Each group has specific responsibilities and the groups cooperatively handle items or issues that span the responsibilities of both groups. Coverage/program guidelines were not met. D4 Claim/service does not indicate the period of time for which this will be needed. W9 Service not paid under jurisdiction allowed outpatient facility fee schedule. PR 204 This service/equipment/drug is not covered under the patients current benefit plan. The basic principles for the correct coding policy are The service represents the standard of care in accomplishing the overall procedure; 230 No available or correlating CPT/HCPCS code to describe this service. Workers' compensation jurisdictional fee schedule adjustment. 167 This (these) diagnosis(es) is (are) not covered. Procedure/treatment/drug is deemed experimental/investigational by the payer. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Multi-tier licensing categories are based on how licensees benefit from X12's work,replacing traditional one-size-fits-all approaches. ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. Additional payment for Dental/Vision service utilization. 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. 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. 204: Denial Code - This is not patient specific. 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. 155 Patient refused the service/procedure. Based on extent of injury. To be used for Property and Casualty only.

Policies and procedures specific to a committee's subordinate groups, like subcommittees, task groups, action groups, and work groups, are also listed in the committee's section. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. To be used for Workers' Compensation only. (Use only with Group Code OA). Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. To be used for Workers' Compensation only. Payer deems the information submitted does not support this length of service. Service was not prescribed prior to delivery. To be used for P&C Auto only. D21 This (these) diagnosis(es) is (are) missing or are invalid. The procedure/revenue code is inconsistent with the patient's age. Online access to all available versions ofX12 products, including The EDI Standard, Code Source Directory, Control Standards, EDI Standard Figures, Guidelines and Technical Reports. 197 Precertification/authorization/notification absent. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Charges exceed our fee schedule or maximum allowable amount. 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). The rendering provider is not eligible to perform the service billed. X12 standards are the workhorse of business to business exchanges proven by the billions of daily transactions within and across many industries including: X12 has developed standards and associated products to facilitate the transmission of electronic business messages for over 40 years. P7 The applicable fee schedule/fee database does not contain the billed code. Webpi 204 denial code descriptions Have Any Questions? shriners hospital sacramento volunteer; pi 204 denial code descriptions. Submit these services to the patient's medical plan for further consideration. Original payment decision is being maintained. Once your claim has been rejected and it bears the CO 4 Denial code, there are two options that you are left with: Check if the modifier is in the consistent mode. Procedure modifier was invalid on the date of service. 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. This care may be covered by another payer per coordination of benefits. P15 Workers Compensation Medical Treatment Guideline 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.) Payment for this claim/service may have been provided in a previous payment. Precertification/authorization/notification/pre-treatment absent. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Flexible spending account payments. Benefits are not available under this dental plan, PR 177 Payment denied because the patient has not met the required eligibility requirements, PR 200 Expenses incurred during lapse in coverage. P3 Workers Compensation case settled. Claim spans eligible and ineligible periods of coverage.

52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. This Payer not liable for claim or service/treatment. For example, using contracted providers not in the member's 'narrow' network. 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. Claim denials fall into three categories: administrative, clinical, and policya majority of claim denials are due to administrative errors. This claim has been forwarded on your behalf. Due to the CO (Contractual Obligation) Group Code, the omitted information is the responsibility of the provider and, therefore, the patient cannot be billed for these claims. 70 Cost outlier Adjustment to compensate for additional costs. PR 1 Deductible Amount Members plan deductible applied to the allowable benefit for the rendered service(s). Patient identification compromised by identity theft. Claim has been forwarded to the patient's hearing plan for further consideration. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The beneficiary is not liable for more than the charge limit for the basic procedure/test.

Your Stop loss deductible has not been met. 109 Claim/service not covered by this payer/contractor. 24 Charges are covered under a capitation agreement/managed care plan. Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. 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. PR 201 Workers Compensation case settled. Additional information will be sent following the conclusion of litigation. 40 Charges do not meet qualifications for emergent/urgent care. Claim/service spans multiple months. B13 Previously paid. When the insurance process the claim 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. Services not documented in patient's medical records. P22 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. To be used for Workers' Compensation only. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The procedure code is inconsistent with the modifier used. Designed by Elegant Themes | Powered by WordPress. Claim has been forwarded to the patient's vision plan for further consideration. Pleaseresubmit a bill with the appropriate fee schedule/fee database code(s) that best describethe service(s) provided and supporting documentation if required. To be used for Property and Casualty only. B11 The claim/service has been transferred to the proper payer/processor for processing.Claim/service not covered by this payer/processor. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. ), Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication, Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 11 The diagnosis is inconsistent with the procedure. Payment is adjusted when performed/billed by a provider of this specialty. (Use only with Group Code CO). 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. (Handled in QTY, QTY01=CD), Patient Interest Adjustment (Use Only Group code PR). Claim spans eligible and ineligible periods of coverage. The attachment/other documentation that was received was the incorrect attachment/document. This Payer not liable for claim or service/treatment. Information is presented as a PowerPoint deck, informational paper, educational material, or checklist. 181 Procedure code was invalid on the date of service. D15 Claim lacks indication that service was supervised or evaluated by a physician. D6 Claim/service denied. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) PR OLD REASON CODE NEW GROUP CODE NEW REASON CODE NEW REMARK CODES 204 PI 16 M30 204 CO 96 M50 204 CO 96 M20 204 CO 96 M20 204 PI 189 204 PR 55 204 PI 16 M84 204 PI 16 M20 204 OA 23 N219 204 PI 109 PI 109 96 PI 198 119 PR 119 96 PR 167 96 PI 16 165 PR 39 39 PR 39 39 PI 198 B11 PI B11 16 OLD 207 National Provider identifier Invalid format. Provider promotional discount (e.g., Senior citizen discount). Usage: To be used for pharmaceuticals only. 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. 225 Penalty or Interest Payment by Payer. 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') for the jurisdictional regulation. The Claim Adjustment Group Codes are internal to the X12 standard. Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. For convenience, the values and definitions are below: *The description you are suggesting for a new code or to replace the description for a current code. B14 Only one visit or consultation per physician per day is covered. Based on industry feedback, X12 is using a phased approach for the recommendations rather than presenting the entire catalog of adopted and mandated transactions at once. Workers' Compensation Medical Treatment Guideline Adjustment. X12 produces three types of documents tofacilitate consistency across implementations of its work. 10 The diagnosis is inconsistent with the patients gender.

In the 258 Claim/service not covered when patient is in custody/incarcerated. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. 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. Alphabetized listing of current X12 members organizations. Attachment/other documentation referenced on the claim was not received in a timely fashion. Previously paid. What does denial code PI mean? The necessary information is still needed to process the claim. PI-204 is used when the service, equipment, or drug is not covered under the patients current benefit plan and must therefore be billed to the patient, while PR-1 Usage: Do not use this code for claims attachment(s)/other documentation. Payer deems the information submitted does not support this day's supply. 144 Incentive adjustment, e.g. 242 Services not provided by network/primary care providers.Reason for this denial PR 242:If your Provider is Not Contracted for this members planSupplies or DME codes are only payable to Authorized DME ProvidersNon- Member ProviderNot covered benefit when using a Non-Contracted planAction : Waiting for Credentiall or to bill patient or to waive the balance as per Cleint instruction. 0 SharonCollachi Guest Messages 2,169 Location Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. The procedure/revenue code is inconsistent with the type of bill. Categories include Commercial, Internal, Developer and more. Same denial code can be adjustment as well as patient responsibility. Exceeds the contracted maximum number of hours/days/units by this provider for this period. The procedure/revenue code is inconsistent with the patient's gender. How to Handle PR 31 Denial Code in Medical Billing Process. 182 Procedure modifier was invalid on the date of service. Benefits are not available under this dental plan. Failure to follow prior payer's coverage rules. 132 Prearranged demonstration project adjustment. Usage: To be used for pharmaceuticals only. 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. endstream endobj 90 0 obj<<158c794e0352a341aae6ddd3b8621099>]/Length 19/Filter/FlateDecode/DecodeParms<>/W[1 1 0]/Type/XRef/Info 6 0 R/Index[7 1 89 2]>>stream These codes describe why a claim or service line was paid differently than it was billed. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Indemnification adjustment - compensation for outstanding member responsibility. 183 The referring provider is not eligible to refer the service billed. The date of birth follows the date of service. The line labeled 001 lists the EOB codes related to the first claim detail. (Use with Group Code CO or OA). The Claim spans two calendar years. To be used for Property and Casualty only. Requested information was not provided or was insufficient/incomplete. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF).

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 245 Provider performance program withhold. Coverage/program guidelines were not met or were exceeded. Service not payable per managed care contract. 48 This (these) procedure(s) is (are) not covered. To be used for Property and Casualty only. Claim received by the medical plan, but benefits not available under this plan. 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. Adjustment amount represents collection against receivable created in prior overpayment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). WebNote: Inactive for 004010, since 2/99. Lifetime reserve days. D12 Claim/service denied. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. Information from another provider was not provided or was insufficient/incomplete. 170 Payment is denied when performed/billed by this type of provider. 20 This injury/illness is covered by the liability carrier. To be used for Property and Casualty Auto only. Claim/service lacks information or has submission/billing error(s). Submit a request for interpretation (RFI) related to the implementation and use of X12 work. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Provider contracted/negotiated rate expired or not on file. 241 Low Income Subsidy (LIS) Co-payment Amount. The attachment/other documentation that was received was incomplete or deficient. If patient said there is no primary insurance then ask patient to call Medicare and update as Medicare is primary. Payer deems the information submitted does not support this level of service. Precertification/notification/authorization/pre-treatment exceeded. Multiple physicians/assistants are not covered in this case. (Handled in QTY, QTY01=LA). Services denied at the time authorization/pre-certification was requested. Action for PR 236 If the service was already been paid as part of another service billed for the same date of service.Check Points:The service which was billed is not compatible with another procedureCheck if we billed the same procedure twice with out modifierCheck the units which was billedCheck all the above and append with appropriate modifier, resubmit the claim as Corrected Claim. Claim/service not covered when patient is in custody/incarcerated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Contracted funding agreement - Subscriber is employed by the provider of services. Claims should be filed to the correct payer the beneficiary resides in at the time of claim submission. 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). PR Patient Responsibility We could bill the patient for this denial however please make sure that any other rejection reason not specified in the EOB. The disposition of this service line is pending further review. Submit these services to the patient's Pharmacy plan for further consideration. Services by an immediate relative or a member of the same household are not covered. P5 Based on payer reasonable and customary fees. B8 Alternative services were available, and should have been utilized. D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. (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.). (Use only with Group Code CO). This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: To be used for pharmaceuticals only. 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). X12 standards are the workhorse of business to business exchanges proven by the billions of transactions based on X12 standards that are used daily in various industries including supply chain, transportation, government, finance, and health care. 22 This care may be covered by another payer per coordination of benefits. National Drug Codes (NDC) not eligible for rebate, are not covered. Payment adjusted based on Preferred Provider Organization (PPO). You must send the claim/service tothe correct payer/contractor.Check if patient has any HMO, and bill to that appropriate payer.Check and submit the claims to Primary carrier. Appeal procedures not followed or time limits not met. No maximum allowable defined bylegislated fee arrangement. The following will be added to this definition on 7/1/2023, Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available. Claim lacks date of patient's most recent physician visit. 138 Appeal procedures not followed or time limits not met. No current requests.

141 Claim spans eligible and ineligible periods of coverage. Your email address will not be published. No maximum allowable defined bylegislated fee arrangement. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Did you receive a code from a health plan, such as: PR32 or CO286? Payer deems the information submitted does not support this dosage. The related or qualifying claim/service was not identified on this claim. Claim received by the medical plan, but benefits not available under this plan. 151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Example: CO-16: Claim/service lacks information or has submission/billing error (s) which is needed for adjudication. This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

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