Denial code decoder

Paste an adjustment line and get the codes explained, starting with the one thing that matters: whether you write it off or bill the patient.

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Group codes: who bears the adjustment

Five codes, and this is the field that decides whether you write the money off or bill it to the patient. The reason code beside it only explains why the adjustment happened.

CO
Contractual Obligation
Write it off. The provider absorbs this under the contract; it cannot be billed to the patient.
PR
Patient Responsibility
Bill the patient. This portion is the patient’s responsibility.
PI
Payer Initiated Reductions
Write it off. A payer-initiated reduction, not billable to the patient.
OA
Other Adjustment
Neither. Used when neither a contractual write-off nor patient responsibility applies.
CR
Corrections and Reversal Note: This value is not to be used with 005010 and up.
Correction or reversal of a prior decision. Retired: not valid in 005010 and later.

Claim adjustment reason codes

All 407 CARCs, as published by X12.

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407 codes

Code	Description
1	Deductible Amount
2	Coinsurance Amount
3	Co-payment Amount
4	The procedure code is inconsistent with the modifier used.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
5	The procedure code/type of bill is inconsistent with the place of service.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
6	The procedure/revenue code is inconsistent with the patient's age.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
7	The procedure/revenue code is inconsistent with the patient's gender.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
8	The procedure code is inconsistent with the provider type/specialty (taxonomy).Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
9	The diagnosis is inconsistent with the patient's age.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
10	The diagnosis is inconsistent with the patient's gender.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
11	The diagnosis is inconsistent with the procedure.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
12	The diagnosis is inconsistent with the provider type.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
13	The date of death precedes the date of service.
14	The date of birth follows the date of service.
15	The authorization number is missing, invalid, or does not apply to the billed services or provider.
16	Claim/service lacks information or has submission/billing error(s).Do not use this code for claims attachment(s)/other documentation. 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.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
17	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.)
18	Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
19	This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20	This injury/illness is covered by the liability carrier.
21	This injury/illness is the liability of the no-fault carrier.
22	This care may be covered by another payer per coordination of benefits.
23	The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
24	Charges are covered under a capitation agreement/managed care plan.
25	Payment denied. Your Stop loss deductible has not been met.
26	Expenses incurred prior to coverage.
27	Expenses incurred after coverage terminated.
28	Coverage not in effect at the time the service was provided.
29	The time limit for filing has expired.
30	Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31	Patient cannot be identified as our insured.
32	Our records indicate the patient is not an eligible dependent.
33	Insured has no dependent coverage.
34	Insured has no coverage for newborns.
35	Lifetime benefit maximum has been reached.
36	Balance does not exceed co-payment amount.
37	Balance does not exceed deductible.
38	Services not provided or authorized by designated (network/primary care) providers.
39	Services denied at the time authorization/pre-certification was requested.
40	Charges do not meet qualifications for emergent/urgent care.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
41	Discount agreed to in Preferred Provider contract.
42	Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
43	Gramm-Rudman reduction.
44	Prompt-pay discount.
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.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. (Use only with Group Codes PR or CO depending upon liability)
46	This (these) service(s) is (are) not covered.
47	This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48	This (these) procedure(s) is (are) not covered.
49	This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
50	These are non-covered services because this is not deemed a 'medical necessity' by the payer.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
51	These are non-covered services because this is a pre-existing condition.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
52	The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
53	Services by an immediate relative or a member of the same household are not covered.
54	Multiple physicians/assistants are not covered in this case.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
55	Procedure/treatment/drug is deemed experimental/investigational by the payer.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
56	Procedure/treatment has not been deemed 'proven to be effective' by the payer.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
57	Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
60	Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
61	Adjusted for failure to obtain second surgical opinion
62	Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
63	Correction to a prior claim.
64	Denial reversed per Medical Review.
65	Procedure code was incorrect. This payment reflects the correct code.
66	Blood Deductible.
67	Lifetime reserve days. (Handled in QTY, QTY01=LA)
68	DRG weight. (Handled in CLP12)
69	Day outlier amount.
70	Cost outlier - Adjustment to compensate for additional costs.
71	Primary Payer amount.
72	Coinsurance day. (Handled in QTY, QTY01=CD)
73	Administrative days.
74	Indirect Medical Education Adjustment.
75	Direct Medical Education Adjustment.
76	Disproportionate Share Adjustment.
77	Covered days. (Handled in QTY, QTY01=CA)
78	Non-Covered days/Room charge adjustment.
79	Cost Report days. (Handled in MIA15)
80	Outlier days. (Handled in QTY, QTY01=OU)
81	Discharges.
82	PIP days.
83	Total visits.
84	Capital Adjustment. (Handled in MIA)
85	Patient Interest Adjustment (Use Only Group code PR)
86	Statutory Adjustment.
87	Transfer amount.
88	Adjustment amount represents collection against receivable created in prior overpayment.
89	Professional fees removed from charges.
90	Ingredient cost adjustment.To be used for pharmaceuticals only.
91	Dispensing fee adjustment.
92	Claim Paid in full.
93	No Claim level Adjustments.
94	Processed in Excess of charges.
95	Plan procedures not followed.
96	Non-covered charge(s). 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.)Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
98	The hospital must file the Medicare claim for this inpatient non-physician service.
99	Medicare Secondary Payer Adjustment Amount.
100	Payment made to patient/insured/responsible party.
101	Predetermination: anticipated payment upon completion of services or claim adjudication.
102	Major Medical Adjustment.
103	Provider promotional discount (e.g., Senior citizen discount).
104	Managed care withholding.
105	Tax withholding.
106	Patient payment option/election not in effect.
107	The related or qualifying claim/service was not identified on this claim.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
108	Rent/purchase guidelines were not met.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
110	Billing date predates service date.
111	Not covered unless the provider accepts assignment.
112	Service not furnished directly to the patient and/or not documented.
113	Payment denied because service/procedure was provided outside the United States or as a result of war.
114	Procedure/product not approved by the Food and Drug Administration.
115	Procedure postponed, canceled, or delayed.
116	The advance indemnification notice signed by the patient did not comply with requirements.
117	Transportation is only covered to the closest facility that can provide the necessary care.
118	ESRD network support adjustment.
119	Benefit maximum for this time period or occurrence has been reached.
120	Patient is covered by a managed care plan.
121	Indemnification adjustment - compensation for outstanding member responsibility.
122	Psychiatric reduction.
123	Payer refund due to overpayment.
124	Payer refund amount - not our patient.
125	Submission/billing error(s). 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.)
126	Deductible -- Major Medical
127	Coinsurance -- Major Medical
128	Newborn's services are covered in the mother's Allowance.
129	Prior processing information appears incorrect. 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.)
130	Claim submission fee.
131	Claim specific negotiated discount.
132	Prearranged demonstration project adjustment.
133	The disposition of this service line is pending further review. (Use only with Group Code OA).Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).
134	Technical fees removed from charges.
135	Interim bills cannot be processed.
136	Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
137	Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138	Appeal procedures not followed or time limits not met.
139	Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.
140	Patient/Insured health identification number and name do not match.
141	Claim spans eligible and ineligible periods of coverage.
142	Monthly Medicaid patient liability amount.
143	Portion of payment deferred.
144	Incentive adjustment, e.g. preferred product/service.
145	Premium payment withholding
146	Diagnosis was invalid for the date(s) of service reported.
147	Provider contracted/negotiated rate expired or not on file.
148	Information from another provider was not provided or was insufficient/incomplete. 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.)
149	Lifetime benefit maximum has been reached for this service/benefit category.
150	Payer deems the information submitted does not support this level of service.
151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
152	Payer deems the information submitted does not support this length of service.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
153	Payer deems the information submitted does not support this dosage.
154	Payer deems the information submitted does not support this day's supply.
155	Patient refused the service/procedure.
156	Flexible spending account payments. Note: Use code 187.
157	Service/procedure was provided as a result of an act of war.
158	Service/procedure was provided outside of the United States.
159	Service/procedure was provided as a result of terrorism.
160	Injury/illness was the result of an activity that is a benefit exclusion.
161	Provider performance bonus
162	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
163	Attachment/other documentation referenced on the claim was not received.
164	Attachment/other documentation referenced on the claim was not received in a timely fashion.
165	Referral absent or exceeded.
166	These services were submitted after this payers responsibility for processing claims under this plan ended.
167	This (these) diagnosis(es) is (are) not covered.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
168	Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
169	Alternate benefit has been provided.
170	Payment is denied when performed/billed by this type of provider.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
171	Payment is denied when performed/billed by this type of provider in this type of facility.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
172	Payment is adjusted when performed/billed by a provider of this specialty.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
173	Service/equipment was not prescribed by a physician.
174	Service was not prescribed prior to delivery.
175	Prescription is incomplete.
176	Prescription is not current.
177	Patient has not met the required eligibility requirements.
178	Patient has not met the required spend down requirements.
179	Patient has not met the required waiting requirements.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
180	Patient has not met the required residency requirements.
181	Procedure code was invalid on the date of service.
182	Procedure modifier was invalid on the date of service.
183	The referring provider is not eligible to refer the service billed.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
184	The prescribing/ordering provider is not eligible to prescribe/order the service billed.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
185	The rendering provider is not eligible to perform the service billed.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
186	Level of care change adjustment.
187	Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
188	This product/procedure is only covered when used according to FDA recommendations.
189	'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
190	Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
191	Not a work related injury/illness and thus not the liability of the workers' compensation carrier 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. 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)
192	Non standard adjustment code from paper remittance.This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. 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.
193	Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
194	Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
195	Refund issued to an erroneous priority payer for this claim/service.
196	Claim/service denied based on prior payer's coverage determination.
197	Precertification/authorization/notification/pre-treatment absent.
198	Precertification/notification/authorization/pre-treatment exceeded.
199	Revenue code and Procedure code do not match.
200	Expenses incurred during lapse in coverage
201	Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) 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.)
202	Non-covered personal comfort or convenience services.
203	Discontinued or reduced service.
204	This service/equipment/drug is not covered under the patient's current benefit plan
205	Pharmacy discount card processing fee
206	National Provider Identifier - missing.
207	National Provider identifier - Invalid format
208	National Provider Identifier - Not matched.
209	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 only with Group code OA)
210	Payment adjusted because pre-certification/authorization not received in a timely fashion
211	National Drug Codes (NDC) not eligible for rebate, are not covered.
212	Administrative surcharges are not covered
213	Non-compliance with the physician self referral prohibition legislation or payer policy.
214	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. 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. 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). To be used for Workers' Compensation only
215	Based on subrogation of a third party settlement
216	Based on the findings of a review organization or the payer's findings.
217	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)
218	Based on entitlement to benefits. 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. 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). To be used for Workers' Compensation only
219	Based on extent of injury.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. 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).
220	The applicable fee schedule/fee database does not contain the billed code. 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. (Note: To be used for Property and Casualty only)
221	Claim is under investigation. 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. 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). (Note: To be used by Property & Casualty only)
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
226	Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. 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.)
227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 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.)
228	Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
229	Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X.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. (Use only with Group Code PR)
230	No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
231	Mutually exclusive procedures cannot be done in the same day/setting.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
232	Institutional Transfer Amount.Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
233	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
234	This procedure is not paid separately. 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.)
235	Sales Tax
236	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.
237	Legislated/Regulatory Penalty. 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.)
238	Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
239	Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
240	The diagnosis is inconsistent with the patient's birth weight.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
241	Low Income Subsidy (LIS) Co-payment Amount
242	Services not provided by network/primary care providers.
243	Services not authorized by network/primary care providers.
244	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
245	Provider performance program withhold.
246	This non-payable code is for required reporting only.
247	Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
248	Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
249	This claim has been identified as a readmission. (Use only with Group Code CO)
250	The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. 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).
251	The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. 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).
252	An attachment/other documentation is required to adjudicate this claim/service. 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).
253	Sequestration - reduction in federal payment
254	Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
255	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
256	Service not payable per managed care contract.
257	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
258	Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
259	Additional payment for Dental/Vision service utilization.
260	Processed under Medicaid ACA Enhanced Fee Schedule
261	The procedure or service is inconsistent with the patient's history.
262	Adjustment for delivery cost.To be used for pharmaceuticals only.
263	Adjustment for shipping cost.To be used for pharmaceuticals only.
264	Adjustment for postage cost.To be used for pharmaceuticals only.
265	Adjustment for administrative cost.To be used for pharmaceuticals only.
266	Adjustment for compound preparation cost.To be used for pharmaceuticals only.
267	Claim/service spans multiple months. 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.)
268	The Claim spans two calendar years. Please resubmit one claim per calendar year.
269	Anesthesia not covered for this service/procedure.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
270	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration.
271	Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)
272	Coverage/program guidelines were not met.
273	Coverage/program guidelines were exceeded.
274	Fee/Service not payable per patient Care Coordination arrangement.
275	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)
276	Services denied by the prior payer(s) are not covered by this payer.
277	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
278	Performance program proficiency requirements not met. (Use only with Group Codes CO or PI)Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
279	Services not provided by Preferred network providers.Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network.
280	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.
281	Deductible waived per contractual agreement. Use only with Group Code CO.
282	The procedure/revenue code is inconsistent with the type of bill.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
283	Attending provider is not eligible to provide direction of care.
284	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.
285	Appeal procedures not followed
286	Appeal time limits not met
287	Referral exceeded
288	Referral absent
289	Services considered under the dental and medical plans, benefits not available.
290	Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.
291	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.
292	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.
293	Payment made to employer.
294	Payment made to attorney.
295	Pharmacy Direct/Indirect Remuneration (DIR)
296	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.
297	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.
298	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.
299	The billing provider is not eligible to receive payment for the service billed.
300	Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.
301	Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.
302	Precertification/notification/authorization/pre-treatment time limit has expired.
303	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)
304	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.
305	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration.
306	Type of bill is inconsistent with the patient status.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
307	Medicare Maximum Fair Price Standard Default Refund Amount 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.)To be used only for the Medicare Drug Price Negotiation Program.
308	Payment is adjusted due to contracted funding agreement between the payer and provider.
A0	Patient refund amount.
A1	Claim/Service denied. 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.)Use this code only when a more specific Claim Adjustment Reason Code is not available.
A2	Contractual adjustment.
A3	Medicare Secondary Payer liability met.
A4	Medicare Claim PPS Capital Day Outlier Amount.
A5	Medicare Claim PPS Capital Cost Outlier Amount.
A6	Prior hospitalization or 30 day transfer requirement not met.
A7	Presumptive Payment Adjustment
A8	Ungroupable DRG.
B1	Non-covered visits.
B2	Covered visits.
B3	Covered charges.
B4	Late filing penalty.
B5	Coverage/program guidelines were not met or were exceeded.
B6	This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B7	This provider was not certified/eligible to be paid for this procedure/service on this date of service.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B8	Alternative services were available, and should have been utilized.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B9	Patient is enrolled in a Hospice.
B10	Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
B11	The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
B12	Services not documented in patient's medical records.
B13	Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14	Only one visit or consultation per physician per day is covered.
B15	This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B16	'New Patient' qualifications were not met.
B17	Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
B18	This procedure code and modifier were invalid on the date of service.
B19	Claim/service adjusted because of the finding of a Review Organization.
B20	Procedure/service was partially or fully furnished by another provider.
B21	The charges were reduced because the service/care was partially furnished by another physician.
B22	This payment is adjusted based on the diagnosis.
B23	Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
D1	Claim/service denied. Level of subluxation is missing or inadequate.
D2	Claim lacks the name, strength, or dosage of the drug furnished.
D3	Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4	Claim/service does not indicate the period of time for which this will be needed.
D5	Claim/service denied. Claim lacks individual lab codes included in the test.
D6	Claim/service denied. Claim did not include patient's medical record for the service.
D7	Claim/service denied. Claim lacks date of patient's most recent physician visit.
D8	Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
D9	Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10	Claim/service denied. Completed physician financial relationship form not on file.
D11	Claim lacks completed pacemaker registration form.
D12	Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D13	Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14	Claim lacks indication that plan of treatment is on file.
D15	Claim lacks indication that service was supervised or evaluated by a physician.
D16	Claim lacks prior payer payment information.
D17	Claim/Service has invalid non-covered days.
D18	Claim/Service has missing diagnosis information.
D19	Claim/Service lacks Physician/Operative or other supporting documentation
D20	Claim/Service missing service/product information.
D21	This (these) diagnosis(es) is (are) missing or are invalid
D22	Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
D23	This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. 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.)
P1	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.
P2	Not a work related injury/illness and thus not the liability of the workers' compensation carrierIf 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. 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). To be used for Workers' Compensation only.
P3	Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)
P4	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment.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. 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). To be used for Workers' Compensation only
P5	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.
P6	Based on entitlement to benefits.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. 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). To be used for Property and Casualty only.
P7	The applicable fee schedule/fee database does not contain the billed code. 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. To be used for Property and Casualty only.
P8	Claim is under investigation.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. 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). To be used for Property and Casualty only.
P9	No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.
P10	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.
P11	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)
P12	Workers' compensation jurisdictional fee schedule adjustment.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). 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. To be used for Workers' Compensation only.
P13	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable.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. 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. To be used for Workers' Compensation only.
P14	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day.Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.
P15	Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.
P16	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)
P17	Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.
P18	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.
P19	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.
P20	Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.
P21	Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies.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. 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. To be used for Property and Casualty Auto only.
P22	Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies.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. 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. To be used for Property and Casualty Auto only.
P23	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment.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). 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. To be used for Property and Casualty Auto only.
P24	Payment adjusted based on Preferred Provider Organization (PPO).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). 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. To be used for Property and Casualty only. Use only with Group Code CO.
P25	Payment adjusted based on Medical Provider Network (MPN).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). 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. To be used for Property and Casualty only. (Use only with Group Code CO).
P26	Payment adjusted based on Voluntary Provider network (VPN).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). 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. To be used for Property and Casualty only. (Use only with Group Code CO).
P27	Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies.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. 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. To be used for Property and Casualty Auto only.
P28	Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies.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. 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. To be used for Property and Casualty Auto only.
P29	Liability Benefits jurisdictional fee schedule adjustment.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). 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. To be used for Property and Casualty Auto only.
P30	Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.
P31	Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.
P32	Payment adjusted due to Apportionment.
W1	Workers' compensation jurisdictional fee schedule adjustment. 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). 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.
W2	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. 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') if the jurisdictional regulation applies. 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. To be used for Workers' Compensation only.
W3	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
W4	Workers' Compensation Medical Treatment Guideline Adjustment.
W5	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)
W6	Referral not authorized by attending physician per regulatory requirement.
W7	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
W8	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
W9	Service not paid under jurisdiction allowed outpatient facility fee schedule.
Y1	Payment denied 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. 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') if the jurisdictional regulation applies. 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. To be used for P&C Auto only.
Y2	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. 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') if the jurisdictional regulation applies. 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. To be used for P&C Auto only.
Y3	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. 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). 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. To be used for P&C Auto only.

Remittance advice remark codes

All 1216 RARCs. These add detail; they never change who pays.

Filter

1216 codes

Code	Description
M1	X-ray not taken within the past 12 months or near enough to the start of treatment.
M2	Not paid separately when the patient is an inpatient.
M3	Equipment is the same or similar to equipment already being used.
M4	Alert: This is the last monthly installment payment for this durable medical equipment.
M5	Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.
M6	Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.
M7	No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price.
M8	We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.
M9	Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.
M10	Equipment purchases are limited to the first or the tenth month of medical necessity.
M11	DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.
M12	Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.
M13	Only one initial visit is covered per specialty per medical group.
M14	No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.
M15	Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
M16	Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.
M17	Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions.
M18	Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home.
M19	Missing oxygen certification/re-certification.
M20	Missing/incomplete/invalid HCPCS.
M21	Missing/incomplete/invalid place of residence for this service/item provided in a home.
M22	Missing/incomplete/invalid number of miles traveled.
M23	Missing invoice.
M24	Missing/incomplete/invalid number of doses per vial.
M25	The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.
M26	The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service/any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office.
M27	Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.
M28	This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.
M29	Missing operative note/report.
M30	Missing pathology report.
M31	Missing radiology report.
M32	Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service.
M33	Missing/incomplete/invalid UPIN for the ordering/referring/performing provider.
M34	Claim lacks the CLIA certification number.
M35	Missing/incomplete/invalid pre-operative photos or visual field results.
M36	This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.
M37	Not covered when the patient is under age 35.
M38	Alert: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges.
M39	Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements.
M40	Claim must be assigned and must be filed by the practitioner's employer.
M41	We do not pay for this as the patient has no legal obligation to pay for this.
M42	The medical necessity form must be personally signed by the attending physician.
M43	Payment for this service previously issued to you or another provider by another carrier/intermediary.
M44	Missing/incomplete/invalid condition code.
M45	Missing/incomplete/invalid occurrence code(s).
M46	Missing/incomplete/invalid occurrence span code(s).
M47	Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN).
M48	Payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service.
M49	Missing/incomplete/invalid value code(s) or amount(s).
M50	Missing/incomplete/invalid revenue code(s).
M51	Missing/incomplete/invalid procedure code(s).
M52	Missing/incomplete/invalid 'from' date(s) of service.
M53	Missing/incomplete/invalid days or units of service.
M54	Missing/incomplete/invalid total charges.
M55	We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.
M56	Missing/incomplete/invalid payer identifier.
M57	Missing/incomplete/invalid provider identifier.
M58	Missing/incomplete/invalid claim information. Resubmit claim after corrections.
M59	Missing/incomplete/invalid 'to' date(s) of service.
M60	Missing Certificate of Medical Necessity.
M61	We cannot pay for this as the approval period for the FDA clinical trial has expired.
M62	Missing/incomplete/invalid treatment authorization code.
M63	We do not pay for more than one of these on the same day.
M64	Missing/incomplete/invalid other diagnosis.
M65	One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.
M66	Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.
M67	Missing/incomplete/invalid other procedure code(s).
M68	Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.
M69	Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
M70	Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item.
M71	Total payment reduced due to overlap of tests billed.
M72	Did not enter full 8-digit date (MM/DD/CCYY).
M73	The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.
M74	This service does not qualify for a HPSA/Physician Scarcity bonus payment.
M75	Multiple automated multichannel tests performed on the same day combined for payment.
M76	Missing/incomplete/invalid diagnosis or condition.
M77	Missing/incomplete/invalid/inappropriate place of service.
M78	Missing/incomplete/invalid HCPCS modifier.
M79	Missing/incomplete/invalid charge.
M80	Not covered when performed during the same session/date as a previously processed service for the patient.
M81	You are required to code to the highest level of specificity.
M82	Service is not covered when patient is under age 50.
M83	Service is not covered unless the patient is classified as at high risk.
M84	Medical code sets used must be the codes in effect at the time of service.
M85	Subjected to review of physician evaluation and management services.
M86	Service denied because payment already made for same/similar procedure within set time frame.
M87	Claim/service(s) subjected to CFO-CAP prepayment review.
M88	We cannot pay for laboratory tests unless billed by the laboratory that did the work.
M89	Not covered more than once under age 40.
M90	Not covered more than once in a 12 month period.
M91	Lab procedures with different CLIA certification numbers must be billed on separate claims.
M92	Services subjected to review under the Home Health Medical Review Initiative.
M93	Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.
M94	Information supplied does not support a break in therapy. A new capped rental period will not begin.
M95	Services subjected to Home Health Initiative medical review/cost report audit.
M96	The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.
M97	Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.
M98	Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN.
M99	Missing/incomplete/invalid Universal Product Number/Serial Number.
M100	We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.
M101	Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier.
M102	Service not performed on equipment approved by the FDA for this purpose.
M103	Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.
M104	Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.
M105	Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.
M106	Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service.
M107	Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.
M108	Missing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test.
M109	We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.
M110	Missing/incomplete/invalid provider identifier for the provider from whom you purchased interpretation services.
M111	We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.
M112	Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.
M113	Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.
M114	This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.
M115	This item is denied when provided to this patient by a non-contract or non-demonstration supplier.
M116	Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program.
M117	Not covered unless submitted via electronic claim.
M118	Letter to follow containing further information.
M119	Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
M120	Missing/incomplete/invalid provider identifier for the substituting physician who furnished the service(s) under a reciprocal billing or locum tenens arrangement.
M121	We pay for this service only when performed with a covered cryosurgical ablation.
M122	Missing/incomplete/invalid level of subluxation.
M123	Missing/incomplete/invalid name, strength, or dosage of the drug furnished.
M124	Missing indication of whether the patient owns the equipment that requires the part or supply.
M125	Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.
M126	Missing/incomplete/invalid individual lab codes included in the test.
M127	Missing patient medical record for this service.
M128	Missing/incomplete/invalid date of the patient's last physician visit.
M129	Missing/incomplete/invalid indicator of x-ray availability for review.
M130	Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.
M131	Missing physician financial relationship form.
M132	Missing pacemaker registration form.
M133	Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.
M134	Performed by a facility/supplier in which the provider has a financial interest.
M135	Missing/incomplete/invalid plan of treatment.
M136	Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.
M137	Part B coinsurance under a demonstration project or pilot program.
M138	Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.
M139	Denied services exceed the coverage limit for the demonstration.
M140	Service not covered until after the patient's 50th birthday, i.e., no coverage prior to the day after the 50th birthday
M141	Missing physician certified plan of care.
M142	Missing American Diabetes Association Certificate of Recognition.
M143	The provider must update license information with the payer.
M144	Pre-/post-operative care payment is included in the allowance for the surgery/procedure.
MA01	Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.
MA02	Alert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice.
MA03	If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied, including reopened appeals if you received a revised decision. You must appeal each claim on time.
MA04	Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.
MA05	Incorrect admission date patient status or type of bill entry on claim.
MA06	Missing/incomplete/invalid beginning and/or ending date(s).
MA07	Alert: The claim information has also been forwarded to Medicaid for review.
MA08	Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.
MA09	Alert: Claim submitted as unassigned but processed as assigned in accordance with our current assignment/participation agreement.
MA10	Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.
MA11	Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources.
MA12	You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).
MA13	Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.
MA14	Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services.
MA15	Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.
MA16	The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.
MA17	We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.
MA18	Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.
MA19	Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.
MA20	Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.
MA21	SSA records indicate mismatch with name and sex.
MA22	Payment of less than $1.00 suppressed.
MA23	Demand bill approved as result of medical review.
MA24	Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.
MA25	A patient may not elect to change a hospice provider more than once in a benefit period.
MA26	Alert: Our records indicate that you were previously informed of this rule.
MA27	Missing/incomplete/invalid entitlement number or name shown on the claim.
MA28	Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice.
MA29	Missing/incomplete/invalid provider name, city, state, or zip code.
MA30	Missing/incomplete/invalid type of bill.
MA31	Missing/incomplete/invalid beginning and ending dates of the period billed.
MA32	Missing/incomplete/invalid number of covered days during the billing period.
MA33	Missing/incomplete/invalid non-covered days during the billing period.
MA34	Missing/incomplete/invalid number of coinsurance days during the billing period.
MA35	Missing/incomplete/invalid number of lifetime reserve days.
MA36	Missing/incomplete/invalid patient name.
MA37	Missing/incomplete/invalid patient's address.
MA38	Missing/incomplete/invalid birth date.
MA39	Missing/incomplete/invalid gender.
MA40	Missing/incomplete/invalid admission date.
MA41	Missing/incomplete/invalid admission type.
MA42	Missing/incomplete/invalid admission source.
MA43	Missing/incomplete/invalid patient status.
MA44	Alert: No appeal rights. Adjudicative decision based on law.
MA45	Alert: As previously advised, a portion or all of your payment is being held in a special account.
MA46	Alert: The new information was considered but additional payment will not be issued.
MA47	Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.
MA48	Missing/incomplete/invalid name or address of responsible party or primary payer.
MA49	Missing/incomplete/invalid six-digit provider identifier for home health agency or hospice for physician(s) performing care plan oversight services.
MA50	Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.
MA51	Missing/incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory.
MA52	Missing/incomplete/invalid date.
MA53	Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
MA54	Physician certification or election consent for hospice care not received timely.
MA55	Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.
MA56	Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.
MA57	Patient submitted written request to revoke his/her election for religious non-medical health care services.
MA58	Missing/incomplete/invalid release of information indicator.
MA59	Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.
MA60	Missing/incomplete/invalid patient relationship to insured.
MA61	Missing/incomplete/invalid social security number.
MA62	Alert: This is a telephone review decision.
MA63	Missing/incomplete/invalid principal diagnosis.
MA64	Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.
MA65	Missing/incomplete/invalid admitting diagnosis.
MA66	Missing/incomplete/invalid principal procedure code.
MA67	Alert: Correction to a prior claim.
MA68	Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.
MA69	Missing/incomplete/invalid remarks.
MA70	Missing/incomplete/invalid provider representative signature.
MA71	Missing/incomplete/invalid provider representative signature date.
MA72	Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the patient on this notice.
MA73	Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.
MA74	Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or returned.
MA75	Missing/incomplete/invalid patient or authorized representative signature.
MA76	Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.
MA77	Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice.
MA78	The patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient.
MA79	Billed in excess of interim rate.
MA80	Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.
MA81	Missing/incomplete/invalid provider/supplier signature.
MA82	Missing/incomplete/invalid provider/supplier billing number/identifier or billing name, address, city, state, zip code, or phone number.
MA83	Did not indicate whether we are the primary or secondary payer.
MA84	Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.
MA85	Our records indicate that a primary payer exists (other than ourselves); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the PlanID when effective.
MA86	Missing/incomplete/invalid group or policy number of the insured for the primary coverage.
MA87	Missing/incomplete/invalid insured's name for the primary payer.
MA88	Missing/incomplete/invalid insured's address and/or telephone number for the primary payer.
MA89	Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
MA90	Missing/incomplete/invalid employment status code for the primary insured.
MA91	Alert: This determination is the result of the appeal you filed.
MA92	Missing plan information for other insurance.
MA93	Non-PIP (Periodic Interim Payment) claim.
MA94	Did not enter the statement 'Attending physician not hospice employee' on the claim form to certify that the rendering physician is not an employee of the hospice.
MA95	A not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA-1500.
MA96	Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.
MA97	Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.
MA98	Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary.
MA99	Missing/incomplete/invalid Medigap information.
MA100	Missing/incomplete/invalid date of current illness or symptoms.
MA101	A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents.
MA102	Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider.
MA103	Hemophilia Add On.
MA104	Missing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician.
MA105	Missing/incomplete/invalid provider number for this place of service.
MA106	PIP (Periodic Interim Payment) claim.
MA107	Paper claim contains more than three separate data items in field 19.
MA108	Paper claim contains more than one data item in field 23.
MA109	Claim processed in accordance with ambulatory surgical guidelines.
MA110	Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.
MA111	Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.
MA112	Missing/incomplete/invalid group practice information.
MA113	Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.
MA114	Missing/incomplete/invalid information on where the services were furnished.
MA115	Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).
MA116	Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution.
MA117	This claim has been assessed a $1.00 user fee.
MA118	Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Coinsurance and/or deductible are applicable.
MA119	Provider level adjustment for late claim filing applies to this claim.
MA120	Missing/incomplete/invalid CLIA certification number.
MA121	Missing/incomplete/invalid x-ray date.
MA122	Missing/incomplete/invalid initial treatment date.
MA123	Your center was not selected to participate in this study, therefore, we cannot pay for these services.
MA124	Processed for IME only.
MA125	Per legislation governing this program, payment constitutes payment in full.
MA126	Pancreas transplant not covered unless kidney transplant performed.
MA127	Reserved for future use.
MA128	Missing/incomplete/invalid FDA approval number.
MA129	This provider was not certified for this procedure on this date of service.
MA130	Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.
MA131	Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.
MA132	Adjustment to the pre-demonstration rate.
MA133	Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.
MA134	Missing/incomplete/invalid provider number of the facility where the patient resides.
N1	Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes. Refer to the URL provided in the ERA for the payer website to access the appeals process guidelines.
N2	This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.
N3	Missing consent form.
N4	Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.
N5	EOB received from previous payer. Claim not on file.
N6	Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.
N7	Alert: Processing of this claim/service has included consideration under Major Medical provisions.
N8	Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.
N9	Adjustment represents the estimated amount a previous payer may pay.
N10	Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.
N11	Denial reversed because of medical review.
N12	Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.
N13	Payment based on professional/technical component modifier(s).
N14	Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
N15	Services for a newborn must be billed separately.
N16	Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.
N17	Per admission deductible.
N18	Payment based on the Medicare allowed amount.
N19	Procedure code incidental to primary procedure.
N20	Service not payable with other service rendered on the same date.
N21	Alert: Your line item has been separated into multiple lines to expedite handling.
N22	Alert: This procedure code was added/changed because it more accurately describes the services rendered.
N23	Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.
N24	Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
N25	This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.
N26	Missing itemized bill/statement.
N27	Missing/incomplete/invalid treatment number.
N28	Consent form requirements not fulfilled.
N29	Missing documentation/orders/notes/summary/report/chart.
N30	Patient ineligible for this service.
N31	Missing/incomplete/invalid prescribing provider identifier.
N32	Claim must be submitted by the provider who rendered the service.
N33	No record of health check prior to initiation of treatment.
N34	Incorrect claim form/format for this service.
N35	Program integrity/utilization review decision.
N36	Claim must meet primary payer's processing requirements before we can consider payment.
N37	Missing/incomplete/invalid tooth number/letter.
N38	Missing/incomplete/invalid place of service.
N39	Procedure code is not compatible with tooth number/letter.
N40	Missing radiology film(s)/image(s).
N41	Authorization request denied.
N42	Missing mental health assessment.
N43	Bed hold or leave days exceeded.
N44	Payer's share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority.
N45	Payment based on authorized amount.
N46	Missing/incomplete/invalid admission hour.
N47	Claim conflicts with another inpatient stay.
N48	Claim information does not agree with information received from other insurance carrier.
N49	Court ordered coverage information needs validation.
N50	Missing/incomplete/invalid discharge information.
N51	Electronic interchange agreement not on file for provider/submitter.
N52	Patient not enrolled in the billing provider's managed care plan on the date of service.
N53	Missing/incomplete/invalid point of pick-up address.
N54	Claim information is inconsistent with pre-certified/authorized services.
N55	Procedures for billing with group/referring/performing providers were not followed.
N56	Procedure code billed is not correct/valid for the services billed or the date of service billed.
N57	Missing/incomplete/invalid prescribing date.
N58	Missing/incomplete/invalid patient liability amount.
N59	Alert: Please refer to your provider manual for additional program and provider information.
N60	A valid NDC is required for payment of drug claims effective October 02.
N61	Rebill services on separate claims.
N62	Dates of service span multiple rate periods. Resubmit separate claims.
N63	Rebill services on separate claim lines.
N64	The 'from' and 'to' dates must be different.
N65	Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.
N66	Missing/incomplete/invalid documentation.
N67	Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.
N68	Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.
N69	Alert: PPS (Prospective Payment System) code changed by claims processing system.
N70	Consolidated billing and payment applies.
N71	Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.
N72	PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.
N73	A Skilled Nursing Facility is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents.
N74	Resubmit with multiple claims, each claim covering services provided in only one calendar month.
N75	Missing/incomplete/invalid tooth surface information.
N76	Missing/incomplete/invalid number of riders.
N77	Missing/incomplete/invalid designated provider number.
N78	The necessary components of the child and teen checkup (EPSDT) were not completed.
N79	Service billed is not compatible with patient location information.
N80	Missing/incomplete/invalid prenatal screening information.
N81	Procedure billed is not compatible with tooth surface code.
N82	Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.
N83	No appeal rights. Adjudicative decision based on the provisions of a demonstration project.
N84	Alert: Further installment payments are forthcoming.
N85	Alert: This is the final installment payment.
N86	A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.
N87	Home use of biofeedback therapy is not covered.
N88	Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care.
N89	Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.
N90	Covered only when performed by the attending physician.
N91	Services not included in the appeal review.
N92	This facility is not certified for digital mammography.
N93	A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.
N94	Claim/Service denied because a more specific taxonomy code is required for adjudication.
N95	This provider type/provider specialty may not bill this service.
N96	Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
N97	Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.
N98	Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.
N99	Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
N100	PPS (Prospect Payment System) code corrected during adjudication.
N101	Additional information is needed in order to process this claim. Please resubmit the claim with the identification number of the provider where this service took place. The Medicare number of the site of service provider should be preceded with the letters 'HSP' and entered into item #32 on the claim form. You may bill only one site of service provider number per claim.
N102	This claim has been denied without reviewing the medical/dental record because the requested records were not received or were not received timely.
N103	Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.
N104	This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.
N105	This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claims processing.
N106	Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.
N107	Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.
N108	Missing/incomplete/invalid upgrade information.
N109	Alert: This claim/service was chosen for complex review.
N110	This facility is not certified for film mammography.
N111	No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
N112	This claim is excluded from your electronic remittance advice.
N113	Only one initial visit is covered per physician, group practice or provider.
N114	During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.
N115	This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.
N116	Alert: This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency's (HHA's) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.
N117	This service is paid only once in a patient's lifetime.
N118	This service is not paid if billed more than once every 28 days.
N119	This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.
N120	Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.
N121	Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.
N122	Add-on code cannot be billed by itself.
N123	Alert: This is a split service and represents a portion of the units from the originally submitted service.
N124	Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.
N125	Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in §§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office.
N126	Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.
N127	This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.
N128	This amount represents the prior to coverage portion of the allowance.
N129	Not eligible due to the patient's age.
N130	Consult plan benefit documents/guidelines for information about restrictions for this service.
N131	Total payments under multiple contracts cannot exceed the allowance for this service.
N132	Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.
N133	Alert: Services for predetermination and services requesting payment are being processed separately.
N134	Alert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service.
N135	Record fees are the patient's responsibility and limited to the specified co-payment.
N136	Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.
N137	Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority.
N138	Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review.
N139	Alert: Under 32 CFR 199.13, a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
N140	Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
N141	The patient was not residing in a long-term care facility during all or part of the service dates billed.
N142	The original claim was denied. Resubmit a new claim, not a replacement claim.
N143	The patient was not in a hospice program during all or part of the service dates billed.
N144	The rate changed during the dates of service billed.
N145	Missing/incomplete/invalid provider identifier for this place of service.
N146	Missing screening document.
N147	Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.
N148	Missing/incomplete/invalid date of last menstrual period.
N149	Rebill all applicable services on a single claim.
N150	Missing/incomplete/invalid model number.
N151	Telephone contact services will not be paid until the face-to-face contact requirement has been met.
N152	Missing/incomplete/invalid replacement claim information.
N153	Missing/incomplete/invalid room and board rate.
N154	Alert: This payment was delayed for correction of provider's mailing address.
N155	Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.
N156	Alert: The patient is responsible for the difference between the approved treatment and the elective treatment.
N157	Transportation to/from this destination is not covered.
N158	Transportation in a vehicle other than an ambulance is not covered.
N159	Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.
N160	The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.
N161	This drug/service/supply is covered only when the associated service is covered.
N162	Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future.
N163	Medical record does not support code billed per the code definition.
N164	Transportation to/from this destination is not covered.
N165	Transportation in a vehicle other than an ambulance is not covered.
N166	Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.
N167	Charges exceed the post-transplant coverage limit.
N168	The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.
N169	This drug/service/supply is covered only when the associated service is covered.
N170	A new/revised/renewed certificate of medical necessity is needed.
N171	Payment for repair or replacement is not covered or has exceeded the purchase price.
N172	The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.
N173	No qualifying hospital stay dates were provided for this episode of care.
N174	This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'.
N175	Missing review organization approval.
N176	Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.
N177	Alert: We did not send this claim to patient's other insurer. They have indicated no additional payment can be made.
N178	Missing pre-operative images/visual field results.
N179	Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.
N180	This item or service does not meet the criteria for the category under which it was billed.
N181	Additional information is required from another provider involved in this service.
N182	This claim/service must be billed according to the schedule for this plan.
N183	Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.
N184	Rebill technical and professional components separately.
N185	Alert: Do not resubmit this claim/service.
N186	Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.
N187	Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.
N188	The approved level of care does not match the procedure code submitted.
N189	Alert: This service has been paid as a one-time exception to the plan's benefit restrictions.
N190	Missing contract indicator.
N191	The provider must update insurance information directly with payer.
N192	Alert: Patient is a Medicaid/Qualified Medicare Beneficiary.
N193	Alert: Specific federal/state/local program may cover this service through another payer.
N194	Technical component not paid if provider does not own the equipment used.
N195	The technical component must be billed separately.
N196	Alert: Patient eligible to apply for other coverage which may be primary.
N197	The subscriber must update insurance information directly with payer.
N198	Rendering provider must be affiliated with the pay-to provider.
N199	Additional payment/recoupment approved based on payer-initiated review/audit.
N200	The professional component must be billed separately.
N201	A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.
N202	Alert: Additional information/explanation will be sent separately.
N203	Missing/incomplete/invalid anesthesia time/units.
N204	Services under review for possible pre-existing condition. Send medical records for prior 12 months
N205	Information provided was illegible.
N206	The supporting documentation does not match the information sent on the claim.
N207	Missing/incomplete/invalid weight.
N208	Missing/incomplete/invalid DRG code.
N209	Missing/incomplete/invalid taxpayer identification number (TIN).
N210	Alert: You may appeal this decision.
N211	Alert: You may not appeal this decision.
N212	Charges processed under a Point of Service benefit.
N213	Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information.
N214	Missing/incomplete/invalid history of the related initial surgical procedure(s).
N215	Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.
N216	We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.
N217	We pay only one site of service per provider per claim.
N218	You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.
N219	Payment based on previous payer's allowed amount.
N220	Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute.
N221	Missing Admitting History and Physical report.
N222	Incomplete/invalid Admitting History and Physical report.
N223	Missing documentation of benefit to the patient during initial treatment period.
N224	Incomplete/invalid documentation of benefit to the patient during initial treatment period.
N225	Incomplete/invalid documentation/orders/notes/summary/report/chart.
N226	Incomplete/invalid American Diabetes Association Certificate of Recognition.
N227	Incomplete/invalid Certificate of Medical Necessity.
N228	Incomplete/invalid consent form.
N229	Incomplete/invalid contract indicator.
N230	Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.
N231	Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.
N232	Incomplete/invalid itemized bill/statement.
N233	Incomplete/invalid operative note/report.
N234	Incomplete/invalid oxygen certification/re-certification.
N235	Incomplete/invalid pacemaker registration form.
N236	Incomplete/invalid pathology report.
N237	Incomplete/invalid patient medical record for this service.
N238	Incomplete/invalid physician certified plan of care.
N239	Incomplete/invalid physician financial relationship form.
N240	Incomplete/invalid radiology report.
N241	Incomplete/invalid review organization approval.
N242	Incomplete/invalid radiology film(s)/image(s).
N243	Incomplete/invalid/not approved screening document.
N244	Incomplete/Invalid pre-operative images/visual field results.
N245	Incomplete/invalid plan information for other insurance.
N246	State regulated patient payment limitations apply to this service.
N247	Missing/incomplete/invalid assistant surgeon taxonomy.
N248	Missing/incomplete/invalid assistant surgeon name.
N249	Missing/incomplete/invalid assistant surgeon primary identifier.
N250	Missing/incomplete/invalid assistant surgeon secondary identifier.
N251	Missing/incomplete/invalid attending provider taxonomy.
N252	Missing/incomplete/invalid attending provider name.
N253	Missing/incomplete/invalid attending provider primary identifier.
N254	Missing/incomplete/invalid attending provider secondary identifier.
N255	Missing/incomplete/invalid billing provider taxonomy.
N256	Missing/incomplete/invalid billing provider/supplier name.
N257	Missing/incomplete/invalid billing provider/supplier primary identifier.
N258	Missing/incomplete/invalid billing provider/supplier address.
N259	Missing/incomplete/invalid billing provider/supplier secondary identifier.
N260	Missing/incomplete/invalid billing provider/supplier contact information.
N261	Missing/incomplete/invalid operating provider name.
N262	Missing/incomplete/invalid operating provider primary identifier.
N263	Missing/incomplete/invalid operating provider secondary identifier.
N264	Missing/incomplete/invalid ordering provider name.
N265	Missing/incomplete/invalid ordering provider primary identifier.
N266	Missing/incomplete/invalid ordering provider address.
N267	Missing/incomplete/invalid ordering provider secondary identifier.
N268	Missing/incomplete/invalid ordering provider contact information.
N269	Missing/incomplete/invalid other provider name.
N270	Missing/incomplete/invalid other provider primary identifier.
N271	Missing/incomplete/invalid other provider secondary identifier.
N272	Missing/incomplete/invalid other payer attending provider identifier.
N273	Missing/incomplete/invalid other payer operating provider identifier.
N274	Missing/incomplete/invalid other payer other provider identifier.
N275	Missing/incomplete/invalid other payer purchased service provider identifier.
N276	Missing/incomplete/invalid other payer referring provider identifier.
N277	Missing/incomplete/invalid other payer rendering provider identifier.
N278	Missing/incomplete/invalid other payer service facility provider identifier.
N279	Missing/incomplete/invalid pay-to provider name.
N280	Missing/incomplete/invalid pay-to provider primary identifier.
N281	Missing/incomplete/invalid pay-to provider address.
N282	Missing/incomplete/invalid pay-to provider secondary identifier.
N283	Missing/incomplete/invalid purchased service provider identifier.
N284	Missing/incomplete/invalid referring provider taxonomy.
N285	Missing/incomplete/invalid referring provider name.
N286	Missing/incomplete/invalid referring provider primary identifier.
N287	Missing/incomplete/invalid referring provider secondary identifier.
N288	Missing/incomplete/invalid rendering provider taxonomy.
N289	Missing/incomplete/invalid rendering provider name.
N290	Missing/incomplete/invalid rendering provider primary identifier.
N291	Missing/incomplete/invalid rendering provider secondary identifier.
N292	Missing/incomplete/invalid service facility name.
N293	Missing/incomplete/invalid service facility primary identifier.
N294	Missing/incomplete/invalid service facility primary address.
N295	Missing/incomplete/invalid service facility secondary identifier.
N296	Missing/incomplete/invalid supervising provider name.
N297	Missing/incomplete/invalid supervising provider primary identifier.
N298	Missing/incomplete/invalid supervising provider secondary identifier.
N299	Missing/incomplete/invalid occurrence date(s).
N300	Missing/incomplete/invalid occurrence span date(s).
N301	Missing/incomplete/invalid procedure date(s).
N302	Missing/incomplete/invalid other procedure date(s).
N303	Missing/incomplete/invalid principal procedure date.
N304	Missing/incomplete/invalid dispensed date.
N305	Missing/incomplete/invalid injury/accident date.
N306	Missing/incomplete/invalid acute manifestation date.
N307	Missing/incomplete/invalid adjudication or payment date.
N308	Missing/incomplete/invalid appliance placement date.
N309	Missing/incomplete/invalid assessment date.
N310	Missing/incomplete/invalid assumed or relinquished care date.
N311	Missing/incomplete/invalid authorized to return to work date.
N312	Missing/incomplete/invalid begin therapy date.
N313	Missing/incomplete/invalid certification revision date.
N314	Missing/incomplete/invalid diagnosis date.
N315	Missing/incomplete/invalid disability from date.
N316	Missing/incomplete/invalid disability to date.
N317	Missing/incomplete/invalid discharge hour.
N318	Missing/incomplete/invalid discharge or end of care date.
N319	Missing/incomplete/invalid hearing or vision prescription date.
N320	Missing/incomplete/invalid Home Health Certification Period.
N321	Missing/incomplete/invalid last admission period.
N322	Missing/incomplete/invalid last certification date.
N323	Missing/incomplete/invalid last contact date.
N324	Missing/incomplete/invalid last seen/visit date.
N325	Missing/incomplete/invalid last worked date.
N326	Missing/incomplete/invalid last x-ray date.
N327	Missing/incomplete/invalid other insured birth date.
N328	Missing/incomplete/invalid Oxygen Saturation Test date.
N329	Missing/incomplete/invalid patient birth date.
N330	Missing/incomplete/invalid patient death date.
N331	Missing/incomplete/invalid physician order date.
N332	Missing/incomplete/invalid prior hospital discharge date.
N333	Missing/incomplete/invalid prior placement date.
N334	Missing/incomplete/invalid re-evaluation date.
N335	Missing/incomplete/invalid referral date.
N336	Missing/incomplete/invalid replacement date.
N337	Missing/incomplete/invalid secondary diagnosis date.
N338	Missing/incomplete/invalid shipped date.
N339	Missing/incomplete/invalid similar illness or symptom date.
N340	Missing/incomplete/invalid subscriber birth date.
N341	Missing/incomplete/invalid surgery date.
N342	Missing/incomplete/invalid test performed date.
N343	Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.
N344	Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.
N345	Date range not valid with units submitted.
N346	Missing/incomplete/invalid oral cavity designation code.
N347	Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.
N348	You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.
N349	The administration method and drug must be reported to adjudicate this service.
N350	Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.
N351	Service date outside of the approved treatment plan service dates.
N352	Alert: There are no scheduled payments for this service. Submit a claim for each patient visit.
N353	Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.
N354	Incomplete/invalid invoice.
N355	Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position. If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision. The law also permits you to request an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination. The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days
N356	Not covered when performed with, or subsequent to, a non-covered service.
N357	Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.
N358	Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.
N359	Missing/incomplete/invalid height.
N360	Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.
N361	Payment adjusted based on multiple diagnostic imaging procedure rules
N362	The number of Days or Units of Service exceeds our acceptable maximum.
N363	Alert: in the near future we are implementing new policies/procedures that would affect this determination.
N364	Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts.
N365	This procedure code is not payable. It is for reporting/information purposes only.
N366	Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.
N367	Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.
N368	You must appeal the determination of the previously adjudicated claim.
N369	Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
N370	Billing exceeds the rental months covered/approved by the payer.
N371	Alert: title of this equipment must be transferred to the patient.
N372	Only reasonable and necessary maintenance/service charges are covered.
N373	It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.
N374	Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.
N375	Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.
N376	Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.
N377	Payment based on a processed replacement claim.
N378	Missing/incomplete/invalid prescription quantity.
N379	Claim level information does not match line level information.
N380	The original claim has been processed, submit a corrected claim.
N381	Alert: Consult our contractual agreement for restrictions/billing/payment information related to these charges.
N382	Missing/incomplete/invalid patient identifier.
N383	Not covered when deemed cosmetic.
N384	Records indicate that the referenced body part/tooth has been removed in a previous procedure.
N385	Notification of admission was not timely according to published plan procedures.
N386	This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. Visit CMS.gov and search for Medicare Coverage Database to find a copy of the policy.
N387	Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information.
N388	Missing/incomplete/invalid prescription number.
N389	Duplicate prescription number submitted.
N390	This service/report cannot be billed separately.
N391	Missing emergency department records.
N392	Incomplete/invalid emergency department records.
N393	Missing progress notes/report.
N394	Incomplete/invalid progress notes/report.
N395	Missing laboratory report.
N396	Incomplete/invalid laboratory report.
N397	Benefits are not available for incomplete service(s)/undelivered item(s).
N398	Missing elective consent form.
N399	Incomplete/invalid elective consent form.
N400	Alert: Electronically enabled providers should submit claims electronically.
N401	Missing periodontal charting.
N402	Incomplete/invalid periodontal charting.
N403	Missing facility certification.
N404	Incomplete/invalid facility certification.
N405	This service is only covered when the donor's insurer(s) do not provide coverage for the service.
N406	This service is only covered when the recipient's insurer(s) do not provide coverage for the service.
N407	You are not an approved submitter for this transmission format.
N408	This payer does not cover deductibles assessed by a previous payer.
N409	This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.
N410	Not covered unless the prescription changes.
N411	This service is allowed one time in a 6-month period.
N412	This service is allowed 2 times in a 12-month period.
N413	This service is allowed 2 times in a benefit year.
N414	This service is allowed 4 times in a 12-month period.
N415	This service is allowed 1 time in an 18-month period.
N416	This service is allowed 1 time in a 3-year period.
N417	This service is allowed 1 time in a 5-year period.
N418	Misrouted claim. See the payer's claim submission instructions.
N419	Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.
N420	Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.
N421	Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.
N422	Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program.
N423	Claim payment was the result of a payer's retroactive adjustment due to a non standard program.
N424	Patient does not reside in the geographic area required for this type of payment.
N425	Statutorily excluded service(s).
N426	No coverage when self-administered.
N427	Payment for eyeglasses or contact lenses can be made only after cataract surgery.
N428	Not covered when performed in this place of service.
N429	Not covered when considered routine.
N430	Procedure code is inconsistent with the units billed.
N431	Not covered with this procedure.
N432	Alert: Adjustment based on a Recovery Audit.
N433	Resubmit this claim using only your National Provider Identifier (NPI).
N434	Missing/Incomplete/Invalid Present on Admission indicator.
N435	Exceeds number/frequency approved /allowed within time period without support documentation.
N436	The injury claim has not been accepted and a mandatory medical reimbursement has been made.
N437	Alert: If the injury claim is accepted, these charges will be reconsidered.
N438	This jurisdiction only accepts paper claims.
N439	Missing anesthesia physical status report/indicators.
N440	Incomplete/invalid anesthesia physical status report/indicators.
N441	This missed/cancelled appointment is not covered.
N442	Payment based on an alternate fee schedule.
N443	Missing/incomplete/invalid total time or begin/end time.
N444	Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation.
N445	Missing document for actual cost or paid amount.
N446	Incomplete/invalid document for actual cost or paid amount.
N447	Payment is based on a generic equivalent as required documentation was not provided.
N448	This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.
N449	Payment based on a comparable drug/service/supply.
N450	Covered only when performed by the primary treating physician or the designee.
N451	Missing Admission Summary Report.
N452	Incomplete/invalid Admission Summary Report.
N453	Missing Consultation Report.
N454	Incomplete/invalid Consultation Report.
N455	Missing Physician Order.
N456	Incomplete/invalid Physician Order.
N457	Missing Diagnostic Report.
N458	Incomplete/invalid Diagnostic Report.
N459	Missing Discharge Summary.
N460	Incomplete/invalid Discharge Summary.
N461	Missing Nursing Notes.
N462	Incomplete/invalid Nursing Notes.
N463	Missing support data for claim.
N464	Incomplete/invalid support data for claim.
N465	Missing Physical Therapy Notes/Report.
N466	Incomplete/invalid Physical Therapy Notes/Report.
N467	Missing Tests and Analysis Report.
N468	Incomplete/invalid Report of Tests and Analysis Report.
N469	Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).
N470	This payment will complete the mandatory medical reimbursement limit.
N471	Missing/incomplete/invalid HIPPS Rate Code.
N472	Payment for this service has been issued to another provider.
N473	Missing certification.
N474	Incomplete/invalid certification.
N475	Missing completed referral form.
N476	Incomplete/invalid completed referral form.
N477	Missing Dental Models.
N478	Incomplete/invalid Dental Models.
N479	Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
N480	Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
N481	Missing Models.
N482	Incomplete/invalid Models.
N483	Missing Periodontal Charts.
N484	Incomplete/invalid Periodontal Charts.
N485	Missing Physical Therapy Certification.
N486	Incomplete/invalid Physical Therapy Certification.
N487	Missing Prosthetics or Orthotics Certification.
N488	Incomplete/invalid Prosthetics or Orthotics Certification.
N489	Missing referral form.
N490	Incomplete/invalid referral form.
N491	Missing/Incomplete/Invalid Exclusionary Rider Condition.
N492	Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.
N493	Missing Doctor First Report of Injury.
N494	Incomplete/invalid Doctor First Report of Injury.
N495	Missing Supplemental Medical Report.
N496	Incomplete/invalid Supplemental Medical Report.
N497	Missing Medical Permanent Impairment or Disability Report.
N498	Incomplete/invalid Medical Permanent Impairment or Disability Report.
N499	Missing Medical Legal Report.
N500	Incomplete/invalid Medical Legal Report.
N501	Missing Vocational Report.
N502	Incomplete/invalid Vocational Report.
N503	Missing Work Status Report.
N504	Incomplete/invalid Work Status Report.
N505	Alert: This response includes only services that could be estimated in real-time. No estimate will be provided for the services that could not be estimated in real-time.
N506	Alert: This is an estimate of the member's liability based on the information available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment.
N507	Plan distance requirements have not been met.
N508	Alert: This real-time claim adjudication response represents the member responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions.
N509	Alert: A current inquiry shows the member's Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.
N510	Alert: A current inquiry shows the member's Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.
N511	Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time.
N512	Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication.
N513	Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication.
N514	Consult plan benefit documents/guidelines for information about restrictions for this service.
N515	Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead)
N516	Records indicate a mismatch between the submitted NPI and EIN.
N517	Resubmit a new claim with the requested information.
N518	No separate payment for accessories when furnished for use with oxygen equipment.
N519	Invalid combination of HCPCS modifiers.
N520	Alert: Payment made from a Consumer Spending Account.
N521	Mismatch between the submitted provider information and the provider information stored in our system.
N522	Duplicate of a claim processed, or to be processed, as a crossover claim.
N523	The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.
N524	Based on policy this payment constitutes payment in full.
N525	These services are not covered when performed within the global period of another service.
N526	Not qualified for recovery based on employer size.
N527	We processed this claim as the primary payer prior to receiving the recovery demand.
N528	Patient is entitled to benefits for Institutional Services only.
N529	Patient is entitled to benefits for Professional Services only.
N530	Not Qualified for Recovery based on enrollment information.
N531	Not qualified for recovery based on direct payment of premium.
N532	Not qualified for recovery based on disability and working status.
N533	Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.
N534	This is an individual policy, the employer does not participate in plan sponsorship.
N535	Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.
N536	We are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us.
N537	We have examined claims history and no records of the services have been found.
N538	A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.
N539	Alert: We processed appeals/waiver requests on your behalf and that request has been denied.
N540	Payment adjusted based on the interrupted stay policy.
N541	Mismatch between the submitted insurance type code and the information stored in our system.
N542	Missing income verification.
N543	Incomplete/invalid income verification.
N544	Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected this will not be paid in the future.
N545	Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.
N546	Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.
N547	A refund request (Frequency Type Code 8) was processed previously.
N548	Alert: Patient's calendar year deductible has been met.
N549	Alert: Patient's calendar year out-of-pocket maximum has been met.
N550	Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future.
N551	Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.
N552	Payment adjusted to reverse a previous withhold/bonus amount.
N553	Payment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status change.
N554	Missing/Incomplete/Invalid Family Planning Indicator.
N555	Missing medication list.
N556	Incomplete/invalid medication list.
N557	This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.
N558	This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.
N559	This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.
N560	The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.
N561	The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.
N562	The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.
N563	Alert: Missing required provider/supplier issuance of advance patient notice of non-coverage. The patient is not liable for payment for this service.
N564	Patient did not meet the inclusion criteria for the demonstration project or pilot program.
N565	Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed.
N566	Alert: This procedure code requires functional reporting. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.
N567	Not covered when considered preventative.
N568	Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.
N569	Not covered when performed for the reported diagnosis.
N570	Missing/incomplete/invalid credentialing data.
N571	Alert: Payment will be issued quarterly by another payer/contractor.
N572	This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.
N573	Alert: You have been overpaid and must refund the overpayment. The refund will be requested separately by another payer/contractor.
N574	Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.
N575	Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.
N576	Services not related to the specific incident/claim/accident/loss being reported.
N577	Personal Injury Protection (PIP) Coverage.
N578	Coverages do not apply to this loss.
N579	Medical Payments Coverage (MPC).
N580	Determination based on the provisions of the insurance policy.
N581	Investigation of coverage eligibility is pending.
N582	Benefits suspended pending the patient's cooperation.
N583	Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.
N584	Not covered based on the insured's noncompliance with policy or statutory conditions.
N585	Benefits are no longer available based on a final injury settlement.
N586	The injured party does not qualify for benefits.
N587	Policy benefits have been exhausted.
N588	The patient has instructed that medical claims/bills are not to be paid.
N589	Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.
N590	Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.
N591	Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).
N592	Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.
N593	Not covered based on failure to attend a scheduled Independent Medical Exam (IME).
N594	Records reflect the injured party did not complete an Application for Benefits for this loss.
N595	Records reflect the injured party did not complete an Assignment of Benefits for this loss.
N596	Records reflect the injured party did not complete a Medical Authorization for this loss.
N597	Adjusted based on a medical/dental provider's apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.
N598	Health care policy coverage is primary.
N599	Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered.
N600	Adjusted based on the applicable fee schedule for the region in which the service was rendered.
N601	In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.
N602	Adjusted based on the Redbook maximum allowance.
N603	This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.
N604	In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.
N605	This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.
N606	The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.
N607	Service provided for non-compensable condition(s).
N608	The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.
N609	80% of the provider's billed amount is being recommended for payment according to Act 6.
N610	Alert: Payment based on an appropriate level of care.
N611	Claim in litigation. Contact insurer for more information.
N612	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.
N613	Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.
N614	Alert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information).
N615	Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under 45 CFR 156.270, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.
N616	Alert: This enrollee is in the first month of the advance premium tax credit grace period.
N617	This enrollee is in the second or third month of the advance premium tax credit grace period.
N618	Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.
N619	Coverage terminated for non-payment of premium.
N620	Alert: This procedure code is for quality reporting/informational purposes only.
N621	Charges for Jurisdiction required forms, reports, or chart notes are not payable.
N622	Not covered based on the date of injury/accident.
N623	Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.
N624	The associated Workers' Compensation claim has been withdrawn.
N625	Missing/Incomplete/Invalid Workers' Compensation Claim Number.
N626	New or established patient E/M codes are not payable with chiropractic care codes.
N627	Service not payable per managed care contract.
N628	Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.
N629	Reviews/documentation/notes/summaries/reports/charts not requested.
N630	Referral not authorized by attending physician.
N631	Medical Fee Schedule does not list this code. An allowance was made for a comparable service.
N632	According to the Official Medical Fee Schedule this service has a relative value of zero and therefore no payment is due.
N633	Additional anesthesia time units are not allowed.
N634	The allowance is calculated based on anesthesia time units.
N635	The Allowance is calculated based on the anesthesia base units plus time.
N636	Adjusted because this is reimbursable only once per injury.
N637	Consultations are not allowed once treatment has been rendered by the same provider.
N638	Reimbursement has been made according to the home health fee schedule.
N639	Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.
N640	Exceeds number/frequency approved/allowed within time period.
N641	Reimbursement has been based on the number of body areas rated.
N642	Adjusted when billed as individual tests instead of as a panel.
N643	The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.
N644	Reimbursement has been made according to the bilateral procedure rule.
N645	Mark-up allowance.
N646	Reimbursement has been adjusted based on the guidelines for an assistant.
N647	Adjusted based on diagnosis-related group (DRG).
N648	Adjusted based on Stop Loss.
N649	Payment based on invoice.
N650	This policy was not in effect for this date of loss. No coverage is available.
N651	No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.
N652	The date of service is before the date of loss.
N653	The date of injury does not match the reported date of loss.
N654	Adjusted based on achievement of maximum medical improvement (MMI).
N655	Payment based on provider's geographic region.
N656	An interest payment is being made because benefits are being paid outside the statutory requirement.
N657	This should be billed with the appropriate code for these services.
N658	The billed service(s) are not considered medical expenses.
N659	This item is exempt from sales tax.
N660	Sales tax has been included in the reimbursement.
N661	Documentation does not support that the services rendered were medically necessary.
N662	Alert: Consideration of payment will be made upon receipt of a final bill.
N663	Adjusted based on an agreed amount.
N664	Adjusted based on a legal settlement.
N665	Services by an unlicensed provider are not reimbursable.
N666	Only one evaluation and management code at this service level is covered during the course of care.
N667	Missing prescription.
N668	Incomplete/invalid prescription.
N669	Adjusted based on the Medicare fee schedule.
N670	This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.
N671	Payment based on a jurisdiction cost-charge ratio.
N672	Alert: Amount applied to Health Insurance Offset.
N673	Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.
N674	Not covered unless a pre-requisite procedure/service has been provided.
N675	Additional information is required from the injured party.
N676	Service does not qualify for payment under the Outpatient Facility Fee Schedule.
N677	Alert: Films/Images will not be returned.
N678	Missing post-operative images/visual field results.
N679	Incomplete/Invalid post-operative images/visual field results.
N680	Missing/Incomplete/Invalid date of previous dental extractions.
N681	Missing/Incomplete/Invalid full arch series.
N682	Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.
N683	Missing/Incomplete/Invalid prior treatment documentation.
N684	Payment denied as this is a specialty claim submitted as a general claim.
N685	Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.
N686	Missing/incomplete/Invalid questionnaire needed to complete payment determination.
N687	Alert: This reversal is due to a retroactive disenrollment.
N688	Alert: This reversal is due to a medical or utilization review decision.
N689	Alert: This reversal is due to a retroactive rate change.
N690	Alert: This reversal is due to a provider submitted appeal.
N691	Alert: This reversal is due to a patient submitted appeal.
N692	Alert: This reversal is due to an incorrect rate on the initial adjudication.
N693	Alert: This reversal is due to a cancellation of the claim by the provider.
N694	Alert: This reversal is due to a resubmission/change to the claim by the provider.
N695	Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication.
N696	Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.
N697	Alert: This reversal is due to a payer's retroactive contract incentive program adjustment.
N698	Alert: This reversal is due to non-payment of the health insurance premiums (Health Insurance Exchange or other) by the end of the premium payment grace period, resulting in loss of coverage.
N699	Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.
N700	Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.
N701	Payment adjusted based on the Value-based Payment Modifier.
N702	Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.
N703	This service is incompatible with previously adjudicated claims or claims in process.
N704	Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
N705	Incomplete/invalid documentation.
N706	Missing documentation.
N707	Incomplete/invalid orders.
N708	Missing orders.
N709	Incomplete/invalid notes.
N710	Missing notes.
N711	Incomplete/invalid summary.
N712	Missing summary.
N713	Incomplete/invalid report.
N714	Missing report.
N715	Incomplete/invalid chart.
N716	Missing chart.
N717	Incomplete/Invalid documentation of face-to-face examination.
N718	Missing documentation of face-to-face examination.
N719	Penalty applied based on plan requirements not being met.
N720	Alert: The patient overpaid you. You may need to issue the patient a refund for the difference between the patient's payment and the amount shown as patient responsibility on this notice.
N721	This service is only covered when performed as part of a clinical trial.
N722	Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item.
N723	Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.
N724	Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.
N725	A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
N726	A conditional payment is not allowed.
N727	A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
N728	A workers' compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
N729	Missing patient medical/dental record for this service.
N730	Incomplete/invalid patient medical/dental record for this service.
N731	Incomplete/Invalid mental health assessment.
N732	Services performed at an unlicensed facility are not reimbursable.
N733	Regulatory surcharges are paid directly to the state.
N734	The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.
N735	Adjustment without review of medical/dental record because the requested records were not received or were not received timely.
N736	Incomplete/invalid Sleep Study Report.
N737	Missing Sleep Study Report.
N738	Incomplete/invalid Vein Study Report.
N739	Missing Vein Study Report.
N740	The member's Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service.
N741	This is a site neutral payment.
N742	Alert: This claim was processed based on one or more ICD-9 codes. The transition to ICD-10 is required by October 1, 2015, for health care providers, health plans, and clearinghouses. More information can be found at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
N743	Adjusted because the services may be related to an employment accident.
N744	Adjusted because the services may be related to an auto/other accident.
N745	Missing Ambulance Report.
N746	Incomplete/invalid Ambulance Report.
N747	This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.
N748	Adjusted because the related hospital charges have not been received.
N749	Missing Blood Gas Report.
N750	Incomplete/invalid Blood Gas Report.
N751	Adjusted because the patient is covered under a Medicare Part D plan.
N752	Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).
N753	Missing/incomplete/invalid Attachment Control Number.
N754	Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.
N755	Missing/incomplete/invalid ICD Indicator.
N756	Missing/incomplete/invalid point of drop-off address.
N757	Adjusted based on the Federal Indian Fees schedule (MLR).
N758	Adjusted based on the prior authorization decision.
N759	Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.
N760	This facility is not authorized to receive payment for the service(s).
N761	This provider is not authorized to receive payment for the service(s).
N762	This facility is not certified for Tomosynthesis (3-D) mammography.
N763	The demonstration code is not appropriate for this claim; resubmit without a demonstration code.
N764	Missing/incomplete/invalid Hematocrit (HCT) value.
N765	This payer does not cover coinsurance assessed by a previous payer.
N766	This payer does not cover co-payment assessed by a previous payer.
N767	The Medicaid state requires provider to be enrolled in the member's Medicaid state program prior to any claim benefits being processed.
N768	Incomplete/invalid initial evaluation report.
N769	A lateral diagnosis is required.
N770	The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the information received.
N771	Alert: Under Federal law you cannot charge more than the limiting charge amount.
N772	Alert: Rebill urgent/emergent and ancillary services separately.
N773	Drug supplied not obtained from specialty vendor.
N774	Alert: Refer to your Third Party Processor Agreement for specific information on fees associated with this payment type.
N775	Payment adjusted based on x-ray radiograph on film.
N776	This service is not a covered Telehealth service.
N777	Missing Assignment of Benefits Indicator.
N778	Missing Primary Care Physician Information.
N779	Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is received.
N780	Missing/incomplete/invalid end therapy date.
N781	Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
N782	Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
N783	Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected copayment. This amount may be billed to a subsequent payer.
N784	Missing comprehensive procedure code.
N785	Missing current radiology film/images.
N786	Benefit limitation for the orthodontic active and/or retention phase of treatment.
N787	Alert: Under 42 CFR 410.43, an eligible Partial Hospitalization Program (PHP) patient/beneficiary requires a minimum of 20 hours of PHP services per week, as evidenced in the plan of care. PHP services must be furnished in accordance with the plan of care.
N788	Alert: The third-party administrator/review organization did not receive the required information.
N789	Clinical Trial is not a covered benefit.
N790	Provider/supplier not accredited for product/service.
N791	Missing history & physical report.
N792	Incomplete/invalid history & physical report.
N793	Alert: Starting January 1, 2020, Medicare will ONLY accept claims submitted with the Medicare Beneficiary Identifier (MBI). Medicare will reject any claims submitted with the Health Insurance Claim Number (HICN) with a few exceptions. Please see www.cms.gov/Medicare/New-Medicare-Card/index.html for more information.
N794	Payment adjusted based on type of technology used.
N795	Item must be resubmitted as a purchase.
N796	Missing/incomplete/invalid Hemoglobin (Hb or Hgb) value.
N797	Missing/incomplete/invalid date qualifier.
N798	Submit a void request for the original claim and resubmit a new claim.
N799	Submitted identifier must be an individual identifier, not group identifier.
N800	Only one service date is allowed per claim.
N801	Services performed in a Medicare participating or CAH facility under a self-insured tribal Group Health Plan, in accordance with Federal Regulation 42 CFR 136.
N802	This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Rendering Physician is located.
N803	Submission of the claim for the service rendered is the responsibility of the Contracted Medical Group or Hospital.
N804	Alert: The claim/service was processed through the Outpatient Code Editor (OCE).
N805	Alert: The claim/service was processed through the Correct Code Editor (CCE).
N806	Payment is included in the Global transplant allowance.
N807	Payment adjustment based on the Merit-based Incentive Payment System (MIPS).
N808	Not covered for this provider type / provider specialty.
N809	Alert: The fee schedule amount for this service was adjusted based on prior competitive bidding rates. For more information, contact your local contractor.
N810	Alert: Due to federal, state or local disaster declaration, this claim has been processed at the in-network level of benefit. At the conclusion or expiration of the disaster declaration, network payment rules will be reinstated.
N811	Missing Federal Sequestration Reduction from Prior Payer.
N812	The start service date through end service date cannot span greater than 18 months.
N815	Missing/Incomplete/Invalid NDC Unit Count
N816	Missing/Incomplete/Invalid NDC Unit of Measure
N817	Alert: Applicable laboratories are required to collect and report private payor data and report that data to CMS between January 1, 2020 - March 31, 2020.
N818	Claims Dates of Service do not match Electronic Visit Verification System.
N819	Patient not enrolled in Electronic Visit Verification System.
N820	Electronic Visit Verification System units do not meet requirements of visit.
N821	Electronic Visit Verification System visit not found.
N822	Missing procedure modifier(s).
N823	Incomplete/Invalid procedure modifier(s).
N824	Electronic Visit Verification (EVV) data must be submitted through EVV Vendor.
N825	Early intervention guidelines were not met.
N826	Patient did not meet the inclusion criteria for the Medicare Shared Savings Program.
N827	Missing/Incomplete/Invalid Federal Information Processing Standard (FIPS) Code.
N828	Alert: Payment is suppressed due to a contracted funding.
N829	Missing/incomplete/invalid Diagnostics Exchange Z-Code Identifier.
N830	Alert: The charge[s] for this service was processed in accordance with Federal/ State, Balance Billing/ No Surprise Billing regulations. As such, any amount identified with OA, CO, or PI cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer. Any amount the provider collected over the identified PR amount must be refunded to the patient within applicable Federal/State timeframes. Payment amounts are eligible for dispute pursuant to any Federal/State documented appeal/grievance process(es).
N831	You have not responded to requests to revalidate your provider/supplier enrollment information.
N832	Duplicate occurrence code/occurrence span code.
N833	Patient share of cost waived.
N834	Jurisdiction exempt from sales and health tax charges.
N835	Unrelated Service/procedure/treatment is reduced. The balance of this charge is the patient's responsibility.
N836	Provider W9 or Payee Registration not on file.
N837	Alert: Missing modifier was added.
N838	Alert: Service/procedure postponed due to a federal, state, or local mandate/disaster declaration. Any amounts applied to deductible or member liability will be applied to the prior plan year from which the procedure was cancelled.
N839	The procedure code was added/changed because the level of service exceeds the compensable condition(s).
N840	Worker's compensation claim filed with a different state.
N841	Alert: North Dakota Administrative Rule 92-01-02-50.3.
N842	Alert: Patient cannot be billed for charges.
N843	Missing/incomplete/invalid Core-Based Statistical Area (CBSA) code.
N844	This claim, or a portion of this claim, was processed in accordance with the Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act.
N845	Alert: Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act.
N846	National Drug Code (NDC) supplied does not correspond to the HCPCs/CPT billed.
N847	National Drug Code (NDC) billed is obsolete.
N848	National Drug Code (NDC) billed cannot be associated with a product.
N849	Missing Tooth Clause: Tooth missing prior to the member effective date.
N850	Missing/incomplete/invalid narrative explaining/describing this service/treatment.
N851	Payment reduced because services were furnished by a therapy assistant.
N852	The pay-to and rendering provider tax identification numbers (TINs) do not match
N853	The number of modalities performed per session exceeds our acceptable maximum.
N854	Alert: If you have primary other health insurance (OHI) coverage that has denied services, you must exhaust all appeal levels with your primary OHI before we can consider your claim for reimbursement.
N855	This coverage is subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
N856	This coverage is not subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
N857	This claim has been adjusted/reversed. Refund any collected copayment to the member.
N858	Alert: State regulations relating to an Out of Network Medical Emergency Care Act were applied to the processing of this claim. Payment amounts are eligible for dispute following the state's documented appeal/ grievance/ arbitration process.
N859	Alert: The Federal No Surprise Billing Act was applied to the processing of this claim. Payment amounts are eligible for dispute pursuant to any Federal documented appeal/ grievance/ dispute resolution process(es).
N860	Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).
N861	Alert: Mismatch between the submitted Patient Liability/Share of Cost and the amount on record for this recipient.
N862	Alert: Member cost share is in compliance with the No Surprises Act, and is calculated using the lesser of the QPA or billed charge.
N863	Alert: This claim is subject to the No Surprises Act (NSA). The amount paid is the final out-of-network rate and was calculated based on an All Payer Model Agreement, in accordance with the NSA.
N864	Alert: This claim is subject to the No Surprises Act provisions that apply to emergency services.
N865	Alert: This claim is subject to the No Surprises Act provisions that apply to nonemergency services furnished by nonparticipating providers during a patient visit to a participating facility.
N866	Alert: This claim is subject to the No Surprises Act provisions that apply to services furnished by nonparticipating providers of air ambulance services.
N867	Alert: Cost sharing was calculated based on a specified state law, in accordance with the No Surprises Act.
N868	Alert: Cost sharing was calculated based on an All-Payer Model Agreement, in accordance with the No Surprises Act.
N869	Alert: Cost sharing was calculated based on the qualifying payment amount, in accordance with the No Surprises Act.
N870	Alert: In accordance with the No Surprises Act, cost sharing was based on the billed amount because the billed amount was lower than the qualifying payment amount.
N871	Alert: This initial payment was calculated based on a specified state law, in accordance with the No Surprises Act.
N872	Alert: This final payment was calculated based on a specified state law, in accordance with the No Surprises Act.
N873	Alert: This final payment was calculated based on an All-Payer Model Agreement, in accordance with the No Surprises Act.
N874	Alert: This final payment was determined through open negotiation, in accordance with the No Surprises Act.
N875	Alert: This final payment equals the amount selected as the out-of-network rate by a Federal Independent Dispute Resolution Entity, in accordance with the No Surprises Act.
N876	Alert: This item or service is covered under the plan. This is a notice of denial of payment provided in accordance with the No Surprises Act. The provider or facility may initiate open negotiation if they desire to negotiate a higher out-of-network rate than the amount paid by the patient in cost sharing.
N877	Alert: This initial payment is provided in accordance with the No Surprises Act. The provider or facility may initiate open negotiation if they desire to negotiate a higher out-of-network rate.
N878	Alert: The provider or facility specified that notice was provided and consent to balance bill obtained, but notice and consent was not provided and obtained in a manner consistent with applicable Federal law. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Surprises Act, and balance billing is prohibited.
N879	Alert: The notice and consent to balance bill, and to be charged out-of-network cost sharing, that was obtained from the patient with regard to the billed services, is not permitted for these services. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Surprises Act, and balance billing is prohibited.
N880	Original claim closed due to changes in submitted data. Adjustment claim will be processed under a new claim number.
N881	Client Obligation, patient responsibility for Home & Community Based Services (HCBS)
N882	Alert: The out-of-network payment and cost sharing amounts were based on the plan's allowance because the provider or facility obtained the patient's consent to waive the balance billing protections under the No Surprises Act.
N883	Alert: Processed according to state law
N884	Alert: The No Surprises Act may apply to this claim. Please contact payer for instructions on how to submit information regarding whether or not the item or service was furnished during a patient visit to a participating facility.
N885	Alert: This claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-network payment requirements. The payer disagrees with your determination that those requirements apply. You may contact the payer to find out why it disagrees. You may appeal this adverse determination on behalf of the patient through the payer’s internal appeals and external review processes.
N886	Alert: A Health Care Claim Request for Additional Information (277 RFAI) has been sent.
N887	Providers not participating in the Medicare Advantage Plan have the right to appeal if the plan has partially or fully denied payment or if the provider believes the plan has not paid the services at the expected Medicare reimbursable rate or type of level/service. Providers may file their appeal in writing within 60 calendar days after the date of the remittance advice. For the plan to review the appeal, the plan will need a completed signed Waiver of Liability Statement. To obtain a Waiver of Liability form, please contact your Medicare Advantage Plan. Once we receive the completed forms, we will give you a decision on your appeal within 60 calendar days.
N888	Alert: An electronic request for additional information has been sent for this claim.
N889	Alert: This claim was originally processed in real-time, and we sent a real-time 835 response.
N890	Electronic Visit Verification Data Element Requirements were not met.
N891	The maximum allowable payment for this service/procedure was paid by the primary insurance. No further payment due.
N892	The claim does not meet the criteria for acceptable use of the Delay Reason Code.
N893	Missing/incomplete/invalid child medical evaluation form/checklist.
N894	Alert: These payments are made subject to a reservation of rights for the Payor to recoup or otherwise recover all or part of these payments based on any of the following: outcome of pending or future litigation/ new or updated state, federal or regulatory guidance/ any other actions that may affect the Payor's obligation to make these payments.
N895	Processed based on a negotiated fee schedule for a specialty drug program.
N896	Missing/incomplete/invalid trauma activation sheet.
N897	Missing/incomplete/invalid proof of member payment.
N898	Missing/incomplete/invalid Resource Utilization Group(s) (RUG) code(s).
N899	Missing Initial Evaluation Report.
N900	Missing Therapy Notes/Report.
N901	Incomplete/Invalid Therapy Notes/Report.
N902	Missing Health Risk Assessment (HRA).
N903	Incomplete/Invalid Health Risk Assessment (HRA).
N904	The transportation vendor is responsible for this claim.
N905	Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is not responsible for payment.
N906	Service is not covered when patient is under age 45.
N907	No refund because this claim has been identified as 340B-eligible with a ceiling price lower than the maximum fair price.
N908	No refund because this drug has been prospectively purchased at the maximum fair price.
N909	Refund amount has been calculated using a methodology that differs from the Standard Default Refund Amount calculation ((Wholesale Acquisition Cost minus Maximum Fair Price) times Quantity).
N910	A refund cannot be provided for this claim at this time. Contact the manufacturer directly regarding your eligibility.
N911	This claim cannot be reimbursed by the manufacturer until the Part D plan submits corrected prescription drug event data to CMS for maximum fair price validation.
N912	Our records indicate that this beneficiary did not elect hospice.
N913	More than one Electronic Visit Verification record exists for the date and time of this service.
N914	This claim was priced and processed in accordance with California AB-72 Health care coverage.
N915	Predetermination of services is not allowed under the member's plan.
N916	The third party will render payment to the provider, and they will reimburse you for covered services.
N917	Alternative refund amount has been calculated because the maximum fair price is below the 340B ceiling price.
N918	No refund because CMS excludes prescription drug event records when a compound code indicates it is for a compounded drug.
N919	Family/member out-of-pocket maximum has been met.
N920	Payment to the provider has been placed on hold as a result of active contract (re)negotiation.
N921	The time limit for filing a reconsideration or appeal has expired.
N922	Missing primary care dentist information.
N923	Not Denied - The Medicare Advantage Organization (MAO) made a payment responsibility determination.
N924	Pending (Not Denied) - The Medicare Advantage Organization (MAO) has not yet made a payment responsibility determination for the service at the time the encounter record was submitted.
N925	Denied - The Medicare Advantage Organization (MAO) determined that it had no payment responsibility for the service at the time the encounter record was submitted.
N926	Partially Denied - The Medicare Advantage Organization (MAO) determined that it had no payment responsibility for one or more service lines, but not all, at the time the encounter record was submitted.
N927	Missing/Incomplete/Invalid x-ray.
N928	Missing/Incomplete/Invalid bitewing or periapical x-ray.
N929	Missing/Incomplete/Invalid photo(s).
N930	Missing/Incomplete/Invalid quadrant identifier.
N931	Missing/Incomplete/Invalid pre- and/or post-operative bitewing or periapical x-ray.
N932	Missing/Incomplete/Invalid pre- and/or post-operative full mouth x-ray.
N933	Missing/Incomplete/Invalid pre- and/or post-operative photo(s).
N934	Missing/Incomplete/Invalid full mouth x-ray.
N935	Alert: Patient is no longer a Medicaid/Qualified Medicare Beneficiary.
N936	This service code has been identified as the secondary or tertiary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.
N937	The service line denial threshold was exceeded.
N938	Alert: Do not resubmit. This claim will be automatically reprocessed.
N939	Alert: You may contact us for a peer-to-peer review.
N940	Missing/Incomplete/Invalid pre- and/or post-operative x-ray.

Snapshot taken 2026-08-25. X12 revises these lists three times a year.

The group code is the answer

Every denial hands you three fields, and the one with the least text on it is the one that decides the money.

A remittance line carries a group code, a reason code and often one or more remark codes. The reason code has all the descriptive language, so it is the one people read. But it only explains why an amount was adjusted. It never says who absorbs it.

That is the group code, two letters in a narrow column. CO and PI are write-offs. PR is billable to the patient. OA is neither. The same reason code under CO and under PR produces opposite actions, which is why this tool leads with the group code and treats everything else as support.

Where this goes wrong

Billing a CO adjustment to a patient is balance billing. Under an in-network contract that is a contract violation, and in some situations it runs into the No Surprises Act as well. It is the expensive direction to get wrong.

The cheap direction is the opposite: writing off a PR amount that the patient genuinely owed. That one only costs the balance.

A third case is worth watching. PR on an in-network claim where you expected a contractual write-off usually means the payer processed it out of network, or applied a benefit you did not expect. That is an appeal, not a statement.

Reading a denial that says nothing

CARC 16, "claim lacks information or has submission billing errors", is the most common denial that carries no useful content on its own. When you see it, the remark codes are the denial. Decode every one of them, because the RARC is what names the missing element.

If you are reading a whole remittance rather than one line, the 835 remittance reader decodes every adjustment on the file and checks that it balances to the deposit.

Terminology

835: The electronic remittance advice. The transaction that carries these codes back from the payer, and the machine-readable version of the paper EOB.
Group code: CO, PR, PI, OA or the retired CR. Decides who bears the adjustment. Not valid on a claim line without an accompanying reason code.
CARC: Claim adjustment reason code. Why the amount changed.
RARC: Remittance advice remark code. Supplementary explanation. Codes beginning with N or M are the common ones; an Alert: prefix means informational rather than a denial reason.
Balance billing: Billing a patient for the portion a contract required you to write off. What happens when a CO adjustment is read as a PR one.

Common questions

What does CO-45 mean?

CO is the group code, Contractual Obligation. 45 is the reason code: the charge exceeds the fee schedule, maximum allowable, or contracted amount.

Together they mean the amount above your contracted rate is written off. It is not billable to the patient. Billing a CO adjustment to a patient is balance billing, and under an in-network contract that is a contract violation.

What is the difference between a CARC and a RARC?

A CARC is the claim adjustment reason code. It states why the amount was adjusted and it always comes paired with a group code. A RARC is a remittance advice remark code, supplementary detail explaining the CARC.

The practical difference: a CARC changes the money. A RARC only explains it. RARCs never decide who pays.

Which field decides whether I can bill the patient?

The group code, not the reason code. There are only 5 of them and just two outcomes that matter.

PR means patient responsibility, so bill the patient. CO and PI are write-offs and cannot be billed to the patient. OA is neither and usually points to another payer or an adjustment handled elsewhere.

This is the single most common reading error, because the reason code carries all the descriptive text and the group code is two letters in a narrow column.

What is CO-45 versus PR-45?

Same reason, opposite outcome. Reason code 45 is "charge exceeds fee schedule or contracted amount" in both cases.

Under CO you absorb it. Under PR the payer is saying the patient owes it, which normally only happens out of network where no contractual write-off applies. If you see PR-45 on an in-network claim, that is worth appealing rather than billing.

What does PR-1, PR-2 or PR-3 mean?

These are the three patient cost-sharing codes and they are the most common PR codes on any remittance. PR-1 is the deductible, PR-2 the coinsurance and PR-3 the copayment.

All three are billable to the patient. They are also the codes worth checking against the eligibility response, because a deductible amount that disagrees with what you quoted at check-in is where patient disputes start.

Why does a denial have several remark codes?

Because a single reason code is often too coarse. A CARC 16, "claim lacks information", says almost nothing on its own, so the payer attaches RARCs naming the specific missing element.

Decode all of them. With CARC 16 the RARCs are the entire actionable content of the denial.

Are these codes payer-specific?

No. CARCs, RARCs and group codes are maintained by X12 and are the same across every payer that submits an 835. That is the point of them.

What is payer-specific is which combinations a payer uses and what it wants in an appeal. The code tells you what happened; the payer manual tells you what to do about it.

How current is this list?

Snapshot taken 2026-08-25, holding 407 reason codes and 1216 remark codes.

X12 revises the lists three times a year, in March, July and November. For a code that is not here, or a description that disagrees with your remittance, check x12.org directly and tell me so it can be refreshed.

Where these figures come from

Code lists and descriptions are transcribed from X12, which maintains and holds the copyright to all three sets: claim adjustment reason codes and remittance advice remark codes. Snapshot taken 2026-08-25. X12 revises the lists three times a year, in March, July and November.

The code descriptions on this page are the copyright of X12 Incorporated. They are reproduced with attribution as a reference for billers reading a remittance, and X12 remains the authority on their current wording. Its terms are set out in the X12 intellectual property use policy. The codes themselves are required for the HIPAA 835 transaction.

The action stated against each group code is not quoted from X12. X12 publishes the code and its name; what a biller does about it is the part every list leaves out, and it is written here from how the codes function on a remittance. Treat it as orientation, not as billing advice.

This page carries no CPT code text. CPT is copyrighted by the American Medical Association, and these are separate X12 code sets that do not include it.

Payer policy outranks this page. If a code here disagrees with your remittance or with x12.org, tell me and it gets fixed.