co 256 denial code descriptions

Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The referring provider is not eligible to refer the service billed. Referral not authorized by attending physician per regulatory requirement. Reason Code 37: Charges do not meet qualifications for emergent/urgent care. Discount agreed to in Preferred Provider contract. Claim received by the medical plan, but benefits not available under this plan. Non-covered personal comfort or convenience services. (Handled in QTY, QTY01=LA). Claim/service not covered by this payer/contractor. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). ), Reason Code 235: Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. Additional information will be sent following the conclusion of litigation. (Note: To be used for Property and Casualty only), Based on entitlement to benefits. The "PR" is a Claim Adjustment Group Code and the description for "32" is below. Webco 256 denial code descriptionshouses for rent by owner in calhoun, ga; co 256 denial code descriptionsjim jon prokes cause of death; co 256 denial code descriptionscafe patachou nutrition information co 256 denial code descriptions. Procedure/treatment has not been deemed 'proven to be effective' by the payer. No available or correlating CPT/HCPCS code to describe this service. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. Please resubmit on claim per calendar year. (Use only with Group Code OA). X12's diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries. Reason Code 115: ESRD network support adjustment. Reason Code 142: Premium payment withholding. Contracted funding agreement - Subscriber is employed by the provider of services. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. Expenses incurred during lapse in coverage, Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. Your Stop loss deductible has not been met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Patient has not met the required spend down requirements. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Used only by Property and Casualty. Information related to the X12 corporation is listed in the Corporate section below. The attachment/other documentation that was received was the incorrect attachment/document. Reason Code 178: Procedure code was invalid on the date of service. preferred product/service. The date of birth follows the date of service. Payment reduced to zero due to litigation. Reason Code 118: Indemnification adjustment - compensation for outstanding member responsibility. Reason Code 154: Service/procedure was provided as a result of an act of war. B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. . Medicare Secondary Payer Adjustment Amount. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 133: Failure to follow prior payer's coverage rules. Lifetime benefit maximum has been reached. Adjustment for shipping cost. That code means that you need to have additional documentation to support the claim. WebCompare physician performance within organization. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lace of premium payment). preferred product/service. Deductible waived per contractual agreement. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. #2. ), Reason Code 15: Duplicate claim/service. Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. The procedure/revenue code is inconsistent with the type of bill. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). MA36: Missing /incomplete/invalid patient name. Alternative services were available, and should have been utilized. Reason Code 121: Payer refund amount - not our patient. Claim received by the medical plan, but benefits not available under this plan. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Benefit maximum for this time period or occurrence has been reached. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. This change effective 7/1/2013: Service/equipment was not prescribed by a physician. 03 Co-payment amount. Usage: To be used for pharmaceuticals only. This injury/illness is covered by the liability carrier. 119/120. (Use only with Group Code PR) At least on remark code must be provider (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an alert.). The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use Group Code OA). ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). This change effective 7/1/2013: Claim is under investigation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Reason Code 22: Payment denied. The procedure code/type of bill is inconsistent with the place of service. To be used for Property & Casualty only. Workers' Compensation Medical Treatment Guideline Adjustment. This payment reflects the correct code. Claim/Service has missing diagnosis information. This (these) diagnosis(es) is (are) not covered. The procedure code/bill type is inconsistent with the place of service. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. (Use only with Group code OA), Reason Code 207: Payment adjusted because pre-certification/authorization not received in a timely fashion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This (these) procedure(s) is (are) not covered. Not authorized to provide work hardening services. The provider cannot collect this amount from the patient. National Drug Codes (NDC) not eligible for rebate, are not covered. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Reason Code 183: Level of care change adjustment. The provider cannot collect this amount from the patient. Patient is covered by a managed care plan. Identity verification required for processing this and future claims. Reason Code 205: National Provider Identifier - Not matched. Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. Information about the X12 organization, its activities, committees & subcommittees, tools, products, and processes. Processed under Medicaid ACA Enhanced Fee Schedule. Reason Code 173: Prescription is not current. PIL02b1 Publishing and Maintaining Externally Developed Implementation Guides, PIL02b2 Publishing and Maintaining Externally Developed Implementation Guides. WebCode Reason Description Remark Code Remark Description SAIF Code Adjustment Description 150 Payer deems the information submitted does not support this level of CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code (s) was submitted that is not covered under a LCD/NCD. The EDI Standard is published onceper year in January. Reason Code 201: This service/equipment/drug is not covered under the patients current benefit plan, Reason Code 202: Pharmacy discount card processing fee. Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. The expected attachment/document is still missing. (Use only with Group Code OA). (Handled in QTY, QTY01=OU), Reason Code 81: Capital Adjustment. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. Webco 256 denial code descriptionspan peninsula canary wharf service charge co 256 denial code descriptions. Reason Code 168: Payment is denied when performed/billed by this type of provider in this type of facility. Claim/Service has invalid non-covered days. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Reason Code 130: The disposition of the claim/service is pending further review. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Not covered unless the provider accepts assignment. Reason Code 51: Multiple physicians/assistants are not covered in this case. This non-payable code is for required reporting only. Claim has been forwarded to the patient's hearing plan for further consideration. Procedure/product not approved by the Food and Drug Administration. Refund to patient if collected. Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. (Use only with Group Code OA). The impact of prior payer(s) adjudication including payments and/or adjustments. Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Based on entitlement to benefits. Reason Code 136: Contracted funding agreement - Subscriber is employed by the provider of services. Submit the form with any questions, comments, or suggestions related to corporate activities or programs. The diagnosis is inconsistent with the procedure. Denial codes are codes assigned by health care insurance companies to faulty insurance claims. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. CO : Contractual Obligations Denial based on the contract and as per the fee schedule amount. The Claim Adjustment Group Codes are internal to the X12 standard. Reason Code 13: Claim/service lacks information which is needed for adjudication. Reason Code 73: Disproportionate Share Adjustment. Medicare Claim PPS Capital Cost Outlier Amount. Reason Code 111: Procedure/product not approved by the Food and Drug Administration. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Code OA). (Handled in QTY, QTY01=CD). Referral not authorized by attending physician per regulatory requirement. Reason Code 9: The diagnosis is inconsistent with the provider type. This product/procedure is only covered when used according to FDA recommendations. Service/procedure was provided outside of the United States. Online access to all available versions ofX12 products, including The EDI Standard, Code Source Directory, Control Standards, EDI Standard Figures, Guidelines and Technical Reports. No maximum allowable defined by legislated fee arrangement. Not covered unless the provider accepts assignment. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. Adjustment for delivery cost. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. All of our contact information is here. Note: Use code 187. Adjustment for compound preparation cost. Claim lacks indication that service was supervised or evaluated by a physician. Are you looking for more than one billing quotes? The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 3: The procedure/revenue code is inconsistent with the patient's age. Reason Code 195: Precertification/authorization exceeded. Additional information will be sent following the conclusion of litigation. Reason Code 17: This injury/illness is covered by the liability carrier. Reason Code 4: The procedure/revenue code is inconsistent with the patient's gender. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration. Basically, its a code that signifies a denial and it Payment denied because service/procedure was provided outside the United States or as a result of war. Upon review, it was determined that this claim was processed properly. Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Claim/Service denied. Reason Code 147: Payer deems the information submitted does not support this level of service. CO/29/ CO/29/N30. National Drug Codes (NDC) not eligible for rebate, are not covered. At least one Remark Code must be provided (may be comprised of either the Procedure postponed, canceled, or delayed. For convenience, the values and definitions are below: *The description you are suggesting for a new code or to replace the description for a current code. About Us. Charges are covered under a capitation agreement/managed care plan. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Reason Code 96: Medicare Secondary Payer Adjustment Amount. Reason Code 11: The date of birth follows the date of service. Reason Code 86: Professional fees removed from charges. Performance program proficiency requirements not met. Lifetime benefit maximum has been reached for this service/benefit category. What steps can we take to avoid this reason code? Prior processing information appears incorrect. preferred product/service. Processed based on multiple or concurrent procedure rules. Reason Code 25: Coverage not in effect at the time the service was provided. Legislated/Regulatory Penalty. Denial Code CO 16: Claim or Service Lacks Information which is needed for adjudication. Based on subrogation of a third-party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. The list below shows the status of change requests which are in process. Maintenance Request Status Maintenance Request Form 5/20/2018 Filter by code: Reset Filter codes by status: To Be Deactivated Deactivated Reason Code 253: Service not payable per managed care contract. Information from another provider was not provided or was insufficient/incomplete. Information is presented as a PowerPoint deck, informational paper, educational material, or checklist. X12 welcomes feedback. MCR 835 Denial Code List. This claim has been identified as a resubmission. Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Reason Code 33: Balance does not exceed co-payment amount. Reason Code 19: This care may be covered by another payer per coordination of benefits. Reason Code 171: Service was not prescribed prior to delivery. The procedure/revenue code is inconsistent with the patient's gender. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. Payer deems the information submitted does not support this length of service. Note: To be used for pharmaceuticals only. X12 appoints various types of liaisons, including external and internal liaisons. Reason Code 137: Patient/Insured health identification number and name do not match. Reason Code 184: Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). These codes generally assign responsibility Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 59: Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. WebThe following document contains common EOB codes that may appear on your MassHealth remittance advice. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 145: Information from another provider was not provided or was insufficient/incomplete. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Attachment/other documentation referenced on the claim was not received in a timely fashion. Content is added to this page regularly. House Votes (7) Date Action Motion Vote Vote Reason Code 236: Claim spans eligible and ineligible periods of coverage. They include reason and remark codes that outline reasons for not The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Reason Code 34: Balance does not exceed deductible. X12 standards are the workhorse of business to business exchanges proven by the billions of transactions based on X12 standards that are used daily in various industries including supply chain, transportation, government, finance, and health care. Search box will appear then put your adjustment reason code in search box e.g. Review Reason Codes and Statements. Claim spans eligible and ineligible periods of coverage. Claim has been forwarded to the patient's dental plan for further consideration. Ingredient cost adjustment. Note: To be used for pharmaceuticals only. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code, This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Reason Code 45: This (these) procedure(s) is (are) not covered. Reason Code 151: Payer deems the information submitted does not support this day's supply. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Reason Code 30: Insured has no dependent coverage. New born's services are covered in the mother's Allowance. To be used for Property and Casualty Auto only. To be used for Property and Casualty only. Reason Code 256: Additional payment for Dental/Vision service utilization. Reason Code 257: Processed under Medicaid ACA Enhance Fee Schedule. Reason Code 258: The procedure or service is inconsistent with the patient's history. Reason Code 259: Adjustment for delivery cost. Note: to be used for pharmaceuticals only. Denial reason: Non-covered charge (s). To be used for Property and Casualty only. Vote Summary: Votes. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Reason Code 252: The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Note: To be used for pharmaceuticals only. From 1/01/22 - 9/13/22, that client had 1,119 claims that contained denial code CO 4. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. This change effective 7/1/2013: Failure to follow prior payer's coverage rules. The advance indemnification notice signed by the patient did not comply with requirements. (Use CARC 45), Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837), Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. Reason Code 69: Coinsurance day. (Use only with Group Code CO). Credentialing Service for Various Practices: : The date of death precedes the date of service. Rebill separate claims. Simplifying Every Step of Credentialing Process, Most trusted and assured Credentialing services for all you need, likePhysician Credentialing Services, Group Credentialing Services, Re-Credentialing Services. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. Sign up now and take control of your revenue cycle today. WebANSI Reason & Remark Codes The Washington Publishing Company maintains a standard code set used industry wide to provide information regarding claim processing.. Reason Code 242: Provider performance program withhold. An attachment is required to adjudicate this claim/service. This change effective 7/1/2013: Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For example, using contracted providers not in the member's 'narrow' network. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. Patient cannot be identified as our insured. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia.) Claim Adjustment Group Codes 974 These codes categorize a payment adjustment. Claim is under investigation. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Level of subluxation is missing or inadequate. Procedure code was invalid on the date of service. Reason Code 74: Covered days. Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: To be used for pharmaceuticals only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. All X12 work products are copyrighted. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. Lifetime reserve days. You see, CO 4 is one of the most common types of denials and you can see how it adds up. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Prior hospitalization or 30 day transfer requirement not met. Reason Code 167: Payment is denied when performed/billed by this type of provider. (Use CARC 45). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. 05 The procedure code/bill type is inconsistent with the place of service. Reason Code 16: This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. To be used for Property & Casualty only. Legislated/Regulatory Penalty. Reason Code 55: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. (Use with Group Code CO or OA). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Diagnosis was invalid for the date(s) of service reported. Allowed amount has been reduced because a component of the basic procedure/test was paid. Lifetime reserve days. Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. More information is available in X12 Liaisons (CAP17). Charges do not meet qualifications for emergent/urgent care. Categories include Commercial, Internal, Developer and more. Reason Code A0: Medicare Secondary Payer liability met. Service was not prescribed prior to delivery. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Edward A. Guilbert Lifetime Achievement Award. Reason Code 209: Administrative surcharges are not covered. Payment denied for exacerbation when treatment exceeds time allowed. To renewan X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. Claim lacks date of patient's most recent physician visit. (Note: To be used for Property and Casualty only). The following changes to the RARC Service not payable per managed care contract. Insurance will deny the claim with denial reason code CO 16

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