Tuesday, November 21, 2017

BCBS denial code list

Reason codes, and the text messages that define those codes, are used to explain why a claim may not have been paid in full. For instance, there are reason codes to indicate that a particular service is never covered by Medicare, that a benefit maximum has been reached, that non-payable charges exceed the fee schedule, or that a psychiatric reduction has been made. Under the standard format, only reason codes approved by the American National Standards Institute (ANSI) Insurance Subcommittee and Medicare-specific supplemental messages approved by CMS may be used.

The ANSI reason codes were designed to replace the large number of different codes used by health payers in this country, and to relieve the burden of medical providers to interpret each of the different coding systems. Although reason codes and CMS message codes will appear in the body of the remittance notice, the text of each code that is used will be printed at the end of the notice to facilitate interpretation. The approximately 10,000 different messages used by Medicare carriers nationwide have been reduced to fewer than 400 messages. The standard messages may expand or change occasionally as the need arises, but CMS plans to limit the frequency of such changes. Here is the example BCBS denial code list.

BCBS Of Tennessee - Commercial Remittance Advice Code Descriptions

Exp. Code Text CARC RARC

002 This charge exceeds the maximum allowable under this member's coverage. 45
008 This service is limited by the member's plan. Benefits were extended by our Utilization Management department. 119
018 This charge exceeds the maximum allowable under this member's coverage 45
01D Processing of this claim was suspended awaiting information requested from this provider or subscriber. 133
02D Benefits for this service are limited to two times per contract year. 273 N435
03D Benefits for this service are limited to one time per three-month period. 273 N435
04D Benefits for this service are limited to one time per thirty-six month period. 273 N435
050 This charge exceeds the maximum allowable under this member's coverage. 59 N644
054 Services denied due to being delegated to another entity. 109 N418
057 We are deducting this amount because of an overpayment on a previous FSA claim.
05D Benefits for this service have a twelve-month waiting period. 179
062 These expenses are not eligible since there is no money left in your Flexible Spending Account. 187
066 This is not a covered service under medical benefits. The service is eligible under the Health Reimbursement Account. 96 N30
068 These expenses are not eligible since there is no money in your Flexible Spending Account. 187
069 These expenses are not eligible since there is no money in your Flexible Spending Account. 187
06D This service was performed on a previously missing tooth. 272
071 Your Dependent Care Flexible Spending Account funds have been exhausted. Payment may be made when additional funds are available. 187
073 Benefits for this service are excluded under this member's plan. 96 N216
077 Long Term Care Hospital Override
079 Line Item Denial Override
07D Benefits for this service are limited to two times per twelve-month period. 273 N412
08D Services for hospital charges, hospital visits, and drugs are not covered. 96 N216
09D Services for premedication and relative analgesia are not covered. 96 N126
0DA This is an adjustment to a previous dental claim that paid to the provider but should have paid to the subscriber. 96 MA67
0s0 Change Secondary Coinsurance Amount
0s1 Change Secondary Copay Amount
104 This member's coverage excludes benefits for the condition for which this service was rendered. 96 N216
10D Benefits for sealants and dietary instruction are not covered. 96 N216
11D The procedure code and tooth number filed do not correspond. An alternate procedure code was used for pricing. 169
12D Benefits for this procedure are limited to once per lifetime, per tooth and tooth surface. 119 N587
13D Appliances due to wear and services to improve bite or to correct congenital or developmental problems are non-covered. 96 N216
14D Benefits for implants, TMJ (Temporomandibular Joint) Dysfunction and periodontal splinting are not covered. 96 N216
15D Benefits for this service are limited to one time per three-month period. 273 N435
16D We cannot process this claim until we receive previously requested information concerning the member's other insurance. 22
17D Benefits for services that are considered to be primarily cosmetic are not covered. 96 N383
17d A portion of these services is considered primarily cosmetic and will not be covered. 96 N383
18D This procedure is not covered, an allowance for a standard procedure was paid. 169
19D Benefits for this service are limited to two times per calendar year. 273 N435
1DA This dental claim is being adjusted due to a corrected billing submitted by the provider. 96 MA67
1DO Temporary procedure has been deducted from the amount of the primary procedure. 169
1s1 Secondary Supplementation Amount
201 Interest is being recouped. 85
20D Relines cannot be billed separately if done within six months of the primary denture and or partial procedure. 273 N435
217 Paid Limit Accumulator Has Been Altered by Med Supp Sequestration Reduced from the Paid Amount
21D Benefits for this service are limited to one time per sixty-month period. 273 N435
22D Benefits for this service have a twenty-four month waiting period. 179
23D These benefits have been paid by the member's medical policy. 168
24D Benefits for this service are limited to one time per six-month period. 273 N435
25D This category of dental benefits has a waiting period as specified in this member's dental contract. 179
26D Benefits for this service are limited to one time per five-month period. 273 N435
27D Benefits for this dental service are not available, per this member's contract. 96 N216
28D Benefits for this service are limited to one time per twelve-month period. 273 N435
29D Benefits for this dental service are not available, per this member's contract. 96 N216
2s2 Secondary Allow Amount
30D This charge is a duplicate of a previously processed claim for this member. 18 N702
30d This procedure is a duplicate of a previously filed procedure. 18 N522
31D This service is denied based on information submitted. Participating dentist should charge only amount in 'Patient Owes'. 96 N10
328 This claim was adjusted to provide corrected benefits. 96 MA67
32D Benefits for this service are limited to one time per four-month period. 273 N435
33D Benefits for this service are limited to one time per two-year period. 273 N435
341 This claim was paid to the wrong payee. 96 MA67
342 This claim was paid to the wrong payee. 96 MA67
343 This claim was paid to the wrong payee. 96 MA67
344 This member's coverage under this plan was not in effect on the date this service was provided. 27 N30
345 Benefits for this service are excluded under this member's plan. 96 N30
346 Duplicate of previous claim. If corrected billing, please resubmit according to billing guidelines. 18 N702
347 Benefits for this service are excluded under this member's plan. 96 N30
348 Benefits are excluded for an on the job injury or for services eligible for Worker's Compensation benefits. 19 N418
349 This claim was adjusted to provide benefits secondary to Medicare. 96 MA67
34D Benefits for this service have a ninety-day waiting period. 179
350 This is a subrogation adjustment. It will not effect previously assigned patient liability. 215
351 This claim was adjusted to provide benefits secondary to this member's other insurance coverage. 96 MA67
352 This claim was previously processed under another member's name or ID number in error. 96 MA67
353 This claim was previously processed under another member's name or ID number in error. 96 MA67
354 This claim was adjusted to provide corrected benefits. 96 MA67
355 This claim was adjusted to provide corrected benefits. 96 MA67
356 This claim was adjusted to provide corrected benefits. 96 MA67
35D Benefits for this service are limited to one time per twenty-four month period. 273 N435
365 This claim was adjusted to provide corrected benefits. 96 MA67
366 This claim was adjusted to provide corrected benefits. 96 MA67
367 This claim was adjusted due to a change in provider information. 96 MA67
368 This claim was adjusted due to a change in provider information. 96 MA67
369 This claim was adjusted to provide benefits secondary to Medicare. 96 MA67
36D These benefits were previously paid under an incorrect provider status. 170 N95
370 This claim was adjusted to provide corrected benefits. 96 MA67
371 This claim was adjusted to provide corrected benefits. 96 MA67
379 This is a subrogation adjustment. It will not effect previously assigned patient liability. 215
37D This service needs to be resubmitted using current American Dental Association procedure codes. 181 M20
37d This service needs to be resubmitted using current American Dental Association procedure codes. 181 M20
380 This claim was adjusted to provide benefits secondary to Medicare. 96 MA67
381 Please submit a copy of the Explanation of Benefits from this member's other insurance carrier. 22 MA92
382 This claim was adjusted to provide benefits secondary to Medicare. 96 MA67
383 This claim was adjusted to provide corrected benefits. 96 MA67
384 This claim was adjusted to provide corrected benefits. 96 MA67
385 This claim was adjusted because we were notified that the provider billed for this service in error. 96 MA67
389 This claim was adjusted to provide corrected benefits . 96 MA67
38D This service has been denied due to contract limitations. 273 N435
390 This claim was adjusted to provide corrected benefits. 96 MA67
391 This service was previously denied as a duplicate in error. 96 MA67
392 This claim was adjusted to provide corrected benefits. 96 MA67
393 This claim was adjusted to provide corrected benefits. 96 MA67
394 This claim was adjusted to provide corrected benefits. 96 MA67
395 This claim was adjusted to provide corrected benefits. 96 MA67
397 ITS Inclusive Grouping Number
39D Benefits for this service are limited to one time per year. 273 N435
3s3 Supplemental Calculation Method
40D This date of service is after this member's termination date. 27 N30
41D This service has been paid based on group's request.
42d McKee Executive Dental payment reimbursement
43D Processing of this claim is suspended awaiting information from the provider. 163 N686
44D This charge exceeds the maximum allowable under this member's contract. 45
46D Processing of this procedure is suspended awaiting information from this member's medical or other carrier's policy. 168
47D Benefits for adult orthodontics are only payable for TMJ diagnosis. 96 N569
48D Benefits for this service are limited to one time per forty-eight month period. 273 N435
4s4 Change Secondary Service Rule
500 Submitting IPA is not related to member's IPA
501 Capitated entity charge amount equal 0.00
502 Prudent Layperson Override
503 Delegated Claim Entity Override
504 Capitation Indicator
505 Capitation Fund
506 Risk Indicator
507 Delegated UM Entity Override
508 Capitation Deduct
509 Opt out override
50D Benefits for this service are limited to three times per twelve-month period. 273 N435
510 Service Area Override
511 Reimbursable allowable amount
51D Grace period for plan limits. 45
54D Benefits for this service are limited to one time per calendar year. 273 N435
55D Benefits for this service are limited to once per lifetime. 273 N435
56D Benefits for this service are limited to four times per calendar year. 273 N435
57D Benefits for this service are limited to one time per three-year period. 96 N130
57d Benefits for this service are limited to one time per three calendar year period. 273 N435
58D Please submit a copy of the Explanation of Benefits from this member's other insurance carrier. 22 N4
59D Benefits for this service are limited to one time per five-year period. 273 N435
5s5 Bypass Secondary Plan Limits

For full list : https://www.bcbst.com/docs/providers/remit-codes/Commercial%20Remittance%20Advice%20Code%20Descriptions%2020180131.pdf

Adjustment Reason Codes and Remark Codes for BC/BS  and BlueCare Family Plan

PROPRIETARY DISPOSITION CODE (DC) ADJUSTMENT REASON CODE (ARC) REMARK CODE (RC)


DC ARC RC REMITTANCE MESSAGE
 
B100 16 FIELD IN ERROR FOR DATE RECEIVED
B101 16 FIELD IN ERROR FOR SUSPENSE CODE
B102 16 FIELD IN ERROR FOR CLAIM NUMBER
B103 16 FIELD IN ERROR FOR CLAIM SEQUENCE
B104 16 FIELD IN ERROR FOR PREP CODE
B105 16 FIELD IN ERROR FOR ADDRESS OVERRIDE INDICATOR
B106 16 FIELD IN ERROR FOR MANAGERS OVERRIDE INDICATOR
B107 16 FIELD IN ERROR FOR ADJUSTMENT REASON CODE
B118 16 M53 FIELD IN ERROR FOR TOTAL UNITS
B119 16 M54 FIELD IN ERROR FOR TOTAL CHARGES
B120 16 FIELD IN ERROR FOR TOTAL SUBMITTED NON COVERED CHARGES
B121 16 FIELD IN ERROR FOR DISCOUNTED AMOUNT PAID
B122 16 FIELD IN ERROR FOR MICROFILM NUMBER
B123 16 FIELD IN ERROR FOR MEDICARE'S INTERNAL CONTROL NUMBER (ICN#)
B124 16 FIELD IN ERROR FOR GROUP NUMBER
B125 16 FIELD IN ERROR FOR CONTRACT CLASS
B126 16 FIELD IN ERROR FOR CONTRACT STATUS CODE
B127 16 FIELD IN ERROR FOR MEMBER TYPE CODE
B128 16 MA50 FIELD IN ERROR FOR INVESTIGATIVE CLAIM INDICATOR
B129 16 FIELD IN ERROR FOR INTERNAL (DERIVED) TYPE OF SERVICE
B130 16 FIELD IN ERROR FOR CLAIM INDICATOR
B131 16 FIELD IN ERROR FOR CARRIER FIELD
B132 16 FIELD IN ERROR FOR ADDRESS OVERRIDE ADDRESSEE INFORMATION
B268 A6 EXPENSES FOR CONVALESCENT/SKILLED NURSING FACILITIES CONSIDERED ONLY FOR ADMISSIONS WITHIN 30 DAYS
FOLLOWING HOSPITALIZATION OF AT LEAST 3 DAYS.
B405 62 A PORTION OF THIS TREATMENT WAS NOT CERTIFIED.
B415 96 ACCORDING TO THE TERMS OF THE PLAN, THIS PROCEDURE IS NOT COVERED.
B420 42 BILLED TIME UNITS ARE IN EXCESS OF ANESTHESIA TIME DOCUMENTED ON CLAIM AND ARE NOT ELIGIBLE FOR
ADDITIONAL REIMBURSEMENT; PARTICIPATING PROVIDERS MAY NOT BALANCE BILL MEMBERS
B424 A2 THIS AMOUNT REPRESENTS COINSURANCE, DEDUCTIBLE AND EXCESS CHARGES PAYABLE UNDER YOUR PLAN. NO PATIENT
BALANCE
B435 119 AN EVALUATION WAS PREVIOUSLY PAID TO THIS PROVIDER FOR THIS MEMBER.
B436 62 PRIOR AUTHORIZATION IS REQUIRED FOR THIS SERVICE.
B438 31 CLAIM VOIDED. CONTRACT CANCELLED.
B440 85 THE PHYSICIAN IS OUT OF NETWORK AND/OR A REFERRAL WAS NOT OBTAINED. SERVICES ARE NOT COVERED.
B444 47 ACCORDING TO THE TERMS OF YOUR PLAN AND BASED ON THE DIAGNOSIS, THIS SERVICE IS NOT PAYABLE.
B449 96 THIS PATIENT IS NOT ELIGIBLE TO RECEIVE BENEFITS FOR THE SERVICES SUBMITTED.
B455 97 PAYMENT FOR THESE SERVICES IS INCLUDED IN THE ALLOWANCE FOR THE PRIMARY PROCEDURE. NO ADDITIONAL
BENEFITS ARE AVAILABLE. PARTICIPATING PROVIDERS SHOULD NOT BILL SEPARATELY FOR THESE SERVICES.
B456 16 N29 BEFORE SERVICES CAN BE CONSIDERED, AN ITEMIZED BILL MUST BE SUBMITTED WITH A COMPLETED DESCRIPTION OF
SERVICES RENDERED.
B460 B11 CHARGES HAVE BEEN REFERRED TO THE NON-PARTICIPATING PROVIDER NETWORK FOR PROCESSING
B467 16 M23 IN ORDER FOR US TO CONSIDER THIS CHARGE, WE REQUIRE THE SUPPLY COMPANY'S BILL. PLEASE RESUBMIT THE CLAIM
WITH THIS INFORMATION.
B467 47 ACCORDING TO THE TERMS OF YOUR PLAN AND BASED ON THE DIAGNOSIS, THIS SERVICE IS NOT PAYABLE.
B468 22 THIS CHARGE HAS BEEN DENIED BY MEDICARE DUE TO LACK OF INFORMATION. THE PROVIDER MUST SUBMIT THE
NECESSARY INFORMATION TO THEM BEFORE WE CAN CONSIDER BENEFITS.
B469 16
ADDITIONAL INFORMATION IS REQUIRED TO PROCESS THIS CLAIM. PLEASE PROVIDE A COPY OF YOUR LAST EXPLANATION
OF BENEFITS FORM YOUR BASIC CARRIER REGARDING YOUR MAJOR MEDICAL DEDUCTIBLES MET PRIOR TO YOUR PLAN
EFFECTIVE DATE WITH US.
B470 40 SERVICES NOT OF AN EMERGENCY NATURE ARE NOT COVERED.
B471 96 EMERGENCY MEDICAL SERVICES NOT RENDERED WITHIN A 60 DAY PERIOD OF LIABILITY ARE NOT COVERED.
B472 96 M42 PLEASE SUBMIT A LETTER OF MEDICAL NECESSITY, WHICH INCLUDES THIS MEMBERS CONDITION. WE WILL FURTHER
CONSIDER THIS CLAIM WHEN WE RECEIVE THE LETTER
B473 97 SEPARATE PAYMENT CANNOT BE MADE FOR THIS RELATED SERVICE.
B475 16 N40 POST-OPERATIVE X-RAY REQUIRED. PLEASE RESUBMIT CLAIM WITH THE X-RAY.
B476 113 MA122 PROCEDURE NOT COMPLETED, NO BENEFITS PROVIDED.
B477 16 N26 ACCORDING TO THE TERMS OF THE PLANS, THE DENTAL SERVICES IS NOT COVERED DUE TO INSUFFICIENT BREAKDOWN.
B478 96 BENEFITS DENIED FOR NONCOMPLIANCE WITH MANAGED CARE PROVISIONS.
B479 47 ACCORDING TO THE TERMS OF YOUR PLAN AND BASED ON THE DIAGNOSIS, THIS SERVICE IS NOT PAYABLE.
B480 16 M67 INVALID OR UNACCEPTABLE PROCEDURE CODE. PLEASE SUBMIT A VALID OR ACCEPTABLE HCPCS OR CPT PROCEDURE
CODE. WHEN WE RECEIVE THIS INFORMATION, WE WILL CONTINUE TO PROCESS THIS CLAIM.
B481 16 M67 INVALID OR UNACCEPTABLE PROCEDURE CODE. PLEASE SUBMIT A VALID OR ACCEPTABLE HCPCS OR CPT PROCEDURE
CODE. WHEN WE RECEIVE THIS INFORMATION, WE WILL CONTINUE TO PROCESS THIS CLAIM.
B482 96 M7 THE RENTAL FEES FOR THIS ITEM HAVE EXCEEDED THE PURCHASE PRICE. NO ADDITIONAL PAYMENT MAY BE MADE.
B483 16 M57 CLAIM DENIED PENDING VERIFICATION OF PROVIDER STATUS/LICENSE/CERTIFICATION IN STATE OF PRACTICE. UPON
RECEIPT OF INFORMATION, YOUR CLAIM WILL BE PROCESSED IN ACCORDANCE WITH YOUR CONTRACT.
B484 62 NO AUTHORIZATION FOR THIS PROCEDURE CODE FOR SERVICES RENDERED BY THIS PROVIDER
B485 62 VISITS EXCEED AUTHORIZATION.
B486 62 N256 NO AUTHORIZATION FOR THIS PROCEDURE CODE FOR THIS DATE OF SERVICE.
B487 62 NO PREAUTHORIZATION FOR INFUSION THERAPY SERVICES, PENALTY APPLIED.
B488 62 NO PRIOR AUTHORIZATION
B500 50 THE CHARGE HAS BEEN DENIED BECAUSE IT HAS BEEN DETERMINED THAT IT IS NOT MEDICALLY NECESSARY.
B506 119 ACCORDING TO THE TERMS OF THE PLAN, THE CONTRACTUAL LIMIT FOR THIS SERVICE HAS PREVIOUSLY BEEN PAID.
B507 119 ACCORDING TO THE TERMS OF THE PLAN, THE CONTRACTUAL LIMIT FOR THIS SERVICE HAS PREVIOUSLY BEEN PAID.
B509 18 THIS SERVICE IS A DUPLICATE TO ONE PRESENTLY BEING REVIEWED.
B510 47 ADDITIONAL INFORMATION IS REQUIRED TO PROCESS THIS CLAIM. PLEASE RESUBMIT A NEW CLAIM WITH THE VALID ICD9 DIAGNOSIS CODE.
B514 97 PAYMENT FOR THESE SERVICES IS INCLUDED IN THE ALLOWANCE FOR THE PRIMARY PROCEDURE. NO ADDITIONAL
BENEFITS ARE AVAILABLE. PARTICIPATING PROVIDERS SHOULD NOT BILL SEPARATELY FOR THESE SERVICES.
B515 96 ACCORDING TO THE TERMS OF THE PLAN, THIS PROCEDURE IS NOT COVERED.
B521 62 A PRIOR AUTHORIZATION NON COMPLIANCE PENALTY WOULD HAVE BEEN ASSESSED HAD YOU NOT BEEN IN A MANAGED
BENEFITS EDUCATION PERIOD.
B524 62 A PRIOR AUTHORIZATION AND SECOND SURGICAL OPINION NONCOMPLIANCE PENALTY WOULD HAVE BEEN ASSESSED HAD
YOU NOT BEEN IN A MANAGED BENEFITS EDUCATION PERIOD.
B541 62 THESE SERVICES ARE NOT PAYABLE AS THE PROVIDER IS NOT LISTED ON THE TREATMENT PLAN.
B542 62 THE CHARGE HAS BEEN DENIED SINCE WE HAVE NOT RECEIVED THE TREATMENT PLAN FROM THE PROVIDER. SHOULD THE
INFORMATION BE RECEIVED AT A LATER DATE THE CHARGE WILL BE REVIEWED.
B543 50 THE CHARGE HAS BEEN DENIED BECAUSE IT HAS BEEN DETERMINED THAT IT IS NOT MEDICALLY NECESSARY.
B548 22 ADDITIONAL INFORMATION IS REQUIRED TO PROCESS THIS CLAIM. PLEASE PROVIDE A COPY OF YOUR EXPLANATION OF
MEDICARE BENEFITS.
B553 B22 EMERGENCY ROOM SERVICES NOT PAYABLE FOR THIS DIAGNOSIS.
B555 54 SURGICAL ASSISTANT SERVICES ARE NOT APPROVED FOR THIS PROCEDURE.
B556 54 SURGICAL ASSISTANT SERVICES NOT PAYABLE AT THIS FACILITY.
B557 47 DIAGNOSIS CODE REQUIRED FOR THIS PROCEDURE WAS OMITTED. PLEASE COMPLETE THE REQUIRED INFORMATION AND
RESUBMIT THIS CLAIM AGAIN.
B560 16 M29 PLEASE RESUBMIT THESE CHARGES WITH THE OPERATIVE/PATHOLOGY REPORT ATTACHED.
B562 109 PLEASE SUBMIT TO YOUR NEW INSURANCE CARRIER.
B563 32 CLAIM IS REJECTED PENDING VERIFICATION OF STUDENT STATUS.
B564 96 BENEFITS DENIED FOR NONCOMPLIANCE WITH MANAGED CARE PROVISIONS.
B569 96 SERVICES NOT COVERED IN ACCORDANCE WITH CONTRACT POLICY.
B577 B11 THE CLAIM HAS BEEN FORWARDED TO THE HOME PLAN WHO WILL PAY THE SUBSCRIBER DIRECTLY.
B580 31 THE ALPHA PREFIX WITH WHICH YOU HAVE SUBMITTED THIS CLAIM IS INVALID. PLEASE VERIFY THE PREFIX ON THE
MEMBER'S CARD AND RESUBMIT.
B582 62 SERVICES ARE BEYOND THE NUMBER OF APPROVED VISITS.
B586 A2 VACCINE PROVIDED AT NO CHARGE BY STATE OR OTHER OUTSIDE SOURCE
B587 62 N54 SERVICES PROVIDED DIFFER FROM WHAT WAS CERTIFIED.
B588 15 NO PRIOR AUTHORIZATION FOR THIS PROVIDER.
B589 62 MAXIMUM PRIOR AUTHORIZED VISITS/DAYS/HOURS FOR THIS TREATMENT PERIOD HAVE BEEN REACHED.
B591 B13 A PROFESSIONAL SERVICE HAS PREVIOUSLY BEEN PAID FOR THIS DAY.
B592 16 N29 SERVICES DENIED. OUTPATIENT TREATMENT REPORT NOT RECEIVED.
B596 97 PAYMENT FOR THESE SERVICES IS INCLUDED IN THE ALLOWANCE FOR THE PRIMARY PROCEDURE. NO ADDITIONAL
BENEFITS ARE AVAILABLE. PARTICIPATING PROVIDERS SHOULD NOT BILL SEPARATELY FOR THESE SERVICES.
B600 133 YOUR HOSPITAL CLAIM HAS BEEN RECEIVED AND IS BEING PROCESSED. YOU WILL BE NOTIFIED SHORTLY OF THE FINAL
DISPOSITION.
B601 125 N34 SUBMISSION OF DATA CORRECTIONS/ADJUSTMENTS ARE NOT ACCEPTED ON A HCFA1500.
B602 A2 CLAIM HAS BEEN REFERRED FOR REVIEW UNDER THE MEMBER'S MEDICAL PLAN BENEFITS ANY BALANCE WILL BE
CONSIDERED UNDER THE DENTAL PLAN BENEFITS.
B603 96 THIS SERVICE IS NOT PAYABLE WHEN PERFORMED BY A NON-PARTICIPATING PROVIDER.
B611 97 PAYMENT FOR THESE SERVICES IS INCLUDED IN THE ALLOWANCE FOR THE PRIMARY PROCEDURE. NO ADDITIONAL
BENEFITS ARE AVAILABLE. PARTICIPATING PROVIDERS SHOULD NOT BILL SEPARATELY FOR THESE SERVICES.
B612 B18 INVALID PROCEDURE CODE SUBMITTED. PLEASE RESUBMIT WITH THE PROPER CPT PROCEDURE CODE.
B620 17 CLAIM CLOSED UNTIL REQUESTED INFORMATION IS RECEIVED.
B623 119 EXCEEDS ONE PER CALENDAR YEAR CONTRACT ALLOWANCE.
B649 38 NON-NETWORK FACILITY UTILIZED.
B650 A2 OUTPATIENT TREATMENT REPORT HAS NOW BEEN RECEIVED FROM PROVIDER. MEMBER IS RESPONSIBLE FOR COST-SHARE
ONLY.
B651 B18
THIS CLAIM WAS SUBMITTED WITH AN INVALID OR UNACCEPTABLE PROCEDURE CODE FOR THIS DATE OF SERVICE. PLEASE
SUBMIT A VALID OR ACCEPTABLE HCPCS OR CPT PROCEDURE CODE. WHEN WE RECEIVE THIS INFORMATION, WE WILL
CONTINUE TO PROCESS THIS CLAIM. PARTICIPATING PRO
B654 96 SERVICES NOT COVERED IN ACCORDANCE WITH CONTRACT POLICY.
B655 96 M97 SURGICAL ASSISTANT SERVICES ARE NOT PAYABLE AT THIS FACILITY.
B657 16 MA29 THE FACILITY CODE REQUIRED FOR PROCESSING THIS TYPE OF SERVICE WAS OMITTED. PLEASE PROVIDE US WITH THE
NAME AND/OR FACILITY CODE
B658 96 M97 THE SERVICES RENDERED ARE NOT COVERED AT THIS LOCATION.
B659 16 M51 THE NARRATIVE/CLAIM NOTE FOR THIS PROCEDURE CODE WAS OMITTED. PLEASE COMPLETE THE REQUIRED
INFORMATION AND RESUBMIT THIS CLAIM AGAIN.
B661 96
THIS SERVICE WAS NOT APPROVED BY MEDICARE AND THEREFORE, CANNOT BE APPROVED BY THE MEMBERS ANTHEM
SUPPLEMENTAL POLICY. THE PATIENT BALANCE IS DEPENDENT ON MEDICARE'S PAYMENT/DENIAL INFORMATION, PLEASE
REFER TO YOUR EXPLANATION OF MEDICARE BENEFITS
B662 133 YOUR HOSPITAL CLAIM HAS BEEN RECEIVED AND IS BEING PROCESSED. YOU WILL BE NOTIFIED SHORTLY OF THE FINAL
DISPOSITION.
B664 A1 NO PAYMENT IS AVAILABLE AT THIS TIME. THE POLICY HOLDER SHOULD CONTACT THEIR EMPLOYER FOR FURTHER
INFORMATION.
B666 16 M118 ADDITIONAL INFORMATION IS REQUIRED TO PROCESS THIS CLAIM. PLEASE CALL YOUR PROVIDER TELEPHONE UNIT FOR
DETAILS ON THE INFORMATION NEEDED.
B667 96 THIS PLAN DOES NOT COVER CHARGES WHICH HAVE BEEN APPLIED TO YOUR MEDICARE DEDUCTIBLE.
B668 22 OUR RECORDS INDICATE WE ARE THE PATIENT'S PRIMARY CARRIER. MEDICARE HAS ALREADY PAID ON THESE CHARGES.
PRIMARY LIABILITY IS BEING RESEARCHED. CLAIMS WILL BE REPROCESSED WHEN PRIMARY LIABILITY IS DETERMINED.
B669 96 OUR RECORDS INDICATE THAT THERE IS NO COVERAGE UNDER THIS IDENTIFICATION NUMBER.
B682 58
B683 58
B684 62 CHARGES OUTSIDE THE APPROVED LENGTH OF STAY ARE NOT COVERED.
B691 A1 THE SERVICES YOU SUBMITTED CANNOT BE APPROVED FOR PAYMENT. ANY QUESTIONS SHOULD BE DIRECTED TO OUR
SPECIAL INVESTIGATIONS UNIT.
B697 8 SERVICES RENDERED BY THIS PROVIDER ARE NOT PAYABLE.
B698 62 CLAIM HAS BEEN REJECTED. PRIOR AUTHORIZATION MUST BE OBTAINED FOR THIS TREATMENT.
B700 62 CHARGES OUTSIDE THE APPROVED LENGTH OF STAY ARE NOT COVERED.
B706 62 THIS CLAIM HAS BEEN REJECTED BASED ON UTILIZATION REVIEW; BENEFITS HAVE BEEN EXHAUSTED.
B708 A2 CHARGES HAVE BEEN PAID IN FULL UNDER THE HOSPITAL PORTION OF YOUR COVERAGE.
B709 B11 YOUR CLAIM HAS BEEN RECEIVED AND WAS FORWARDED TO THE PROPER DEPARTMENT FOR TIMELY PROCESSING.
B724 5 RECORDS INDICATE THIS SERVICE WAS PERFORMED IN OUTPATIENT SETTING. CLAIM BILLED AS INPATIENT. PLEASE
RESUBMIT WITH CORRECT PLACE-OF-SERVICE CODE.
B728 133 YOUR CLAIM IS BEING HELD PENDING A REVIEW OF MEDICAL RECORDS. AS SOON AS A DECISION IS MADE WE WILL
CONTINUE PROCESSING YOUR CLAIM.
B732 30 M118
ADDITIONAL INFORMATION IS REQUIRED REGARDING POSSIBLE PRE-EXISTING CONDITION. WE HAVE REQUESTED THE
INFORMATION FROM YOU UNDER SEPARATE COVER. WHEN THIS INFORMATION IS RECEIVED, YOU CLAIM WILL BE
RECONSIDERED.
B733 A1 THE SERVICES YOU SUBMITTED CANNOT BE APPROVED FOR PAYMENT. ANY QUESTIONS SHOULD BE DIRECTED TO OUR
SPECIAL INVESTIGATIONS UNIT.
B735 96 M67 INVALID PROCEDURE CODE. PLEASE CONTACT OUR REIMBURSEMENT DEPARTMENT TO ADD THIS PROCEDURE TO YOUR
PRICING PROFILE.
B738 A2 THIS CLAIM HAS BEEN CREDITED DUE TO THE ORIGINAL CLAIM BEING SUBMITTED IN ERROR.
B753 96 BENEFITS FOR THIS PROCEDURE ARE NOT PAYABLE BASED ON THE CONDITIONS AND LIMITATIONS OF THE PATIENT'S
POLICY.
B756 96 M67 SECOND OPINION SERVICES NOT PAYABLE WITH THIS PROCEDURE CODE. PLEASE RESUBMIT THE CLAIM WITH AN OFFICE
VISIT CODE.
B757 96 ACCORDING TO THE TERMS OF THE PLAN, THIS PROCEDURE IS NOT COVERED.
B758 96 ACCORDING TO THE TERMS OF THE PLAN, HOME AND OFFICE MEDICAL CARE IS NOT COVERED BY THE PATIENT'S
CONTRACT.
B759 96 ACCORDING TO THE TERMS OF THE PLAN, LABORATORY TEST ARE NOT COVERED BY THE PATIENT'S CONTRACT.
B760 96 ACCORDING TO THE TERMS OF THE PLAN, PHYSICAL EXAMINATIONS AND/OR ROUTINE IMMUNIZATIONS ARE NOT
COVERED.
B761 96 ACCORDING TO THE TERMS OF THE PLAN, ROUTINE GYNECOLOGICAL EXAMINATIONS ARE NOT COVERED BY THE PATIENT'S
CONTRACT.
B769 125 PLEASE SUBMIT TWO SEPARATE BILLS, ONE FOR EMERGENCY ROOM SERVICES AND ANOTHER FOR THE INPATIENT
ADMISSION.
B779 109 THIS SERVICE IS PROCESSED BY A VENDOR. HANDLE DIRECT WITH THE HOME PLAN.
B789 22
OUR RECORDS INDICATE THE PATIENT HAS OTHER INSURANCE. SUBMIT THESE CHARGES TO THE OTHER INSURANCE
CARRIER AND SEND US THEIR ITEMIZED STATEMENT OF PAYMENT OF DENIAL ONLY. DO NOT RESUBMIT THE CLAIM. ONCE
THIS INFORMATION HAS BEEN RECEIVED YOUR CLAIM WILL BE RECONSIDERED FOR PAYMENT.
B794 96 COSMETIC SURGERY IS NOT COVERED.
B800 96 UNDER THIS CONTRACT NUMBER, THERE IS NO COVERAGE FOR THIS SERVICE.
B801 26 SERVICES OR ADMISSION RENDERED PRIOR TO THE CONTRACT EFFECTIVE DATE.
B802 96 UNDER THIS CONTRACT NUMBER, THERE IS NO COVERAGE FOR THIS SERVICE.
B803 31 PATIENT NOT ON CONTRACT AT THE TIME OF SERVICE.
B805 27 SERVICES WERE RENDERED AFTER THE CANCELLATION DATE FOR THIS MEMBER.
B809 31 CLAIM SUBMITTED WITH AN INVALID IDENTIFICATION NUMBER. PLEASE SUBMIT WITH THE CORRECT IDENTIFICATION
NUMBER.
B812 B11 YOUR CLAIM HAS BEEN RECEIVED AND WAS FORWARDED TO THE PROPER DEPARTMENT FOR TIMELY PROCESSING.
B813 32 PATIENT'S AGE EXCEEDS THE MAXIMUM AGE LIMIT.
B814 31 THE PATIENT'S LAST NAME DOES NOT MATCH OUR MEMBERSHIP RECORDS. PLEASE HAVE THE MEMBER CONTACT US.
ADDITIONAL INFORMATION IS NEEDED BEFORE CLAIMS CAN BE PROCESSED.
B820 16 N257 THIS CLAIM WAS SUBMITTED WITH THE INCORRECT PROVIDER OFFICE LOCATION NUMBER. PLEASE RESUBMIT WITH THE
ACTIVE OFFICE NUMBER.
B821 31 PATIENT NOT ON CONTRACT AT THE TIME OF SERVICE.
B822 31 PATIENT IS NOT LISTED AS AN ELIGIBLE MEMBER. PLEASE CHECK NAME, AGE, GENDER AND ANTHEM ID CARD NUMBER. IF
NO ERRORS ARE FOUND PLEASE CONTACT US BY PHONE.
B823 31 PATIENT IS NOT LISTED AS AN ELIGIBLE MEMBER.
B825 31 PATIENT IS NOT LISTED AS AN ELIGIBLE ADULT MEMBER.
B826 32 PATIENT IS NOT LISTED AS AN ELIGIBLE CHILD DEPENDENT.
B828 27 SERVICES WERE RENDERED AFTER THE GROUP'S CANCELLATION DATE.
B829 29 ACCORDING TO THE TERMS OF THE PLAN, THERE IS NO REIMBURSEMENT AVAILABLE FOR THIS SERVICE AS THE CLAIM
WAS NOT SUBMITTED WITHIN THE CONTRACTUALLY ESTABLISHED TIME LIMIT.

For full list https://www11.anthem.com/edi/noapplication/f3/s1/t0/pw_ad080244.pdf?ref...



Code Description

01 Deductible amount.
02 Coinsurance amount.
03 Co-payment amount.
04 The procedure code is inconsistent with the modifier used, or a required modifier is missing.
05 The procedure code/bill type is inconsistent with the place of service.
06 The procedure/revenue code is inconsistent with the patient’s age.
07 The procedure/revenue code is inconsistent with the patient's gender.
08 The procedure code is inconsistent with the provider type/specialty (taxonomy).
09 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.
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using remittance advice remarks codes whenever appropriate.
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 because charges have been paid by another payer.
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.
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.
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 Benefit maximum has been reached.
36 Balance does not exceed co-payment amount.
37 Balance does not exceed deductible.
38 Services not provided or authorized by designated (network) providers.
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.
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.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48 This (these) procedure(s) is (are) not covered.
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 provider is not eligible to refer/prescribe/order/perform the service billed.
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 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.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59 Charges are reduced based on multiple surgery rules or concurrent anesthesia rules.
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.
62 Payment denied/reduced for absence of, or exceeded, precertification/ authorization.
63 Correction to a prior claim.
64 Denial reversed per Medical Review.
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood deductible.
67 Lifetime reserve days.
68 DRG weight.
69 Day outlier amount.
70 Cost outlier. Adjustment to compensate for additional costs.
71 Primary payer amount.
72 Coinsurance day.
73 Administrative days.
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days.
78 Non-covered days/Room charge adjustment.
79 Cost report days.
80 Outlier days.
81 Discharges.
82 PIP days.
83 Total visits.
84 Capital Adjustment.
85 Interest amount.
86 Statutory Adjustment.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim paid in full.
93 No claim level adjustments.
94 Processed in excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charges.
97 Payment is included in the allowance for another service/procedure.
98 The hospital must file the Medicare claim for this inpatient non-physician service.
99 Medicare Secondary Payer Adjustment amount.
100 Payment made to patient/insured/responsible party.
101 Predetermination. Anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
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 paid or identified on the claim.
108 Payment adjusted because rent/purchase guidelines were not met.
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.
113 Payment denied because service/procedure was provided outside the United
States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or cancelled.
116 Payment denied. The advance indemnification notice signed by the patient
did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period has been reached.
120 Patient is covered by a managed care plan.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
124 Payer refund amount – not our patient.
125 Payment adjusted due to a submission/billing error(s). Additional information
is supplied using the remittance advice remarks codes whenever appropriate.
126 Deductible – Major Medical.
127 Coinsurance – Major Medical.
128 Newborn’s services are covered in the mother’s allowance.
129 Payment denied. Prior processing information appears incorrect.
130 Claim submission fee.
131 Claim specific negotiated discount.
132 Prearranged demonstration project adjustment.
133 The disposition of this claim/service is pending further review.
134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claim adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 Claim/Service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement. Subscriber is employed by the provider of the services.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment, e.g., preferred product/service.
145 Premium payment withholding.
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual adjustment.
A3 Medicare Secondary Payer liability met.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
A7 Presumptive Payment Adjustment.
A8 Claim denied; ungroupable DRG.
B1 Non-covered visits.
B2 Covered visits.
B3 Covered charges.
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 Claim/service not covered/reduced because alternative services were available, and should not have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 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.
B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
B12 Services not documented in patient’s medical records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Payment denied because only one visit or consultation per physician per day is covered.
B15 Payment adjusted because this service/procedure is not paid separately.
B16 Payment adjusted because "new patient" qualifications were not met.
B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B18 Payment denied because this procedure code/modifier was invalid on the
date of service or claim submission.
B19 Claim/service adjusted because of the finding of a Review Organization.
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
B21 The charges were reduced because the service/care was partially furnished by another physician.
B22 This payment is adjusted based on the diagnosis.
B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
D1 Claim/service denied. Level of subluxation is missing or inadequate.
D2 Claim lacks the name, strength, or dosage of the drug furnished.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4 Claim/service does not indicate the period of time for which this will be needed.
D5 Claim/service denied. Claim lacks individual lab codes included in the test.
D6 Claim/service denied. Claim did not include patient's medical record for the service.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
D8 Claim/service denied. Claim lacks indicator that "x-ray is available for review”.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10 Claim/service denied. Completed physician financial relationship form not on file.
D11 Claim lacks completed pacemaker registration form.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14 Claim lacks indication that plan of treatment is on file.
D15 Claim lacks indication that service was supervised or evaluated by a physician. W1 Workers Compensation State Fee Schedule Adjustment.

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