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REASON SEARCH:

 
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Reason Codes


Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. If there is no adjustment to a claim/line, then there is no adjustment reason code.

The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR).

Thanks to Janice Humphries of Medical Billing Guide, author of How To Do Medical Billing

You searched for : Reason :

Code : CO10
Description : The diagnosis is inconsistent with the patient's gender.
Code : CO100
Description : Payment made to patient/insured/responsible party.
Code : CO101
Description : Predetermination: anticipated payment upon completion of services or claim adjudication.
Code : CO102
Description : Major Medical Adjustment.
Code : CO103
Description : Provider promotional discount (e.g., Senior citizen discount).
Code : CO104
Description : Managed care withholding.
Code : CO105
Description : Tax withholding.
Code : CO106
Description : Patient payment option/election not in effect.
Code : CO107
Description : Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim.
Code : CO108
Description : Payment adjusted because rent/purchase guidelines were not met.
Code : CO109
Description : Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Code : CO11
Description : The diagnosis is inconsistent with the procedure.
Code : CO110
Description : Billing date predates service date.
Code : CO111
Description : Not covered unless the provider accepts assignment.
Code : CO112
Description : Payment adjusted as not furnished directly to the patient and/or not documented.
Code : CO113
Description : Payment denied because service/procedure was provided outside the United States or as a result of war.
Code : CO114
Description : Procedure/product not approved by the Food and Drug Administration.
Code : CO115
Description : Payment adjusted as procedure postponed or canceled.
Code : CO116
Description : Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
Code : CO117
Description : Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
Code : CO118
Description : Charges reduced for ESRD network support.
Code : CO119
Description : Benefit maximum for this time period has been reached.
Code : CO12
Description : The diagnosis is inconsistent with the provider type.
Code : CO120
Description : Patient is covered by a managed care plan.
Code : CO121
Description : Indemnification adjustment.
Code : CO122
Description : Psychiatric reduction.
Code : CO123
Description : Payer refund due to overpayment.
Code : CO124
Description : Payer refund amount - not our patient.
Code : CO125
Description : Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
Code : CO126
Description : Deductible -- Major Medical
Code : CO127
Description : Coinsurance -- Major Medical
Code : CO128
Description : Newborn's services are covered in the mother's Allowance.
Code : CO129
Description : Payment denied - Prior processing information appears incorrect.
Code : CO13
Description : The date of death precedes the date of service.
Code : CO130
Description : Claim submission fee.
Code : CO131
Description : Claim specific negotiated discount.
Code : CO132
Description : Prearranged demonstration project adjustment.
Code : CO133
Description : The disposition of this claim/service is pending further review.
Code : CO134
Description : Technical fees removed from charges.
Code : CO135
Description : Claim denied. Interim bills cannot be processed.
Code : CO136
Description : Claim Adjusted. Plan procedures of a prior payer were not followed.
Code : CO137
Description : Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Code : CO138
Description : Claim/service denied. Appeal procedures not followed or time limits not met.
Code : CO139
Description : Contracted funding agreement - Subscriber is employed by the provider of services.
Code : CO14
Description : The date of birth follows the date of service.
Code : CO140
Description : Patient/Insured health identification number and name do not match.
Code : CO141
Description : Claim adjustment because the claim spans eligible and ineligible periods of coverage.
Code : CO142
Description : Claim adjusted by the monthly Medicaid patient liability amount.
Code : CO143
Description : Portion of payment deferred.
Code : CO144
Description : Incentive adjustment, e.g. preferred product/service.
Code : CO145
Description : Premium payment withholding
Code : CO146
Description : Payment denied because the diagnosis was invalid for the date(s) of service reported.
Code : CO147
Description : Provider contracted/negotiated rate expired or not on file.
Code : CO148
Description : Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
Code : CO149
Description : Lifetime benefit maximum has been reached for this service/benefit category.
Code : CO15
Description : Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
Code : CO150
Description : Payment adjusted because the payer deems the information submitted does not support this level of service.
Code : CO151
Description : Payment adjusted because the payer deems the information submitted does not support this many services.
Code : CO152
Description : Payment adjusted because the payer deems the information submitted does not support this length of service.
Code : CO153
Description : Payment adjusted because the payer deems the information submitted does not support this dosage.
Code : CO154
Description : Payment adjusted because the payer deems the information submitted does not support this day's supply.
Code : CO155
Description : This claim is denied because the patient refused the service/procedure.
Code : CO16
Description : Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.
Code : CO165
Description : Payment denied/reduced for absence of, or exceeded, referral.
Code : CO167
Description : This (these) diagnosis (es) is (are) not covered.
Code : CO169
Description : Payment adjusted because an alternate benefit has been provided.
Code : CO17
Description : Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate.
Code : CO170
Description : Payment denied when performed/billed by this type of provider.
Code : CO171
Description : Payment denied when performed/billed by this type of provider in this type of facility.
Code : CO172
Description : Payment adjusted when performed/billed by a provider of this specialty.
Code : CO177
Description : Payment denied because patient has not met the required eligibility requirements.
Code : CO178
Description : Payment adjusted because the patient has not met the required spend down requirements.
Code : CO18
Description : Duplicate claim/service.
Code : CO181
Description : Payment adjusted because this procedure code was invalid on the date of service.
Code : CO183
Description : The referring provider is not eligible to refer the service billed.
Code : CO185
Description : The rendering provider is not eligible to perform the service billed.
Code : CO19
Description : Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Code : CO2
Description : Coinsurance Amount
Code : CO20
Description : Claim denied because this injury/illness is covered by the liability carrier.
Code : CO21
Description : Claim denied because this injury/illness is the liability of the no-fault carrier.
Code : CO22
Description : Payment adjusted because this care may be covered by another payer per coordination of benefits.
Code : CO23
Description : Payment adjusted because charges have been paid by another payer.
Code : CO24
Description : Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
Code : CO25
Description : Payment denied. Your Stop loss deductible has not been met.
Code : CO26
Description : Expenses incurred prior to coverage.
Code : CO27
Description : Expenses incurred after coverage terminated.
Code : CO28
Description : Coverage not in effect at the time the service was provided.
Code : CO29
Description : The time limit for filing has expired.
Code : CO3
Description : Co-payment Amount
Code : CO30
Description : Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Code : CO31
Description : Claim denied as patient cannot be identified as our insured.
Code : CO32
Description : Our records indicate that this dependent is not an eligible dependent as defined.
Code : CO33
Description : Claim denied. Insured has no dependent coverage.
Code : CO34
Description : Claim denied. Insured has no coverage for newborns.
Code : CO35
Description : Lifetime benefit maximum has been reached.
Code : CO36
Description : Balance does not exceed co-payment amount.
Code : CO37
Description : Balance does not exceed deductible.
Code : CO38
Description : Services not provided or authorized by designated (network/primary care) providers.
Code : CO39
Description : Services denied at the time authorization/pre-certification was requested.
Code : CO4
Description : The procedure code is inconsistent with the modifier used or a required modifier is missing.
Code : CO40
Description : Charges do not meet qualifications for emergent/urgent care.
Code : CO41
Description : Discount agreed to in Preferred Provider contract.
Code : CO42
Description : Charges exceed our fee schedule or maximum allowable amount.
Code : CO43
Description : Gramm-Rudman reduction.
Code : CO44
Description : Prompt-pay discount.
Code : CO45
Description : Charges exceed your contracted/ legislated fee arrangement.
Code : CO46
Description : This (these) service(s) is (are) not covered.
Code : CO47
Description : This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Code : CO48
Description : This (these) procedure(s) is (are) not covered.
Code : CO49
Description : These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Code : CO5
Description : The procedure code/bill type is inconsistent with the place of service.
Code : CO50
Description : These are non-covered services because this is not deemed a `medical necessity' by the payer.
Code : CO51
Description : These are non-covered services because this is a pre-existing condition.
Code : CO52
Description : The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Code : CO53
Description : Services by an immediate relative or a member of the same household are not covered.
Code : CO54
Description : Multiple physicians/assistants are not covered in this case.
Code : CO55
Description : Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
Code : CO56
Description : Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
Code : CO57
Description : 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.
Code : CO58
Description : Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Code : CO59
Description : Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Code : CO6
Description : The procedure/revenue code is inconsistent with the patient's age.
Code : CO60
Description : Charges for outpatient services with this proximity to inpatient services are not covered.
Code : CO61
Description : Charges adjusted as penalty for failure to obtain second surgical opinion.
Code : CO62
Description : Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Code : CO63
Description : Correction to a prior claim.
Code : CO64
Description : Denial reversed per Medical Review.
Code : CO65
Description : Procedure code was incorrect. This payment reflects the correct code.
Code : CO66
Description : Blood Deductible.
Code : CO67
Description : Lifetime reserve days. (Handled in QTY, QTY01=LA)
Code : CO68
Description : DRG weight. (Handled in CLP12)
Code : CO69
Description : Day outlier amount.
Code : CO7
Description : The procedure/revenue code is inconsistent with the patient's gender.
Code : CO70
Description : Cost outlier - Adjustment to compensate for additonal costs.
Code : CO71
Description : Primary Payer amount.
Code : CO72
Description : Coinsurance day. (Handled in QTY, QTY01=CD)
Code : CO73
Description : Administrative days.
Code : CO74
Description : Indirect Medical Education Adjustment.
Code : CO75
Description : Direct Medical Education Adjustment.
Code : CO76
Description : Disproportionate Share Adjustment.
Code : CO77
Description : Covered days. (Handled in QTY, QTY01=CA)
Code : CO78
Description : Non-Covered days/Room charge adjustment.
Code : CO79
Description : Cost Report days. (Handled in MIA15)
Code : CO8
Description : The procedure code is inconsistent with the provider type/specialty (taxonomy).
Code : CO80
Description : Outlier days. (Handled in QTY, QTY01=OU)
Code : CO81
Description : Discharges.
Code : CO82
Description : PIP days.
Code : CO83
Description : Total visits.
Code : CO84
Description : Capital Adjustment. (Handled in MIA)
Code : CO85
Description : Interest amount.
Code : CO86
Description : Statutory Adjustment.
Code : CO87
Description : Transfer amount.
Code : CO88
Description : Adjustment amount represents collection against receivable created in prior overpayment.
Code : CO89
Description : Professional fees removed from charges.
Code : CO9
Description : The diagnosis is inconsistent with the patient's age.
Code : CO90
Description : Ingredient cost adjustment.
Code : CO91
Description : Dispensing fee adjustment.
Code : CO92
Description : Claim Paid in full.
Code : CO93
Description : No Claim level Adjustments.
Code : CO94
Description : Processed in Excess of charges.
Code : CO95
Description : Benefits adjusted. Plan procedures not followed.
Code : CO96
Description : Non-covered charge(s).
Code : CO97
Description : Payment is included in the allowance for another service/procedure.
Code : CO98
Description : The hospital must file the Medicare claim for this inpatient non-physician service.
Code : CO99
Description : Medicare Secondary Payer Adjustment Amount.
Code : COA0
Description : Patient refund amount.
Code : COA1
Description : Claim denied charges.
Code : COA2
Description : Contractual adjustment.
Code : COA3
Description : Medicare Secondary Payer liability met.
Code : COA4
Description : Medicare Claim PPS Capital Day Outlier Amount.
Code : COA5
Description : Medicare Claim PPS Capital Cost Outlier Amount.
Code : COA6
Description : Prior hospitalization or 30 day transfer requirement not met.
Code : COA7
Description : Presumptive Payment Adjustment
Code : COA8
Description : Claim denied; ungroupable DRG
Code : COB1
Description : Non-covered visits.
Code : COB10
Description : 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.
Code : COB11
Description : The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Code : COB12
Description : Services not documented in patients' medical records.
Code : COB13
Description : Previously paid. Payment for this claim/service may have been provided in a previous payment.
Code : COB14
Description : Payment denied because only one visit or consultation per physician per day is covered.
Code : COB15
Description : Payment adjusted because this procedure/service is not paid separately.
Code : COB16
Description : Payment adjusted because `New Patient' qualifications were not met.
Code : COB17
Description : Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
Code : COB18
Description : Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
Code : COB19
Description : Claim/service adjusted because of the finding of a Review Organization.
Code : COB2
Description : Covered visits.
Code : COB20
Description : Payment adjusted because procedure/service was partially or fully furnished by another provider.
Code : COB21
Description : The charges were reduced because the service/care was partially furnished by another physician.
Code : COB22
Description : This payment is adjused based on the diagnosis.
Code : COB23
Description : Payment denied because this provider has failed an aspect of a proficiency testing program.
Code : COB3
Description : Covered charges.
Code : COB4
Description : Late filing penalty.
Code : COB5
Description : Payment adjusted because coverage/program guidelines were not met or were exceeded.
Code : COB6
Description : This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
Code : COB7
Description : This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Code : COB8
Description : Claim/service not covered/reduced because alternative services were available, and should have been utilized.
Code : COB9
Description : Services not covered because the patient is enrolled in a Hospice.
Code : COD1
Description : Claim/service denied. Level of subluxation is missing or inadequate.
Code : COD10
Description : Claim/service denied. Completed physician financial relationship form not on file.
Code : COD11
Description : Claim lacks completed pacemaker registration form.
Code : COD12
Description : Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
Code : COD13
Description : Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
Code : COD14
Description : Claim lacks indication that plan of treatment is on file.
Code : COD15
Description : Claim lacks indication that service was supervised or evaluated by a physician.
Code : COD18
Description : Inactive for 4010 as of 2/99.
Code : COD19
Description : Claim service lacks physician/operative or other supporting documentation (inactive as of version 5010; use code 16).
Code : COD2
Description : Claim lacks the name, strength, or dosage of the drug furnished.
Code : COD21
Description : This (these) diagnosis (es) is (are) missing or is (are) invalid.
Code : COD3
Description : Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Code : COD4
Description : Claim/service does not indicate the period of time for which this will be needed.
Code : COD5
Description : Claim/service denied. Claim lacks individual lab codes included in the test.
Code : COD6
Description : Claim/service denied. Claim did not include patient's medical record for the service.
Code : COD7
Description : Claim/service denied. Claim lacks date of patient's most recent physician visit.
Code : COD8
Description : Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
Code : COD9
Description : Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
Code : COW1
Description : Workers Compensation State Fee Schedule Adjustment
Code : CR A2
Description : Contractual adjustment (inactive for 004060; use code 45 with group code CO).
Code : CR07
Description : The procedure/revenue code is inconsistent with the patients gender.
Code : CR1
Description : Deductible amount.
Code : CR10
Description : The diagnosis is inconsistent with the patients gender.
Code : CR100
Description : Payment made to patient/insured/responsible party.
Code : CR102
Description : Major medical adjustment.
Code : CR104
Description : Managed care withholding.
Code : CR107
Description : Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
Code : CR109
Description : Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Code : CR11
Description : The diagnosis is inconsistent with the patients gender.
Code : CR112
Description : Payment adjusted as not furnished directly to the patient and/or not documented.
Code : CR119
Description : Benefit maximum for this time period or occurrence has been reached.
Code : CR121
Description : Indemnification adjustment.
Code : CR125
Description : Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
Code : CR127
Description : Coinsurance - major medical.
Code : CR129
Description : Payment denied. Prior processing information appears incorrect.
Code : CR13
Description : The date of death precedes the date of service.
Code : CR131
Description : Claim specific negotiated discount.
Code : CR133
Description : The disposition of the claim/service is pending further review.
Code : CR137
Description : Payment/reduction for surcharges, assessments, allowances, or health related taxes.
Code : CR144
Description : Incentive adjustment, e.g., preferred product/service.
Code : CR145
Description : Premium payment withholding.
Code : CR148
Description : Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
Code : CR149
Description : Lifetime benefit maximum has been reached for this service/benefit category.
Code : CR150
Description : Payment adjusted because the payer deems the information submitted does not support this level of service.
Code : CR151
Description : Payment adjusted because the payer deems the information submitted does not support this many services.
Code : CR16
Description : Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
Code : CR165
Description : Payment denied/reduced for absence of, or exceeded, referral.
Code : CR17
Description : Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
Code : CR170
Description : Payment adjusted when performed/billed by a provider of this type of provider.
Code : CR172
Description : Payment adjusted when performed/billed by a provider of this specialty.
Code : CR179
Description : Payment adjusted because the patient has not met the required waiting requirements.
Code : CR18
Description : Duplicate claim/service.
Code : CR180
Description : Payment adjusted because the patient has not met the required residency requirements.
Code : CR183
Description : The referring provider is not eligible to refer the service billed.
Code : CR185
Description : The rendering provider is not eligible to perform the service billed.
Code : CR187
Description : Health savings account payments.
Code : CR19
Description : Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
Code : CR2
Description : Coinsurance amount.
Code : CR20
Description : Claim denied because this injury/illness is covered by the liability carrier.
Code : CR21
Description : Claim denied because this injury/illness is the liability of the no-fault carrier.
Code : CR22
Description : Payment adjusted because this care may be covered by another payer per coordination of benefits.
Code : CR23
Description : Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.
Code : CR24
Description : Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
Code : CR26
Description : Expenses incurred prior to coverage.
Code : CR27
Description : Expenses incurred after coverage terminated.
Code : CR29
Description : The time limit for filing has expired.
Code : CR3
Description : Copayment amount.
Code : CR30
Description : Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Code : CR31
Description : Claim denied as patient cannot be identified as our insured.
Code : CR32
Description : Our records indicate that this dependent is not an eligible dependent as defined.
Code : CR33
Description : Claim denied - insured has no dependent coverage.
Code : CR34
Description : Claim denied - insured has no coverage for newborns.
Code : CR35
Description : Lifetime benefit maximum has been reached.
Code : CR38
Description : Services not provided or authorized by designated (network/primary care) providers.
Code : CR39
Description : Services denied at the time authorization/precertification was requested.
Code : CR4
Description : The procedure code is inconsistent with the modifier used or a required modifier is missing.
Code : CR40
Description : Charges do not meet qualifications for emergent/urgent care.
Code : CR42
Description : Charges exceed our fee schedule or maximum allowable amount.
Code : CR45
Description : 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.
Code : CR46
Description : This (these) service (s) is (are) not covered.
Code : CR47
Description : This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Code : CR48
Description : This (these) procedure (s) is (are) not covered.
Code : CR49
Description : These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Code : CR5
Description : The procedure code/bill type is inconsistent with the place of service.
Code : CR50
Description : These are noncovered services because this is not deemed a "medical necessity" by the payer.
Code : CR51
Description : These are noncovered services because this is a preexisting condition.
Code : CR52
Description : The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Code : CR54
Description : Multiple physicians/assistants are not covered in this case.
Code : CR55
Description : Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
Code : CR56
Description : Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
Code : CR57
Description : 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.
Code : CR58
Description : Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Code : CR59
Description : Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Code : CR6
Description : The procedure/revenue code is inconsistent with the patient's age.
Code : CR62
Description : Payment denied/reduced for absence of, or exceeded, precertification/authorization.
Code : CR63
Description : Correction to a prior claim.
Code : CR7
Description : The procedure/revenue code is inconsistent with the patients gender.
Code : CR85
Description : Interest amount.
Code : CR88
Description : Adjustment amount represents collection against receivable created in prior overpayment.
Code : CR9
Description : The diagnosis is inconsistent with the patients age.
Code : CR94
Description : Processed in excess of charges.
Code : CR95
Description : Benefits adjusted. Plan procedures not followed.
Code : CR96
Description : Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
Code : CR97
Description : Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Code : CRA1
Description : 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.
Code : CRA2
Description : Contractual adjustment (inactive for 004060; use code 45 with group code CO).
Code : CRA6
Description : Prior hospitalization or 30-day transfer requirement not met.
Code : CRB1
Description : Noncovered visits.
Code : CRB10
Description : 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.
Code : CRB11
Description : Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Code : CRB12
Description : Services not documented in patient's medical records.
Code : CRB13
Description : Previously paid. Payment for this claim/service may have been provided in a previous payment.
Code : CRB14
Description : Payment denied because only one visit or consultation per physician per day is covered.
Code : CRB15
Description : Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
Code : CRB16
Description : Payment adjusted because "new patient" qualifications were not met.
Code : CRB18
Description : Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
Code : CRB20
Description : Payment adjusted because procedure/service was partially or fully furnished by another provider.
Code : CRB22
Description : This payment is adjusted based on the diagnosis.
Code : CRB3
Description : Covered charges.
Code : CRB5
Description : Payment adjusted because coverage/program guidelines were not met or were exceeded.CRB6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
Code : CRB7
Description : This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Code : CRB9
Description : Services not covered because the patient is enrolled in hospice.
Code : CRD19
Description : Claim/service lacks physician/operative or other supporting documentation.
Code : CRD21
Description : This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Code : NC
Description : Precert not obtained.
Code : PR02
Description : Coinsurance amount.
Code : PR07
Description : The procedure/revenue code is inconsistent with the patients gender.
Code : PR1
Description : Deductible amount.
Code : PR10
Description : The diagnosis is inconsistent with the patients gender.
Code : PR100
Description : Payment made to patient/insured/responsible party.
Code : PR104
Description : Managed care withholding.
Code : PR107
Description : Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
Code : PR109
Description : Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Code : PR11
Description : The diagnosis is inconsistent with the procedure.
Code : PR111
Description : Not covered unless the provider accepts assignment.
Code : PR112
Description : Payment adjusted as not furnished directly to the patient and/or not documented.
Code : PR117
Description : Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
Code : PR119
Description : Benefit maximum for this time period or occurrence has been reached.
Code : PR125
Description : Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
Code : PR126
Description : Deductible - major medical.
Code : PR127
Description : Coinsurance - major medical.
Code : PR129
Description : Payment denied. Prior processing information appears incorrect.
Code : PR13
Description : The date of death precedes the date of service.
Code : PR131
Description : Claim specific negotiated discount.
Code : PR133
Description : The disposition of the claim/service is pending further review.
Code : PR136
Description : Claim adjusted based on failure to follow prior payer's coverage rules.
Code : PR137
Description : Payment/reduction for regulatory surcharges, assessments, allowances, or health related taxes.
Code : PR138
Description : Claim/service denied. Appeal procedures not followed or time limits not met.
Code : PR140
Description : Patient/insured health identification number and name do not match.
Code : PR141
Description : Claim adjustment because the claim spans eligible and ineligible periods of coverage.
Code : PR145
Description : Premium payment withholding.
Code : PR147
Description : Provider contracted/negotiated rate expired or not on file.
Code : PR149
Description : Lifetime benefit maximum has been reached for this service/benefit category.
Code : PR15
Description : Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
Code : PR150
Description : Payment adjusted because the payer deems the information submitted does not support this level of service.
Code : PR151
Description : Payment adjusted because the payer deems the information submitted does not support this many services.
Code : PR156
Description : Flexible spending account payments.
Code : PR16
Description : Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
Code : PR167
Description : This (these) diagnosis (es) is (are) not covered.
Code : PR17
Description : Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/07: at least one remark code
Code : PR170
Description : Payment denied when performed/billed by this type of provider.
Code : PR171
Description : Payment denied when performed/billed by this type of provider in this type of facility.
Code : PR172
Description : Payment adjusted when performed/billed by a provider of this specialty.
Code : PR177
Description : Payment denied because the patient has not met the required eligibility requirements.
Code : PR179
Description : Payment adjusted because the patient has not met the required waiting requirements.
Code : PR18
Description : Duplicate claim/service.
Code : PR180
Description : Payment adjusted because the patient has not met the required residency requirements.
Code : PR183
Description : The referring provider is not eligible to refer the service billed.
Code : PR184
Description : The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Code : PR185
Description : The rendering provider is not eligible to perform the service billed.
Code : PR19
Description : Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
Code : PR2
Description : Coinsurance amount.
Code : PR20
Description : Claim denied because this injury/illness is covered by the liability carrier.
Code : PR21
Description : Claim denied because this injury/illness is the liability of the no-fault carrier.
Code : PR22
Description : Payment adjusted because this care may be covered by another payer per coordination of benefits.
Code : PR23
Description : Payment adjusted due to the impact of prior payer's) adjudication including payments and/or adjustments.
Code : PR24
Description : Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
Code : PR26
Description : Expenses incurred prior to coverage.
Code : PR27
Description : Expenses incurred after coverage terminated.
Code : PR28
Description : Coverage not in effect at the time the service was provided.
Code : PR29
Description : The time limit for filing has expired.
Code : PR3
Description : Copayment amount.
Code : PR30
Description : Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Code : PR31
Description : Claim denied as patient cannot be identified as our insured.
Code : PR32
Description : Our records indicate that this dependent is not an eligible dependent as defined.
Code : PR33
Description : Claim denied - insured has no dependent coverage.
Code : PR34
Description : Claim denied - insured has no coverage for newborns.
Code : PR35
Description : Lifetime benefit maximum has been reached.
Code : PR38
Description : Services not provided or authorized by designated (network/primary care) providers.
Code : PR39
Description : Services denied at the time authorization/precertification was requested.
Code : PR4
Description : The procedure code is inconsistent with the modifier used or a required modifier is missing.
Code : PR40
Description : Charges do not meet qualifications for emergent/urgent care.
Code : PR42
Description : Charges exceed our fee schedule or maximum allowable amount.
Code : PR45
Description : 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.
Code : PR46
Description : This (these) service (s) is (are) not covered.
Code : PR47
Description : This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Code : PR48
Description : This (these) procedure (s) is (are) not covered.
Code : PR49
Description : These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Code : PR5
Description : Procedure code/bill type is inconsistent with the place of service.
Code : PR50
Description : These are noncovered services because this is not deemed a "medical necessity" by the payer.
Code : PR51
Description : These are noncovered services because this is a preexisting condition.
Code : PR52
Description : The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Code : PR54
Description : Multiple physicians/assistants are not covered in this case.
Code : PR55
Description : Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
Code : PR56
Description : Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
Code : PR57
Description : 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.
Code : PR58
Description : Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Code : PR59
Description : Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Code : PR6
Description : The procedure/revenue code is inconsistent with the patient's age.
Code : PR62
Description : Payment denied/reduced for absence of, or exceeded, precertification/authorization.
Code : PR63
Description : Correction to a prior claim.
Code : PR7
Description : The procedure/revenue code is inconsistent with the patients gender.
Code : PR8
Description : The procedure code is inconsistent with the provider type/specialty (taxonomy).
Code : PR87
Description : Transfer amount.
Code : PR9
Description : The diagnosis is inconsistent with the patients age.
Code : PR92
Description : Claim paid in full.
Code : PR94
Description : Processed in excess of charges.
Code : PR95
Description : Benefits adjusted. Plan procedures not followed.
Code : PR96
Description : Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
Code : PR97
Description : Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Code : PRA1
Description : 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.
Code : PRA2
Description : Contractual adjustment (inactive for 004060; use code 45 with group code CO).
Code : PRA6
Description : Prior hospitalization or 30-day transfer requirement not met.
Code : PRB1
Description : Noncovered visits.
Code : PRB11
Description : Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Code : PRB12
Description : Services not documented in patient's medical records.
Code : PRB13
Description : Previously paid. Payment for this claim/service may have been provided in a previous payment.
Code : PRB14
Description : Payment denied because only one visit or consultation per physician per day is covered.
Code : PRB15
Description : Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
Code : PRB16
Description : Payment adjusted because "new patient" qualifications were not met.
Code : PRB18
Description : Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
Code : PRB20
Description : Payment adjusted because procedure/service was partially or fully furnished by another provider.
Code : PRB22
Description : This payment is adjusted based on the diagnosis.
Code : PRB5
Description : Payment adjusted because coverage/program guidelines were not met or were exceeded.
Code : PRB6
Description : This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
Code : PRB7
Description : This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Code : PRB8
Description : Claim/service not covered/reduced because alternative services were available and should have been utilized.
Code : PRB9
Description : Services not covered because the patient is enrolled in hospice.
Code : PRD19
Description : Claim/service lacks physician/operative or other supporting documentation.
Code : PRD21
Description : This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Code : WB
Description : Paid at wrong benefit amount.


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