The format is always two alpha characters. Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837), Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Reason Code 211: Workers' Compensation claim adjudicated as non-compensable. Please resubmit on claim per calendar year. Reason Code 109: Service not furnished directly to the patient and/or not documented. (Handled in QTY, QTY01=LA), Reason Code 65: DRG weight. Reason Code 37: Charges do not meet qualifications for emergent/urgent care. Note: To be used for pharmaceuticals only. Upon review, it was determined that this claim was processed properly. Procedure postponed, canceled, or delayed. Based on subrogation of a third-party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Submission/billing error(s). Adjustment for delivery cost. Benefit maximum for this time period or occurrence has been reached. The necessary information is still needed to process the claim. Reason Code 31: Insured has no coverage for new borns. Rent/purchase guidelines were not met. CODES Claim lacks prior payer payment information. (Note: To be used for Property and Casualty only), Based on entitlement to benefits. Reason Code 62: Procedure code was incorrect. The qualifying other service/procedure has not been received/adjudicated. Denial codes are codes assigned by health care insurance companies to faulty insurance claims. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). denial Reason Code 187: Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Additional information will be sent following the conclusion of litigation. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Coinsurance day. CO/31/ CO/31/ Medi-Cal specialty mental health billing. All of our contact information is here. Reason Code 258: The procedure or service is inconsistent with the patient's history. Reason Code 4: The procedure/revenue code is inconsistent with the patient's gender. Payment adjusted based on Voluntary Provider network (VPN). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 196: Revenue code and Procedure code do not match. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Claim received by the medical plan, but benefits not available under this plan. Reason Code 122: Submission/billing error(s). Submit these services to the patient's Behavioral Health Plan for further consideration. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Provider promotional discount (e.g., Senior citizen discount). Reason Code 59: Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Procedure modifier was invalid on the date of service. To be used for Property & Casualty only. Ingredient cost adjustment. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR). (Use only with Group Code OA). Webco 256 denial code descriptions. Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. The provider cannot collect this amount from the patient. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Coverage/program guidelines were exceeded. Procedure/treatment has not been deemed 'proven to be effective' by the payer. Contracted funding agreement - Subscriber is employed by the provider of services. Reason Code 71: Indirect Medical Education Adjustment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The authorization number is missing, invalid, or does not apply to the billed services or provider. Institutional Transfer Amount. Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. Expenses incurred during lapse in coverage, Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. The procedure or service is inconsistent with the patient's history. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Reason Code 50: Services by an immediate relative or a member of the same household are not covered. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. CO/200/ CO/26/N30. To be used for Property and Casualty only. Reason Code 167: Payment is denied when performed/billed by this type of provider. Reason Code 116: Benefit maximum for this time period or occurrence has been reached. To be used for Property and Casualty only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Performance program proficiency requirements not met. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Webco 256 denial code descriptions co 256 denial code descriptions on November 29, 2022 on November 29, 2022 At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Medicare Claim PPS Capital Day Outlier Amount. (Use only with Group Code OA). This product/procedure is only covered when used according to FDA recommendations. WebThe Remittance Advice will contain the following codes when this denial is appropriate. Reason Code 55: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. (Use only with Group Code OA). (Use only with Group Code OA). The necessary information is still needed to process the claim. To be used for Property and Casualty only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Charges do not meet qualifications for emergent/urgent care. Patient/Insured health identification number and name do not match. Charges do not meet qualifications for emergent/urgent care. Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Services by an immediate relative or a member of the same household are not covered. WebCode Description 01 Deductible amount. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Patient has not met the required residency requirements. Claim received by the medical plan, but benefits not available under this plan. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. : The procedure code is inconsistent with the provider type/specialty (taxonomy). However, this amount may be billed to subsequent payer. Submit these services to the patient's medical plan for further consideration. Expenses incurred after coverage terminated. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. Charges for outpatient services are not covered when performed within a period of time prior to orafter inpatient services. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. Workers' compensation jurisdictional fee schedule adjustment. Claim/service not covered by this payer/contractor. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Reason Code 91: Processed in Excess of charges. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Service was not prescribed prior to delivery. co 256 denial code descriptions . Attachment/other documentation referenced on the claim was not received. Did you receive a code from a health plan, such as: PR32 or CO286? Patient is covered by a managed care plan. (Use only with Group Code PR). Reason Code 156: Service/procedure was provided as a result of terrorism. Content is added to this page regularly. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. codes Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. Medicare Secondary Payer Adjustment Amount. It will not be updated until there are new requests. Payment is adjusted when performed/billed by a provider of this specialty. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Just hold control key and press F. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. The diagnosis is inconsistent with the patient's birth weight. This service/equipment/drug is not covered under the patients current benefit plan, National Provider identifier - Invalid format. Reason Code 104: The related or qualifying claim/service was not identified on this claim. Reason Code 95: The hospital must file the Medicare claim for this inpatient non-physician service. Revenue code and Procedure code do not match. This change effective 7/1/2013: Service/equipment was not prescribed by a physician. Note: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. ), Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication, Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Reason Code 215: Based on entitlement to benefits. CALL : 1- (877)-394-5567. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Reason Code 43: This (these) service(s) is (are) not covered. (Handled in QTY, QTY01=CD), Patient Interest Adjustment (Use Only Group code PR). Codes co 256 denial code descriptions Adjustment for shipping cost. Adjustment for postage cost. Committee-level information is listed in each committee's separate section. Expenses incurred after coverage terminated. Did you receive a code from a health plan, such as: PR32 or CO286? Reason Code 179: Procedure modifier was invalid on the date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Credentialing Service for Various Practices: : The date of death precedes the date of service. Alphabetized listing of current X12 members organizations. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
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