Monday, May 24, 2010

Medicaid denial reason code list

Medicaid Claim Denial Codes

1  Deductible Amount

2  Coinsurance Amount

3  Co-payment Amount

4  The procedure code is inconsistent with the modifier used or a required modifier is missing.

5  The procedure code/bill type is inconsistent with the place of service.

6  The procedure/revenue code is inconsistent with the patient's age.

7  The procedure/revenue code is inconsistent with the patient's gender.

8  The procedure code is inconsistent with the provider type/specialty (taxonomy).

9  The diagnosis is inconsistent with the patient's age.

10  The diagnosis is inconsistent with the patient's gender.

11 The diagnosis is inconsistent with the procedure.

12 The diagnosis is inconsistent with the provider type.

13 The date of death precedes the date of service.

14 The date of birth follows the date of service.

15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

 16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate Note: Changed as of 2/02

17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate.
Note: Changed as of 2/02

18 Duplicate claim/service.

19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

20 Claim denied because this injury/illness is covered by the liability carrier.

21 Claim denied because this injury/illness is the liability of the no-fault carrier.

22 Payment adjusted because this care may be covered by another payer per coordination of benefits.

23 Payment adjusted due to the impact of prior payer(s) adjudication including payments
and/or adjustments

24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.

25 Payment denied. Your Stop loss deductible has not been met.

26 Expenses incurred prior to coverage.

27 Expenses incurred after coverage terminated.

28 Coverage not in effect at the time the service was provided. Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.

29 The time limit for filing has expired.

30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.

31 Claim denied as patient cannot be identified as our insured.

32 Our records indicate that this dependent is not an eligible dependent as defined.

33 Claim denied. Insured has no dependent coverage.

34 Claim denied. Insured has no coverage for newborns.

35 Lifetime benefit maximum has been reached.
Note: Changed as of 10/02

36 Balance does not exceed co-payment amount.
Note: Inactive for 003040

37 Balance does not exceed deductible.
Note: Inactive for 003040

38 Services not provided or authorized by designated (network/primary care) providers.
Note: Changed as of 6/03

39 Services denied at the time authorization/pre-certification was requested.

40 Charges do not meet qualifications for emergent/urgent care.

41 Discount agreed to in Preferred Provider contract.
Note: Inactive for 003040

42 Charges exceed our fee schedule or maximum allowable amount.

43 Gramm-Rudman reduction.

44 Prompt-pay discount.

45 Charges exceed your contracted/ legislated fee arrangement.

46 This (these) service(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.

47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.

48 This (these) procedure(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.

49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.

50 These are non-covered services because this is not deemed a `medical necessity' by the payer.

51 These are non-covered services because this is a pre-existing condition

52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.

53 Services by an immediate relative or a member of the same household are not covered.

54 Multiple physicians/assistants are not covered in this case .

55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.

56 Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer.

57 Payment denied/reduced because the payer deems the information submitted does not
support this level of service, this many services, this length of service, this dosage, or
this day's supply.
Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.

58 Payment adjusted because treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service.
Note: Changed as of 2/01

59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Note: Changed as of 6/00

60 Charges for outpatient services with this proximity to inpatient services are not
covered.

61 Charges adjusted as penalty for failure to obtain second surgical opinion.
Note: Changed as of 6/00

62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Note: Changed as of 2/01

63 Correction to a prior claim.
Note: Inactive for 003040

64 Denial reversed per Medical Review.
Note: Inactive for 003040

65 Procedure code was incorrect. This payment reflects the correct code.

66 Blood Deductible.

67 Lifetime reserve days. (Handled in QTY, QTY01=LA)
Note: Inactive for 003040

68 DRG weight. (Handled in CLP12)
Note: Inactive for 003040

69 Day outlier amount.

70 Cost outlier - Adjustment to compensate for additional costs.
Note: Changed as of 6/01

71 Primary Payer amount.
Note: Deleted as of 6/00. Use code 23.

72 Coinsurance day. (Handled in QTY, QTY01=CD)
Note: Inactive for 003040

73 Administrative days.
Note: Inactive for 003050

74 Indirect Medical Education Adjustment.

75 Direct Medical Education Adjustment.

76 Disproportionate Share Adjustment.

77 Covered days. (Handled in QTY, QTY01=CA)
Note: Inactive for 003040

78 Non-Covered days/Room charge adjustment.

79 Cost Report days. (Handled in MIA15)
Note: Inactive for 003050

80 Outlier days. (Handled in QTY, QTY01=OU)
Note: Inactive for 003050

81 Discharges.
Note: Inactive for 003040

82 PIP days.
Note: Inactive for 003040

83 Total visits.
Note: Inactive for 003040

84 Capital Adjustment. (Handled in MIA)
Note: Inactive for 003050

85 Interest amount.

86 Statutory Adjustment.
Note: Inactive for 004010, since 6/98. Duplicative of code 45.

87 Transfer amount.

88 Adjustment amount represents collection against receivable created in prior overpayment.
Note: Inactive for 004050.

89 Professional fees removed from charges.

90 Ingredient cost adjustment.

91 Dispensing fee adjustment.

92 Claim Paid in full.
Note: Inactive for 003040

93 No Claim level Adjustments.
Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.

94 Processed in Excess of charges.

95 Benefits adjusted. Plan procedures not followed. Note: Changed as of 6/00

96 Non-covered charge(s).

97 Payment is included in the allowance for another service/procedure. Note: Changed as of 2/99

98 The hospital must file the Medicare claim for this inpatient non-physician service. Note: Inactive for 003040

99 Medicare Secondary Payer Adjustment Amount. Note: Inactive for 003040

100 Payment made to patient/insured/responsible party.

101 Predetermination: anticipated payment upon completion of services or claim adjudication. Note: Changed as of 2/99

102 Major Medical Adjustment.

103 Provider promotional discount (e.g., Senior citizen discount).
Note: Changed as of 6/01

104 Managed care withholding.

105 Tax withholding.

106 Patient payment option/election not in effect.

107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. Note: Changed as of 6/03

108 Payment adjusted because rent/purchase guidelines were not met. Note: Changed as of 6/02

109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

110 Billing date predates service date.

111 Not covered unless the provider accepts assignment.

112 Payment adjusted as not furnished directly to the patient and/or not documented.
Note: Changed as of 2/01

113 Payment denied because service/procedure was provided outside the United States or
as a result of war. Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159.

114 Procedure/product not approved by the Food and Drug Administration.

115 Payment adjusted as procedure postponed or canceled. Note: Changed as of 2/01

116 Payment denied. The advance indemnification notice signed by the patient did not
comply with requirements. Note: Changed as of 2/01

117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. Note: Changed as of 2/01

118 Charges reduced for ESRD network support.

119 Benefit maximum for this time period or occurrence has been reached. Note: Changed as of 2/04

120 Patient is covered by a managed care plan. Note: Inactive for 004030, since 6/99. Use code 24.

121 Indemnification adjustment.

122 Psychiatric reduction.

123 Payer refund due to overpayment.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.

124 Payer refund amount - not our patient. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.

125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
Note: Changed as of 2/02

126 Deductible -- Major Medical
Note: New as of 2/97

127 Coinsurance -- Major Medical
Note: New as of 2/97

128 Newborn's services are covered in the mother's Allowance. Note: New as of 2/97




Alabama Medicaid Denial codes.

Explanation of Benefit (EOB) Codes EOB CODE EOB        DESCRIPTION       HIPAA ADJUSTMENT REASON CODE     HIPAA REMARK CODE

201 INVALID PAY-TO PROVIDER NUMBER 125 N280
202 BILLING PROVIDER ID IN INVALID FORMAT 125 N257
203 RECIPIENT I.D. NUMBER MISSING 31 N382
206 PRESCRIBING PROVIDER NUMBER NOT IN VALID FORMAT 16 N31
210 BRAND MEDICALLY NECESSARY INDICATOR INVALID 125
211 INVALID REFILL INDICATOR VALUE 16
212 MISSING PRESCRIPTION NUMBER 16 N388
215 DATE DISPENSED IS MISSING 16 N304
216 DATE DISPENSED IS INVALID 16 N304
217 MISSING DRUG CODE 16 M119
218 INVALID DRUG CODE 16 M119
219 QUANTITY DISPENSED IS MISSING 16 N378
220 QUANTITY DISPENSED IS INVALID 16 N378
223 MISSING DIAGNOSIS INDICATOR 16 M76
224 DIAGNOSIS TREATMENT INDICATOR INVALID 16 M76
225 REFERRING PROVIDER - INVALID FORMAT 16 N286
226 ANESTHESIA CLAIMS REQUIRE REFERRING PROVIDER 16 N286
228 CLAIMANT SIGNATURE MISSING 16 MA75
229 SOURCE OF ADMISSION MISSING 16 MA42
230 MISSING ATTENDING SURGEON PRESCRIBER NUMBER 16 N262
231 CLAIM WAS FILED WITHOUT SERVICING PROVIDER 16 N290
233 UNITS OF SERVICE MISSING 16 M53
234 PROCEDURE CODE MISSING 16 M51
235 PROCEDURE CODE NOT IN VALID FORMAT 16 M51
238 RECIPIENT NAME IS MISSING 16 MA36
239 DETAIL TO DATE OF SERVICE IS MISSING 16 M59
240 THE DETAIL "TO" DATE IS INVALID 16 M59

For Full list, go to the below Medicaid site.


http://medicaid.alabama.gov/documents/6.0_providers/6.7_manuals/6.7.2_provider_manuals_2010/6.7.2.1_january_2010/6.7.2.1_jan10_j.pdf





Top 50 Billing Error Reason Codes With Common Resolutions 

 On the following Link you will find the top 50 Error Reason Codes with Common Resolutions for denied claims at Virginia Medicaid. This list has been provided to assist you with resolving these denied claims prior to calling the Helpline. Please print and post this list within your office for easy reference and use. Whenever you are advised to contact the Helpline or MediCall please access the following telephone numbers.

http://www.dmas.virginia.gov/Content_atchs/cb/cb6.pdf


LOUISIANA MEDICAID Denial Code

ERROR CORE  SHORT DESCRIPTION LONG DESCRIPTION    GRP RSN CODE CODE     CLAIM STATUS    ADJ REMARK  CODE
----------------------------------------------------------------------------------------------------------------------------------

 001 INVALID CLM TYP MOD INVALID CLAIM TYPE MODIFIER 2 16 N34 021
 002 INVALID PROVIDER NO PROVIDER NUMBER MISSING OR NOT NUMERIC 2 16 N77 021 153
 003 RECIPIENT # INVALID RECIPIENT NUMBER INVALID OR LESS THAN 13 DIGITS 3 31 021 153
 005 INVAL SERV FROM DATE SERVICE FROM DATE MISSING/INVALID 2 16 M52 021 188
 006 INVAL SERV THRU DATE INVALID OR MISSING THRU DATE 2 16 M59 021 188
 007 SERV THRU LT SERV FM SERVICE THRU DATE LESS THAN SERVICE FROM DATE 2 16 MA31 021 188
 008 SERV FRM GT ENTR DTE SERVICE FROM DATE LATER THAN DATE PROCESSED 2 110 021 188
 009 SERV THR GT ENTR DTE SERVICE THRU DATE GREATER THAN DATE OF ENTRY 2 16 MA31 021 188
 010 INV PRIOR AUTH DATE PRIOR AUTHORIZATION DATE NOT NUMERIC 133 252
 011 INVALID TPL INDICATR TPL INDICATOR NOT Y, N, OR SPACE 2 16 MA92 021 361
 012 ORG CLM W/ADJ/VD CDE ORIGINAL CLAIM WITH AN ADJUSTMENT OR VOID REASON CODE 2 16 MA30 021 521
 013 ORG CLM W ADJ/VD ICN ORIGINAL CLAIM WITH AN ADJUSTMENT OR VOID ICN 2 16 MA30 021 584
 014 IMM COMPL MISS/INVLD IMMUN COMPLETE AND CURRENT FOR THIS AGE PATIENT MISSING 133 021 331 564
 015 NOT USED - AVAILABLE NOT USED - AVAILABLE 2 16 N305 365
 016 NOT USED - AVAILABLE NOT USED - AVAILABLE 2 16 N305 365
 017 NOT USED - AVAILABLE NOT USED - AVAILABLE 133 021 564
 020 INVAL/MISS DIAG CODE INVALID OR MISSING DIAGNOSIS CODE 2 16 MA63 255
 021 INVALID FORMER REFNO FORMER REFERENCE NUMBER MISSING OR INVALID 2 16 M47 464
 022 INVALID BILLED CHRGS BILLED CHARGES MISSING OR NOT NUMERIC 2 16 M79 178
 023 INV PARTIAL RECIP RECIPIENT NAME IS MISSING 2 16 MA36 021 504
 024 INV BILLING PROV NO BILLING PROVIDER NUMBER NOT NUMERIC 2 16 N257 021 153
 025 IMM NOT COMP RSN MIS IMMUN NOT COMPLETE AND CURRENT REASON CODE MISSING 133 021 331 564
 026 INVALID TOT DOC CHG TOTAL DOCUMENT CHARGE MISSING OR NOT NUMERIC 2 16 M54 178
 027 PROC NEEDS DOCUMENT. PROCEDURE CODE NOT SUBSTANTIATED BY DOCUMENT 3 150 294 287
 028 INVAL/MISS PROC CODE INVALID OR MISSING PROCEDURE CODE 2 16 M51 454
 029 SERV MORE THAN 12 MO SERVICE MORE THAN 12 MONTHS OLD 3 29 263
 030 SERV THRU DT TOO OLD SERV THRU DATE MORE THAN TWO YEARS OLD 3 29 187
 031 NOT EMC ELIGIBLE PROVIDER NOT APPROVED FOR EMC BY STATE OFS 3 95 496
 032 EOB/CARR.CD MISMATCH EOB(S) ATTACHED/CARRIER CODE DOES NOT MATCH 1 251 N4 286
 033 NEED EOB-CARR/RECIP. NEED EOB FOR EACH CARRIER INDICATED ON RESOURCE FILE 1 251 N4 286
 034 22 MOD.NOT JUSTIFIED 22 MOD.SERVICES NOT JUSTIFIED/PAID AT UNMODIFIED RATE 3 150 047
 035 REBILL CORRECT HCPC ASC,OP FAC/PHYS.BILLED DIFF CODE;REBILL CORRECT HCPC 2 16 M20 454
 037 MEDICARE ADJUSTMENT MEDICARE ADJUSTMENT/VOID,ADJUST OR ADJUST MEDICARE CLAI 1 252 N4 101
 038 99297-52 NICU REDUCE 99297-52 NICU PAID AT REDUCED RATE 3 150 628
 039 MOD.NOT USED FOR CLM MODIFIER NOT USED TO PROCESS CLAIM 2 4 N519 453
 040 INV ADMISSION DATE ADMISSION DATE MISSING OR INVALID 2 16 MA40 189
 042 INVALID UB92 BILL CD INVALID UB92 TYPE BILL CODE 2 16 MA30 228
 043 INV ATTENDING PHYS ATTENDING PHYSICIAN NUMBER NOT NUMERIC 2 16 N290 132
 044 INV NATURE OF ADMIT NATURE OF ADMISSION MISSING OR INVALID 2 16 MA41 231
 045 INV PATIENT STATUS PATIENT STATUS CODE INVALID OR MISSING 2 16 MA43 021 431
 046 NOT USED - AVAILABLE NOT USED - AVAILABLE 2 16 M59 021 387
 047 NOT USED - AVAILABLE NOT USED - AVAILABLE 2 16 M59 021 387
 048 INVALID/MISS PROC INVALID OR MISSING PROCEDURE CODE 2 16 M51 021 454
 049 INV/CONFLIC SURG DTE INVALID/CONFLICT SURGICAL DATE 2 16 N301 021 666
 050 INV BLOOD NOT REPL BLOOD NOT REPLACED AMOUNT INVALID 133 021 236
 051 INV BLOOD/PINT CHG BLOOD CHARGE PER PINT INVALID 133 021 235
 052 >12 MONTH QTY LIMIT > 12 MONTH QTY LIMIT MD FAX OVERRIDE FORM 866-797-2329 3 198 N351

Full list of Denial code.

https://www.lamedicaid.com/provweb1/Forms/Error_Code/ERROR_CODE.pdf







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