
N381
N381
N65
N657
N657
N362
N362
N381
N381
MA130
MA67
MA67
M20
M20
N142
N142
N362
N362
M53
M53
M119
M70
M70
N657
N657
MA130
M86
MA130
MA130
MA130
MA130
N20
N20
MA130
MA130
M80
M86
M80
N245
N245
N362
N362
N362
N362
N381
N381
M86
M86
M86
N20
M16
M16
M16
M16
M16
M16
MA130
MA130
M16
M79
M86
M86
N362
N362
M119
N142
N171
N171
N435
N435
M86
N30
M86
M86
M86
M86
M139
N54
N357
M80
M80
N161
N19
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M80
M86
M86
N20
N20
N20
N20
M86
N357
N362
N362
N362
N362
N362
M86
MA130
M139
M139
M139
M139
M139
M139
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N20
N19
N20
N20
N20
N20
N19
N20
M86
N20
N20
N20
N20
N20
N20
N20
N20
N30
N30
N20
M67
M86
N45
N45
M86
M86
N20
N381
M80
N182
M86
N161
M80
N20
M86
M86
M86
M86
M86
M86
M86
M86
M86
M86
N362
N362
N362
N199
N362
N362
N362
N362
N362
N362
N362
M86
N362
N362
N362
N362
HIPAA
CLAIMS HIPAA CLAIMS
STATUS STATUS CODE
HIPAA REMARK CODE DESCRIPTION CODE DESCRIPTION
Rebill services on separate claim lines. 187 Date(s) of service.

Missing/incomplete/invalid billing provider/supplier primary Entity's Medicaid
identifier. 132 provider id.
Missing/incomplete/invalid billing provider/supplier primary Missing or invalid
identifier. 21 information.
Missing/incomplete/invalid/ deactivated/withdrawn National Missing or invalid

Drug Code (NDC). 21 information.
Missing/incomplete/invalid/ deactivated/withdrawn National

Drug Code (NDC). 218 NDC number.
Your claim contains incomplete and/or invalid information,
and no appeal rights are afforded because the claim is
unprocessable. Please submit a new claim with the Missing or invalid
complete/correct information. 21 information.
unprocessable. Please submit a new claim with the Procedure code for
complete/correct information. 454 services rendered.
Missing or invalid
Missing/incomplete/invalid principal procedure code. 21 information.
Procedure code not

Missing/incomplete/invalid principal procedure code. 475 valid for patient age
Diagnosis code(s)
for the services
Missing/incomplete/invalid principal procedure code. 488 rendered.
Missing or invalid
Missing/incomplete/invalid diagnosis or condition. 21 information.
Procedure code not

Missing/incomplete/invalid diagnosis or condition. 475 valid for patient age
Diagnosis code(s)
for the services
Missing/incomplete/invalid diagnosis or condition. 488 rendered.
109 Entity not eligible.

Entity not eligible
for medical benefits
for submitted dates
90 of service.

Entity not eligible
for submitted dates
90 of service.
Verifying premium
734 payment
Procedure code and
patient gender
Missing/incomplete/invalid diagnosis or condition. 474 mismatch
Diagnosis and
patient gender
Missing/incomplete/invalid diagnosis or condition. 86 mismatch.
Entity's National
Provider Identifier
Missing/incomplete/invalid billing provider taxonomy. 562 (NPI).
Entity not
eligible/not
approved for dates
Missing/incomplete/invalid billing provider taxonomy. 91 of service.
Entity's National
Missing/incomplete/invalid billing provider/supplier primary Provider Identifier
identifier. 562 (NPI).
Entity not
eligible/not
Missing/incomplete/invalid billing provider/supplier primary approved for dates
identifier. 91 of service.
Entity's National
Mismatch between the submitted provider information and Provider Identifier
the provider information stored in our system. 562 (NPI).
Entity not
eligible/not
Mismatch between the submitted provider information and approved for dates
the provider information stored in our system. 91 of service.
Entity's National
Provider Identifier
562 (NPI).
Entity not
eligible/not
approved for dates
91 of service.
Payment based on the findings of a review
organization/professional consult/manual adjudication/medical Medical
or dental advisor. 297 notes/report.
This claim/service must be billed according to the schedule for Supporting
this plan. 294 documentation.
Supporting
294 documentation.
Resubmit a new claim with the requested information. 255 Diagnosis code.
Duplicate of a
previously
Service denied because payment already made for processed
same/similar procedure within set time frame. 54 claim/line.
Service not
84 authorized.
Missing or invalid
Missing consent form. 21 information.
Medical
Missing consent form. 297 notes/report.
Missing or invalid
Missing/incomplete/invalid type of bill. 21 information.
Missing/incomplete/invalid type of bill. 218 NDC number.
Missing or invalid
Type of bill for UB

Missing/incomplete/invalid principal procedure code. 228 claim
Procedure Code
Modifier(s) for
Missing/incomplete/invalid principal procedure code. 453 Service(s) Rendered
Missing or invalid
Missing/incomplete/invalid revenue code(s). 21 information.
Missing/incomplete/invalid revenue code(s). 218 NDC number.
Missing or invalid
Missing/incomplete/invalid procedure code(s). 21 information.
Missing/incomplete/invalid procedure code(s). 218 NDC number.

Missing or invalid
Type of bill for UB

Missing/incomplete/invalid diagnosis or condition. 228 claim
Procedure Code
Modifier(s) for
Missing/incomplete/invalid diagnosis or condition. 453 Service(s) Rendered
Missing or invalid
Missing/incomplete/invalid diagnosis or condition. 255 Diagnosis code.

Diagnosis code
pointer is missing or
Missing/incomplete/invalid diagnosis or condition. 477 invalid
178 Submitted charges.
Other payer's
Secondary payment cannot be considered without the identity Explanation of
of or payment information from the primary payer. The Benefits/payment
information was either not reported or was illegible. 286 information.
Type of bill for UB
Missing/incomplete/invalid type of bill. 228 claim
Missing/incomplete/invalid type of bill. 249 Place of service.

Revenue code for
Missing/incomplete/invalid type of bill. 455 services rendered.
Type of bill for UB
Missing/incomplete/invalid revenue code(s). 228 claim
Missing/incomplete/invalid revenue code(s). 249 Place of service.

Revenue code for
Missing/incomplete/invalid revenue code(s). 455 services rendered.
Procedure code for
Missing/incomplete/invalid procedure code(s). 454 services rendered.
Revenue code for
Type of bill for UB
Missing/incomplete/invalid place of service. 228 claim
Missing/incomplete/invalid place of service. 249 Place of service.

Revenue code for
Missing/incomplete/invalid place of service. 455 services rendered.
Missing/incomplete/invalid total charges. 178 Submitted charges.

Missing/incomplete/invalid _x001A_from_x001A_ date(s) of
service. 187 Date(s) of service.
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of Facility admission
service. 189 date
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of Missing or invalid
service. 21 information.
No qualifying hospital stay dates were provided for this
episode of care. 187 Date(s) of service.
No qualifying hospital stay dates were provided for this Facility admission
episode of care. 189 date
No qualifying hospital stay dates were provided for this Missing or invalid
episode of care. 21 information.
Referral/authorizatio
Missing consent form. 48 n.
Missing or invalid
Medical
Missing or invalid
Missing documentation/orders/notes/summary/report/chart. 21 information.
Supporting
Missing documentation/orders/notes/summary/report/chart. 294 documentation.
Missing or invalid
Medical
Missing or invalid
Medical
Days/units for
procedure/revenue
Missing/incomplete/invalid days or units of service. 258 code.
Missing or invalid
Missing/incomplete/invalid days or units of service. 476 units of service
This item or service does not meet the criteria for the Medical necessity
category under which it was billed. 287 for service.
187 Date(s) of service.

Service denied because payment already made for Frequency of
same/similar procedure within set time frame. 259 service.
Service denied because payment already made for Per Day Limit
same/similar procedure within set time frame. 612 Amount
Consult plan benefit documents/guidelines for information Frequency of
about restrictions for this service. 259 service.
Missing or invalid
21 information.
Service not
84 authorized.
Duplicate of a
previously
Secondary payment cannot be considered without the identity
of or payment information from the primary payer. The Claim submitted to
information was either not reported or was illegible. 116 incorrect payer.
Missing/incomplete/invalid beginning and ending dates of the
period billed. 187 Date(s) of service.
period billed. 510 Future date.
Missing/incomplete/invalid beginning and ending dates of the Entity's Received
period billed. 756 Date.
Incorrect claim form/format for this service. 277 Paper claim.

Information was
requested by a non-
Incorrect claim form/format for this service. 59 electronic method.
Missing/incomplete/invalid billing provider taxonomy. 25 Entity not approved.
This provider type/provider specialty may not bill this service. 25 Entity not approved.
Days/units for
procedure/revenue
Days/units for
procedure/revenue
Date range not valid with units submitted. 258 code.
Frequency of
Policy benefits have been exhausted. 259 service.
Diagnosis code(s)
for the services
456 Covered Day(s)

Duplicate of a
previously
Alert: You may appeal this decision in writing within the Entity not eligible
required time limits following receipt of this notice by for benefits for
following the instructions included in your contract or plan submitted dates of
benefit documents. 88 service.
Entity not eligible
for benefits for
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of submitted dates of
service. 88 service.
Other insurance
Secondary payment cannot be considered without the identity coverage
of or payment information from the primary payer. The information (health,
information was either not reported or was illegible. 171 liability, auto, etc.).
Other payer's
Maximum coverage
Consult our contractual agreement for amount met or
restrictions/billing/payment information related to these exceeded for benefit
charges. 483 period.
Consult our contractual agreement for
restrictions/billing/payment information related to these Claim/line has been
charges. 65 paid.
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of Entity's date of

service. 158 birth.
Entity not eligible
for benefits for
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of submitted dates of
service. 88 service.
Missing/incomplete/invalid social security number or health Missing or invalid
insurance claim number. 21 information.
Missing/incomplete/invalid social security number or health Claim submitter's
insurance claim number. 478 identifier
Service not
84 authorized.
Entity not eligible
Payment based on the findings of a review for dental benefits
organization/professional consult/manual adjudication/medical for submitted dates
or dental advisor. 89 of service.
Missing or invalid
Missing/incomplete/invalid patient liability amount. 21 information.
Missing or invalid
Supporting
Medical
Missing documentation/orders/notes/summary/report/chart. 297 notes/report.
Patient's medical
Missing documentation/orders/notes/summary/report/chart. 317 records.
Missing/incomplete/invalid beginning and ending dates of the Facility admission
period billed. 189 date
Facility admission
Missing/incomplete/invalid patient liability amount. 189 date
Missing or invalid
Missing or invalid
Missing/incomplete/invalid patient status. 21 information.
Patient's
condition/functional
status at time of
Missing/incomplete/invalid patient status. 431 service.
Entity not eligible
for submitted dates
Missing/incomplete/invalid patient status. 90 of service.
Awaiting eligibility
56 determination.
Our records indicate the ordering/referring provider is of a Entity not
type/specialty that cannot order or refer. Please verify that eligible/not
the claim ordering/referring provider information is accurate approved for dates
or contact the ordering/referring provider. 91 of service.
Subscriber and
subscriber id not
33 found.
Patient eligibility not

97 found with entity.
Missing or invalid
Medical
Missing or invalid
Medical
Missing or invalid
Not paid separately when the patient is an inpatient. 21 information.
Procedure code for
Revenue code for
Procedure Code
Modifier(s) for
Invalid combination of HCPCS modifiers. 453 Service(s) Rendered
Missing/incomplete/invalid total charges. 178 Submitted charges.
Facility discharge
Missing/incomplete/invalid discharge or end of care date. 190 date
Alert: You may request a review in writing within the required
time limits following receipt of this notice by following the
instructions included in your contract or plan benefit Internal
documents. 46 review/audit.
Missing or invalid
Missing/incomplete/invalid tooth surface information. 21 information.
Tooth surface(s)
Missing/incomplete/invalid tooth surface information. 240 involved.
Missing or invalid
Missing/incomplete/invalid tooth number/letter. 21 information.
Dental
Missing/incomplete/invalid tooth number/letter. 245 quadrant/arch.
Revenue code for
Subscriber and
subscriber id
Missing/incomplete/invalid patient name. 30 mismatched.
Missing or invalid
Missing/incomplete/invalid HCPCS. 21 information.
Missing/incomplete/invalid HCPCS. 507 HCPCS

Missing or invalid
Missing/incomplete/invalid revenue code(s). 507 HCPCS
Days/units for
Service not payable with other service rendered on the same procedure/revenue
date. 258 code.
Service date outside of the approved treatment plan service
dates. 187 Date(s) of service.
Missing or invalid
21 information.
Authorization/certifi
cation number. This
change effective
11/1/2011: Entity's
authorization/certific
252 ation number.

Procedure code billed is not correct/valid for the services Medical
billed or the date of service billed. 297 notes/report.
Ambulance
Procedure code billed is not correct/valid for the services certification/docume
billed or the date of service billed. 337 ntation.
Procedure code billed is not correct/valid for the services Ambulance Run
billed or the date of service billed. 472 Sheet
Days/units for
date. 258 code.
Not covered when performed during the same session/date as Procedure code for
a previously processed service for the patient. 454 services rendered.
Alert: You may appeal this decision in writing within the
required time limits following receipt of this notice by
following the instructions included in your contract or plan Procedure code for
benefit documents. 454 services rendered.
Service not payable with other service rendered on the same Frequency of
date. 259 service.
Missing/incomplete/invalid total charges. 187 Date(s) of service.

Missing or invalid
Missing/incomplete/invalid total charges. 21 information.
Missing or invalid
21 information.
cation number. This
change effective
11/1/2011: Entity's
252 ation number.
Days/units for
date. 258 code.
Denied Charge or
585 Non-covered Charge
Alert: You may request a review in writing within the required
time limits following receipt of this notice by following the
instructions included in your contract or plan benefit Internal
documents. 46 review/audit.
The number of Days or Units of Service exceeds our Frequency of
acceptable maximum. 259 service.
The number of Days or Units of Service exceeds our Per Day Limit
acceptable maximum. 612 Amount
Supporting
Patient ineligible for this service. 294 documentation.
Entity not eligible
for submitted dates
Patient ineligible for this service. 90 of service.
Other payer's
cation number. This
change effective
11/1/2011: Entity's
252 ation number.
Entity is not
selected primary
93 care provider.
cation number. This
change effective
11/1/2011: Entity's
252 ation number.
UB04/HCFA-
1450/1500 claim
276 form
Diagnosis code(s)
for the services
Processed according
to contract
provisions (Contract
refers to provisions
that exist between
Secondary payment cannot be considered without the identity the Health Plan and
of or payment information from the primary payer. The a Provider of Health
information was either not reported or was illegible. 107 Care Services)
of or payment information from the primary payer. The Total Medicare Paid
information was either not reported or was illegible. 655 Amount
Days/units for
date. 258 code.
Service not payable with other service rendered on the same Supporting
date. 294 documentation.

Days/units for
Service denied because payment already made for procedure/revenue
same/similar procedure within set time frame. 258 code.
Days/units for
date. 258 code.

Days/units for
procedure/revenue
258 code.

The approved level of care does not match the procedure Missing or invalid
code submitted. 21 information.
Procedure Code
The approved level of care does not match the procedure Modifier(s) for
code submitted. 453 Service(s) Rendered
Incomplete/invalid Missing or invalid

documentation/orders/notes/summary/report/chart. 21 information.
Procedure Code
Incomplete/invalid Modifier(s) for
documentation/orders/notes/summary/report/chart. 453 Service(s) Rendered
Missing or invalid
Missing or invalid
Missing/incomplete/invalid admission source. 21 information.
Hospital admission
Missing/incomplete/invalid admission source. 229 source.
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Procedure code for
Missing/incomplete/invalid principal procedure code. 454 services rendered.
Procedure code for
Missing/incomplete/invalid procedure date(s). 454 services rendered.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Missing or invalid
Days/units for
procedure/revenue
Missing/incomplete/invalid procedure code(s). 258 code.
Days/units for
date. 258 code.
Time frame requirements between this
service/procedure/supply and a related Frequency of
service/procedure/supply have not been met. 259 service.
Days/units for
date. 258 code.

Exceeds number/frequency approved /allowed within time Frequency of

period without support documentation. 259 service.
Maximum coverage
amount met or
Service denied because payment already made for exceeded for benefit
same/similar procedure within set time frame. 483 period.
Maximum coverage
amount met or
Consult plan benefit documents/guidelines for information exceeded for benefit
about restrictions for this service. 483 period.
Missing or invalid
21 information.
Missing or invalid
21 information.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Not covered when performed during the same session/date as procedure/revenue
a previously processed service for the patient. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
unprocessable. Please submit a new claim with the
complete/correct information. 187 Date(s) of service.
complete/correct information. 298 Operative report.
Not covered when performed during the same session/date as Medical necessity
a previously processed service for the patient. 287 for service.
Not covered when performed during the same session/date as Supporting

a previously processed service for the patient. 294 documentation.
Duplicate of a
previously
Duplicate of a
previously
Days/units for
procedure/revenue
258 code.
Duplicate of a
previously
Days/units for
procedure/revenue
258 code.
Entity not
eligible/not
approved for dates
91 of service.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
restrictions/billing/payment information related to these Procedure code for
charges. 454 services rendered.
Missing or invalid
Missing/incomplete/invalid admission type. 21 information.
Hospital admission
Missing/incomplete/invalid admission type. 231 type.
Missing or invalid
date. 259 service.
of or payment information from the primary payer. The NUBC Occurrence
information was either not reported or was illegible. 720 Code Date(s)
Additional
information
requested from
Missing/incomplete/invalid value code(s) or amount(s). 123 entity.
Missing or invalid
Missing/incomplete/invalid value code(s) or amount(s). 21 information.
NUBC Value Code

Missing/incomplete/invalid value code(s) or amount(s). 726 Amount(s)
Duplicate of a
previously
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Procedure code for

454 services rendered.
Procedure code for

Not paid separately when the patient is an inpatient. 454 services rendered.
Duplicate of a
previously
Procedure code for
Procedure code for
Procedure code for
Duplicate of a
previously
Duplicate of a
previously
Procedure code for

Principal Procedure
Code for Service(s)
465 Rendered
Procedure code for

Procedure code for
Duplicate of a
previously
Duplicate of a
previously
Service denied because payment already made for Procedure code for
same/similar procedure within set time frame. 454 services rendered.
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Missing/incomplete/invalid billing provider/supplier primary processed
identifier. 54 claim/line.
Duplicate of a
previously
Missing/incomplete/invalid billing provider/supplier primary processed
identifier. 54 claim/line.
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
restrictions/billing/payment information related to these Frequency of
charges. 259 service.
Maximum coverage
Exceeds number/frequency approved/allowed within time Frequency of
period. 259 service.
Maximum coverage
amount met or
Exceeds number/frequency approved/allowed within time exceeded for benefit
period. 483 period.
Frequency of
Not covered more than once in a 12 month period. 259 service.
Frequency of
Maximum coverage
amount met or
exceeded for benefit
Not covered more than once in a 12 month period. 483 period.
Maximum coverage
Maximum coverage
Maximum coverage
amount met or
period. 483 period.
Days/units for
procedure/revenue
258 code.
Maximum coverage
Maximum coverage
amount met or
period. 483 period.
Missing or invalid
21 information.
Frequency of
Days/units for
procedure/revenue
Missing/incomplete/invalid place of service. 258 code.
Days/units for
Procedure code billed is not correct/valid for the services procedure/revenue
billed or the date of service billed. 258 code.
Missing or invalid
Rebill services on separate claims. 21 information.
Processed according
to plan provisions
(Plan refers to
provisions that exist
between the Health
Plan and the
Consumer or
104 Patient)
Maximum coverage
Missing or invalid
21 information.
Missing or invalid
476 units of service
Procedure Code
Modifier(s) for
Missing/incomplete/invalid procedure date(s). 453 Service(s) Rendered
Missing/incomplete/invalid procedure date(s). 457 Non-Covered Day(s)
Procedure Code
Procedure code billed is not correct/valid for the services Modifier(s) for
billed or the date of service billed. 453 Service(s) Rendered
Procedure code billed is not correct/valid for the services
billed or the date of service billed. 457 Non-Covered Day(s)
Procedure Code
Procedure code for
Length of time for
Missing documentation/orders/notes/summary/report/chart. 263 services rendered.
Supporting
Days/units for
Days/units for
service/procedure/supply and a related Per Day Limit
service/procedure/supply have not been met. 612 Amount
Procedure code for

Denied Charge or
Missing operative note/report. 298 Operative report.
Pathology
Missing operative note/report. 311 notes/report.
Claim/line has been
Missing operative note/report. 65 paid.
Missing pathology report. 298 Operative report.
Pathology
Missing pathology report. 311 notes/report.
Claim/line has been

Missing pathology report. 65 paid.
Pathology
Missing operative note/report. 311 notes/report.
Claim/line has been

Missing operative note/report. 65 paid.
Missing pathology report. 298 Operative report.
Pathology
Missing pathology report. 311 notes/report.
Claim/line has been

Missing pathology report. 65 paid.
Days/units for

Frequency of
259 service.
Maximum coverage

Maximum coverage

Missing or invalid
Missing/incomplete/invalid tooth number/letter. 21 information.
Tooth numbers,
surfaces, and/or
Missing/incomplete/invalid tooth number/letter. 242 quadrants involved.
Procedure code for
Missing/incomplete/invalid principal procedure code. 454 services rendered.
Duplicate of a
previously
processed
Missing/incomplete/invalid principal procedure code. 54 claim/line.
Frequency of
complete/correct information. 25 Entity not approved.



Exceeds number/frequency approved/allowed within time Length of time for

period. 263 services rendered.
Exceeds number/frequency approved/allowed within time Per Day Limit

period. 612 Amount
Frequency of
Duplicate of a
previously
Not covered when performed during the same session/date as processed
a previously processed service for the patient. 54 claim/line.
Days/units for
date. 258 code.
Days/units for
Not covered when performed during the same session/date as Per Day Limit
a previously processed service for the patient. 612 Amount
Days/units for
Days/units for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Primary diagnosis
code. This change
effective 11/1/2011:
Principal doagnosis
Missing/incomplete/invalid diagnosis or condition. 254 code.
Frequency of
Frequency of
259 service.
This should be billed with the appropriate code for these

services. 277 Paper claim.
This should be billed with the appropriate code for these Supporting
services. 294 documentation.
Diagnosis code(s)
This should be billed with the appropriate code for these for the services
services. 488 rendered.
Diagnosis code(s)
This should be billed with the appropriate code for these Missing or invalid
services. 21 information.
services. 277 Paper claim.
This should be billed with the appropriate code for these Supporting
services. 294 documentation.
48 n.
Service not
84 authorized.
Processed according
to contract
that exist between
the Health Plan and
a Provider of Health
107 Care Services)
Claim submitted to
116 incorrect payer.
Frequency of
Missing/incomplete/invalid days or units of service. 259 service.
Missing or invalid
Only one initial visit is covered per specialty per medical Missing or invalid
group. 21 information.
Only one initial visit is covered per specialty per medical Procedure code for
group. 454 services rendered.
Frequency of
259 service.
Procedure Code
Modifier(s) for
453 Service(s) Rendered




required time limits following receipt of this notice by Days/units for
following the instructions included in your contract or plan procedure/revenue
benefit documents. 258 code.
Days/units for
date. 258 code.
Principal Procedure
Code for Service(s)
465 Rendered
Maximum coverage
Days/units for
date. 258 code.

Maximum coverage
Maximum coverage
amount met or
period. 483 period.
Frequency of
259 service.
Procedure Code
Modifier(s) for
Frequency of


Frequency of
Frequency of
259 service.
Service not
84 authorized.
Frequency of
Frequency of
This item or service does not meet the criteria for the
category under which it was billed. 278 Signed claim form.
Frequency of
Only one initial visit is covered per specialty per medical Missing or invalid
group. 21 information.
Only one initial visit is covered per specialty per medical Procedure code for
group. 454 services rendered.
Frequency of
Frequency of
Missing or invalid
Missing/incomplete/invalid principal procedure code. 239 Dental information.

period billed. 187 Date(s) of service.
Missing/incomplete/invalid beginning and ending dates of the Missing or invalid
period billed. 21 information.
Missing/incomplete/invalid days or units of service. 187 Date(s) of service.

Missing or invalid
Missing/incomplete/invalid days or units of service. 21 information.
Claim information is inconsistent with pre-certified/authorized Referral/authorizatio
services. 48 n.
Frequency of
259 service.
Frequency of
259 service.
Procedure Code
Modifier(s) for
Purchase and rental
No rental payments after the item is purchased, or after the price of durable
total of issued rental payments equals the purchase price. 186 medical equipment.
Purchase and rental
Consult plan benefit documents/guidelines for information price of durable
about restrictions for this service. 186 medical equipment.
Purchase and rental
Purchase and rental
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Days/units for
procedure/revenue
Information provided was illegible 258 code.
following the instructions included in your contract or plan Missing or invalid
benefit documents. 21 information.
Exceeds number/frequency approved/allowed within time Missing or invalid
period. 21 information.
Missing or invalid
Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. 21 information.
Other payer's
Explanation of
Benefits/payment
Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. 286 information.
Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. 456 Covered Day(s)

Days/units for
This item or service does not meet the criteria for the procedure/revenue
category under which it was billed. 258 code.
restrictions/billing/payment information related to these Per Day Limit
charges. 612 Amount
Frequency of
259 service.
Procedure Code
Modifier(s) for
Days/units for
The number of Days or Units of Service exceeds our procedure/revenue
acceptable maximum. 258 code.
Consult our contractual agreement for Days/units for
restrictions/billing/payment information related to these procedure/revenue
charges. 258 code.
charges. 612 Amount
Processed according
to plan provisions
(Plan refers to
between the Health
Plan and the
Consumer or
104 Patient)
Missing/incomplete/invalid/ deactivated/withdrawn National Procedure code for
Drug Code (NDC). 454 services rendered.
Processed according
to plan provisions
(Plan refers to
between the Health
Plan and the
Missing/incomplete/invalid billing provider/supplier primary Consumer or
identifier. 104 Patient)
Entity's
license/certification
Missing/incomplete/invalid CLIA certification number. 142 number.
Missing or invalid
Missing/incomplete/invalid CLIA certification number. 21 information.
Referring CLIA
Missing/incomplete/invalid CLIA certification number. 630 Number
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Facility admission
Missing/incomplete/invalid type of bill. 189 date
Missing or invalid
Missing/incomplete/invalid beginning and ending dates of the Facility admission

period billed. 189 date

Duplicate of a
previously
Days/units for
date. 258 code.
Entity not eligible
for submitted dates
Entity's
Missing/incomplete/invalid CLIA certification number. 142 number.
Missing or invalid
Missing/incomplete/invalid CLIA certification number. 21 information.
Referring CLIA
Missing/incomplete/invalid CLIA certification number. 630 Number
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Clinical Laboratory
Improvement
Missing/incomplete/invalid CLIA certification number. 544 Amendment
Missing/incomplete/invalid/ deactivated/withdrawn National Prescription
Drug Code (NDC). 219 number.
Missing/incomplete/invalid/ deactivated/withdrawn National Drug days supply
Drug Code (NDC). 221 and dosage.
Missing/incomplete/invalid name, strength, or dosage of the Missing or invalid
drug furnished. 21 information.
Missing/incomplete/invalid name, strength, or dosage of the Drug days supply
drug furnished. 221 and dosage.
Service not
84 authorized.
Entity's National
Days/units for
date. 258 code.

Not covered when performed during the same session/date as Frequency of
a previously processed service for the patient. 259 service.
Days/units for
date. 258 code.
Procedure code for

Consult plan benefit documents/guidelines for information Procedure code for

about restrictions for this service. 454 services rendered.
Length of time for
Missing documentation/orders/notes/summary/report/chart. 263 services rendered.
Supporting
Frequency of
Missing/incomplete/invalid prescribing date. 259 service.

Service denied because payment already made for Medical necessity

same/similar procedure within set time frame. 287 for service.
Service denied because payment already made for Supporting

same/similar procedure within set time frame. 294 documentation.
Exceeds number/frequency approved /allowed within time Frequency of

period without support documentation. 259 service.
Exceeds number/frequency approved /allowed within time Medical necessity

period without support documentation. 287 for service.
Exceeds number/frequency approved /allowed within time Supporting
period without support documentation. 294 documentation.

Please refer to your provider manual for additional program Missing or invalid
and provider information. 21 information.
Entity not
eligible/not
approved for dates
Days/units for
procedure/revenue
Not paid separately when the patient is an inpatient. 258 code.
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Patient ineligible for this service. 258 code.
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Service not payable with other service rendered on the same Procedure code for
date. 454 services rendered.
Days/units for
date. 258 code.
Days/units for
charges. 258 code.


Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Entity acknowledges
receipt of
19 claim/encounter.
Non-payable
Professional
Component Billed
598 Amount
Days/units for
date. 258 code.

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Missing or invalid
Revenue code for

Missing/incomplete/invalid HCPCS. 455 services rendered.
Missing or invalid
Revenue code for

Missing or invalid
Principal Procedure
Code for Service(s)
Missing/incomplete/invalid principal procedure code. 465 Rendered
Missing or invalid
Missing/incomplete/invalid admission hour. 21 information.
Days/units for
procedure/revenue
restrictions/billing/payment information related to these Denied Charge or
charges. 585 Non-covered Charge
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.

Days/units for
Exceeds number/frequency approved/allowed within time procedure/revenue
period. 258 code.
period. 476 units of service
Service denied because payment already made for Missing or invalid

same/similar procedure within set time frame. 21 information.


Days/units for
date. 258 code.
Days/units for
date. 258 code.




Days/units for
date. 258 code.
unprocessable. Please submit a new claim with the Frequency of
complete/correct information. 259 service.
Missing or invalid
Missing or invalid
Missing/incomplete/invalid charge. 21 information.
Processed according
to contract
that exist between
the Health Plan and
Missing/incomplete/invalid prescription quantity. 107 Care Services)
Frequency of
259 service.
Days/units for
date. 258 code.
Missing or invalid
Days/units for
procedure/revenue
Days/units for
date. 258 code.

Procedure code billed is not correct/valid for the services Missing or invalid
billed or the date of service billed. 21 information.
Claim has been
adjudicated and is
This should be billed with the appropriate code for these awaiting payment
services. 3 cycle.

Not covered when performed during the same session/date as Medical

a previously processed service for the patient. 297 notes/report.
Not covered when performed during the same session/date as Medical

a previously processed service for the patient. 297 notes/report.
Frequency of
259 service.
Days/units for
procedure/revenue
Procedure Code
Modifier(s) for
Missing/incomplete/invalid days or units of service. 453 Service(s) Rendered
Medical record does not support code billed per the code Medical
definition. 297 notes/report.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Entity acknowledges
receipt of
19 claim/encounter.
Non-payable
Professional
Component Billed
598 Amount
Missing or invalid
Revenue code for

Missing or invalid
Missing/incomplete/invalid discharge information. 21 information.
Revenue code for

Missing/incomplete/invalid discharge information. 455 services rendered.
Missing or invalid
Revenue code for

Missing or invalid
Revenue code for

Missing/incomplete/invalid discharge information. 455 services rendered.
services. 255 Diagnosis code.
Procedure Code
Service not payable with other service rendered on the same Modifier(s) for
date. 453 Service(s) Rendered
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
UB04/HCFA-
1450/1500 claim
Rebill services on separate claims. 276 form
Claim/submission
Rebill services on separate claims. 481 format is invalid.

Denied Charge or
No agreement with
96 entity.
Denied Charge or
Days/units for
date. 258 code.
Missing or invalid

Missing or invalid
Missing/incomplete/invalid value code(s) or amount(s). 725 NUBC Value Code(s)
Days/units for
Time frame requirements between this Procedure Code

service/procedure/supply and a related Modifier(s) for
service/procedure/supply have not been met. 453 Service(s) Rendered
Consult our contractual agreement for Procedure Code

restrictions/billing/payment information related to these Modifier(s) for
charges. 453 Service(s) Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Special handling
Incomplete/invalid required at payer
documentation/orders/notes/summary/report/chart. 41 site.
Special handling
required at payer
Missing documentation/orders/notes/summary/report/chart. 41 site.

Medical review
Incomplete/invalid attachment/informa
documentation/orders/notes/summary/report/chart. 421 tion for service(s)
Missing or invalid
Medical review
attachment/informa
Missing documentation/orders/notes/summary/report/chart. 421 tion for service(s)
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Maximum coverage
amount met or
Maximum coverage
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
The approved level of care does not match the procedure Frequency of
code submitted. 259 service.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Missing or invalid
Entity not eligible
for submitted dates
Missing/incomplete/invalid patient liability amount. 90 of service.
One or more
originally submitted
procedure codes
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of have been
service. 12 combined.
Days/units for
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of procedure/revenue
service. 258 code.
One or more
procedure codes
have been
Missing/incomplete/invalid days or units of service. 12 combined.
Days/units for
procedure/revenue
One or more
procedure codes
Missing/incomplete/invalid _x001A_to_x001A_ date(s) of have been
service. 12 combined.
Days/units for
Missing/incomplete/invalid _x001A_to_x001A_ date(s) of procedure/revenue
service. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Service not
84 authorized.
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Entity's Medicaid
Missing/incomplete/invalid designated provider number. 132 provider id.
Missing or invalid
Missing/incomplete/invalid designated provider number. 21 information.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
unprocessable. Please submit a new claim with the Entity's Medicaid
complete/correct information. 132 provider id.
unprocessable. Please submit a new claim with the Entity's specialty
complete/correct information. 144 license number.
Entity's Medicaid
Missing/incomplete/invalid designated provider number. 132 provider id.
Days/units for
date. 258 code.
Days/units for
Time frame requirements between this Days/units for
service/procedure/supply and a related procedure/revenue
service/procedure/supply have not been met. 258 code.
Days/units for
The number of Days or Units of Service exceeds our
acceptable maximum. 255 Diagnosis code.
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Rebill services on separate claim lines. 277 Paper claim.

Claim/service must
Rebill services on separate claim lines. 279 be itemized
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Procedure code billed is not correct/valid for the services Missing or invalid
billed or the date of service billed. 21 information.
Procedure code billed is not correct/valid for the services Family Planning
billed or the date of service billed. 568 Indicator
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Alert: Our records do not indicate that other insurance is on
file. Please submit other insurance information for our Claim submitted to
records. 116 incorrect payer.
Days/units for
Missing or invalid
Missing/incomplete/invalid payer identifier. 21 information.
Procedure code for
Missing/incomplete/invalid payer identifier. 454 services rendered.
Frequency of
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
The number of Days or Units of Service exceeds our Missing or invalid
acceptable maximum. 476 units of service
charges. 258 code.
restrictions/billing/payment information related to these Missing or invalid
charges. 476 units of service
Days/units for
date. 258 code.
charges. 21 information.
Consult our contractual agreement for Other Procedure
restrictions/billing/payment information related to these Code for Service(s)
charges. 490 Rendered
Procedure Code
Modifier(s) for
Procedure Code
Modifier(s) for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Missing or invalid
Type of bill for UB

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for
Procedure code for
Procedure code for

Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Duplicate of a
previously
Procedure code for

Procedure code for
Procedure code for
Procedure code for
Procedure code for
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Principal Procedure
Code for Service(s)
465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for

Add-on code cannot be billed by itself. 454 services rendered.
This drug/service/supply is covered only when the associated Procedure code for
service is covered. 454 services rendered.
Procedure code for

Procedure code incidental to primary procedure. 454 services rendered.
Procedure code for

Procedure code for

Procedure code for

Procedure code for
Days/units for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Days/units for
charges. 258 code.
charges. 612 Amount
Procedure code for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Not covered based on the insured's noncompliance with policy Missing or invalid
or statutory conditions. 21 information.
Not covered based on the insured's noncompliance with policy Procedure code for
or statutory conditions. 454 services rendered.

period. 21 information.
Exceeds number/frequency approved/allowed within time Procedure code for

Missing or invalid
Days/units for
procedure/revenue
Days/units for
date. 258 code.
date. 259 service.
date. 259 service.
Days/units for
charges. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 259 service.
Days/units for
457 Non-Covered Day(s)
The patient was not in a hospice program during all or part of

the service dates billed. 457 Non-Covered Day(s)
Service not payable with other service rendered on the same

date. 187 Date(s) of service.

Service denied because payment already made for Medical necessity

same/similar procedure within set time frame. 287 for service.

service/procedure/supply and a related Medical necessity
service/procedure/supply have not been met. 287 for service.
service/procedure/supply and a related Supporting
service/procedure/supply have not been met. 294 documentation.
Days/units for
procedure/revenue
258 code.
Days/units for
Days/units for
and no appeal rights are afforded because the claim is Procedure Code
unprocessable. Please submit a new claim with the Modifier(s) for
complete/correct information. 453 Service(s) Rendered
Entity not eligible
for submitted dates
90 of service.
date. 259 service.
date. 259 service.
Special Program
Missing/incomplete/invalid diagnosis or condition. 650 Indicator
Days/units for
Missing/incomplete/invalid days or units of service. 216 Drug information.
Frequency of
Maximum coverage
amount met or
Missing/incomplete/invalid days or units of service. 483 period.
Entity not eligible
for submitted dates
Supporting
Entity not eligible
for submitted dates
Supporting
Missing or invalid
21 information.
Frequency of
259 service.
Denied Charge or
255 Diagnosis code.
Diagnosis code(s)
for the services
488 rendered.
Missing or invalid
Resubmit a new claim with the requested information. 21 information.
Procedure Code
Modifier(s) for
Resubmit a new claim with the requested information. 453 Service(s) Rendered
Missing/incomplete/invalid attending provider primary Missing or invalid

Missing or invalid
21 information.
Procedure Code
Modifier(s) for
Missing or invalid
21 information.
Procedure Code
Modifier(s) for
Missing or invalid
Missing/incomplete/invalid rendering provider taxonomy. 21 information.
Missing/incomplete/invalid rendering provider primary Missing or invalid

256 DRG code(s).
273 Weight.
Procedure code for
The administration method and drug must be reported to Procedure code for
adjudicate this service. 454 services rendered.

Procedure code billed is not correct/valid for the services Frequency of

billed or the date of service billed. 259 service.
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Frequency of
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for
Procedure code for
Procedure code for
239 Dental information.
Payment reflects
usual and
66 customary charges.
Alert: Please see our web site, mailings, or bulletins for more Missing or invalid
details concerning this policy/procedure/decision. 21 information.
Procedure Code
Alert: Please see our web site, mailings, or bulletins for more Modifier(s) for
details concerning this policy/procedure/decision. 453 Service(s) Rendered
Procedure Code
This should be billed with the appropriate code for these Modifier(s) for
services. 453 Service(s) Rendered
Procedure Code
Alert: Please see our web site, mailings, or bulletins for more Modifier(s) for
details concerning this policy/procedure/decision. 453 Service(s) Rendered
Procedure Code
Maximum coverage
amount met or
Maximum coverage
amount met or
The number of Days or Units of Service exceeds our exceeded for benefit
acceptable maximum. 483 period.
Denied Charge or
This provider type/provider specialty may not bill this service. 585 Non-covered Charge
Days/units for
date. 258 code.
Diagnosis code(s)
Missing or invalid
Missing/incomplete/invalid initial treatment date. 21 information.



Procedure Code
Modifier(s) for
Missing/incomplete/invalid procedure code(s). 453 Service(s) Rendered
Missing or invalid
21 information.
Procedure Code
Modifier(s) for
This drug/service/supply is not included in the fee schedule or Denied Charge or

contracted/legislated fee arrangement. 585 Non-covered Charge
Information
submitted
inconsistent with
Missing/incomplete/invalid procedure code(s). 732 billing guidelines.
Information
submitted
inconsistent with
Missing/incomplete/invalid rendering provider taxonomy. 732 billing guidelines.

Days/units for
Days/units for
Not covered when performed during the same session/date as
a previously processed service for the patient. 187 Date(s) of service.

Procedure Code
Not covered when performed during the same session/date as Modifier(s) for
a previously processed service for the patient. 453 Service(s) Rendered
Procedure code incidental to primary procedure. 187 Date(s) of service.
Frequency of
Procedure code incidental to primary procedure. 259 service.
Procedure Code
Modifier(s) for
Procedure code incidental to primary procedure. 453 Service(s) Rendered

Medical review
Incomplete/invalid attachment/informa
documentation/orders/notes/summary/report/chart. 421 tion for service(s)
Missing or invalid
Medical review
attachment/informa
Missing documentation/orders/notes/summary/report/chart. 421 tion for service(s)
Missing or invalid
Primary diagnosis
code. This change
Principal doagnosis
Missing/incomplete/invalid principal procedure code. 254 code.
Diagnosis code(s)
for the services
Missing or invalid
Primary diagnosis
code. This change
Principal doagnosis
Diagnosis code(s)
for the services
Frequency of
259 service.
Days/units for
Days/units for
charges. 258 code.
Days/units for
date. 258 code.
unprocessable. Please submit a new claim with the Denied Charge or
complete/correct information. 585 Non-covered Charge
unprocessable. Please submit a new claim with the Policy Compliance
complete/correct information. 615 Code
Claim/line has been
Payment based on an alternate fee schedule. 65 paid.
Days/units for
date. 258 code.
Frequency of
Days/units for

Days/units for
Missing or invalid
Resubmit a new claim with the requested information. 21 information.
Procedure Code
Modifier(s) for
Resubmit a new claim with the requested information. 453 Service(s) Rendered
Procedure Code
date. 259 service.
date. 259 service.
Missing/incomplete/invalid revenue code(s). 256 DRG code(s).

Revenue code for
Claim/line has been
Missing/incomplete/invalid revenue code(s). 65 paid.
restrictions/billing/payment information related to these
charges. 256 DRG code(s).
restrictions/billing/payment information related to these Revenue code for
charges. 65 paid.
NUBC Condition
Missing/incomplete/invalid condition code. 460 Code(s)
Days/units for
date. 258 code.
Procedure Code
Service denied because payment already made for Modifier(s) for
same/similar procedure within set time frame. 453 Service(s) Rendered
Procedure Code
The number of Days or Units of Service exceeds our Modifier(s) for
acceptable maximum. 453 Service(s) Rendered
Diagnosis code(s)
for the services
Missing/incomplete/invalid provider number of the facility
where the patient resides. 109 Entity not eligible.
Claim information is inconsistent with pre-certified/authorized Service not
services. 84 authorized.
Service denied because payment already made for Service not
same/similar procedure within set time frame. 84 authorized.
Claim submitted to
Claim submitted to
Claim information is inconsistent with pre-certified/authorized Procedure code for
services. 454 services rendered.
Claim information is inconsistent with pre-certified/authorized Revenue code for

Procedure code not

Not eligible due to the patient's age. 475 valid for patient age
Procedure code and
patient gender
474 mismatch
Procedure Code
Medicare
entitlement
information is
Secondary payment cannot be considered without the identity required to
of or payment information from the primary payer. The determine primary
information was either not reported or was illegible. 283 coverage

Not covered when performed during the same session/date as Revenue code for
Service denied because payment already made for

same/similar procedure within set time frame. 187 Date(s) of service.
Service denied because payment already made for Revenue code for

Service not payable with other service rendered on the same Revenue code for

Not covered when performed during the same session/date as Revenue code for

Service denied because payment already made for Revenue code for

Service not payable with other service rendered on the same Revenue code for
Entity not
eligible/not
approved for dates
UB04/HCFA-
1450/1500 claim
Incorrect claim form/format for this service. 276 form
Claim/submission
Incorrect claim form/format for this service. 481 format is invalid.
Entity received
claim/encounter,
but returned invalid
Missing/incomplete/invalid replacement claim information. 18 status.
Missing or invalid
Entity's Postal/Zip
Missing/incomplete/invalid value code(s) or amount(s). 500 Code.
NUBC Value Code

Missing or invalid
NUBC Value Code
Days/units for
date. 258 code.
services. 48 n.
For more detailed
Claim information is inconsistent with pre-certified/authorized information, see
services. 1 remittance advice.


date. 259 service.
Procedure Code
date. 259 service.
Procedure Code
239 Dental information.
Payment reflects
usual and
66 customary charges.
Missing or invalid
NUBC Value Code

complete/correct information. 25 Entity not approved.
Other Procedure
Code for Service(s)
490 Rendered
Maximum coverage
amount met or
Maximum coverage
amount met or
restrictions/billing/payment information related to these Service not
charges. 84 authorized.
services. 48 n.
services. 48 n.
Alert: Please see our web site, mailings, or bulletins for more
details concerning this policy/procedure/decision. 25 Entity not approved.
Your claim contains incomplete and/or invalid information, Entity received
and no appeal rights are afforded because the claim is claim/encounter,
unprocessable. Please submit a new claim with the but returned invalid
complete/correct information. 18 status.
cation number. This
change effective
11/1/2011: Entity's
Claim information is inconsistent with pre-certified/authorized authorization/certific
services. 252 ation number.
restrictions/billing/payment information related to these Procedure code for
services. 48 n.
Entity not
eligible/not
approved for dates
Days/units for
date. 258 code.
Missing or invalid
Days/units for
date. 258 code.
Awaiting related
42 charges.
Days/units for
date. 258 code.

Days/units for
date. 258 code.
Missing or invalid
21 information.
255 Diagnosis code.
Principal Procedure
Code for Service(s)
Missing/incomplete/invalid procedure code(s). 465 Rendered
Missing or invalid
Other payer's
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Maximum coverage
Days/units for
Days/units for
Days/units for
The number of Days or Units of Service exceeds our Supporting

acceptable maximum. 294 documentation.
charges. 258 code.
restrictions/billing/payment information related to these Supporting
charges. 294 documentation.
Maximum coverage
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Your claim contains incomplete and/or invalid information, Entity not
and no appeal rights are afforded because the claim is eligible/not
unprocessable. Please submit a new claim with the approved for dates
complete/correct information. 91 of service.

Frequency of
Missing or invalid
Entity's National
Provider Identifier
The provider must update license information with the payer. 562 (NPI).
Entity not
eligible/not
approved for dates
The provider must update license information with the payer. 91 of service.
This service/claim is
included in the
allowance for
another service or
Not paid separately when the patient is an inpatient. 735 claim.
Procedure code for


Processed according
to plan provisions
(Plan refers to
between the Health
Plan and the
Per legislation governing this program, payment constitutes Consumer or
payment in full. 104 Patient)
Not paid separately when the patient is an inpatient. 249 Place of service.
Not paid separately when the patient is an inpatient. 250 Type of service.
Missing/incomplete/invalid place of service. 250 Type of service.
Not paid separately when the patient is an inpatient. 249 Place of service.
Not paid separately when the patient is an inpatient. 250 Type of service.

Missing/incomplete/invalid provider number of the facility
where the patient resides. 109 Entity not eligible.
Not covered when performed in this place of service. 249 Place of service.
Missing/incomplete/invalid other payer rendering provider Missing or invalid
Entity's National
Missing/incomplete/invalid other payer rendering provider Provider Identifier
Missing/incomplete/invalid other payer rendering provider Missing or invalid
Entity's National
Missing/incomplete/invalid other payer rendering provider Provider Identifier
Alert: Patient eligible to apply for other coverage which may Claim submitted to
be primary. 116 incorrect payer.
Patient's
condition/functional
status at time of
Missing/incomplete/invalid condition code. 431 service.
NUBC Condition
Missing or invalid
Type of bill for UB

Alert: Please see our web site, mailings, or bulletins for more Reimbursement
details concerning this policy/procedure/decision. 631 Rate
Entity's Medicaid
132 provider id.
Entity not
eligible/not
approved for
dates of
91 service.
Claim Total Denied
Missing/incomplete/invalid diagnosis or condition. 542 Charge Amount
Entity not eligible
for benefits for
submitted dates of
Resubmit a new claim with the requested information. 88 service.
Claim combined
Rebill services on separate claims. 103 with other claim(s).
Frequency of
259 service.
Procedure Code
Modifier(s) for
Frequency of
259 service.
Procedure Code
Modifier(s) for
Frequency of
259 service.
Procedure Code
Modifier(s) for
Purchase and rental
No rental payments after the item is purchased, or after the Claim/line has been
total of issued rental payments equals the purchase price. 65 paid.
Purchase and rental
Consult plan benefit documents/guidelines for information Claim/line has been
about restrictions for this service. 65 paid.
Purchase price for
the rented durable
Missing/incomplete/invalid diagnosis or condition. 184 medical equipment.
Entity not eligible
for benefits for
submitted dates of
Missing/incomplete/invalid discharge or end of care date. 88 service.
restrictions/billing/payment information related to these Service not
charges. 84 authorized.
Processed according
to contract
that exist between
the Health Plan and
Alert: Do not resubmit this claim/service. 107 Care Services)
Denied Charge or
Alert: Do not resubmit this claim/service. 585 Non-covered Charge
Entity not eligible
for dental benefits
for submitted dates
No payment will be
9 made for this claim.
Other payer's
Explanation of
Benefits/payment
286 information.
Days/units for
Days/units for
Missing or invalid
Revenue code for
Procedure code billed is not correct/valid for the services Procedure code for
billed or the date of service billed. 454 services rendered.
Denied Charge or
Days/units for
charges. 258 code.
Denied Charge or
Facility discharge
Missing/incomplete/invalid patient status. 190 date
Procedures for billing with group/referring/performing Entity's Medicaid

providers were not followed. 132 provider id.
Procedures for billing with group/referring/performing Missing or invalid

providers were not followed. 21 information.
Procedure Code
Modifier(s) for
Entity's date of
159 death.
Facility discharge
190 date
Missing or invalid
Procedure code for

Procedure code for

Service not payable with other service rendered on the same Missing or invalid
date. 21 information.
Maximum coverage
Frequency of
259 service.
Duplicate of a
previously
Frequency of
259 service.
Per Day Limit

612 Amount
same/similar procedure within set time frame. 442 Modalities of service
service/procedure/supply and a related
service/procedure/supply have not been met. 442 Modalities of service
Days/units for
Exceeds number/frequency approved/allowed within time procedure/revenue
period. 258 code.
Reason for
Exceeds number/frequency approved/allowed within time transport by
period. 428 ambulance
Days/units for
date. 258 code.
Reason for
Exceeds number/frequency approved/allowed within time transport by
period. 428 ambulance
Days/units for
procedure/revenue
258 code.
Missing or invalid
Anesthesia
522 Modifying Units
Missing or invalid
same/similar procedure within set time frame. 476 units of service
Days/units for
procedure/revenue
Add-on code cannot be billed by itself. 258 code.
Procedure code for

Anesthesia Unit
Add-on code cannot be billed by itself. 523 Count
Days/units for
date. 258 code.
For more detailed
Please refer to your provider manual for additional program information, see
and provider information. 1 remittance advice.
Days/units for
charges. 258 code.
Consult plan benefit documents/guidelines for information
about restrictions for this service. 187 Date(s) of service.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure Code
Modifier(s) for
Not eligible due to the patient's age. 453 Service(s) Rendered
Procedure Code
Consult plan benefit documents/guidelines for information Modifier(s) for
about restrictions for this service. 453 Service(s) Rendered
about restrictions for this service. 187 Date(s) of service.
Drug Code (NDC). 457 Non-Covered Day(s)
Not covered when performed during the same session/date as Denied Charge or
a previously processed service for the patient. 585 Non-covered Charge
Service denied because payment already made for Denied Charge or

same/similar procedure within set time frame. 585 Non-covered Charge
Service not payable with other service rendered on the same Denied Charge or
date. 585 Non-covered Charge
Missing or invalid
21 information.
Purchase and rental
Purchase and rental
Purchase and rental
Purchase and rental
Purchase price for
No rental payments after the item is purchased, or after the the rented durable
Purchase price for
No rental payments after the item is purchased, or after the the rented durable
Entity not
eligible/not
approved for dates
Missing/incomplete/invalid diagnosis or condition. 91 of service.
Duplicate of a
previously
Duplicate of a
previously
Days/units for
Diagnosis code(s)
for the services
Procedure Code
Procedure Code
date. 259 service.
Procedure Code
Procedure code for
Purchase and rental
Payment for repair or replacement is not covered or has price of durable
exceeded the purchase price. 186 medical equipment.
Maximum coverage
amount met or
Payment for repair or replacement is not covered or has exceeded for benefit
exceeded the purchase price. 483 period.
Purchase and rental
Exceeds number/frequency approved /allowed within time price of durable
period without support documentation. 186 medical equipment.
Maximum coverage
amount met or
Exceeds number/frequency approved /allowed within time exceeded for benefit
period without support documentation. 483 period.
date. 259 service.
Service not payable with other service rendered on the same Per Day Limit
date. 612 Amount
Frequency of
259 service.
Per Day Limit
612 Amount

Purchase and rental
Maximum coverage
amount met or
Purchase and rental
Maximum coverage
amount met or
Procedure code for
Missing or invalid
Entity's Postal/Zip
Missing/incomplete/invalid value code(s) or amount(s). 500 Code.
NUBC Value Code

and no appeal rights are afforded because the claim is Procedure Code
unprocessable. Please submit a new claim with the Modifier(s) for
complete/correct information. 453 Service(s) Rendered
Maximum coverage
amount met or
Days/units for
date. 258 code.

The number of Days or Units of Service exceeds our Procedure code for
acceptable maximum. 454 services rendered.
Claim could not
complete
adjudication in real
time. Claim will
continue processing
in a batch mode. Do
Alert: Do not resubmit this claim/service. 685 not resubmit.
Claim could not
complete
time. Claim will
continue processing
in a batch mode. Do
Procedure code for
Claim could not
complete
time. Claim will
continue processing
in a batch mode. Do
Entity's
specialty/taxonomy
Missing/incomplete/invalid principal procedure code. 145 code.
Entity's
specialty/taxonomy
Missing/incomplete/invalid procedure date(s). 145 code.
Service denied because payment already made for X-rays/radiology
same/similar procedure within set time frame. 318 films
service/procedure/supply and a related X-rays/radiology
service/procedure/supply have not been met. 318 films
restrictions/billing/payment information related to these X-rays/radiology
charges. 318 films
Internal
Alert: Do not resubmit this claim/service. 46 review/audit.
charges. 318 films
charges. 318 films
Special handling
required at payer
Alert: Do not resubmit this claim/service. 41 site.
Claim could not
complete
time. Claim will
continue processing
in a batch mode. Do
Awaiting next
periodic
Alert: Do not resubmit this claim/service. 38 adjudication cycle.
Internal
Claim could not
complete
time. Claim will
continue processing
in a batch mode. Do
Service denied because payment already made for Medical
same/similar procedure within set time frame. 297 notes/report.
The number of Days or Units of Service exceeds our Medical
acceptable maximum. 297 notes/report.

date. 218 NDC number.
Duplicate of a
previously
Service not payable with other service rendered on the same processed
date. 54 claim/line.
Frequency of
This service is paid only once in a patient_x001A_s lifetime. 259 service.
Missing or invalid
Medical
Missing or invalid
Medical
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Duplicate of a
previously
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Not covered unless a pre-requisite procedure/service has procedure/revenue
been provided. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Frequency of
Days/units for
date. 258 code.
Days/units for
date. 258 code.

HCPCS Payable
Service denied because payment already made for Amount Home
same/similar procedure within set time frame. 574 Health

HCPCS Payable
The number of Days or Units of Service exceeds our Amount Home
acceptable maximum. 574 Health
Days/units for
date. 258 code.
Diagnosis code(s)
for the services
Missing/incomplete/invalid other procedure code(s). 488 rendered.
Missing or invalid
Medical
Entity's National
Provider Identifier
562 (NPI).
Entity not
eligible/not
approved for dates
91 of service.
Missing or invalid
Medical
Days/units for
procedure/revenue
This provider type/provider specialty may not bill this service. 258 code.
Maximum coverage
Maximum coverage
amount met or
Maximum coverage
amount met or
Days/units for
Days/units for
Days/units for
Maximum coverage
amount met or
Days/units for
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Missing or invalid
Principal Procedure
Code for Service(s)
Missing or invalid
Principal Procedure
Code for Service(s)
Missing or invalid
Principal Procedure
Code for Service(s)
Missing or invalid
Principal Procedure
Code for Service(s)
date. 259 service.
Duplicate of a
previously
Days/units for
date. 258 code.
date. 259 service.
charges. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Claim/service must
Missing plan information for other insurance. 279 be itemized
Other payer's
Explanation of
Benefits/payment
Missing plan information for other insurance. 286 information.
Claim is out of
Missing plan information for other insurance. 400 balance
Days/units for
date. 258 code.
Days/units for

Days/units for
date. 258 code.
Missing/incomplete/invalid billing provider/supplier address. 126 Entity's address.

Missing or invalid
Missing/incomplete/invalid billing provider/supplier address. 21 information.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Duplicate of a
previously
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for

Rebill services on separate claim lines. 454 services rendered.
complete/correct information. 216 Drug information.
Missing or invalid
Missing/incomplete/invalid gender. 21 information.
Diagnosis and
patient gender
Missing/incomplete/invalid gender. 86 mismatch.
Missing or invalid
Diagnosis and
patient gender
Missing/incomplete/invalid diagnosis or condition. 86 mismatch.
date. 259 service.
Processed according
to contract
that exist between
the Health Plan and
Procedure code incidental to primary procedure. 107 Care Services)
Procedure Code
Modifier(s) for
Processed according
to contract
that exist between
the Health Plan and
Service not payable with other service rendered on the same a Provider of Health
date. 107 Care Services)
Procedure Code
Processed according
to contract
that exist between
Consult our contractual agreement for the Health Plan and
restrictions/billing/payment information related to these a Provider of Health
charges. 107 Care Services)

Processed according
to contract
that exist between
the Health Plan and
Procedure code incidental to primary procedure. 107 Care Services)
Procedure Code
Modifier(s) for
Processed according
to contract
that exist between
the Health Plan and
Service not payable with other service rendered on the same a Provider of Health
date. 107 Care Services)
Procedure Code
Processed according
to contract
that exist between
Consult our contractual agreement for the Health Plan and
restrictions/billing/payment information related to these a Provider of Health
charges. 107 Care Services)

Days/units for
date. 258 code.
date. 259 service.
date. 259 service.
Days/units for

Waiting for final
Missing review organization approval. 40 approval.
Missing or invalid
Procedure code for
Maximum coverage
amount met or
Maximum coverage
amount met or
Denied services exceed the coverage limit for the exceeded for benefit
demonstration. 483 period.
Missing or invalid
Diagnosis code(s)
for the services
Missing or invalid
Diagnosis code(s)
for the services
Waiting for final
Missing review organization approval. 40 approval.
Missing or invalid
Diagnosis code(s)
for the services
48 n.
Other payer's
Explanation of
Benefits/payment
286 information.
Entity not
eligible/not
approved for dates
91 of service.
Days/units for
Maximum coverage
amount met or
Days/units for
Maximum coverage
amount met or
Days/units for
Mismatch between the submitted provider information and Service not

the provider information stored in our system. 84 authorized.
Diagnosis code(s)
for the services
Service not
Missing/incomplete/invalid principal diagnosis. 84 authorized.
255 Diagnosis code.

Service not
84 authorized.
Claim information is inconsistent with pre-certified/authorized
Procedure code for
Maximum coverage

Diagnosis code(s)
Other payer's
Explanation of
Benefits/payment
286 information.
Missing/incomplete/invalid principal diagnosis. 255 Diagnosis code.

Procedure code for
Claim information is inconsistent with pre-certified/authorized
Diagnosis code(s)
for the services
488 rendered.
Missing/incomplete/invalid referring provider primary Missing or invalid
Missing/incomplete/invalid referring provider primary Entity's primary
identifier. 755 identifier.
Entity not
eligible/not
approved for dates
91 of service.
Missing/incomplete/invalid physical location (name and
address, or PIN) where the service(s) were rendered in a
Health Professional Shortage Area (HPSA). 153 Entity's id number.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
Missing/incomplete/invalid attending provider primary approved for dates
Procedure code for
Denied Charge or
Missing or invalid
Revenue code for
Denied Charge or
Entity's
specialty/taxonomy
Please refer to your provider manual for additional program Procedure code for
and provider information. 454 services rendered.
Procedure code for
Original date of
prescription/orders/
Missing/incomplete/invalid prescribing date. 214 referral.
NUBC Condition
Procedure Code


Procedure Code

service/procedure/supply have not been met. 187 Date(s) of service.
Procedure Code
Modifier(s) for
Service not payable with other service rendered on the same Medical
date. 297 notes/report.

same/similar procedure within set time frame. 26 Entity not found.





Drug Code (NDC). 476 units of service
Missing/incomplete/invalid days or units of service. 218 NDC number.
Missing or invalid
Alert: The NDC code submitted for this service was translated
to a HCPCS code for processing, but please continue to
submit the NDC on future claims for this item. 218 NDC number.
to a HCPCS code for processing, but please continue to Missing or invalid
submit the NDC on future claims for this item. 476 units of service










Entity's National
Missing/incomplete/invalid ordering provider primary Provider Identifier
Missing/incomplete/invalid ordering provider primary Entity must be a
identifier. 741 person.
Entity's National
Provider Identifier
562 (NPI).
Entity must be a
741 person.
Entity's National
Missing/incomplete/invalid operating provider primary Provider Identifier
Other insurance
coverage
information (health,
Missing/incomplete/invalid patient liability amount. 171 liability, auto, etc.).
Days/units for
charges. 258 code.
charges. 612 Amount
Your claim contains incomplete and/or invalid information, Duplicate of a
and no appeal rights are afforded because the claim is previously
unprocessable. Please submit a new claim with the processed
complete/correct information. 54 claim/line.
Procedure code not

475 valid for patient age
Information
submitted
This should be billed with the appropriate code for these inconsistent with
services. 732 billing guidelines.
Type of bill for UB
Missing/incomplete/invalid place of service. 228 claim

Procedure code for
Missing or invalid
Missing/incomplete/invalid last x-ray date. 21 information.
Missing/incomplete/invalid procedure date(s). 187 Date(s) of service.

Test Performed
Missing/incomplete/invalid procedure date(s). 653 Date
Treatment plan for
Missing/incomplete/invalid diagnosis or condition. 345 service/diagnosis
Missing/incomplete/invalid diagnosis or condition. 557 Diagnosis Date
Missing/incomplete/invalid diagnosis date. 255 Diagnosis code.

Treatment plan for
Missing/incomplete/invalid diagnosis date. 345 service/diagnosis
Missing/incomplete/invalid diagnosis date. 557 Diagnosis Date

Diagnosis code(s)


Procedure code for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Other Procedure
This drug/service/supply is covered only when the associated Code for Service(s)
service is covered. 490 Rendered

Missing/incomplete/invalid diagnosis or condition. 745 Identifier Qualifier

This item or service does not meet the criteria for the Procedure code for
category under which it was billed. 454 services rendered.
Diagnosis code(s)
This item or service does not meet the criteria for the for the services
category under which it was billed. 488 rendered.



Procedure code for

Procedure code for

Alert: Do not resubmit this claim/service. 126 Entity's address.





date. 259 service.





date. 259 service.
same/similar procedure within set time frame. 21 information.
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Days/units for
date. 258 code.
Frequency of
259 service.
Procedure Code
Modifier(s) for
Days/units for
This drug/service/supply is covered only when the associated procedure/revenue
service is covered. 258 code.
Missing/incomplete/invalid Electronic Funds Transfer (EFT) Denied Charge or

banking information. 585 Non-covered Charge
Missing or invalid
unprocessable. Please submit a new claim with the Amount must be
complete/correct information. 402 greater than zero.
Electronic interchange agreement not on file for Missing or invalid
provider/submitter. 21 information.
Processed according
to contract
that exist between
the Health Plan and
Missing/incomplete/invalid days or units of service. 107 Care Services)
Missing/incomplete/invalid name, strength, or dosage of the
drug furnished. 216 Drug information.
date. 259 service.
Procedure Code
Modifier(s) for
Missing or invalid
21 information.
Procedure Code
Modifier(s) for
Other payer's
of or payment information from the primary payer. The Total Medicare Paid
information was either not reported or was illegible. 655 Amount
Days/units for
date. 258 code.
Missing/incomplete/invalid provider number of the facility Missing or invalid

where the patient resides. 21 information.
Entity's National
Missing/incomplete/invalid provider number of the facility Provider Identifier
where the patient resides. 562 (NPI).
Missing/incomplete/invalid attending provider primary Missing or invalid

Entity's National
Missing/incomplete/invalid attending provider primary Provider Identifier
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Days/units for
date. 258 code.
Frequency of
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Missing or invalid
Principal Procedure
Code for Service(s)
Not covered unless a pre-requisite procedure/service has Missing or invalid

been provided. 21 information.
Principal Procedure
Not covered unless a pre-requisite procedure/service has Code for Service(s)
been provided. 465 Rendered
Maximum coverage
amount met or
Maximum coverage
amount met or
Principal Procedure
This drug/service/supply is covered only when the associated Code for Service(s)
service is covered. 465 Rendered
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Exceeds number/frequency approved/allowed within time Procedure code for
Exceeds number/frequency approved/allowed within time Per Day Limit
period. 612 Amount
Frequency of
Missing/incomplete/invalid procedure code(s). 259 service.
Procedure code for
Frequency of
Missing/incomplete/invalid procedure code(s). 259 service.
Procedure code for
Lifetime Reserve
Missing/incomplete/invalid procedure code(s). 459 Day(s)
Entity's
specialty/taxonomy
Missing/incomplete/invalid rendering provider taxonomy. 145 code.
Missing or invalid
Entity's
specialty/taxonomy
Missing/incomplete/invalid attending provider taxonomy. 145 code.
Missing or invalid
Missing/incomplete/invalid attending provider taxonomy. 21 information.
Entity's
specialty/taxonomy
Missing/incomplete/invalid billing provider taxonomy. 145 code.
Missing or invalid
Missing/incomplete/invalid billing provider taxonomy. 21 information.
Missing or invalid
Missing/incomplete/invalid pay-to provider primary identifier. 21 information.
Entity's National
Provider Identifier
Missing/incomplete/invalid pay-to provider primary identifier. 562 (NPI).
Missing or invalid
Missing/incomplete/invalid prescribing provider identifier. 21 information.
Entity's National
Provider Identifier
Missing/incomplete/invalid prescribing provider identifier. 562 (NPI).
Missing or invalid
Entity's National
Provider Identifier
Missing or invalid
Entity's National
Provider Identifier
Days/units for
Days/units for
Days/units for
This drug/service/supply is covered only when the associated procedure/revenue
service is covered. 258 code.
Entity not
eligible/not
approved for dates
91 of service.
Entity_x001A_s
credential/enrollmen
743 t information.
Missing or invalid
Type of bill for UB
Missing or invalid
Revenue code for
Days/units for
Maximum coverage
amount met or
Days/units for
Maximum coverage
amount met or
date. 259 service.
Not covered when performed during the same session/date as Missing or invalid
a previously processed service for the patient. 21 information.
Days/units for

service/procedure/supply and a related Procedure code for
service/procedure/supply have not been met. 454 services rendered.

Procedure Code

Principal Procedure
Code for Service(s)
Add-on code cannot be billed by itself. 465 Rendered
Principal Procedure
Code for Service(s)
Procedure code incidental to primary procedure. 465 Rendered
Denied Charge or
Denied Charge or
Service denied because payment already made for Entity's date of

same/similar procedure within set time frame. 159 death.
Days/units for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Alert: Please see our web site, mailings, or bulletins for more Frequency of
details concerning this policy/procedure/decision. 259 service.
Alert: Please see our web site, mailings, or bulletins for more Frequency of
details concerning this policy/procedure/decision. 259 service.
Frequency of
Diagnosis code(s)
for the services
Policy benefits have been exhausted. 488 rendered.
Service denied because payment already made for Other Procedure
same/similar procedure within set time frame. 492 Date
Days/units for
Days/units for
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Procedure code for

Procedure code for

Entity's
specialty/taxonomy
Entity not
eligible/not
approved for dates
Missing/incomplete/invalid designated provider number. 91 of service.
Missing/incomplete/invalid designated provider number. 26 Entity not found.

Entity's health
maintenance
139 provider id (HMO).
Maximum coverage
amount met or
Maximum coverage
Time frame requirements between this amount met or
service/procedure/supply and a related exceeded for benefit
service/procedure/supply have not been met. 483 period.
Separately billed services/tests have been bundled as they are
considered components of the same procedure. Separate Denied Charge or
payment is not allowed. 585 Non-covered Charge
Denied Charge or
Procedure code incidental to primary procedure. 585 Non-covered Charge

and no appeal rights are afforded because the claim is For more detailed
unprocessable. Please submit a new claim with the information, see
complete/correct information. 1 remittance advice.
Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
Your claim contains incomplete and/or invalid information, claim. Correct the
and no appeal rights are afforded because the claim is payer claim control
unprocessable. Please submit a new claim with the number and re-
complete/correct information. 495 submit.
For more detailed
information, see
Missing/incomplete/invalid replacement claim information. 1 remittance advice.
Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
claim. Correct the
payer claim control
number and re-
Missing/incomplete/invalid replacement claim information. 495 submit.

Service date outside of the approved treatment plan service Procedure code for
dates. 454 services rendered.
This provider type/provider specialty may not bill this service. 187 Date(s) of service.
Procedure code for
This provider type/provider specialty may not bill this service. 454 services rendered.
Procedure code for
Procedure code for
The original claim was denied. Resubmit a new claim, not a Missing or invalid
replacement claim. 476 units of service
Procedure Code


Days/units for
Claim information is inconsistent with pre-certified/authorized procedure/revenue
services. 258 code.
services. 48 n.
Claim information is inconsistent with pre-certified/authorized Authorization
services. 674 exceeded
The number of Days or Units of Service exceeds our Authorization
acceptable maximum. 674 exceeded


Missing or invalid
Missing or invalid
Missing/incomplete/invalid revenue code(s). 476 units of service


Frequency of
259 service.
Entity not
eligible/not
approved for dates
91 of service.
Missing/incomplete/invalid rendering provider primary
identifier. 26 Entity not found.
Family Planning
Missing/Incomplete/Invalid Family Planning Indicator. 568 Indicator
complete/correct information. 239 Dental information.
services. 256 DRG code(s).
Procedure code for
Primary diagnosis
code. This change
Principal doagnosis
Missing/incomplete/invalid principal diagnosis. 254 code.
Related Causes
Code (Accident,
auto accident,
Missing/incomplete/invalid diagnosis or condition. 633 employment)
Missing/incomplete/invalid rendering provider primary

identifier. 153 Entity's id number.
Days/units for
procedure/revenue
Other payer's
Explanation of
Benefits/payment
286 information.
Missing/incomplete/invalid internal or document control Document Control
number. 559 Identifier
Missing or invalid
Procedure code for
Missing or invalid
Principal Procedure
Code for Service(s)
Missing or invalid
Missing/incomplete/invalid principal diagnosis. 21 information.
Primary diagnosis
code. This change
Principal doagnosis
Missing/incomplete/invalid principal diagnosis. 254 code.
Missing or invalid
Missing/incomplete/invalid oral cavity designation code. 21 information.
Tooth numbers,
surfaces, and/or
Missing/incomplete/invalid oral cavity designation code. 242 quadrants involved.
Missing or invalid
Procedure Code

Missing/incomplete/invalid billing provider/supplier primary Missing or invalid
Entity's National
Missing or invalid
Missing/Incomplete/Invalid Present on Admission indicator. 21 information.
Present on
Admission Indicator
for reported
Missing/Incomplete/Invalid Present on Admission indicator. 688 diagnosis code(s).
and no appeal rights are afforded because the claim is Were services
unprocessable. Please submit a new claim with the related to an
complete/correct information. 471 emergency?
Other payer's
Explanation of
Benefits/payment
286 information.
Missing/incomplete/invalid admitting diagnosis. 232 Admitting diagnosis.

Principal Procedure
Missing/incomplete/invalid principal procedure date. 486 Date
Hospital discharge
Missing/incomplete/invalid discharge hour. 233 hour.
Facility discharge
Missing/incomplete/invalid discharge or end of care date. 190 date
Missing/incomplete/invalid _x001A_from_x001A_ date(s) of Facility admission
service. 189 date
NUBC Occurrence
Missing/incomplete/invalid occurrence date(s). 720 Code Date(s)
NUBC Occurrence
Missing/incomplete/invalid occurrence date(s). 720 Code Date(s)
Missing/incomplete/invalid internal or document control Claim submitter's
number. 478 identifier
Patient discharge
Missing/incomplete/invalid discharge information. 234 status.
Facility discharge
Missing/incomplete/invalid discharge information. 190 date
Entity's date of
Missing/incomplete/invalid subscriber birth date. 158 birth.
NUBC Condition
NUBC Occurrence
Missing/incomplete/invalid occurrence code(s). 719 Code(s)
NUBC Condition
NUBC Condition
NUBC Occurrence
Missing/incomplete/invalid occurrence span date(s). 722 Span Code Date(s)
Rebill services on separate claim lines. 456 Covered Day(s)
Rebill services on separate claim lines. 456 Covered Day(s)
Primary diagnosis
code. This change
Principal doagnosis
Missing/incomplete/invalid number of coinsurance days during
the billing period. 458 Coinsurance Day(s)
Missing/incomplete/invalid noncovered days during the billing
period. 457 Non-Covered Day(s)
Other payer's
Explanation of
Benefits/payment
286 information.
NUBC Occurrence
Missing/incomplete/invalid occurrence span date(s). 722 Span Code Date(s)
Other payer's
Explanation of
Benefits/payment
286 information.
Entity's date of
Missing/incomplete/invalid patient birth date. 158 birth.
Entity's date of
Missing/incomplete/invalid patient birth date. 158 birth.
Payer Assigned
Claim Control
Missing/incomplete/invalid replacement claim information. 464 Number
unprocessable. Please submit a new claim with the Claim/submission
complete/correct information. 481 format is invalid.
Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for







Procedure code for
Procedure code for






















Procedure code for

Procedure code for





included in the
allowance for
Not covered when performed during the same session/date as another service or
a previously processed service for the patient. 735 claim.
included in the
allowance for
Service not payable with other service rendered on the same another service or
date. 735 claim.
Procedure code for

Procedure code for

included in the
allowance for
Not covered when performed during the same session/date as another service or
a previously processed service for the patient. 735 claim.
included in the
allowance for
Service not payable with other service rendered on the same another service or
date. 735 claim.











Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for












Procedure code for

Procedure code for

Procedure code for

Procedure code for





Days/units for

Maximum coverage
amount met or
Maximum coverage
Maximum coverage
amount met or
Maximum coverage
considered components of the same procedure. Separate Procedure code for
payment is not allowed. 454 services rendered.


Days/units for
charges. 258 code.
Days/units for
charges. 258 code.




Principal Procedure
Code for Service(s)
Principal Procedure
Code for Service(s)
Frequency of
Frequency of
Anesthesia Unit
523 Count
Frequency of
259 service.
Maximum coverage
Maximum coverage
Maximum coverage
charges. 21 information.
Procedure Code
Procedure Code
Procedure Code
Frequency of
259 service.
Procedure Code
Modifier(s) for
date. 259 service.





date. 259 service.
date. 259 service.




date. 259 service.
Procedure Code

Procedure Code

Procedure Code
Days/units for
Days/units for
date. 258 code.
date. 259 service.
Procedure code for

Revenue code for

Procedure code for

Revenue code for

Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
For more detailed
information, see
Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
claim. Correct the
payer claim control
number and re-
Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
For more detailed
information, see
Requests for re-
adjudication must
reference the newly
assigned payer
claim control
number for this
previously adjusted
claim. Correct the
payer claim control
number and re-
Procedure code or procedure rate count cannot be
determined, or was not on file, for the date of Procedure code for
service/provider. 454 services rendered.
determined, or was not on file, for the date of Revenue code for
service/provider. 455 services rendered.
No payment will be
Missing/incomplete/invalid prescription quantity. 9 made for this claim.
No payment will be
Duplicate of a
previously
Days/units for
Days/units for
Purchase and rental
Purchase and rental
No payment will be
No payment will be
No payment will be
No payment will be
Procedure code for

Procedure code for

considered components of the same procedure. Separate
payment is not allowed. 187 Date(s) of service.
Separately billed services/tests have been bundled as they are Procedure Code
considered components of the same procedure. Separate Modifier(s) for
payment is not allowed. 453 Service(s) Rendered

Procedure Code

Procedure Code
No payment will be
No payment will be
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Internal
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Medical necessity
Consult plan benefit documents/guidelines for information for non-routine
about restrictions for this service. 411 service(s)
Services/charges
related to the
treatment of a
hospital-acquired
condition or
Consult plan benefit documents/guidelines for information preventable medical
about restrictions for this service. 744 error.
Medical necessity
Consult plan benefit documents/guidelines for information for non-routine
about restrictions for this service. 411 service(s)
Services/charges
related to the
treatment of a
hospital-acquired
condition or
Consult plan benefit documents/guidelines for information preventable medical
about restrictions for this service. 744 error.
Type of bill for UB
228 claim
Claim Frequency
535 Code
Type of bill for UB
228 claim
Services/charges
related to the
treatment of a
hospital-acquired
condition or
This should be billed with the appropriate code for these preventable medical
services. 744 error.
Missing/incomplete/invalid other diagnosis. 255 Diagnosis code.

Alert: This decision may be reviewed if additional
documentation as described in the contract or plan benefit Supporting
documents is submitted. 294 documentation.
Alert: This decision may be reviewed if additional Procedure Code

documentation as described in the contract or plan benefit Modifier(s) for
documents is submitted. 453 Service(s) Rendered
documentation as described in the contract or plan benefit Per Day Limit
documents is submitted. 612 Amount
The number of Days or Units of Service exceeds our Supporting

acceptable maximum. 294 documentation.
Procedure Code
Procedure Code
Modifier(s) for
Missing/incomplete/invalid days or units of service. 453 Service(s) Rendered
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
charges. 258 code.

Procedure Code

Procedure Code
Days/units for
charges. 258 code.
charges. 612 Amount
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code


Procedure Code

date. 259 service.
Procedure Code


Procedure Code
date. 259 service.
Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
charges. 258 code.
charges. 258 code.
Days/units for
procedure/revenue
Frequency of
Missing or invalid
service/procedure/supply and a related Missing or invalid
service/procedure/supply have not been met. 476 units of service
Days/units for
Days/units for
procedure/revenue
Frequency of
Missing or invalid
service/procedure/supply and a related Missing or invalid
service/procedure/supply have not been met. 476 units of service
Days/units for
Days/units for
date. 258 code.
Duplicate of a
previously
Frequency of
259 service.
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Days/units for
date. 258 code.
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Duplicate of a
previously
Days/units for
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
Duplicate of a
previously
Days/units for
procedure/revenue
Days/units for
procedure/revenue
charges. 258 code.
Procedure Code
Modifier(s) for
Missing or invalid
Frequency of
259 service.
Per Day Limit
612 Amount
Other Procedure
Service denied because payment already made for Code for Service(s)
same/similar procedure within set time frame. 490 Rendered
Other Procedure
Service not payable with other service rendered on the same Code for Service(s)
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Principal Procedure
Code for Service(s)
Principal Procedure
Code for Service(s)
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Days/units for
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Not covered when performed during the same session/date as Code for Service(s)
a previously processed service for the patient. 490 Rendered
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Other Procedure
Other Procedure
date. 490 Rendered
Procedure code for
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Missing or invalid
Missing/incomplete/invalid billing provider taxonomy. 21 information.
Claim waiting for
internal provider
Missing/incomplete/invalid billing provider taxonomy. 50 verification.
Entity's National
Provider Identifier
Missing/incomplete/invalid billing provider taxonomy. 562 (NPI).
Missing or invalid
Claim waiting for
internal provider
Missing/incomplete/invalid rendering provider taxonomy. 50 verification.
Entity's National
Provider Identifier
Missing/incomplete/invalid rendering provider taxonomy. 562 (NPI).
Missing or invalid
Missing/incomplete/invalid attending provider taxonomy. 21 information.
Claim waiting for
internal provider
Missing/incomplete/invalid attending provider taxonomy. 50 verification.
Entity's National
Provider Identifier
Missing/incomplete/invalid attending provider taxonomy. 562 (NPI).
Claim has been

adjudicated and is
awaiting payment
3 cycle.
Missing/incomplete/invalid patient liability amount. 126 Entity's address.
Missing or invalid
Missing/incomplete/invalid rendering provider taxonomy. 26 Entity not found.
Missing/incomplete/invalid patient liability amount. 126 Entity's address.

Missing or invalid
Internal
Internal
Internal
Internal
Internal
Internal
Other payer's
Explanation of
Benefits/payment
286 information.
No payment will be
No payment will be
Procedure code for

Procedure code for

Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code
Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Entity's
specialty/taxonomy
Missing/incomplete/invalid accident date. 727 Accident date

complete/correct information. 564 EPSDT Indicator
Other Entity's
Adjudication or
Payment/Remittanc
Missing/incomplete/invalid adjudication or payment date. 516 e Date.
Type of bill for UB
Entity's
specialty/taxonomy
charges. 258 code.
Procedure Code
Procedure Code
Procedure Code
date. 612 Amount
Frequency of
Frequency of

date. 259 service.

Frequency of
Maximum coverage
amount met or
This service is paid only once in a patient_x001A_s lifetime. 483 period.
Days/units for
Frequency of
Missing or invalid
Days/units for
Not paid separately when the patient is an inpatient. 187 Date(s) of service.
Procedure code for
Rebill services on separate claims. 187 Date(s) of service.

Procedure code for
Rebill services on separate claims. 454 services rendered.
Claim overlaps inpatient stay. Rebill only those services
rendered outside the inpatient stay. 187 Date(s) of service.
Claim overlaps inpatient stay. Rebill only those services Procedure code for
rendered outside the inpatient stay. 454 services rendered.
Not paid separately when the patient is an inpatient. 187 Date(s) of service.
Procedure code for
Not covered when performed during the same session/date as Internal

a previously processed service for the patient. 46 review/audit.
Service denied because payment already made for Internal

same/similar procedure within set time frame. 46 review/audit.
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Maximum coverage
amount met or




Maximum coverage
amount met or

This claim has been denied without reviewing the medical
record because the requested records were not received or Supporting
were not received timely. 294 documentation.
documentation as described in the contract or plan benefit Internal
documents is submitted. 46 review/audit.
Days/units for
Days/units for

Days/units for
The number of Days or Units of Service exceeds our Denied Charge or

acceptable maximum. 585 Non-covered Charge
Days/units for

Days/units for
Days/units for

Days/units for

Days/units for

Days/units for

Procedure code for
Procedure Code
Additional
information
requested from
Missing documentation/orders/notes/summary/report/chart. 123 entity.
Medical
Missing documentation/orders/notes/summary/report/chart. 297 notes/report.
Days/units for
procedure/revenue
Rebill services on separate claims. 258 code.
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Days/units for
Days/units for

services. 48 n.
services. 48 n.
services. 48 n.
Days/units for
charges. 258 code.
charges. 612 Amount
Maximum coverage
amount met or
Days/units for
Maximum coverage
amount met or
charges. 258 code.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
date. 258 code.
date. 259 service.
date. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
charges. 258 code.
charges. 612 Amount
Frequency of
259 service.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
charges. 612 Amount

same/similar procedure within set time frame. 250 Type of service.
Duplicate of a
previously

Duplicate of a
previously

Duplicate of a
previously

Duplicate of a
previously

Duplicate of a
previously

Duplicate of a
previously
Duplicate of a
previously

Duplicate of a
previously

Duplicate of a
previously
Procedure Code
Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Maximum coverage
amount met or
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Procedure code for
Other Procedure
Code for Service(s)
Procedure code for
Surgical Procedure
666 Code
Principal Procedure
Code for Service(s)
Principal Procedure
Code for Service(s)
Maximum coverage
amount met or
Maximum coverage
amount met or
This should be billed with the appropriate code for these Procedure code not
services. 475 valid for patient age
Denied Charge or
Service denied because payment already made for Service not
same/similar procedure within set time frame. 84 authorized.
service/procedure/supply and a related Service not
service/procedure/supply have not been met. 84 authorized.
Denied Charge or
Denied Charge or
Denied Charge or
Denied Charge or


Service not payable with other service rendered on the same Medical necessity
date. 287 for service.


date. 259 service.

date. 259 service.



Days/units for
Days/units for
date. 258 code.


Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Frequency of
Not paid separately when the patient is an inpatient. 259 service.

date. 259 service.
date. 259 service.
Missing or invalid
Add-on code cannot be billed by itself. 21 information.
Principal Procedure
Code for Service(s)
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Maximum coverage
amount met or

date. 259 service.


date. 259 service.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
Days/units for
Days/units for
date. 258 code.
date. 259 service.
Missing or invalid
Add-on code cannot be billed by itself. 21 information.
Principal Procedure
Code for Service(s)
Missing or invalid
Procedure code incidental to primary procedure. 21 information.
Principal Procedure
Code for Service(s)
Procedure code for

Principal Procedure
Code for Service(s)
Procedure code for

Principal Procedure
Code for Service(s)
Days/units for

service/procedure/supply and a related Denied Charge or
service/procedure/supply have not been met. 585 Non-covered Charge
Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for

Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for

Days/units for
Days/units for
Days/units for
Frequency of
259 service.
Procedure Code
Modifier(s) for
Maximum coverage
amount met or
Maximum coverage
amount met or
date. 259 service.
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Maximum coverage
Maximum coverage
Maximum coverage
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
charges. 258 code.
Days/units for
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or

required time limits following receipt of this notice by Days/units for
following the instructions included in your contract or plan procedure/revenue
benefit documents. 258 code.
cation number. This
change effective
11/1/2011: Entity's
252 ation number.
Other Procedure
Code for Service(s)
490 Rendered
Days/units for
Procedure Code
Procedure Code
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
acceptable maximum.
Maximum coverage
amount met or
Maximum coverage
amount met or
acceptable maximum.
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Maximum coverage
amount met or
Days/units for
Days/units for
Verifying premium
Alert: Do not resubmit this claim/service. 734 payment
unprocessable. Please submit a new claim with the Revenue code for
Denied Charge or
No agreement with
96 entity.
Denied Charge or
Patient ineligible for this service. 585 Non-covered Charge
Days/units for
charges. 258 code.
charges. 612 Amount
Days/units for
Days/units for
charges. 258 code.
Days/units for
charges. 258 code.
Maximum coverage
amount met or
Maximum coverage
amount met or
Frequency of
Entity's
specialty/taxonomy
Missing or invalid
This provider type/provider specialty may not bill this service. 21 information.
Rendering provider must be affiliated with the pay-to No agreement with

provider. 96 entity.
Denied Charge or
No agreement with
96 entity.

Drug Code (NDC). 216 Drug information.
about restrictions for this service. 216 Drug information.
Maximum coverage
Hospital s room
Missing/incomplete/invalid room and board rate. 181 rate.
Procedure code for

Principal Procedure
Code for Service(s)
465 Rendered
The number of Days or Units of Service exceeds our Principal Procedure
acceptable maximum. 486 Date
Maximum coverage
amount met or
No payment will be
No payment will be
No payment will be
No payment will be
No payment will be
No payment will be


Procedure code for
Procedure code for


Procedure code for
Procedure code for

Procedure code for


Days/units for
Procedure code for

Procedure code for
Procedure code for
Procedure code for
Procedure code for
Procedure code for
Maximum coverage
amount met or
Days/units for
Procedure code for

Procedure code for

Procedure Code
Not covered unless a pre-requisite procedure/service has Modifier(s) for
been provided. 453 Service(s) Rendered
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code

Procedure code for

Procedure code for

Procedure Code
Procedure Code

Procedure Code
Procedure Code

Procedure Code

Procedure Code
Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code

Procedure Code


Procedure Code


date. 259 service.

Procedure Code



date. 259 service.

Procedure Code

Procedure Code



date. 259 service.

Procedure Code
Procedure Code


date. 259 service.

date. 259 service.
Principal Procedure
Code for Service(s)

date. 259 service.

date. 259 service.

date. 259 service.
Days/units for

Procedure Code


date. 259 service.
Days/units for

date. 259 service.

date. 259 service.
Procedure Code
Consult plan benefit documents/guidelines for information Modifier(s) for
about restrictions for this service. 453 Service(s) Rendered
Procedure Code

Days/units for
Procedure Code

Procedure Code

Procedure Code


date. 259 service.
Days/units for

Procedure Code

Procedure Code

Days/units for
Principal Procedure
Code for Service(s)
Days/units for
Days/units for
Days/units for
Procedure Code

Procedure Code

Procedure Code


Procedure Code

Principal Procedure
Code for Service(s)
Days/units for
This should be billed with the appropriate code for these procedure/revenue
services. 258 code.
Awaiting eligibility
56 determination.

This item or service does not meet the criteria for the Missing or invalid
category under which it was billed. 21 information.
Diagnosis code(s)
Days/units for
Diagnosis code(s)
Missing or invalid
Supporting
Missing/incomplete/invalid principal procedure code. 294 documentation.
Procedure Code
Modifier(s) for
Missing/incomplete/invalid principal procedure code. 453 Service(s) Rendered
Missing or invalid
Supporting
Procedure Code
Modifier(s) for
Missing documentation/orders/notes/summary/report/chart. 453 Service(s) Rendered
Frequency of
Diagnosis code(s)
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Duplicate of a
previously
Diagnosis code(s)
Frequency of
259 service.
Frequency of
Frequency of
Necessity for
concurrent care
(more than one
Service denied because payment already made for physician treating
same/similar procedure within set time frame. 414 the patient)
Duplicate of a
previously
Necessity for
concurrent care
(more than one
Service denied because payment already made for physician treating
same/similar procedure within set time frame. 414 the patient)
Duplicate of a
previously
Duplicate of a
previously
Days/units for
date. 258 code.
Days/units for
Days/units for
procedure/revenue
258 code.
Days/units for
procedure/revenue
258 code.
Duplicate of a
previously
Days/units for
Days/units for
Frequency of
Frequency of
Procedure code for

Procedure code for

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Please refer to your provider manual for additional program procedure/revenue
and provider information. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Days/units for
procedure/revenue
Days/units for
date. 258 code.
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for

Procedure code for
Procedure code for



Days/units for
Maximum coverage
amount met or
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
Procedure Code
documentation as described in the contract or plan benefit
documents is submitted. 187 Date(s) of service.

Procedure Code
Procedure Code
documentation as described in the contract or plan benefit
documents is submitted. 187 Date(s) of service.

Procedure Code
Procedure Code
Procedure Code
Procedure Code
Service denied because payment already made for Length of time for
Maximum coverage
amount met or
Procedure code for
Procedure Code
Procedure Code
Procedure Code


Procedure Code


Procedure Code

date. 259 service.
Procedure Code


Procedure Code


Procedure Code

date. 259 service.
Procedure Code


Procedure Code

date. 259 service.
Procedure Code

Procedure Code

date. 259 service.
Procedure Code
Procedure code for

Procedure Code

Procedure Code

Procedure Code

Procedure Code
Procedure Code
Not covered when performed in this place of service. 249 Place of service.
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Please refer to your provider manual for additional program Missing or invalid
and provider information. 21 information.
Maximum coverage
amount met or
Please refer to your provider manual for additional program exceeded for benefit
and provider information. 483 period.
charges. 178 Submitted charges.
Payment reflects
This allowance has been made in accordance with the most usual and
appropriate course of treatment provision of the plan. 66 customary charges.
Consult our contractual agreement for Payment reflects
restrictions/billing/payment information related to these usual and
charges. 66 customary charges.
Payment reflects
This allowance has been made in accordance with the most usual and
appropriate course of treatment provision of the plan. 66 customary charges.
Consult our contractual agreement for Payment reflects
restrictions/billing/payment information related to these usual and
charges. 66 customary charges.
charges. 178 Submitted charges.
Maximum coverage
Maximum coverage
Entity not
eligible/not
approved for dates
91 of service.
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
Maximum coverage
amount met or
Maximum coverage
Alert: Please see our web site, mailings, or bulletins for more Denied Charge or
details concerning this policy/procedure/decision. 585 Non-covered Charge
Processed according
to contract
that exist between
the Health Plan and
Alert: Do not resubmit this claim/service. 107 Care Services)
Coordination of
Benefits Total
Alert: Do not resubmit this claim/service. 551 Submitted Charge
Days/units for
procedure/revenue
Rebill services on separate claims. 258 code.
Claim/submission
Rebill services on separate claims. 481 format is invalid.


Days/units for
Entity not
eligible/not
approved for dates
91 of service.
Missing/incomplete/invalid principal procedure code. 457 Non-Covered Day(s)
Missing/incomplete/invalid principal procedure date. 457 Non-Covered Day(s)
The patient was not in a hospice program during all or part of

the service dates billed. 457 Non-Covered Day(s)
Missing or invalid
Missing/incomplete/invalid date. 21 information.
UB04/HCFA-
1450/1500 claim
Missing/incomplete/invalid date. 276 form
Procedure code for
Revenue code for
Procedure code for
Revenue code for

Revenue code for
Claim/line has been
charges. 65 paid.
Revenue code for
Claim/line has been
charges. 65 paid.
Incorrect admission date patient status or type of bill entry on Missing or invalid
claim. 21 information.
Incorrect admission date patient status or type of bill entry on Type of bill for UB
claim. 228 claim
Claim/service not
submitted within the
required timeframe
718 (timely filing).
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
approved for dates
91 of service.
Entity not
eligible/not
Missing/incomplete/invalid attending provider primary approved for dates
153 Entity's id number.
153 Entity's id number.

Entity's
specialty/taxonomy
145 code.
Entity not
eligible/not
approved for dates
Missing/incomplete/invalid rendering provider taxonomy. 91 of service.
Entity's
specialty/taxonomy
Entity's
specialty/taxonomy
145 code.
Claim submitted to
Entity not
eligible/not
approved for dates
91 of service.

Claim information is inconsistent with pre-certified/authorized Frequency of
services. 259 service.
Claim information is inconsistent with pre-certified/authorized Frequency of
services. 259 service.
Claim information is inconsistent with pre-certified/authorized Per Day Limit
services. 612 Amount
Missing/incomplete/invalid referring provider primary Missing or invalid
Consolidated billing and payment applies. 247 Line information.
Specific federal/state/local program may cover this service
through another payer. 247 Line information.

Denied Charge or
No agreement with
96 entity.
Missing or invalid
Missing or invalid

Alert: Do not resubmit this claim/service. 97 found with entity.

Patient ineligible for this service. 97 found with entity.
Days/units for
services. 258 code.
Days/units for
services. 258 code.
Days/units for
services. 258 code.
Days/units for
procedure/revenue
258 code.
Service not
84 authorized.
Days/units for
procedure/revenue
258 code.
Service not
84 authorized.

Procedure code for
Frequency of
259 service.
Days/units for
Diagnosis code(s)
The number of Days or Units of Service exceeds our for the services
acceptable maximum. 488 rendered.
The number of Days or Units of Service exceeds our Referral/authorizatio
acceptable maximum. 48 n.
The number of Days or Units of Service exceeds our Service not
acceptable maximum. 84 authorized.
complete/correct information. 275 Claim.
unprocessable. Please submit a new claim with the Claim/submission
complete/correct information. 481 format is invalid.
Denied Charge or
services. 48 n.
Additional
information
Alert: The claim information has also been forwarded to requested from
Medicaid for review. 123 entity.
Alert: The claim information has also been forwarded to Missing or invalid
Medicaid for review. 21 information.
Alert: The claim information has also been forwarded to Estimated Claim
Medicaid for review. 565 Due Amount
Days/units for

Days/units for


Procedure code not

Not eligible due to the patient's age. 475 valid for patient age

period. 476 units of service
Entity's
Alert: Do not resubmit this claim/service. 142 number.
The original claim was denied. Resubmit a new claim, not a
replacement claim. 218 NDC number.
Days/units for
charges. 258 code.
Additional
information
requested from
Missing/incomplete/invalid HCPCS. 123 entity.
Revenue code for

NUBC Value Code

Entity not
eligible/not
approved for dates
91 of service.
Procedure code for
Technical component not paid if provider does not own the Procedure code for
equipment used. 454 services rendered.
and no appeal rights are afforded because the claim is Cannot provide
unprocessable. Please submit a new claim with the further status
complete/correct information. 0 electronically.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Rebill services on separate claims. 187 Date(s) of service.

Procedure code for
This claim/service must be billed according to the schedule for
this plan. 216 Drug information.
This claim/service must be billed according to the schedule for
this plan. 275 Claim.
Claim/service not
submitted within the
This claim/service must be billed according to the schedule for required timeframe
this plan. 718 (timely filing).
Days/units for
charges. 258 code.
complete/correct information. 218 NDC number.
Missing or invalid
Medical
Days/units for
charges. 258 code.
Frequency of
unprocessable. Please submit a new claim with the Supporting
complete/correct information. 294 documentation.

Missing/incomplete/invalid billing provider/supplier name. 97 found with entity.

Missing/incomplete/invalid designated provider number. 97 found with entity.
Procedure Code

Days/units for
Days/units for
details concerning this policy/procedure/decision. 476 units of service
Alert: Please see our web site, mailings, or bulletins for more Per Day Limit
details concerning this policy/procedure/decision. 612 Amount

Procedure Code

Procedure Code

Procedure Code
Procedure Code

Procedure Code
Procedure code for

Procedure code for

Procedure code for

Diagnosis code(s)
Total visits in total
number of
hours/day and total
Service denied because payment already made for number of
same/similar procedure within set time frame. 452 hours/week
Alert: Please see our web site, mailings, or bulletins for more Drug days supply
details concerning this policy/procedure/decision. 221 and dosage.
Hospital admission
Missing/incomplete/invalid admission hour. 230 hour.
Missing or invalid
Type of bill for UB

Missing/incomplete/invalid type of bill. 256 DRG code(s).
Missing or invalid
Missing/incomplete/invalid patient status. 21 information.
Type of bill for UB

Missing/incomplete/invalid patient status. 228 claim
Missing/incomplete/invalid patient status. 256 DRG code(s).

and no appeal rights are afforded because the claim is Diagnosis code(s)
unprocessable. Please submit a new claim with the for the services
complete/correct information. 488 rendered.
Missing or invalid
Missing/incomplete/invalid admitting diagnosis. 21 information.
Missing/incomplete/invalid admitting diagnosis. 232 Admitting diagnosis.
Missing/incomplete/invalid admitting diagnosis. 256 DRG code(s).

Missing or invalid
Missing/incomplete/invalid principal diagnosis. 21 information.
Diagnosis code(s)
for the services
Missing/incomplete/invalid principal diagnosis. 488 rendered.
Missing or invalid
Missing/incomplete/invalid other diagnosis. 21 information.
Missing/incomplete/invalid other diagnosis. 256 DRG code(s).

Missing or invalid

Missing or invalid

Missing or invalid

Missing or invalid

Missing or invalid

Missing or invalid

Diagnosis and
This should be billed with the appropriate code for these patient gender
services. 86 mismatch.

Diagnosis and

Diagnosis and

Diagnosis and

Diagnosis and

Diagnosis and
Diagnosis and

Diagnosis and

Diagnosis and
This should be billed with the appropriate code for these Hospital admission
services. 231 type.
services. 232 Admitting diagnosis.
Missing or invalid

Diagnosis code(s)
for the services
Missing/incomplete/invalid other diagnosis. 488 rendered.
Missing or invalid
Missing/incomplete/invalid principal procedure code. 256 DRG code(s).

Principal Procedure
Code for Service(s)
Missing or invalid
Missing/incomplete/invalid other procedure code(s). 21 information.
Missing/incomplete/invalid other procedure code(s). 256 DRG code(s).

Other Procedure
Code for Service(s)
Missing/incomplete/invalid other procedure code(s). 490 Rendered
Missing or invalid

Other Procedure
Code for Service(s)
Missing or invalid

Other Procedure
Code for Service(s)
Missing or invalid

Other Procedure
Code for Service(s)
Missing or invalid

Other Procedure
Code for Service(s)
following the instructions included in your contract or plan
benefit documents. 256 DRG code(s).
required time limits following receipt of this notice by Principal Procedure
following the instructions included in your contract or plan Code for Service(s)
benefit documents. 465 Rendered
required time limits following receipt of this notice by Procedure code and
following the instructions included in your contract or plan patient gender
benefit documents. 474 mismatch
required time limits following receipt of this notice by Other Procedure

Diagnosis code(s)
for the services
Duplicate of a
previously
processed
Missing/incomplete/invalid other diagnosis. 54 claim/line.
Missing/incomplete/invalid diagnosis or condition. 256 DRG code(s).

Diagnosis code(s)
for the services
Duplicate of a
previously
processed
Missing/incomplete/invalid diagnosis or condition. 54 claim/line.

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed

Diagnosis code(s)
for the services
Duplicate of a
previously
processed
Missing operative note/report. 256 DRG code(s).

Procedure code for
Missing operative note/report. 454 services rendered.
benefit documents. 298 Operative report.

Procedure code for
Procedure code for

Procedure code for


Procedure code for
Hospital discharge
Missing/incomplete/invalid discharge hour. 233 hour.
Missing or invalid
Missing/incomplete/invalid admission hour. 21 information.
Hospital admission
Hospital discharge
Missing or invalid
Hospital admission
Missing/incomplete/invalid discharge information. 230 hour.
Hospital discharge
Missing/incomplete/invalid discharge information. 233 hour.
Missing/incomplete/invalid revenue code(s). 256 DRG code(s).

Revenue code for
Claim/line has been
charges. 256 DRG code(s).
charges. 65 paid.
determined, or was not on file, for the date of
service/provider. 256 DRG code(s).
Diagnosis code(s)
Days/units for
charges. 258 code.
256 DRG code(s).

Claim was
processed as
adjustment to
Correction to a prior claim. 101 previous claim.
Correction to a prior claim. 256 DRG code(s).

Revenue code for

The original claim was denied. Resubmit a new claim, not a Revenue code for
replacement claim. 455 services rendered.
replacement claim. 507 HCPCS
Procedure code for
Missing/incomplete/invalid days or units of service. 454 services rendered.
Denied Charge or
Missing/incomplete/invalid days or units of service. 585 Non-covered Charge
to a HCPCS code for processing, but please continue to Missing or invalid
submit the NDC on future claims for this item. 21 information.
to a HCPCS code for processing, but please continue to Procedure code for
submit the NDC on future claims for this item. 454 services rendered.
This should be billed with the appropriate code for these Procedure code for
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Duplicate of a
previously
Missing or invalid
Incomplete/invalid plan information for other insurance . 21 information.
Missing or invalid
Incomplete/invalid plan information for other insurance . 21 information.

The number of Days or Units of Service exceeds our Length of time for
Days/units for
charges. 258 code.
Days/units for
Days/units for
date. 258 code.
No agreement with
96 entity.
No agreement with
96 entity.
details concerning this policy/procedure/decision. 218 NDC number.
Alert: Please see our web site, mailings, or bulletins for more Procedure code for
details concerning this policy/procedure/decision. 454 services rendered.
Alert: Please see our web site, mailings, or bulletins for more Procedure code for
details concerning this policy/procedure/decision. 454 services rendered.
complete/correct information. 218 NDC number.
Denied Charge or
Missing/incomplete/invalid charge. 585 Non-covered Charge
Maximum coverage
amount met or
Maximum coverage
amount met or
Purchase and rental

Maximum coverage
amount met or
Purchase and rental

Maximum coverage
amount met or
Procedure code for
Denied Charge or
Procedure code for
Denied Charge or
Duplicate of a
previously
Denied Charge or


Maximum coverage
amount met or
Maximum coverage
amount met or
Claim information is inconsistent with pre-certified/authorized exceeded for benefit
services. 483 period.
Maximum coverage
Procedure code for
Procedure Code
Procedure Code
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Service denied because payment already made for No payment will be
same/similar procedure within set time frame. 9 made for this claim.
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Maximum coverage
amount met or
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Days/units for
date. 258 code.
Procedure code for

Days/units for
date. 258 code.
Days/units for
date. 258 code.
Entity not eligible
for dental benefits
for submitted dates
Entity not eligible
for dental benefits
for submitted dates
Service not payable with other service rendered on the same Medical
date. 297 notes/report.
Procedure code for
Missing/incomplete/invalid other procedure code(s). 454 services rendered.

Maximum coverage
amount met or
Payment based on authorized amount. 483 period.
Maximum coverage
amount met or
Payment based on authorized amount. 483 period.

Days/units for
date. 258 code.
Maximum coverage

Procedure code for
The number of Days or Units of Service exceeds our No payment will be
acceptable maximum. 9 made for this claim.
Additional payment/recoupment approved based on payer- Reimbursement

initiated review/audit. 631 Rate
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Days/units for
Duplicate of a
previously
Days/units for
Days/units for
Days/units for
Days/units for
ENTITY ID ENTITY DESCRIPTION
1P PROVIDER
1P PROVIDER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
85 BILLING PROVIDER
40 RECEIVER
40 RECEIVER
40 RECEIVER
1P PROVIDER
1P PROVIDER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
QC PATIENT
QC PATIENT
QC PATIENT
DOCTOR OF
OD OPTOMETRY
IN INSURER
IN INSURER
IN INSURER
IN INSURER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
INSURED OR
IL SUBSCRIBER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
QC PATIENT
1P PROVIDER
1P PROVIDER
1P PROVIDER
71 ATTENDING PHYSICIAN
QC PATIENT
IN INSURER
IN INSURER
IN INSURER
IN INSURER
HEALTH MAINTENANCE
1E ORGANIZATION (HMO)
HEALTH MAINTENANCE
HEALTH MAINTENANCE
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
QC PATIENT
40 RECEIVER
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
SUPPLIER/MANUFACTU
SU RER
SUPPLIER/MANUFACTU
SU RER
SUPPLIER/MANUFACTU
SU RER
SUPPLIER/MANUFACTU
SU RER
40 RECEIVER
QC PATIENT
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
1P PROVIDER
1P PROVIDER
INSURED OR
IL SUBSCRIBER
SJ SERVICE PROVIDER
SJ SERVICE PROVIDER
SJ SERVICE PROVIDER
SJ SERVICE PROVIDER
1P PROVIDER
INSURED OR
IL SUBSCRIBER
INSURED OR
IL SUBSCRIBER
SUPPLIER/MANUFACTU
SU RER
SUPPLIER/MANUFACTU
SU RER
INSURED OR
IL SUBSCRIBER
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
FA FACILITY
FA FACILITY
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
DN REFERRING PROVIDER
85 BILLING PROVIDER
77 SERVICE LOCATION
DK ORDERING PHYSICIAN
SJ SERVICE PROVIDER
82 RENDERING PROVIDER
SUPPLIER/MANUFACTU
SU RER
SUPPLIER/MANUFACTU
SU RER
FA FACILITY
SUPERVISING
DQ PHYSICIAN
SUPERVISING
DQ PHYSICIAN
72 OPERATING PHYSICIAN
73 OTHER PHYSICIAN
73 OTHER PHYSICIAN
DD ASSISTANT SURGEON
DD ASSISTANT SURGEON
FA FACILITY
77 SERVICE LOCATION
FA FACILITY
FA FACILITY
FA FACILITY
FA FACILITY
85 BILLING PROVIDER
85 BILLING PROVIDER
87 PAY-TO PROVIDER
87 PAY-TO PROVIDER
1P PROVIDER
1P PROVIDER
87 PAY-TO PROVIDER
87 PAY-TO PROVIDER
87 PAY-TO PROVIDER
87 PAY-TO PROVIDER
1P PROVIDER
1P PROVIDER
QC PATIENT
QC PATIENT
QC PATIENT
1P PROVIDER
QC PATIENT
QC PATIENT
HEALTH MAINTENANCE
HEALTH MAINTENANCE
HEALTH MAINTENANCE
INSURED OR
IL SUBSCRIBER
SJ SERVICE PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
QC PATIENT
QC PATIENT
7C PLACE OF OCCURRENCE
INSURED OR
IL SUBSCRIBER
QC PATIENT
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
85 BILLING PROVIDER
HEALTH MAINTENANCE
HEALTH MAINTENANCE
1P PROVIDER
1P PROVIDER
HEALTH MAINTENANCE
HEALTH MAINTENANCE
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
77 SERVICE LOCATION
85 BILLING PROVIDER
SJ SERVICE PROVIDER
77 SERVICE LOCATION
85 BILLING PROVIDER
HEALTH MAINTENANCE
HEALTH MAINTENANCE
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
QC PATIENT
1P PROVIDER
1P PROVIDER
1P PROVIDER
1P PROVIDER
QC PATIENT
QA PHARMACY
QA PHARMACY
HEALTH MAINTENANCE
HEALTH MAINTENANCE

EOB Code Crosswalk To HIPPA Standard Codes

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EOB Code Crosswalk To HIPPA Standard Codes

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HIPAA

Ndc Missing, Invalid Or Not On State File. Correct 11 Digi

Ndc Missing, Invalid Or Not On State File. Correct 11 Digi

Service Not Covered By The Medicaid Program; Pharmacy:

Service Not Covered By The Medicaid Program; Pharmacy:

00011 Recipient Not Eligible On Service Date 16

00011 Recipient Not Eligible On Service Date 177

00011 Recipient Not Eligible On Service Date 177

00011 Recipient Not Eligible On Service Date 227

00012 Diagnosis Or Service Invalid For Recipient Sex 16

00012 Diagnosis Or Service Invalid For Recipient Sex 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00013 Provider Id Is Not Eligible On Service Date 16

00018 Claim Denied. No History To Justify Time Limit Override 16

00018 Claim Denied. No History To Justify Time Limit Override 29

Exact Duplicate-Same Dos/Same Procedure/Same

00023 Service Requires Prior Approval 197

00023 Service Requires Prior Approval 252

00023 Service Requires Prior Approval 252

Procedure Code, Procedure/Modifier Combination Or Revenue

Procedure Code, Procedure/Modifier Combination Or Revenue

Diagnosis Code Missing Or Invalid. Verify And Enter The

Please Indicate Part B Medicare Payment In Form Locator 54

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00036 Invalid Place Of Service For Procedure Or Revenue Code 16

00041 Federal Sterilization Consent Form Guidelines Not Met 16

00041 Federal Sterilization Consent Form Guidelines Not Met 252

00041 Federal Sterilization Consent Form Guidelines Not Met 252

00041 Federal Sterilization Consent Form Guidelines Not Met 252

00042 Sterilization/Abortion Guidelines Not Met 16

00042 Sterilization/Abortion Guidelines Not Met 16

00042 Sterilization/Abortion Guidelines Not Met 16

00042 Sterilization/Abortion Guidelines Not Met 16

00042 Sterilization/Abortion Guidelines Not Met 252

00042 Sterilization/Abortion Guidelines Not Met 252

00049 Medical Necessity Is Not Apparent 50

00054 Radiation Management Allowed Once Per Day 119

00054 Radiation Management Allowed Once Per Day 119

00066 Duplicate Payment To Other Provider 97

00068 Bill Medicare Part B Carrier 22

00069 Bill Medicare Part A Carrier 22

00074 Reimbursement Amount Exceeds Set Dollar Amount 16

00074 Reimbursement Amount Exceeds Set Dollar Amount 16

00081 Procedure Only Allowed Once In A Lifetime 149

Service Is Not Consistent With/Or Not Covered For This

00090 Duplicate Charge Denied 97

Patient Deceased Per State Eligibility File. If Dos And