Submit Documentation for Drugs and Biologicals & Emergency Room, Observation for processing


Drugs and Biologicals

·         Please be sure documentation submitted is legible.

·         Please submit records for all dates of service on the claim.

·         Please ensure that the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:

o    Pretreatment/initial treatment plan including history and physical.

o    Plan of care including the drug dosage, frequency and expected duration of treatment.

o    Progress notes – initial and most recent (including patient weight at each treatment).

o    Medication records/infusion flow sheets.

o    Laboratory reports.

o    Consultation report.

o    Documentation of any drug wastage.

o    Signatures/credentials of professionals providing services.

o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.


Emergency Room, Observation

·         Please be sure documentation submitted is legible.

·         Please submit records for all dates of service on the claim.

·         Please ensure that the medical records submitted provide proof that the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:

o    History and physical.

o    Medication records.

o    Nurse’s notes.

o    Operative reports.

o    Pathology reports.

o    Physician’s progress notes.

o    Physician’s orders.

o    Procedure notes.

o    Signatures/credentials of professionals providing services.

o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as, documentation specifically requested in the Additional Documentation Request (ADR) letter.

Documentation needed for Outpatient Therapy

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Current level of function.
o    Prior level of function.
o    Initial therapy evaluation.
o    Any previous therapy administered.
o    Diagnosis onset date.
o    Grid reflecting services(s)/HCPCS.
o    Medical diagnosis.
o    Physician certification and recertification.
o    Physician’s orders.
o    Progress notes detailing services provided for each date of service billed.
o   
o    Treatment diagnosis.
o    Treatment plan with long- and short-term goals.
o    Description of instrument used for selective or sharp debridement for wound care services (if applicable).
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.

File End Stage Renal Disease (ESRD) Clinic Claim along with Document

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician’s orders for all services rendered (i.e., standing orders, annual renewal orders and specific orders for all services billed during the dates of service).
o    Written long-term program (revised annually), written patient care plan.
o    Short-Term Care Plan (STCP).
o    Diagnosis.
o    Dialysis start date.
o    Daily dialysis flow sheets.
o    Dietitian’s notes.
o    History and physical.
o    Social worker’s notes.
o    Nurse’s notes.
o    Physician’s progress notes.
o    Medication administration records, indicating amount given, wastage, route of administration, dates and time given.
o    Copies of provider’s protocols utilized to tailor a patient’s therapy, with reports of diagnostic tests, treatments and clinical findings.
o    Signatures/credentials of professionals providing services.
Plus any documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.

Remark Code   Description

PR1 Deductible Amount

PR2 Coinsurance Amount

PR3 Co-payment Amount

OA4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

OA5 The procedure code/bill type is inconsistent with the place of service.

OA6 The procedure/revenue code is inconsistent with the patient's age.

OA7 The procedure/revenue code is inconsistent with the patient's gender.

OA8 The procedure code is inconsistent with the provider type/specialty (taxonomy).

OA9 The diagnosis is inconsistent with the patient's age.

OA10 The diagnosis is inconsistent with the patient's gender.

OA11 The diagnosis is inconsistent with the procedure.

OA12 The diagnosis is inconsistent with the provider type.

OA13 The date of death precedes the date of service.

OA14 The date of birth follows the date of service.

CO15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

OA16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

PI17 Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

OA18 Duplicate claim/service.

OA19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

OA20 Claim denied because this injury/illness is covered by the liability carrier.

OA21 Claim denied because this injury/illness is the liability of the no-fault carrier.

CO22 Payment adjusted because this care may be covered by another payer per coordination of benefits.

PI23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments

CO24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.

PR25 Payment denied. Your Stop loss deductible has not been met.

PR26 Expenses incurred prior to coverage.

PR27 Expenses incurred after coverage terminated.

CO29 The time limit for filing has expired.

PR31 Claim denied as patient cannot be identified as our insured.

PR32 Our records indicate that this dependent is not an eligible dependent as defined.

PR33 Claim denied. Insured has no dependent coverage.

PR34 Claim denied. Insured has no coverage for newborns.

PR35 Lifetime benefit maximum has been reached.

CO38 Services not provided or authorized by designated (network/primary care) providers.

CO39 Services denied at the time authorization/pre-certification was requested.

OA40 Charges do not meet qualifications for emergent/urgent care.

OA44 Prompt-pay discount.

CO45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).

CO49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.

CO50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.

CO51 These are non-covered services because this is a pre-existing condition

OA53 Services by an immediate relative or a member of the same household are not covered.

CO54 Multiple physicians/assistants are not covered in this case .

CO55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.

CO56 Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by the payer.

CO58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

OA59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)

CO60 Charges for outpatient services with this proximity to inpatient services are not covered.

OA61 Charges adjusted as penalty for failure to obtain second surgical opinion.

CO66 Blood Deductible.

CO69 Day outlier amount.

CO70 Cost outlier - Adjustment to compensate for additional costs.

OA74 Indirect Medical Education Adjustment.

OA75 Direct Medical Education Adjustment.

CO76 Disproportionate Share Adjustment.

CO78 Non-Covered days/Room charge adjustment.

PR85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)

OA87 Transfer amount.

CO89 Professional fees removed from charges.

OA90 Ingredient cost adjustment.

CO91 Dispensing fee adjustment.

CO94 Processed in Excess of charges.

OA95 Benefits adjusted. Plan procedures not followed.

CO96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

PI97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated

OA100 Payment made to patient/insured/responsible party.

CO101 Predetermination: anticipated payment upon completion of services or claim adjudication.

CO102 Major Medical Adjustment.

CO103 Provider promotional discount (e.g., Senior citizen discount).

OA104 Managed care withholding.

OA105 Tax withholding.

OA106 Patient payment option/election not in effect.

CO107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.

PI108 Payment adjusted because rent/purchase guidelines were not met.

OA109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

CO110 Billing date predates service date.

CO111 Not covered unless the provider accepts assignment.

PI112 Payment adjusted as not furnished directly to the patient and/or not documented.

CO114 Procedure/product not approved by the Food and Drug Administration.

PI115 Payment adjusted as procedure postponed or canceled. This change effective 1/1/2008: Payment adjusted as procedure postponed, canceled, or delayed.

OA116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.

CO117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.

OA118 Charges reduced for ESRD network support.

CO119 Benefit maximum for this time period or occurrence has been reached.

OA121 Indemnification adjustment.

OA122 Psychiatric reduction.

CO125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

PR126 Deductible -- Major Medical

PR127 Coinsurance -- Major Medical

CO128 Newborn's services are covered in the mother's Allowance.

CR129 Payment denied - Prior processing information appears incorrect.

OA130 Claim submission fee.

OA131 Claim specific negotiated discount.

OA132 Prearranged demonstration project adjustment.

OA133 The disposition of this claim/service is pending further review.

OA134 Technical fees removed from charges.

CO135 Claim denied. Interim bills cannot be processed.

OA136 Claim adjusted based on failure to follow prior payer's coverage rules. (Use Group Code OA).

OA137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

CO138 Claim/service denied. Appeal procedures not followed or time limits not met.

CO139 Contracted funding agreement - Subscriber is employed by the provider of services.

PR140 Patient/Insured health identification number and name do not match.

OA141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.

CR142 Claim adjusted by the monthly Medicaid patient liability amount.

OA143 Portion of payment deferred.

CR144 Incentive adjustment, e.g. preferred product/service.

PI145 Premium payment withholding

CO146 Payment denied because the diagnosis was invalid for the date(s) of service reported.

OA147 Provider contracted/negotiated rate expired or not on file.

OA148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.

PR149 Lifetime benefit maximum has been reached for this service/benefit category.

PI150 Payment adjusted because the payer deems the information submitted does not support this level of service.

PI151 Payment adjusted because the payer deems the information submitted does not support this many services.

PI152 Payment adjusted because the payer deems the information submitted does not support this length of service.

PI153 Payment adjusted because the payer deems the information submitted does not support this dosage.

PI154 Payment adjusted because the payer deems the information submitted does not support this day's supply.

OA155 This claim is denied because the patient refused the service/procedure.

OA156 Flexible spending account payments

CO157 Payment denied/reduced because service/procedure was provided as a result of an act of war.

CO158 Payment denied/reduced because the service/procedure was provided outside of the United States.

CO159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.

CO160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.

OA161 Provider performance bonus

CO162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.

CR163 Claim/Service adjusted because the attachment referenced on the claim was not received.

CR164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.

CO165 Payment denied /reduced for absence of, or exceeded referral

PR166 These services were submitted after this payers responsibility for processing claims under this plan ended.

CO167 This (these) diagnosis(es) is (are) not covered.

PR168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan

PI169 Payment adjusted because an alternate benefit has been provided

CO170 Payment is denied when performed/billed by this type of provider.

CO171 Payment is denied when performed/billed by this type of provider in this type of facility.

CO172 Payment is adjusted when performed/billed by a provider of this specialty

CR173 Payment adjusted because this service was not prescribed by a physician

CO174 Payment denied because this service was not prescribed prior to delivery

CO175 Payment denied because the prescription is incomplete

CO176 Payment denied because the prescription is not current

PR177 Payment denied because the patient has not met the required eligibility requirements

CR178 Payment adjusted because the patient has not met the required spend down requirements.

CR179 Payment adjusted because the patient has not met the required waiting requirements

CR180 Payment adjusted because the patient has not met the required residency requirements

CR181 Payment adjusted because this procedure code was invalid on the date of service

CR182 Payment adjusted because the procedure modifier was invalid on the date of service

CO183 The referring provider is not eligible to refer the service billed.

CO184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.

CO185 The rendering provider is not eligible to perform the service billed.

OA186 Payment adjusted since the level of care changed

OA187 Health Savings account payments

CO188 This product/procedure is only covered when used according to FDA recommendations.

OA189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

CO190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

CO191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers' compensation carrier.

OA192 Non standard adjustment code from paper remittance advice.

CO193 Original payment decision is being maintained. This claim was processed properly the first time.

PI194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician

PI195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service

PI197 Payment adjusted for absence of precertification/authorization. This change effective 1/1/2008: Payment adjusted for absence of precertification/authorization/notification.

PI198 Payment Adjusted for exceeding precertification/ authorization.

OA199 Revenue code and Procedure code do not match.

PR200 Expenses incurred during lapse in coverage

PR201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC €œMedicare set aside arrangement or other agreement. (Use group code PR).

PI202 Payment adjusted due to non-covered personal comfort or convenience services.

PI203 Payment adjusted for discontinued or reduced service.

PR204 This service/equipment/drug is not covered under the patient's current benefit plan

CO205 Pharmacy discount card processing fee

OA206 NPI denial - missing

OA208 NPI denial - not matched

OA209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)

PI210 Payment adjusted because pre-certification/authorization not received in a timely fashion

CO211 National Drug Codes (NDC) not eligible for rebate, are not covered.

PIA0 Patient refund amount.

OAA1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

COA4 Medicare Claim PPS Capital Day Outlier Amount.

COA5 Medicare Claim PPS Capital Cost Outlier Amount.

OAA6 Prior hospitalization or 30 day transfer requirement not met.

COA7 Presumptive Payment Adjustment

OAA8 Claim denied; un-groupable DRG

PRB1 Non-covered visits.

COB10 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.

OAB11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

OAB12 Services not documented in patients' medical records.

OAB13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

COB14 Payment denied because only one visit or consultation per physician per day is covered.

OAB15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

COB16 Payment adjusted because 'New Patient' qualifications were not met.

OAB18 Payment adjusted because this procedure code and modifier were invalid on the date of service

OAB20 Payment adjusted because procedure/service was partially or fully furnished by another provider.

OAB22 This payment is adjusted based on the diagnosis.

COB23 Payment denied because this provider has failed an aspect of a proficiency testing program.

COB4 Late filing penalty.

COB5 Payment adjusted because coverage/program guidelines were not met or were exceeded.

COB7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.

CRB8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.

PRB9 Services not covered because the patient is enrolled in a Hospice.

PIW1 Workers Compensation State Fee Schedule Adjustment



Last Updated ( Friday, 24 June 2011 21:51 )

Health Care Claim Status Codes convey the status of an entire claim or a specific service line.

00   Cannot provide further status electronically.  Start: 01/01/1995
01   For more detailed information, see remittance advice.  Start: 01/01/1995
02   More detailed information in letter.  Start: 01/01/1995
03   Claim has been adjudicated and is awaiting payment cycle.  Start: 01/01/1995
04   This is a subsequent request for information from the original request.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
05   This is a final request for information.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
06   Balance due from the subscriber.  Start: 01/01/1995
07   Claim may be reconsidered at a future date.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
08   No payment due to contract/plan provisions.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
09   No payment will be made for this claim.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
10   All originally submitted procedure codes have been combined.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
11   Some originally submitted procedure codes have been combined.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
12   One or more originally submitted procedure codes have been combined.  Start: 01/01/1995 | Last Modified: 06/30/2001
13   All originally submitted procedure codes have been modified.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
14   Some all originally submitted procedure codes have been modified.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
15   One or more originally submitted procedure code have been modified.  Start: 01/01/1995 | Last Modified: 06/30/2001
16   Claim/encounter has been forwarded to entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
17   Claim/encounter has been forwarded by third party entity to entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
18   Entity received claim/encounter, but returned invalid status. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
19   Entity acknowledges receipt of claim/encounter. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
20   Accepted for processing.  Start: 01/01/1995 | Last Modified: 06/30/2001
21   Missing or invalid information. Note: At least one other status code is required to identify the missing or invalid information.  Start: 01/01/1995 | Last Modified: 07/09/2007
22   ... before entering the adjudication system.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
23   Returned to Entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
24   Entity not approved as an electronic submitter. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
25   Entity not approved. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
26   Entity not found. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
27   Policy canceled.  Start: 01/01/1995 | Last Modified: 06/30/2001
28   Claim submitted to wrong payer.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
29   Subscriber and policy number/contract number mismatched.  Start: 01/01/1995
30   Subscriber and subscriber id mismatched.  Start: 01/01/1995
31   Subscriber and policyholder name mismatched.  Start: 01/01/1995
32   Subscriber and policy number/contract number not found.  Start: 01/01/1995
33   Subscriber and subscriber id not found.  Start: 01/01/1995
34   Subscriber and policyholder name not found.  Start: 01/01/1995
35   Claim/encounter not found.   Start: 01/01/1995
37   Predetermination is on file, awaiting completion of services.  Start: 01/01/1995
38   Awaiting next periodic adjudication cycle.  Start: 01/01/1995
39   Charges for pregnancy deferred until delivery.  Start: 01/01/1995
40   Waiting for final approval.  Start: 01/01/1995
41   Special handling required at payer site.  Start: 01/01/1995
42   Awaiting related charges.  Start: 01/01/1995
44   Charges pending provider audit.  Start: 01/01/1995
45   Awaiting benefit determination.  Start: 01/01/1995
46   Internal review/audit.  Start: 01/01/1995
47   Internal review/audit - partial payment made.  Start: 01/01/1995
48   Referral/authorization.  Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 01/01/2012  Notes: Refer to codes 252 and 761.
49   Pending provider accreditation review.  Start: 01/01/1995
50   Claim waiting for internal provider verification.  Start: 01/01/1995
51   Investigating occupational illness/accident.  Start: 01/01/1995
52   Investigating existence of other insurance coverage.  Start: 01/01/1995
53   Claim being researched for Insured ID/Group Policy Number error.  Start: 01/01/1995
54   Duplicate of a previously processed claim/line.  Start: 01/01/1995
55   Claim assigned to an approver/analyst.  Start: 01/01/1995
56   Awaiting eligibility determination.  Start: 01/01/1995
57   Pending COBRA information requested.  Start: 01/01/1995
59   Information was requested by a non-electronic method. Note: At least one other status code is required to identify the requested information.  Start: 01/01/1995 | Last Modified: 10/17/2010
60   Information was requested by an electronic method. Note: At least one other status code is required to identify the requested information.  Start: 01/01/1995 | Last Modified: 10/17/2010
61   Eligibility for extended benefits.  Start: 01/01/1995
64   Re-pricing information.  Start: 01/01/1995
65   Claim/line has been paid.  Start: 01/01/1995
66   Payment reflects usual and customary charges.  Start: 01/01/1995
67   Payment made in full.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
68   Partial payment made for this claim.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
69   Payment reflects plan provisions.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
70   Payment reflects contract provisions.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
71   Periodic installment released.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
72   Claim contains split payment.  Start: 01/01/1995
73   Payment made to entity, assignment of benefits not on file. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
78   Duplicate of an existing claim/line, awaiting processing.  Start: 01/01/1995
81   Contract/plan does not cover pre-existing conditions.  Start: 01/01/1995
83   No coverage for newborns.  Start: 01/01/1995
84   Service not authorized.  Start: 01/01/1995
85   Entity not primary. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
86   Diagnosis and patient gender mismatch.  Start: 01/01/1995 | Last Modified: 02/28/2000
87   Denied: Entity not found. (Use code 26 with appropriate Claim Status category Code)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
88   Entity not eligible for benefits for submitted dates of service. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
89   Entity not eligible for dental benefits for submitted dates of service. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
90   Entity not eligible for medical benefits for submitted dates of service. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
91   Entity not eligible/not approved for dates of service. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
92   Entity does not meet dependent or student qualification. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
93   Entity is not selected primary care provider. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
94   Entity not referred by selected primary care provider. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
95   Requested additional information not received.  Start: 01/01/1995 | Last Modified: 07/09/2007  Notes: If known, the payer must report a second claim status code identifying the requested information.
96   No agreement with entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
97   Patient eligibility not found with entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
98   Charges applied to deductible.  Start: 01/01/1995
99   Pre-treatment review.  Start: 01/01/1995
100  Pre-certification penalty taken.  Start: 01/01/1995
101  Claim was processed as adjustment to previous claim.  Start: 01/01/1995
102  Newborn's charges processed on mother's claim.  Start: 01/01/1995
103  Claim combined with other claim(s).  Start: 01/01/1995
104  Processed according to plan provisions (Plan refers to provisions that exist between the Health Plan and the Consumer or Patient)  Start: 01/01/1995 | Last Modified: 06/01/2008
105  Claim/line is capitated.  Start: 01/01/1995
106  This amount is not entity's responsibility. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010 
107  Processed according to contract provisions (Contract refers to provisions that exist between t  he Health Plan and a Provider of Health Care Services)  Start: 01/01/1995 | Last Modified: 06/01/2008
108  Coverage has been canceled for this entity. (Use code 27)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
109  Entity not eligible. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
110  Claim requires pricing information.  Start: 01/01/1995
111  At the policyholder's request these claims cannot be submitted electronically.  Start: 01/01/1995
112  Policyholder processes their own claims.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
113  Cannot process individual insurance policy claims.  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008
114  Claim/service should be processed by entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
115  Cannot process HMO claims  Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008  
116  Claim submitted to incorrect payer.  Start: 01/01/1995  
117  Claim requires signature-on-file indicator.  Start: 01/01/1995
118  TPO rejected claim/line because payer name is missing. (Use status code 21 and status code 125 with entity code IN)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
119  TPO rejected claim/line because certification information is missing. (Use status code 21 and status code 252)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
120  TPO rejected claim/line because claim does not contain enough information. (Use status code 21)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
121  Service line number greater than maximum allowable for payer.  Start: 01/01/1995
122  Missing/invalid data prevents payer from processing claim. (Use CSC Code 21)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
123  Additional information requested from entity. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
124  Entity's name, address, phone and id number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
125  Entity's name. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
126  Entity's address. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
127  Entity's Communication Number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 06/06/2010
128  Entity's tax id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
129  Entity's Blue Cross provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
130  Entity's Blue Shield provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
131  Entity's Medicare provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
132  Entity's Medicaid provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
133  Entity's UPIN. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
134  Entity's CHAMPUS provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
135  Entity's commercial provider id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
136  Entity's health industry id number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
137  Entity's plan network id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
138  Entity's site id . Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
139  Entity's health maintenance provider id (HMO). Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
140  Entity's preferred provider organization id (PPO). Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
141  Entity's administrative services organization id (ASO). Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
142  Entity's license/certification number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
143  Entity's state license number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
144  Entity's specialty license number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
145  Entity's specialty/taxonomy code. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
146  Entity's anesthesia license number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
147  Entity's qualification degree/designation (e.g. RN,PhD,MD). Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 02/11/2010
148  Entity's social security number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010  
149  Entity's employer id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
150  Entity's drug enforcement agency (DEA) number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
152  Pharmacy processor number.  Start: 01/01/1995
153  Entity's id number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
154  Relationship of surgeon & assistant surgeon.  Start: 01/01/1995
155  Entity's relationship to patient. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
156  Patient relationship to subscriber  Start: 01/01/1995
157  Entity's Gender. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
158  Entity's date of birth. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
159  Entity's date of death. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
160  Entity's marital status. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
161  Entity's employment status. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
162  Entity's health insurance claim number (HICN). Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
163  Entity's policy number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
164  Entity's contract/member number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
165  Entity's employer name, address and phone. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
166  Entity's employer name. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
167  Entity's employer address. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
168  Entity's employer phone number. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
169  Entity's employer id.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
170  Entity's employee id. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
171  Other insurance coverage information (health, liability, auto, etc.).  Start: 01/01/1995
172  Other employer name, address and telephone number.  Start: 01/01/1995
173  Entity's name, address, phone, gender, DOB, marital status, employment status and relation to subscriber. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
174  Entity's student status. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
175  Entity's school name. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
176  Entity's school address. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
177  Transplant recipient's name, date of birth, gender, relationship to insured.  Start: 01/01/1995 | Last Modified: 02/28/2000
178  Submitted charges.  Start: 01/01/1995
179  Outside lab charges.  Start: 01/01/1995
180  Hospital s semi-private room rate.  Start: 01/01/1995
181  Hospital s room rate.  Start: 01/01/1995
182  Allowable/paid from other entities coverage NOTE: This code requires the use of an entity code.  Start: 01/01/1995 | Last Modified: 01/24/2010
183  Amount entity has paid. Note: This code requires use of an Entity Code.  Start: 01/01/1995 | Last Modified: 02/11/2010
184  Purchase price for the rented durable medical equipment.  Start: 01/01/1995
185  Rental price for durable medical equipment.  Start: 01/01/1995
186  Purchase and rental price of durable medical equipment.  Start: 01/01/1995
187  Date(s) of service.  Start: 01/01/1995
188  Statement from-through dates.  Start: 01/01/1995
189  Facility admission date  Start: 01/01/1995 | Last Modified: 10/31/2006
190  Facility discharge date  Start: 01/01/1995 | Last Modified: 10/31/2006
191  Date of Last Menstrual Period (LMP)  Start: 02/28/1997
192  Date of first service for current series/symptom/illness.  Start: 01/01/1995
193  First consultation/evaluation date.  Start: 02/28/1997
194  Confinement dates.  Start: 01/01/1995
195  Unable to work dates/Disability Dates.  Start: 01/01/1995 | Last Modified: 09/20/2009
196  Return to work dates.  Start: 01/01/1995
197  Effective coverage date(s).  Start: 01/01/1995
198  Medicare effective date.  Start: 01/01/1995
199  Date of conception and expected date of delivery.  Start: 01/01/1995
200  Date of equipment return.  Start: 01/01/1995
201  Date of dental appliance prior placement.  Start: 01/01/1995
202  Date of dental prior replacement/reason for replacement.  Start: 01/01/1995
203  Date of dental appliance placed.  Start: 01/01/1995
204  Date dental canal(s) opened and date service completed.  Start: 01/01/1995
205  Date(s) dental root canal therapy previously performed.  Start: 01/01/1995
206  Most recent date of curettage, root planing, or periodontal surgery.  Start: 01/01/1995
207  Dental impression and seating date.  Start: 01/01/1995
208  Most recent date pacemaker was implanted.  Start: 01/01/1995
209  Most recent pacemaker battery change date.  Start: 01/01/1995
210  Date of the last x-ray.  Start: 01/01/1995
211  Date(s) of dialysis training provided to patient.  Start: 01/01/1995
212  Date of last routine dialysis.  Start: 01/01/1995
213  Date of first routine dialysis.  Start: 01/01/1995
214  Original date of prescription/orders/referral.  Start: 02/28/1997
215  Date of tooth extraction/evolution.  Start: 01/01/1995
216  Drug information.  Start: 01/01/1995
217  Drug name, strength and dosage form.  Start: 01/01/1995
218  NDC number.  Start: 01/01/1995
219  Prescription number.  Start: 01/01/1995
220  Drug product id number. (Use code 218)  Start: 01/01/1995 | Last Modified: 10/17/2010 | Stop: 07/01/2011
221  Drug days supply and dosage.  Start: 01/01/1995 | Last Modified: 01/24/2010 | Stop: 01/01/2012
222  Drug dispensing units and average wholesale price (AWP).  Start: 01/01/1995
223  Route of drug/myelogram administration.  Start: 01/01/1995
224  Anatomical location for joint injection.  Start: 01/01/1995
225  Anatomical location.  Start: 01/01/1995
226  Joint injection site.  Start: 01/01/1995
227  Hospital information.  Start: 01/01/1995
228  Type of bill for UB claim  Start: 01/01/1995 | Last Modified: 10/31/2006
229  Hospital admission source.  Start: 01/01/1995
230  Hospital admission hour.  Start: 01/01/1995
231  Hospital admission type.  Start: 01/01/1995
232  Admitting diagnosis.  Start: 01/01/1995
233  Hospital discharge hour  Start: 01/01/1995
234  Patient discharge status.  Start: 01/01/1995
235  Units of blood furnished.  Start: 01/01/1995
236  Units of blood replaced.  Start: 01/01/1995
237  Units of deductible blood.  Start: 01/01/1995
238  Separate claim for mother/baby charges.  Start: 01/01/1995
239  Dental information.  Start: 01/01/1995
240  Tooth surface(s) involved.  Start: 01/01/1995
241  List of all missing teeth (upper and lower).  Start: 01/01/1995
242  Tooth numbers, surfaces, and/or quadrants involved.  Start: 01/01/1995
243  Months of dental treatment remaining.  Start: 01/01/1995
244  Tooth number or letter.  Start: 01/01/1995
245  Dental quadrant/arch.  Start: 01/01/1995
246  Total orthodontic service fee, initial appliance fee, monthly fee, length of service.  Start: 01/01/1995
247  Line information.  Start: 01/01/1995
248  Accident date, state, description and cause.  Start: 01/01/1995 | Last Modified: 01/24/2010 | Stop: 01/01/2012
249  Place of service.  Start: 01/01/1995
250  Type of service.  Start: 01/01/1995
251  Total anesthesia minutes.  Start: 01/01/1995
252  Authorization/certification number. This change effective 11/1/2011: Entity's authorization/certification number. Note: This code requires the use of an Entity Code.  Start: 01/01/1995 | Last Modified: 01/30/2011
253  Procedure/revenue code for service(s) rendered. Use codes 454 or 455.  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
254  Primary diagnosis code. This change effective 11/1/2011: Principal doagnosis code.  Start: 01/01/1995 | Last Modified: 01/30/2011
255  Diagnosis code.  Start: 01/01/1995
256  DRG code(s).  Start: 01/01/1995
257  ADSM-III-R code for services rendered.  Start: 01/01/1995
258  Days/units for procedure/revenue code.  Start: 01/01/1995
259  Frequency of service.  Start: 01/01/1995
260  Length of medical necessity, including begin date.  Start: 02/28/1997
261  Obesity measurements.  Start: 01/01/1995
262  Type of surgery/service for which anesthesia was administered.  Start: 01/01/1995
263  Length of time for services rendered.  Start: 01/01/1995
264  Number of liters/minute & total hours/day for respiratory support.  Start: 01/01/1995
265  Number of lesions excised.  Start: 01/01/1995
266  Facility point of origin and destination - ambulance.  Start: 01/01/1995
267  Number of miles patient was transported.  Start: 01/01/1995
268  Location of durable medical equipment use.  Start: 01/01/1995
269  Length/size of laceration/tumor.  Start: 01/01/1995
270  Subluxation location.  Start: 01/01/1995
271  Number of spine segments.  Start: 01/01/1995
272  Oxygen contents for oxygen system rental.  Start: 01/01/1995
273  Weight.  Start: 01/01/1995
274  Height.  Start: 01/01/1995
275  Claim.  Start: 01/01/1995
276  UB04/HCFA-1450/1500 claim form  Start: 01/01/1995 | Last Modified: 10/31/2006
277  Paper claim.  Start: 01/01/1995
278  Signed claim form.  Start: 01/01/1995 | Stop: 11/01/2011
279  Claim/service must be itemized  Start: 01/01/1995 | Last Modified: 10/17/2010
280  Itemized claim by provider.  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 279
281  Related confinement claim.  Start: 01/01/1995
282  Copy of prescription.  Start: 01/01/1995
283  Medicare entitlement information is required to determine primary coverage  Start: 01/01/1995 | Last Modified: 01/27/2008
284  Copy of Medicare ID card.  Start: 01/01/1995
285  Vouchers/explanation of benefits (EOB).  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 286
286  Other payer's Explanation of Benefits/payment information.  Start: 01/01/1995
287  Medical necessity for service.  Start: 01/01/1995
288  Hospital late charges  Start: 01/01/1995 | Last Modified: 10/17/2010
289  Reason for late discharge.  Start: 01/01/1995 | Stop: 11/01/2011
290  Pre-existing information.  Start: 01/01/1995
291  Reason for termination of pregnancy.  Start: 01/01/1995
292  Purpose of family conference/therapy.  Start: 01/01/1995
293  Reason for physical therapy.  Start: 01/01/1995
294  Supporting documentation. Note: At least one other status code is required to identify the supporting documentation.  Start: 01/01/1995 | Last Modified: 10/17/2010
295  Attending physician report.  Start: 01/01/1995
296  Nurse's notes.  Start: 01/01/1995
297  Medical notes/report.  Start: 02/28/1997
298  Operative report.  Start: 01/01/1995
299  Emergency room notes/report.  Start: 01/01/1995
300  Lab/test report/notes/results.  Start: 02/28/1997
301  MRI report.  Start: 01/01/1995
302  Refer to codes 300 for lab notes and 311 for pathology notes  Start: 01/01/1995 | Stop: 01/31/1997
303  Physical therapy notes. Use code 297:6O (6 'OH' - not zero)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
304  Reports for service.  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 297, 298, 299, 300
305  Radiology/x-ray reports and/or interpretation  Start: 01/01/1995 | Last Modified: 01/30/2011
306  Detailed description of service.  Start: 01/01/1995
307  Narrative with pocket depth chart.  Start: 01/01/1995
308  Discharge summary.  Start: 01/01/1995
309  Code was duplicate of code 299  Start: 01/01/1995 | Stop: 01/31/1997
310  Progress notes for the six months prior to statement date.  Start: 01/01/1995
311  Pathology notes/report.  Start: 01/01/1995
312  Dental charting.  Start: 01/01/1995
313  Bridgework information.  Start: 01/01/1995
314  Dental records for this service.  Start: 01/01/1995
315  Past perio treatment history.  Start: 01/01/1995
316  Complete medical history.  Start: 01/01/1995
317  Patient's medical records.  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 297 or other specific report type codes
318  X-rays/radiology films  Start: 01/01/1995 | Last Modified: 10/17/2010
319  Pre/post-operative x-rays/photographs.  Start: 02/28/1997
320  Study models.  Start: 01/01/1995
321  Radiographs or models. (Use codes 318 and/or 320)  Start: 01/01/1995 | Last Modified: 10/17/2010 | Stop: 07/01/2011
322  Recent Full Mouth X-rays  Start: 01/01/1995 | Last Modified: 10/17/2010
323  Study models, x-rays, and/or narrative.  Start: 01/01/1995
324  Recent x-ray of treatment area and/or narrative.  Start: 01/01/1995
325  Recent fm x-rays and/or narrative.  Start: 01/01/1995
326  Copy of transplant acquisition invoice.  Start: 01/01/1995
327  Periodontal case type diagnosis and recent pocket depth chart with narrative.  Start: 01/01/1995
328  Speech therapy notes. Use code 297:6R  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
329  Exercise notes.  Start: 01/01/1995
330  Occupational notes.  Start: 01/01/1995
331  History and physical.  Start: 01/01/1995 | Last Modified: 08/01/2007
332  Authorization/certification (include period covered). (Use code 252)  Start: 02/28/1997 | Last Modified: 07/09/2007 | Stop: 01/01/2008
333  Patient release of information authorization.  Start: 01/01/1995
334  Oxygen certification.  Start: 01/01/1995
335  Durable medical equipment certification.  Start: 01/01/1995
336  Chiropractic certification.  Start: 01/01/1995
337  Ambulance certification/documentation.  Start: 01/01/1995
338  Home health certification. Use code 332:4Y  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
339  Enteral/parenteral certification.  Start: 01/01/1995
340  Pacemaker certification.  Start: 01/01/1995
341  Private duty nursing certification.  Start: 01/01/1995
342  Podiatric certification.  Start: 01/01/1995
343  Documentation that facility is state licensed and Medicare approved as a surgical facility.  Start: 01/01/1995
344  Documentation that provider of physical therapy is Medicare Part B approved.  Start: 01/01/1995
345  Treatment plan for service/diagnosis  Start: 01/01/1995
346  Proposed treatment plan for next 6 months.  Start: 01/01/1995
347  Refer to code 345 for treatment plan and code 282 for prescription  Start: 01/01/1995 | Stop: 01/31/1997
348  Chiropractic treatment plan. (Use 345:QL)  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
349  Psychiatric treatment plan. Use codes 345:5I, 5J, 5K, 5L, 5M, 5N, 5O (5 'OH' - not zero), 5P  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
350  Speech pathology treatment plan. Use code 345:6R  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
351  Physical/occupational therapy treatment plan. Use codes 345:6O (6 'OH' - not zero), 6N  Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997
352  Duration of treatment plan.  Start: 01/01/1995
353  Orthodontics treatment plan.  Start: 01/01/1995
354  Treatment plan for replacement of remaining missing teeth.  Start: 01/01/1995
355  Has claim been paid?  Start: 01/01/1995 | Stop: 11/01/2011
356  Was blood furnished?  Start: 01/01/1995 | Stop: 11/01/2011 Notes: Refer to code 235
357  Has or will blood be replaced?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 236
358  Does provider accept assignment of benefits? (Use code 589)  Start: 01/01/1995 | Last Modified: 10/17/2010 | Stop: 07/01/2011
359  Is there a release of information signature on file? (Use code 333)  Start: 01/01/1995 | Last Modified: 10/17/2010 | Stop: 07/01/2011
360  Benefits Assignment Certification Indicator  Start: 01/01/1995 | Last Modified: 10/17/2010
361  Is there other insurance?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 171 and 550
362  Is the dental patient covered by medical insurance?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 171
363  Possible Workers' Compensation  Start: 01/01/1995 | Last Modified: 10/17/2010
364  Is accident/illness/condition employment related?  Start: 01/01/1995
365  Is service the result of an accident?   Start: 01/01/1995
366  Is injury due to auto accident?  Start: 01/01/1995   367 Is service performed for a recurring condition or new condition?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 397
368  Is medical doctor (MD) or doctor of osteopath (DO) on staff of this facility?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 676
369  Does patient condition preclude use of ordinary bed?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 287, 335
370  Can patient operate controls of bed?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 287, 335
371  Is patient confined to room?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 287, 335, 527
372  Is patient confined to bed?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 287, 335, 527
373  Is patient an insulin diabetic?  Start: 01/01/1995 | Stop: 11/01/2011
374  Is prescribed lenses a result of cataract surgery?  Start: 01/01/1995
375  Was refraction performed?  Start: 01/01/1995
376  Was charge for ambulance for a round-trip?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 453
377  Was durable medical equipment purchased new or used?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 184, 185, 186, 335
378  Is pacemaker temporary or permanent?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 340
379  Were services performed supervised by a physician?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to codes 453, 454, 666 & procedure code
380  CRNA supervision/medical direction.  Start: 01/01/1995 | Last Modified: 10/17/2010
381  Is drug generic?  Start: 01/01/1995 | Stop: 11/01/2011  Notes: Refer to code 216
382  Did provider authorize generic or brand name dispensing?  Start: 01/01/1995
383  Nerve block use (surgery vs. pain management)  Start: 01/01/1995 | Last Modified: 10/17/2010
384  Is prosthesis/crown/inlay placement an initial placement or a replacement?  Start: 01/01/1995
385  Is appliance upper or lower arch & is appliance fixed or removable?  Start: 01/01/1995
386  Orthodontic Treatment/Purpose Indicator  Start: 01/01/1995 | Last Modified: 10/17/2010
387  Date patient last examined by entity. Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 02/11/2010
388  Date post-operative care assumed  Start: 02/28/1997
389  Date post-operative care relinquished  Start: 02/28/1997
390  Date of most recent medical event necessitating service(s)  Start: 02/28/1997
391  Date(s) dialysis conducted  Start: 02/28/1997
392  Date(s) of blood transfusion(s)  Start: 02/28/1997 | Stop: 11/01/2011
393  Date of previous pacemaker check  Start: 02/28/1997 | Stop: 11/01/2011
394  Date(s) of most recent hospitalization related to service  Start: 02/28/1997
395  Date entity signed certification/recertification Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 02/11/2010
396  Date home dialysis began  Start: 02/28/1997
397  Date of onset/exacerbation of illness/condition  Start: 02/28/1997
398  Visual field test results  Start: 02/28/1997
399  Report of prior testing related to this service, including dates  Start: 02/28/1997 | Stop: 11/01/2011  Notes: Refer to code 417
400  Claim is out of balance  Start: 02/28/1997
401  Source of payment is not valid  Start: 02/28/1997
402  Amount must be greater than zero. Note: At least one other status code is required to identify which amount element is in error.  Start: 02/28/1997 | Last Modified: 09/20/2009
403  Entity referral notes/orders/prescription  Start: 02/28/1997
404  Specific findings, complaints, or symptoms necessitating service  Start: 02/28/1997 | Stop: 11/01/2011  Notes: Refer to codes 287, 488
405  Summary of services  Start: 02/28/1997 | Stop: 11/01/2011  Notes: Refer to code 306
406  Brief medical history as related to service(s)  Start: 02/28/1997
407  Complications/mitigating circumstances  Start: 02/28/1997
408  Initial certification  Start: 02/28/1997
409  Medication logs/records (including medication therapy)  Start: 02/28/1997
410  Explain differences between treatment plan and patient's condition  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 297 or other specific report type codes
411  Medical necessity for non-routine service(s)  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 287
412  Medical records to substantiate decision of non-coverage  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 297 or other specific report type codes
413  Explain/justify differences between treatment plan and services rendered.  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 297 or other specific report type codes
414  Necessity for concurrent care (more than one physician treating the patient)  Start: 02/28/1997 | Last Modified: 10/17/2010
415  Justify services outside composite rate  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 287
416  Verification of patient's ability to retain and use information  Start: 02/28/1997 | Stop: 11/01/2011Notes: Refer to code 297 or other specific report type codes
417  Prior testing, including result(s) and date(s) as related to service(s)  Start: 02/28/1997
418  Indicating why medications cannot be taken orally  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
419  Individual test(s) comprising the panel and the charges for each test  Start: 02/28/1997
420  Name, dosage and medical justification of contrast material used for radiology procedure  Start: 02/28/1997
421  Medical review attachment/information for service(s)  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
422  Homebound status  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 575
423  Prognosis  Start: 02/28/1997 | Last Modified: 07/09/2007 | Stop: 01/01/2008
424  Statement of non-coverage including itemized bill  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 279 & 286
425  Itemize non-covered services  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 279 & 286
426  All current diagnoses  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 255, 232 & 488
427  Emergency care provided during transport  Start: 02/28/1997 | Stop: 11/01/2011
428  Reason for transport by ambulance  Start: 02/28/1997
429  Loaded miles and charges for transport to nearest facility with appropriate services  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to codes 267, 178, 430
430  Nearest appropriate facility  Start: 02/28/1997
431  Patient's condition/functional status at time of service.  Start: 02/28/1997 | Last Modified: 10/17/2010
432  Date benefits exhausted  Start: 02/28/1997
433  Copy of patient revocation of hospice benefits  Start: 02/28/1997
434  Reasons for more than one transfer per entitlement period  Start: 02/28/1997
435  Notice of Admission  Start: 02/28/1997
436  Short term goals  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 345
437  Long term goals  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 345
438  Number of patients attending session  Start: 02/28/1997 | Stop: 11/01/2011
439  Size, depth, amount, and type of drainage wounds  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
440  why non-skilled caregiver has not been taught procedure  Start: 02/28/1997 | Stop: 11/01/2011
441  Entity professional qualification for service(s)  Start: 02/28/1997
442  Modalities of service  Start: 02/28/1997
443  Initial evaluation report  Start: 02/28/1997
444  Method used to obtain test sample  Start: 02/28/1997 | Stop: 11/01/2011
445  Explain why hearing loss not correctable by hearing aid  Start: 02/28/1997 | Stop: 11/01/2011 Notes: Refer to code 287
446  Documentation from prior claim(s) related to service(s)  Start: 02/28/1997 | Stop: 11/01/2011
447  Plan of teaching  Start: 02/28/1997 | Stop: 11/01/2011
448  Invalid billing combination. See STC12 for details. This code should only be used to indicate an inconsistency between two or more data elements on the claim. A detailed explanation is required in STC12 when this code is used.  Start: 02/28/1997 | Last Modified: 01/24/2010 | Stop: 01/01/2012
449  Projected date to discontinue service(s)  Start: 02/28/1997
450  Awaiting spend down determination  Start: 02/28/1997
451  Preoperative and post-operative diagnosis  Start: 02/28/1997
452  Total visits in total number of hours/day and total number of hours/week  Start: 02/28/1997
453  Procedure Code Modifier(s) for Service(s) Rendered  Start: 02/28/1997
454  Procedure code for services rendered.  Start: 02/28/1997
455  Revenue code for services rendered.  Start: 02/28/1997
456  Covered Day(s)  Start: 02/28/1997
457  Non-Covered Day(s)  Start: 02/28/1997
458  Coinsurance Day(s)  Start: 02/28/1997
459  Lifetime Reserve Day(s)  Start: 02/28/1997
460  NUBC Condition Code(s)  Start: 02/28/1997
461  NUBC Occurrence Code(s) and Date(s)  Start: 02/28/1997 | Last Modified: 01/24/2010 | Stop: 01/01/2012
462  NUBC Occurrence Span Code(s) and Date(s)  Start: 02/28/1997 | Last Modified: 01/24/2010 | Stop: 01/01/2012
463  NUBC Value Code(s) and/or Amount(s)  Start: 02/28/1997 | Last Modified: 01/24/2010 | Stop: 01/01/2012
464  Payer Assigned Claim Control Number  Start: 02/28/1997 | Last Modified: 10/31/2004
465  Principal Procedure Code for Service(s) Rendered  Start: 02/28/1997
466  Entities Original Signature. Note: This code requires use of an Entity Code. This change effective 11/1/2011: Entity's Original Signature. Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 01/30/2011
467  Entity Signature Date. Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 02/11/2010
468  Patient Signature Source  Start: 02/28/1997
469  Purchase Service Charge  Start: 02/28/1997
470  Was service purchased from another entity? Note: This code requires use of an Entity Code.  Start: 02/28/1997 | Last Modified: 02/11/2010
471  Were services related to an emergency?  Start: 02/28/1997
472  Ambulance Run Sheet  Start: 02/28/1997
473  Missing or invalid lab indicator  Start: 06/30/1998
474  Procedure code and patient gender mismatch  Start: 06/30/1998 | Last Modified: 02/29/2000
475  Procedure code not valid for patient age  Start: 06/30/1998 | Last Modified: 02/29/2000
476  Missing or invalid units of service  Start: 06/30/1998
477  Diagnosis code pointer is missing or invalid  Start: 06/30/1998
478  Claim submitter's identifier  Start: 06/30/1998 | Last Modified: 01/24/2010
479  Other Carrier payer ID is missing or invalid  Start: 06/30/1998
480  Entity's claim filing indicator. Note: This code requires use of an Entity Code.  Start: 06/30/1998 | Last Modified: 06/06/2010
481  Claim/submission format is invalid.  Start: 10/31/1998
482  Date Error, Century Missing  Start: 02/28/1999 | Last Modified: 09/20/2009 | Stop: 10/01/2010
483  Maximum coverage amount met or exceeded for benefit period.  Start: 06/30/1999
484  Business Application Currently Not Available  Start: 02/29/2000
485  More information available than can be returned in real time mode. Narrow your current search criteria.  Start: 02/28/2001
486  Principal Procedure Date  Start: 10/31/2001 | Last Modified: 07/01/2009
487  Claim not found, claim should have been submitted to/through 'entity'. Note: This code requires use of an Entity Code.  Start: 02/28/2002 | Last Modified: 02/11/2010
488  Diagnosis code(s) for the services rendered.  Start: 06/30/2002
489  Attachment Control Number  Start: 10/31/2002
490  Other Procedure Code for Service(s) Rendered  Start: 02/28/2003
491  Entity not eligible for encounter submission. Note: This code requires use of an Entity Code.  Start: 02/28/2003 | Last Modified: 02/11/2010
492  Other Procedure Date   Start: 02/28/2003
493  Version/Release/Industry ID code not currently supported by information holder  Start: 02/28/2003
494  Real-Time requests not supported by the information holder, resubmit as batch request  Start: 02/28/2003
495  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-submit.  Start: 10/31/2003
496  Submitter not approved for electronic claim submissions on behalf of this entity. Note: This code requires use of an Entity Code.  Start: 02/29/2004 | Last Modified: 02/11/2010
497  Sales tax not paid  Start: 06/30/2004
498  Maximum leave days exhausted  Start: 06/30/2004
499  No rate on file with the payer for this service for this entity Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
500  Entity's Postal/Zip Code. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
501  Entity's State/Province. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
502  Entity's City. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
503  Entity's Street Address. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
504  Entity's Last Name. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
505  Entity's First Name. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
506  Entity is changing processor/clearinghouse. This claim must be submitted to the new processor/clearinghouse. Note: This code requires use of an Entity Code.  Start: 06/30/2004 | Last Modified: 02/11/2010
507  HCPCS  Start: 10/31/2004
508  ICD9 NOTE: At least one other status code is required to identify the related procedure code or diagnosis code.  Start: 10/31/2004 | Last Modified: 07/01/2009
509  E-Code. This change effective 11/1/2011: External Cause of Injury Code (E-code).  Start: 10/31/2004 | Last Modified: 01/30/2011
510  Future date. Note: At least one other status code is required to identify the data element in error.  Start: 10/31/2004 | Last Modified: 09/20/2009
511  Invalid character. Note: At least one other status code is required to identify the data element in error.  Start: 10/31/2004 | Last Modified: 09/20/2009
512  Length invalid for receiver's application system. Note: At least one other status code is required to identify the data element in error.  Start: 10/31/2004 | Last Modified: 09/20/2009
513  HIPPS Rate Code for services Rendered  Start: 10/31/2004
514  Entities Middle Name Note: This code requires use of an Entity Code. This change effective 11/1/2011: Entity's Middle Name Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 01/30/2011
515  Managed Care review  Start: 10/31/2004
516  Other Entity's Adjudication or Payment/Remittance Date. Note: An Entity code is required to identify the Other Payer Entity, i.e. primary, secondary.  Start: 10/31/2004 | Last Modified: 11/29/2009
517  Adjusted Repriced Claim Reference Number  Start: 10/31/2004
518  Adjusted Repriced Line item Reference Number  Start: 10/31/2004
519  Adjustment Amount  Start: 10/31/2004
520  Adjustment Quantity  Start: 10/31/2004
521  Adjustment Reason Code  Start: 10/31/2004
522  Anesthesia Modifying Units  Start: 10/31/2004
523  Anesthesia Unit Count  Start: 10/31/2004
524  Arterial Blood Gas Quantity  Start: 10/31/2004
525  Begin Therapy Date  Start: 10/31/2004
526  Bundled or Unbundled Line Number  Start: 10/31/2004
527  Certification Condition Indicator  Start: 10/31/2004
528  Certification Period Projected Visit Count  Start: 10/31/2004
529  Certification Revision Date  Start: 10/31/2004
530  Claim Adjustment Indicator  Start: 10/31/2004
531  Claim Disproportinate Share Amount  Start: 10/31/2004
532  Claim DRG Amount  Start: 10/31/2004
533  Claim DRG Outlier Amount  Start: 10/31/2004
534  Claim ESRD Payment Amount  Start: 10/31/2004
535  Claim Frequency Code  Start: 10/31/2004
536  Claim Indirect Teaching Amount  Start: 10/31/2004
537  Claim MSP Pass-through Amount  Start: 10/31/2004
538  Claim or Encounter Identifier  Start: 10/31/2004
539  Claim PPS Capital Amount  Start: 10/31/2004
540  Claim PPS Capital Outlier Amount  Start: 10/31/2004
541  Claim Submission Reason Code  Start: 10/31/2004
542  Claim Total Denied Charge Amount  Start: 10/31/2004
543  Clearinghouse or Value Added Network Trace  Start: 10/31/2004
544  Clinical Laboratory Improvement Amendment  Start: 10/31/2004
545  Contract Amount  Start: 10/31/2004
546  Contract Code  Start: 10/31/2004
547  Contract Percentage  Start: 10/31/2004
548  Contract Type Code  Start: 10/31/2004
549  Contract Version Identifier  Start: 10/31/2004
550  Coordination of Benefits Code  Start: 10/31/2004
551  Coordination of Benefits Total Submitted Charge  Start: 10/31/2004
552  Cost Report Day Count  Start: 10/31/2004
553  Covered Amount  Start: 10/31/2004
554  Date Claim Paid  Start: 10/31/2004
555  Delay Reason Code  Start: 10/31/2004
556  Demonstration Project Identifier  Start: 10/31/2004
557  Diagnosis Date  Start: 10/31/2004
558  Discount Amount  Start: 10/31/2004
559  Document Control Identifier  Start: 10/31/2004
560  Entity's Additional/Secondary Identifier. Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 02/11/2010
561  Entity's Contact Name. Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 02/11/2010
562  Entity's National Provider Identifier (NPI). Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 02/11/2010
563  Entity's Tax Amount. Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 02/11/2010
564  EPSDT Indicator  Start: 10/31/2004
565  Estimated Claim Due Amount  Start: 10/31/2004
566  Exception Code  Start: 10/31/2004
567  Facility Code Qualifier  Start: 10/31/2004
568  Family Planning Indicator  Start: 10/31/2004
569  Fixed Format Information  Start: 10/31/2004
570  Free Form Message Text  Start: 10/31/2004
571  Frequency Count  Start: 10/31/2004
572  Frequency Period  Start: 10/31/2004
573  Functional Limitation Code  Start: 10/31/2004
574  HCPCS Payable Amount Home Health  Start: 10/31/2004
575  Homebound Indicator  Start: 10/31/2004
576  Immunization Batch Number  Start: 10/31/2004
577  Industry Code  Start: 10/31/2004
578  Insurance Type Code  Start: 10/31/2004
579  Investigational Device Exemption Identifier  Start: 10/31/2004
580  Last Certification Date  Start: 10/31/2004
581  Last Worked Date  Start: 10/31/2004
582  Lifetime Psychiatric Days Count  Start: 10/31/2004
583  Line Item Charge Amount  Start: 10/31/2004
584  Line Item Control Number  Start: 10/31/2004
585  Denied Charge or Non-covered Charge  Start: 10/31/2004 | Last Modified: 07/09/2007
586  Line Note Text  Start: 10/31/2004
587  Measurement Reference Identification Code  Start: 10/31/2004
588  Medical Record Number  Start: 10/31/2004
589  Provider Accept Assignment Code  Start: 10/31/2004 | Last Modified: 10/17/2010
590  Medicare Coverage Indicator  Start: 10/31/2004
591  Medicare Paid at 100% Amount  Start: 10/31/2004
592  Medicare Paid at 80% Amount  Start: 10/31/2004
593  Medicare Section 4081 Indicator  Start: 10/31/2004
594  Mental Status Code  Start: 10/31/2004
595  Monthly Treatment Count  Start: 10/31/2004
596  Non-covered Charge Amount  Start: 10/31/2004
597  Non-payable Professional Component Amount  Start: 10/31/2004
598  Non-payable Professional Component Billed Amount  Start: 10/31/2004
599  Note Reference Code  Start: 10/31/2004
600  Oxygen Saturation Qty  Start: 10/31/2004
601  Oxygen Test Condition Code  Start: 10/31/2004
602  Oxygen Test Date  Start: 10/31/2004
603  Old Capital Amount  Start: 10/31/2004
604  Originator Application Transaction Identifier  Start: 10/31/2004
605  Orthodontic Treatment Months Count  Start: 10/31/2004
606  Paid From Part A Medicare Trust Fund Amount  Start: 10/31/2004
607  Paid From Part B Medicare Trust Fund Amount  Start: 10/31/2004
608  Paid Service Unit Count  Start: 10/31/2004
609  Participation Agreement  Start: 10/31/2004
610  Patient Discharge Facility Type Code  Start: 10/31/2004
611  Peer Review Authorization Number  Start: 10/31/2004
612  Per Day Limit Amount  Start: 10/31/2004
613  Physician Contact Date  Start: 10/31/2004
614  Physician Order Date  Start: 10/31/2004
615  Policy Compliance Code  Start: 10/31/2004
616  Policy Name  Start: 10/31/2004
617  Postage Claimed Amount  Start: 10/31/2004
618  PPS-Capital DSH DRG Amount  Start: 10/31/2004
619  PPS-Capital Exception Amount  Start: 10/31/2004
620  PPS-Capital FSP DRG Amount  Start: 10/31/2004
621  PPS-Capital HSP DRG Amount  Start: 10/31/2004
622  PPS-Capital IME Amount  Start: 10/31/2004
623  PPS-Operating Federal Specific DRG Amount  Start: 10/31/2004
624  PPS-Operating Hospital Specific DRG Amount  Start: 10/31/2004
625  Predetermination of Benefits Identifier  Start: 10/31/2004
626  Pregnancy Indicator  Start: 10/31/2004
627  Pre-Tax Claim Amount  Start: 10/31/2004
628  Pricing Methodology  Start: 10/31/2004
629  Property Casualty Claim Number  Start: 10/31/2004
630  Referring CLIA Number  Start: 10/31/2004
631  Reimbursement Rate  Start: 10/31/2004
632  Reject Reason Code  Start: 10/31/2004
633  Related Causes Code (Accident, auto accident, employment)  Start: 10/31/2004 | Last Modified: 10/17/2010
634  Remark Code  Start: 10/31/2004
635  Repriced Ambulatory Patient Group Code  Start: 10/31/2004
636  Repriced Line Item Reference Number  Start: 10/31/2004
637  Repriced Saving Amount  Start: 10/31/2004
638  Repricing Per Diem or Flat Rate Amount  Start: 10/31/2004
639  Responsibility Amount  Start: 10/31/2004
640  Sales Tax Amount  Start: 10/31/2004
641  Service Adjudication or Payment Date. Note: Use code 516.  Start: 10/31/2004 | Last Modified: 09/20/2009 | Stop: 10/01/2010
642  Service Authorization Exception Code  Start: 10/31/2004
643  Service Line Paid Amount  Start: 10/31/2004
644  Service Line Rate  Start: 10/31/2004
645  Service Tax Amount  Start: 10/31/2004
646  Ship, Delivery or Calendar Pattern Code  Start: 10/31/2004
647  Shipped Date  Start: 10/31/2004
648  Similar Illness or Symptom Date  Start: 10/31/2004
649  Skilled Nursing Facility Indicator  Start: 10/31/2004
650  Special Program Indicator  Start: 10/31/2004
651  State Industrial Accident Provider Number  Start: 10/31/2004
652  Terms Discount Percentage  Start: 10/31/2004
653  Test Performed Date  Start: 10/31/2004
654  Total Denied Charge Amount  Start: 10/31/2004
655  Total Medicare Paid Amount  Start: 10/31/2004
656  Total Visits Projected This Certification Count  Start: 10/31/2004
657  Total Visits Rendered Count  Start: 10/31/2004
658  Treatment Code  Start: 10/31/2004
659  Unit or Basis for Measurement Code  Start: 10/31/2004
660  Universal Product Number  Start: 10/31/2004
661  Visits Prior to Recertification Date Count CR702  Start: 10/31/2004
662  X-ray Availability Indicator  Start: 10/31/2004
663  Entity's Group Name. Note: This code requires use of an Entity Code.  Start: 10/31/2004 | Last Modified: 02/11/2010
664  Orthodontic Banding Date  Start: 10/31/2004
665  Surgery Date  Start: 10/31/2004
666  Surgical Procedure Code  Start: 10/31/2004
667  Real-Time requests not supported by the information holder, do not resubmit   Start: 02/28/2005
668  Missing Endodontics treatment history and prognosis  Start: 06/30/2005
669  Dental service narrative needed.  Start: 10/31/2005
670  Funds applied from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts  Start: 06/30/2006 | Last Modified: 02/28/2007
671  Funds may be available from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts  Start: 06/30/2006 | Last Modified: 02/28/2007
672  Other Payer's payment information is out of balance  Start: 10/31/2006
673  Patient Reason for Visit  Start: 10/31/2006
674  Authorization exceeded  Start: 10/31/2006
675  Facility admission through discharge dates  Start: 10/31/2006
676  Entity possibly compensated by facility. Note: This code requires use of an Entity Code.  Start: 10/31/2006 | Last Modified: 02/11/2010
677  Entity not affiliated. Note: This code requires use of an Entity Code.  Start: 10/31/2006 | Last Modified: 02/11/2010
678  Revenue code and patient gender mismatch  Start: 10/31/2006
679  Submit newborn services on mother's claim  Start: 10/31/2006
680  Entity's Country. Note: This code requires use of an Entity Code.  Start: 10/31/2006 | Last Modified: 02/11/2010
681  Claim currency not supported  Start: 10/31/2006
682  Cosmetic procedure  Start: 02/28/2007
683  Awaiting Associated Hospital Claims  Start: 02/28/2007
684  Rejected. Syntax error noted for this claim/service/inquiry. See Functional or Implementation Acknowledgement for details. (Note: Only for use to reject claims or status requests in transactions that were 'accepted with errors' on a 997 or 999 Acknowledgement.)  Start: 11/05/2007
685  Claim could not complete adjudication in real time. Claim will continue processing in a batch mode. Do not resubmit.  Start: 01/27/2008
686  The claim/ encounter has completed the adjudication cycle and the entire claim has been voided  Start: 01/27/2008
687  Claim estimation can not be completed in real time. Do not resubmit.  Start: 01/27/2008
688  Present on Admission Indicator for reported diagnosis code(s).  Start: 01/27/2008
689  Entity was unable to respond within the expected time frame. Note: This code requires use of an Entity Code.  Start: 06/01/2008 | Last Modified: 02/11/2010
690  Multiple claims or estimate requests cannot be processed in real time.  Start: 06/01/2008
691  Multiple claim status requests cannot be processed in real time.  Start: 06/01/2008
692  Contracted funding agreement-Subscriber is employed by the provider of services  Start: 09/21/2008
693  Amount must be greater than or equal to zero. Note: At least one other status code is required to identify which amount element is in error.  Start: 01/25/2009
694  Amount must not be equal to zero. Note: At least one other status code is required to identify which amount element is in error.  Start: 01/25/2009
695  Entity's Country Subdivision Code. Note: This code requires use of an Entity Code.  Start: 01/25/2009 | Last Modified: 02/11/2010
696  Claim Adjustment Group Code.  Start: 01/25/2009
697  Invalid Decimal Precision. Note: At least one other status code is required to identify the data element in error.  Start: 07/01/2009
698  Form Type Identification  Start: 07/01/2009
699  Question/Response from Supporting Documentation Form  Start: 07/01/2009
700  ICD10. Note: At least one other status code is required to identify the related procedure code or diagnosis code.  Start: 07/01/2009
701  Initial Treatment Date  Start: 07/01/2009
702  Repriced Claim Reference Number  Start: 11/01/2009
703  Advanced Billing Concepts (ABC) code   Start: 01/24/2010
704  Claim Note Text  Start: 01/24/2010
705  Repriced Allowed Amount  Start: 01/24/2010
706  Repriced Approved Amount  Start: 01/24/2010
707  Repriced Approved Ambulatory Patient Group Amount  Start: 01/24/2010
708  Repriced Approved Revenue Code  Start: 01/24/2010
709  Repriced Approved Service Unit Count  Start: 01/24/2010
710  Line Adjudication Information. Note: At least one other status code is required to identify the data element in error.  Start: 01/24/2010
711  Stretcher purpose  Start: 01/24/2010
712  Obstetric Additional Units  Start: 01/24/2010
713  Patient Condition Description  Start: 01/24/2010
714  Care Plan Oversight Number  Start: 01/24/2010
715  Acute Manifestation Date  Start: 01/24/2010
716  Repriced Approved DRG Code  Start: 01/24/2010
717  This claim has been split for processing.  Start: 01/24/2010
718  Claim/service not submitted within the required timeframe (timely filing).   Start: 01/24/2010
719  NUBC Occurrence Code(s)  Start: 01/24/2010
720  NUBC Occurrence Code Date(s)  Start: 01/24/2010
721  NUBC Occurrence Span Code(s)  Start: 01/24/2010
722  NUBC Occurrence Span Code Date(s)  Start: 01/24/2010
723  Drug days supply  Start: 01/24/2010
724  Drug dosage  Start: 01/24/2010
725  NUBC Value Code(s)  Start: 01/24/2010
726  NUBC Value Code Amount(s)  Start: 01/24/2010
727  Accident date  Start: 01/24/2010
728  Accident state  Start: 01/24/2010
729  Accident description  Start: 01/24/2010
730  Accident cause  Start: 01/24/2010
731  Measurement value/test result  Start: 01/24/2010
732  Information submitted inconsistent with billing guidelines. Note: At least one other status code is required to identify the inconsistent information.  Start: 01/24/2010
733  Prefix for entity's contract/member number.  Start: 01/24/2010
734  Verifying premium payment  Start: 06/06/2010
735  This service/claim is included in the allowance for another service or claim.  Start: 06/06/2010
736  A related or qualifying service/claim has not been received/adjudicated.  Start: 06/06/2010
737  Current Dental Terminology (CDT) Code  Start: 06/06/2010
738  Home Infusion EDI Coalition (HEIC) Product/Service Code  Start: 06/06/2010
739  Jurisdiction Specific Procedure or Supply Code  Start: 06/06/2010
740  Drop-Off Location  Start: 06/06/2010
741  Entity must be a person. Note: This code requires use of an Entity Code.  Start: 06/06/2010
742  Payer Responsibility Sequence Number Code  Start: 06/06/2010
743  Entity's credential/enrollment information. Note: This code requires use of an Entity Code.  Start: 10/17/2010
744  Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.  Start: 10/17/2010
745  Identifier Qualifier Note: At least one other status code is required to identify the specific identifier qualifier in error.  Start: 10/17/2010
746  Duplicate Submission Note: use only at the information receiver level in the Health Care Claim Acknowledgement transaction.  Start: 10/17/2010
747  Hospice Employee Indicator  Start: 10/17/2010
748  Corrected Data Note: Requires a second status code to identify the corrected data.  Start: 10/17/2010
749  Date of Injury/Illness  Start: 10/17/2010
750  Invalid Auto Accident State or Province Code. This change effective 11/1/2011: Auto Accident State or Province Code  Start: 10/17/2010 | Last Modified: 01/30/2011
751  Invalid Ambulance Pick-up State or Province Code. This change effective 11/1/2011: Ambulance Pick-up State or Province Code  Start: 10/17/2010 | Last Modified: 01/30/2011
752  Invalid Ambulance Drop-off State or Province Code. This change effective 11/1/2011: Ambulance Drop-off State or Province Code  Start: 10/17/2010 | Last Modified: 01/30/2011
753  Co-pay status code.  Start: 01/30/2011
754  Entity Name Suffix. Note: This code requires the use of an Entity Code.  Start: 01/30/2011
755  Entity's primary identifier. Note: This code requires the use of an Entity Code.  Start: 01/30/2011
756  Entity's Received Date. Note: This code requires the use of an Entity Code.  Start: 01/30/2011
757  Last seen date.  Start: 01/30/2011
758  Repriced approved HCPCS code.  Start: 01/30/2011
759  Round trip purpose description.  Start: 01/30/2011
760  Tooth status code.  Start: 01/30/2011
761  Entity's referral number. Note: This code requires the use of an Entity Code.  Start: 01/30/2011

Medicare Presumptive Payment Adjustments & Denials

Medicare presumptive payments are based upon the Social Security issuing a presumptive SSI that someone will actually start benefits before they have officially qualified. There are many severe conditions that will help a person to qualify for presumptive Medicare allow them to start paying into this category to get benefits to kick in. The standard method could take six months for all of the paperwork to be completed and the claim to be reviewed. This way, a person can begin Medicare benefits and healthcare immediately.

When a patient is under presumptive Medicare, they will visit the doctor as they would with any other type of insurance. The doctor's billing company then needs to use the proper code for Presumptive payment. If the Presumptive payment code is used for anything other than for this reason, there may be a denial, often as an A7 denial code: Presumptive payment adjustment.

The reason that many medical providers are getting the A7 denial code, however, is because they are using it to force balance the transactions. FIs, or Fiscal Intermediaries, are reporting the add-on payment in the claim/service adjustment segment as an additional payment that has already been included in the allowed amount. This is what's causing the out-of balance on the books, which is why many are using A7 to offset the difference.

The Medicare Presumptive payment adjustment doesn't typically affect the patients in a negative way. In fact, it will help most of them when used properly because they will get the care that they need in a timely manner as opposed to waiting for paperwork to process. They will be able to pay only what is required (if anything) so that they can get treatment.

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


(ROUTINE EXAMINATIONS AND RELATED SERVICES NOT COVERED)



Resources/tips for avoiding this denial

Denial indicates the procedure code and/or evaluation and management (E/M) service was billed with a screening diagnosis.

• Note: Medicare does not cover diagnostic/screening procedures or E/M services for routine or screening purposes, such as an annual physical. This denial would be appropriate in this case.



• Before submitting a claim, you may access the Procedure to Diagnosis Lookup/Service Indication Report to determine if the procedure code to be billed is payable under the specific diagnosis.

• Refer to the “Active/Future/Retired LCDs” medical coverage policies for a list of procedure codes, relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.



Tips to correct the denied claim

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.

PR 50 These are non-covered services because this is not deemed a “medical necessity” by the payer


(MEDICARE WILL NOT PAY FOR THIS SERVICE FOR THIS CONDITION)

Resources/tips for avoiding this denial

Denial indicates the procedure code billed is incompatible with the diagnosis, for payment purposes.

• Refer to the “Active/Future/Retired LCDs” medical coverage policies for a list of procedure codes, relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.

• Before billing a claim, you may access the Procedure to Diagnosis Lookup/Service Indication Report to determine if the procedure code to be billed is payable under the specific diagnosis.

• Note: Medicare does not cover diagnostic or screening procedures for screening purposes, such as an annual physical. This denial would be appropriate in this case.

• Respond promptly to a request for additional documentation (ADR). Failure to respond to an ADR will result in claim denials.



Tips to correct the denied claim

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.

• If a claim is denied based on failure to respond to an additional documentation request, a request for a redetermination will be necessary to correct the denial.

CO 58 - Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service


(PLACE OF SERVICE CONFLICTS WITH PROCEDURE CODE. SUBMIT NEW CLAIM)



Resources/tips for avoiding this denial

Denial indicates the procedure code billed is incompatible with the place of service (POS) code.

• Before billing a claim, refer to billing guidelines for the procedure or service being performed.

• The Current Procedural Terminology (CPT) code definition may indicate the place of service. Refer to the current year’s CPT manual for this information.

• Example: A code described as an outpatient service would not be valid if billed with an inpatient POS.



• Respond promptly to a request for additional documentation (ADR). Failure to respond to an ADR will result in claim denials.


Tips to correct the denied claim

Correct the place of service (POS) code or CPT code and resubmit the corrected claim

CO 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated


(DENIED/REDUCED SERVICE/PROCEDURE NOT PAID SEPARATELY)

(PRE/POST OP CARE INCLUDED IN SURGERY. YOU MAY NOT BILL PATIENT)

(SEPARATE PAYMENT NOT MADE FOR THIS SERVICE. DO NOT BILL PATIENT)



Resources/tips for avoiding this denial

Denial indicates service(s) billed has/have already been paid as part of another service billed for the same date of service (services were bundled).

• Please make note of quarterly updates to the National Correct Coding Initiative (NCCI) edits .

• The purpose of NCCI edits is to ensure the most comprehensive codes, rather than component codes, are billed.

If billing for split-care, be sure to apply appropriate modifiers to surgical codes when billing the services to Medicare. Note: Coordinate split-care billing activities with other providers involved in the patient's care, to ensure the surgical code is billed before post-op care, as this will sometimes cause denial issues.

• Modifier 54 indicates pre- and intra-operative services performed.

• Modifier 55 indicates post-operative management services only.

• Modifier 56 indicates pre-op services only

Some services may always be bundled into other services provided or not separately payable. For instance:

• Evaluation and management (E/M) services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.



• Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.

• Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day (e.g., inpatient/outpatient hospital).

• Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.



Tips to correct the denied claim

If a modifier is applicable to the claim, apply the appropriate modifier, and resubmit the claim. Be sure to submit only the corrected line. Resubmitting an entire claim will cause a duplicate claim denial.

(MEDICARE DOES NOT PAY FOR THIS MANY SERVICES OR SUPPLIES)


Resources/tips for avoiding this denial

Medicare has specific guidelines that apply to certain services, especially laboratory services. The guidelines for these services (including preventive services) may have utilization guidelines which do not allow the services to be covered if they are performed within a specified timeframe after a previous service.

Prior to performing a preventive service, if you are unsure if a beneficiary has had a specific preventive service within the utilization guidelines, to determine the patient's eligibility for the current preventive service that you will be rendering.


Common example

Cardiovascular disease screening and Healthcare Common Procedure Coding System (HCPCS) code 80061 When conducting cardiovascular disease screening, the following HCPCS codes are allowed:

• 80061-- Lipid Panel, which includes

• 82465 -- Cholesterol, serum or whole blood, total

• 83718 -- Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

• 84478 -- Triglycerides

Per the Medicare billing instructions, effective for dates of service January 1, 2005, and later, Part B Medicare administrative contractors (MACs) shall pay for cardiovascular disease screenings once every 5 years (60 months).

A claim submitted for Cardiovascular Disease Screening should contain the following:

• HCPCS codes 80061, 82465, 83718 or 84478, submitted with one of the following ICD-9-CM diagnose codes:

• V81.0 -- Special screening for ischemic heart disease

• V81.1 -- Special screening for hypertension or

• V81.2 -- Special screening for other and unspecified cardiovascular conditions



Tips to correct the denied claim

This denial is usually correct, as utilization is checked against the common working file (CWF) for the patient.

If you have submitted the claim with a GA modifier and have an Advanced Beneficiary Notice (ABN) on file, you may hold the patient financially responsible.

However, if you submitted the claim erroneously without the GA or other modifier, submit your claim for a redetermination.

Carrier appeals process for redeterminations


The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.

For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.

The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.



There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.



The five levels of appeal are as follows:

1st Level - Redetermination

Time limit to file request: 120 days from date of receipt of the initial determination notice

Monetary threshold: None

Request is sent directly to the carrier



2nd Level - Reconsideration

Time limit to file request: 180 days from date of receipt of the redetermination

Monetary threshold: None

Request is sent directly to the QIC

3rd Level - Administrative Law Judge (ALJ) Hearing

Time limit to file request: 60 days from the date of receipt of the reconsideration

Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).


4th Level - Departmental Appeals Board (DAB) Review

Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision

Monetary threshold: None

5th Level - Federal Court Review

Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB

Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.



Overpayment appeals address

The address for overpayment appeals is as follows:

First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248

Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.

Can minor errors or omissions be corrected outside of the appeals process?

A. Yes. A clerical error reopening can be initiated via the telephone or in writing; or, in many cases, the denied service(s) can simply be resubmitted. Resubmitting claims to correct minor clerical errors or omissions is the most efficient method for addressing certain denied services.*

*Resubmit the denied service(s) ONLY - resubmitting an entire claim will create a duplicate denial.

If these issues are received via written and telephone requests, it may take up to 60 days to process and finalize an adjustment, versus 14-30 days for a resubmitted claim. Ensure that you review the type of clerical error or omission you are attempting to correct and select the most efficient option available.

Note: Single-line clerical reopenings can now be requested through the Part B Interactive Voice Response unit (IVR).

Determine if the error can be corrected and resubmitted prior to writing in or calling to request a clerical error reopening.

• Minor clerical errors or omissions that can be corrected and resubmitted:

• Change of diagnosis codes

• Add, change, or delete modifiers (e.g., 24, 25, 50, 59, 78, 79, RT, LT)

• Incorrect place of service

• Written or telephone clerical error reopenings are appropriate only for services that were processed and received an approved amount, and could include the following types of situations:

• Number of services (NB) billed

• Submitted charge amount

• Date of service (DOS)

• Add, change or delete certain modifiers

• Procedure code; excluding codes requiring documentation on the initial submission or codes being upcoded

Q: During the appeal process, at what point can additional records be submitted?

A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records to the affiliated contractor, or First Coast Service Options Inc.



Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?

A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.



Q: What does the term “amount in controversy” mean?

A: The amount in controversy (AIC) is the amount in dispute, at a minimum, that you must have for the administrative law judge (ALJ) and judicial review levels in the appeal process.



Q: Is there a resource that highlights for providers or beneficiaries what would be considered a relevant appeal to submit?

A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the Centers for Medicare & Medicaid Services (CMS), Internet only manuals (IOM).



Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?

A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.



Q: What are the reason code ranges for claims when they’ve denied?

A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.

PR 96 Non-covered charge(s)


(THE PROCEDURE CODE SUBMITTED IS A NON-COVERED MEDICARE SERVICE)



Resources/tips for avoiding this denial

There are multiple resources available to verify if services are covered by Medicare we can use that resources.


Tips to correct the denied claim

This denial is not usually able to be corrected.

• If you are submitting non-covered services to receive a denial for secondary or supplemental insurance, ensure to bill services with the modifier GY, indicating "statutorily non-covered services."



CO 170 This payment is adjusted when performed/billed by this type of provider.


(THIS SERVICE BY A CHIROPRACTOR IS NOT COVERED BY MEDICARE)

Resources/tips for avoiding this denial

Chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered.



Tip to correct the denied claim

Services not covered by Medicare should not be billed to Medicare.

• Billing denied services to Medicare for coordination of benefits is allowable.

The following tips will assist in completing the adjustment form

• Complete only one adjustment request form per claim; a separate adjustment request form for each line item on a single claim is not necessary.

• Reference only one ICN per adjustment request form.

• If requesting a review of a previously denied adjustment, reference the original ICN and resubmit with all supporting documentation related to the adjustment. Do not reference the ICN for the denied adjustment.

• Include a copy of the appropriate RA with each adjustment request. If multiple RAs were involved in the claim payment process, include copies of each RA.

• Include a copy of the claim that is referenced on the adjustment request.

Note: This is not required for electronically submitted claims.

• When the adjustment request involves a corrected or revised claim, send both the original and revised claim. Do not obliterate previously paid details on the claim.

• Include pertinent information on a separate sheet of paper. Do not write information on the back of the adjustment form, RAs, etc.

• Ensure that all of the information submitted with the adjustment request is legible.

• Send only the medical records that pertain to the services rendered. If it is necessary to send records with other information included, identify the portion of the record that is significant to the adjustment request.

• Only the claim that pertains to the payment or denial in question should be submitted with the adjustment request. Do not submit any other claims with the adjustment request. Claims for service dates that have not been submitted should be filed on a new day claim, including late charges for codes not previously filed.

• When submitting an adjustment to Medicaid due to a Medicare-adjusted voucher, attach both the original voucher and the adjusted Medicare voucher. Reference the ICN of the original voucher.

• If requesting a review of a previous partial payment or a partial recoup adjustment, reference the ICN for the adjustment and resubmit with all supporting documentation related to the adjustment.

• Adjustments equal to or less than $1.00 will be denied.

The most common mistakes that are made when filing adjustments are these:

• Incomplete or invalid MID information or ICNs

• Multiple ICNs on the same form

• Unspecified or too-general reason for the adjustment request

• Missing copy of the RA related to the request

• Missing reference to the original ICN, or use of a denied adjustment ICN

• A partial payment or partial recoupment number is not referenced as the original ICN

• Filing the adjustment after the 18-month time limit

Note: If an adjustment is not filed until the 17th month from the date of service, the original claim may no longer be available in the system for adjustment. Submit adjustments as soon as possible so they can be processed within the 18-month time limit.

• Missing required documentation (Medicare vouchers, medical records, operative records, etc).

• Referencing the NPI on the adjustment request

Note: This form requests the MPN in the blank specified for Provider Number.

MA 130 - Claims returned as unprocessable as appeal requests

There are large volume of appeals have been filed on claims that were returned as unprocessable. An unprocessable claim is one that was filed with incomplete and/or invalid information.

Claims that are unprocessable cannot be appealed. Therefore, when a provider files an appeal on an unprocessable claim, the correspondence is returned to the provider with a letter instructing the provider to refile a new claim. Response letters are typically not generated for at least 30-40 business days after the original request was submitted. To avoid delays in payments, providers must resubmit claims returned as unprocessable. Filing an appeal only delays payment on claims and could result in a timely filing denial if the incomplete/invalid claim is not re-filed with the correct information with the timely filing period.

Identifying an unprocessable claim

Claims returned as unprocessable will typically include the MA130 remittance advice message with a corresponding reason code message to denote why the claim was incomplete or invalid.

Communication letters to top providers that file appeals on unprocessable claims

CMS will be sending communication letters to providers in the future if appeals are continually filed on unprocessable claims. These letters will provide details on the number of appeals requests received on unprocessable claims by the applicable providers and the impacts that such requests have on regular appeal and inquiry inventories.

Documentation needed for Psychiatry Services

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician’s progress notes.
o    Physician orders.
o    Procedure notes.
o    Physician supervision and evaluation.
o    History and physical.
o    Individualized treatment plan for psychiatric services.
o    Daily individual and group therapy notes.
o    Nurse’s notes.
o    Medication records.
o    Initial psychiatric/psychological evaluation/mental status exam.
o    Medical and psychiatric history.
o    Any diagnostic tests and results.
o    Any re-evaluations.
o    All progress notes/summaries.
o    Plan of treatment.
o    Any adjustments or revisions to the plan of treatment.
o    Treatment plan reviews.
o    Patient goals and progress toward goals.
o    Evidence of attempts to decrease frequency of visits and results of those attempts if treatment is ongoing.
o    Signatures/credentials of professionals providing services.
o    Documentation to support type of or timed codes billed.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.

RA Requirements for Paper Adjustments


• Paper adjustment processing procedures require that providers attach a copy of all paper Medicaid RA pages related to the referenced claim.

• A provider-generated RA, or a copy of the electronic RA (835 transaction) is not an acceptable substitute for the paper copy mailed to providers by HP Enterprise Services. Provider-generated RAs have varied formats and do not include all information necessary for manual adjustment processing.

• Paper adjustments that do not include the required RA will be denied with EOB 812, “Adjustment denied. Please refile with all related RA’s, including original processing.” Providers receiving this denial should resubmit a copy of their adjustment with the requested RA.

• If you do not have a copy of the paper RA, contact HP Enterprise Services Provider Services to request a replacement. (There is a per-page charge for RA requests that are more than 10 checkwrites old. RA reprints for the last 10 checkwrites are provided at no charge. Refer to How to Request a Duplicate Remittance and Status Report in Section 9, Remittance and Status Report, for additional information.)

Submitting an Adjustment Electronically

With the implementation of standard claims transactions to comply with the Health Insurance Portability and Accountability Act (HIPAA), adjustments may be filed electronically. Electronic adjustments are the preferred method to report an overpayment or underpayment to NC Medicaid. There are two separate actions that may be filed:

1. Void—in order to file a claim to be voided, the provider must mark the claim as a voided claim using the Claim Submission Reason Field (Dental and CMS-1500) and Type of Bill (UB-04) on the 837 electronic claim transaction. The ICN for the original claim to be voided must also be provided. When processed, the claim associated with the original ICN will be recouped from the patient’s record and the payment will be recouped from the provider’s RA.

2. Replacement—a replacement claim may be filed by completing a corrected electronic claim and marking the claim as a replacement using the Claim Submission Reason Field (Dental and CMS-1500) and Type of Bill (UB04) on the electronic claim transaction. The ICN for the original claim to be replaced must also be provided. The original claim will be recouped from the patient’s record and shown as a recoupment on the RA when the replacement claim processes and pays without error. If the replacement claim is denied, the entire replacement process will be denied, including the recoupment.

N.C. Medicaid will continue to accept and process paper adjustments. Although adjustments may be filed electronically, providers are advised to file adjustments on paper when paper documentation is required.

If claims are denied for eligibility reasons, the following steps should help resolve the denial and obtain reimbursement for covered dates of service for eligible recipients.

Step 1—Check for Errors on the Claim

Compare the recipient’s eligibility information to the information entered on the claim.

If the information on the claim and the recipient’s eligibility information do not match, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, request a time limit override by submitting the claim and a completed Medicaid Resolution Inquiry form. Include a copy of the Remittance and Status Report (RA) or other documentation of timely filing.

• If the claim was originally received and processed within the 365-day claim filing time limit, resubmit the claim on paper or electronically as a new day claim, ensuring that the recipient’s MID number, provider number, “from” date of service, and total billed match the original claim exactly.

Step 2—Check for Data Entry Errors

Compare the RA to the information entered on the claim.

If the RA indicates that the recipient’s name, MID number, or date of service has been keyed incorrectly, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, follow the instructions in Step 1 for requesting a time limit override.

• If the claim was originally received and processed within the 365-day claim filing time limit, follow the instructions in Step 1 for resubmitting the claim.

Step 3—When All Information Matches

Verify that the recipient’s eligibility information has been updated in the state eligibility file by utilizing the Recipient Eligibility Verification Web Tool or by calling the AVR system.

If the Recipient Eligibility Verification Web Tool or the AVR system indicates that the recipient is ineligible, submit a Medicaid Resolution Inquiry form to DMA Claims Analysis. Include the recipient eligibility information, the claim, and the RA. Mail to claim mailing address

The Claims Analysis unit will review and update the information in EIS and resubmit the claim. Do not mail eligibility denials to HP Enterprise Services, as this will delay the processing of your claim.
For further information, refer to Appendix F, Verifying Recipient Eligibility and Appendix A, Automated Voice Response System.