This is the complete list of denial codes (Claim Adjustment Reason Codes) with an explanation of each denial. If you want to know how to fix a denial, click on the link which will lead to a post that explains how to address the denial code. The Claim Adjustment Reason Codes are copyright of X12 and are described below for educational purposes.
1. Claim Adjustment Reason Code 1
Denial code 1 indicates that the claim has been denied due to the deductible amount not being met. This denial code has been effective since 01/01/1995. When this code is used, it signifies that the patient has not yet reached the required deductible amount as per their insurance plan.
2. Claim Adjustment Reason Code 2
Denial code 2 signifies that the claim has been denied due to the coinsurance amount not being met. This code has been effective since 01/01/1995. It indicates that the patient has not paid the required coinsurance percentage as per their insurance plan.
3. Claim Adjustment Reason Code 3
Denial code 3 indicates that the claim has been denied due to the co-payment amount not being met. This code has been effective since 01/01/1995. It signifies that the patient has not paid the required fixed co-payment amount as per their insurance plan.
4. Claim Adjustment Reason Code 4
Denial code 4 is used when the procedure code is inconsistent with the modifier used. This denial is effective since 01/01/1995, with the last modification on 03/01/2020. It is recommended to refer to the 835 Healthcare Policy Identification Segment for further details if present.
5. Claim Adjustment Reason Code 5
Denial code 5 is applied when the procedure code/type of bill is inconsistent with the place of service. This code has been effective since 01/01/1995, with the last modification on 03/01/2018. It is advised to refer to the 835 Healthcare Policy Identification Segment for additional information if present.
6. Claim Adjustment Reason Code 6
Denial code 6 is used when the procedure/revenue code is inconsistent with the patient’s age. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is recommended to refer to the 835 Healthcare Policy Identification Segment for more details if present.
7. Claim Adjustment Reason Code 7
Denial code 7 indicates that the procedure/revenue code is inconsistent with the patient’s gender. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is advisable to refer to the 835 Healthcare Policy Identification Segment for further clarification if present.
8. Claim Adjustment Reason Code 8
Denial code 8 is applied when the procedure code is inconsistent with the provider type/specialty (taxonomy). This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is recommended to refer to the 835 Healthcare Policy Identification Segment for additional information if present.
9. Claim Adjustment Reason Code 9
Denial code 9 is used when the diagnosis is inconsistent with the patient’s age. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is advised to refer to the 835 Healthcare Policy Identification Segment for more details if present.
10. Claim Adjustment Reason Code 10
Denial code 10 signifies that the diagnosis is inconsistent with the patient’s gender. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is advisable to refer to the 835 Healthcare Policy Identification Segment for further clarification if present.
11. Claim Adjustment Reason Code 12
Denial code 12 is used when the diagnosis is inconsistent with the provider type. This denial code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is recommended to refer to the 835 Healthcare Policy Identification Segment for additional information if present.
12. Claim Adjustment Reason Code 14
Denial code 14 indicates that the date of birth follows the date of service. This code has been effective since 01/01/1995. It signifies that the patient’s date of birth is after the date of service, leading to the denial of the claim.
13. Claim Adjustment Reason Code 16
Denial code 16 is used when the claim/service lacks information or has submission/billing errors. This code has been effective since 01/01/1995, with the last modification on 03/01/2018. It is recommended to provide at least one Remark Code and refer to the 835 Healthcare Policy Identification Segment for further details if present.
14. Claim Adjustment Reason Code 18
Denial code 18 is applied in cases of an exact duplicate claim/service. This code has been effective since 01/01/1995, with the last modification on 06/02/2013. It is typically used with Group Code OA, except where state workers’ compensation regulations require CO.
15. Claim Adjustment Reason Code 19
Denial code 19 signifies that the injury/illness is work-related and thus the liability of the Worker’s Compensation Carrier. This code has been effective since 01/01/1995, with the last modification on 09/30/2007.
16. Claim Adjustment Reason Code 20
Denial code 20 indicates that the injury/illness is covered by the liability carrier. This code has been effective since 01/01/1995, with the last modification on 09/30/2007.
17. Claim Adjustment Reason Code 21
Denial code 21 signifies that the injury/illness is the liability of the no-fault carrier. This code has been effective since 01/01/1995, with the last modification on 09/30/2007.
18. Claim Adjustment Reason Code 22
Denial code 22 indicates that the care may be covered by another payer per coordination of benefits. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It suggests that another insurance provider may be responsible for covering the care.
19. Claim Adjustment Reason Code 23
Denial code 23 is used to explain the impact of prior payer(s) adjudication, including payments and/or adjustments. This code has been effective since 01/01/1995, with the last modification on 09/30/2012. It is typically used with Group Code OA.
20. Claim Adjustment Reason Code 24
Denial code 24 indicates that charges are covered under a capitation agreement/managed care plan. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It signifies that the charges are included in a pre-arranged capitation agreement or managed care plan.
21. Claim Adjustment Reason Code 26
Denial code 26 is applied when expenses were incurred prior to coverage. This code has been effective since 01/01/1995. It indicates that the expenses were accrued before the insurance coverage became effective.
22. Claim Adjustment Reason Code 27
Denial code 27 signifies that expenses were incurred after coverage terminated. This code has been effective since 01/01/1995. It indicates that the expenses were accrued after the insurance coverage had ended.
23. Claim Adjustment Reason Code 29
Denial code 29 is used when the time limit for filing the claim has expired. This code has been effective since 01/01/1995. It indicates that the claim was not submitted within the specified timeframe for filing.
24. Claim Adjustment Reason Code 31
Denial code 31 indicates that the patient cannot be identified as the insured. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It signifies that the patient’s identification does not match the insured individual on the policy.
25. Claim Adjustment Reason Code 32
Denial code 32 is used when the records indicate that the patient is not an eligible dependent. This code has been effective since 01/01/1995, with the last modification on 03/01/2018. It indicates that the patient is not considered an eligible dependent under the insurance policy.
26. Claim Adjustment Reason Code 33
Denial code 33 signifies that the insured has no dependent coverage. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It indicates that the insured individual does not have coverage for dependents under the policy.
27. Claim Adjustment Reason Code 34
Denial code 34 indicates that the insured has no coverage for newborns. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It signifies that the insurance policy does not provide coverage for newborns.
28. Claim Adjustment Reason Code 35
Denial code 35 indicates that the lifetime benefit maximum has been reached. This code has been effective since 01/01/1995, with the last modification on 10/31/2002. It signifies that the maximum benefit amount allowed under the policy for a specific service or benefit category has been exhausted.
29. Claim Adjustment Reason Code 39
Denial code 39 is applied when services are denied at the time authorization/pre-certification was requested. This code has been effective since 01/01/1995. It indicates that the services were denied because they were not authorized or pre-certified as required by the insurance plan.
30. Claim Adjustment Reason Code 40
Denial code 40 signifies that charges do not meet qualifications for emergent/urgent care. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the charges did not meet the criteria for emergent or urgent care as defined by the insurance policy.
31. Claim Adjustment Reason Code 44
Denial code 44 indicates a prompt-pay discount. This code has been effective since 01/01/1995. It signifies that a discount was applied for prompt payment of the claim.
32. Claim Adjustment Reason Code 45
Denial code 45 is used when the charge exceeds the fee schedule/maximum allowable or contracted/legislated fee arrangement. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the charge exceeds the maximum allowable amount as per the fee schedule or contract.
33. Claim Adjustment Reason Code 49
Denial code 49 indicates that the service is non-covered because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It signifies that the service is not covered as it falls under routine or preventive care.
34. Claim Adjustment Reason Code 50
Denial code 50 is used when services are non-covered because they are not deemed a ‘medical necessity’ by the payer. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the services provided are not considered medically necessary by the insurance payer.
35. Claim Adjustment Reason Code 51
Denial code 51 signifies that services are non-covered because they are related to a pre-existing condition. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the services are not covered due to being associated with a pre-existing condition.
36. Claim Adjustment Reason Code 53
Denial code 53 is applied when services are provided by an immediate relative or a member of the same household, and they are not covered. This code has been effective since 01/01/1995. It signifies that services provided by family members or individuals from the same household are not eligible for coverage.
37. Claim Adjustment Reason Code 54
Denial code 54 indicates that multiple physicians/assistants are not covered in this case. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It signifies that the involvement of multiple physicians or assistants in the same case is not covered under the insurance policy.
38. Claim Adjustment Reason Code 55
Denial code 55 is used when a procedure/treatment/drug is deemed experimental/investigational by the payer. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the procedure, treatment, or drug is considered experimental or investigational by the insurance payer.
39. Claim Adjustment Reason Code 56
Denial code 56 is applied when a procedure/treatment has not been deemed ‘proven to be effective’ by the payer. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It signifies that the procedure or treatment has not been recognized as effective by the insurance payer.
40. Claim Adjustment Reason Code 58
Denial code 58 is used when treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It indicates that the location where the treatment was provided is considered inappropriate or invalid by the insurance payer.
41. Claim Adjustment Reason Code 59
Denial code 59 is applied when a claim is processed based on multiple or concurrent procedure rules. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is recommended to refer to the 835 Healthcare Policy Identification Segment for additional information if present.
42. Claim Adjustment Reason Code 60
Denial code 60 indicates that charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. This code has been effective since 01/01/1995, with the last modification on 06/01/2008. It signifies that certain outpatient services are not covered when performed in close proximity to inpatient services.
43. Claim Adjustment Reason Code 61
Denial code 61 is adjusted for the failure to obtain a second surgical opinion. This code has been effective since 01/01/1995, with the last modification on 03/01/2017. It is important to note that the description effective date was corrected to 1/1/2017 on 7/1/2016.
44. Claim Adjustment Reason Code 66
Denial code 66 signifies a blood deductible. This code has been effective since 01/01/1995. It indicates that a deductible specific to blood-related services has not been met.
45. Claim Adjustment Reason Code 69
Denial code 69 indicates a day outlier amount. This code has been effective since 01/01/1995. It is used to adjust for situations where the number of days for a particular service exceeds the norm.
46. Claim Adjustment Reason Code 70
Denial code 70 signifies a cost outlier adjustment to compensate for additional costs. This code has been effective since 01/01/1995, with the last modification on 06/30/2001. It is used to adjust for additional costs incurred beyond the standard amount.
47. Claim Adjustment Reason Code 74
Denial code 74 indicates an Indirect Medical Education Adjustment. This code has been effective since 01/01/1995. It is used to adjust for indirect medical education costs associated with teaching hospitals.
48. Claim Adjustment Reason Code 75
Denial code 75 signifies a Direct Medical Education Adjustment. This code has been effective since 01/01/1995. It is used to adjust for direct medical education costs associated with teaching hospitals.
49. Claim Adjustment Reason Code 76
Denial code 76 indicates a Disproportionate Share Adjustment. This code has been effective since 01/01/1995. It is used to adjust for disproportionate share payments made to hospitals that serve a large number of low-income patients.
50. Claim Adjustment Reason Code 78
Denial code 78 is applied for a non-covered days/room charge adjustment. This code has been effective since 01/01/1995. It is used to adjust charges for non-covered days or room charges.
51. Claim Adjustment Reason Code 85
Denial code 85 indicates a Patient Interest Adjustment. This code has been effective since 01/01/1995, with the last modification on 07/09/2007. It is used when the payment of interest is the responsibility of the patient.
52. Claim Adjustment Reason Code 89
Denial code 89 signifies professional fees removed from charges. This code has been effective since 01/01/1995. It is used when professional fees are deducted from the total charges.
53. Claim Adjustment Reason Code 90
Denial code 90 indicates an ingredient cost adjustment, to be used for pharmaceuticals only. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is specifically used for adjusting the cost of ingredients in pharmaceutical products.
54. Claim Adjustment Reason Code 91
Denial code 91 signifies a dispensing fee adjustment. This code has been effective since 01/01/1995. It is used to adjust the dispensing fee associated with providing medications.
55. Claim Adjustment Reason Code 94
Denial code 94 indicates that the claim was processed in excess of charges. This code has been effective since 01/01/1995. It is used when the claim has been processed for an amount exceeding the actual charges.
56. Claim Adjustment Reason Code 95
Denial code 95 signifies that plan procedures were not followed. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used when procedures outlined by the insurance plan were not adhered to.
57. Claim Adjustment Reason Code 96
Denial code 96 indicates non-covered charges. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is used when charges are not covered under the insurance policy.
58. Claim Adjustment Reason Code 97
Denial code 97 signifies that the benefit for a service is included in the payment/allowance for another service/procedure that has already been adjudicated. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is used when the payment for a service is already included in another service’s payment.
59. Claim Adjustment Reason Code 100
Denial code 100 indicates a payment made to the patient/insured/responsible party. This code has been effective since 01/01/1995, with the last modification on 05/01/2018. It is used when a payment is made directly to the patient, insured individual, or responsible party.
60. Claim Adjustment Reason Code 101
Denial code 101 signifies predetermination, anticipated payment upon completion of services or claim adjudication. This code has been effective since 01/01/1995, with the last modification on 02/28/1999. It is used when payment is anticipated after the completion of services or claim adjudication.
61. Claim Adjustment Reason Code 102
Denial code 102 indicates a Major Medical Adjustment. This code has been effective since 01/01/1995. It is used for adjustments related to major medical expenses covered under the insurance policy.
62. Claim Adjustment Reason Code 103
Denial code 103 signifies a Provider promotional discount, e.g., Senior citizen discount. This code has been effective since 01/01/1995, with the last modification on 06/30/2001. It is used for adjustments related to promotional discounts offered by providers.
63. Claim Adjustment Reason Code 104
Denial code 104 indicates a Managed care withholding. This code has been effective since 01/01/1995. It is used for adjustments related to managed care withholdings.
64. Claim Adjustment Reason Code 105
Denial code 105 signifies a Tax withholding. This code has been effective since 01/01/1995. It is used for adjustments related to tax withholdings.
65. Claim Adjustment Reason Code 106
Denial code 106 indicates that the patient payment option/election is not in effect. This code has been effective since 01/01/1995. It is used when the patient’s chosen payment option or election is not currently active.
66. Claim Adjustment Reason Code 108
Denial code 108 is applied when rent/purchase guidelines were not met. This code has been effective since 01/01/1995, with the last modification on 07/01/2017. It is used when the guidelines for renting or purchasing equipment or services were not followed.
67. Claim Adjustment Reason Code 110
Denial code 110 indicates that the billing date predates the service date. This code has been effective since 01/01/1995. It is used when the billing date is earlier than the date the service was provided.
68. Claim Adjustment Reason Code 111
Denial code 111 signifies that the service is not covered unless the provider accepts assignment. This code has been effective since 01/01/1995. It is used when the service is only covered if the provider agrees to accept assignment of benefits.
69. Claim Adjustment Reason Code 112
Denial code 112 indicates that the service was not furnished directly to the patient and/or not documented. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used when the service was not provided directly to the patient or if the documentation is insufficient.
70. Claim Adjustment Reason Code 114
Denial code 114 signifies that the procedure/product was not approved by the Food and Drug Administration. This code has been effective since 01/01/1995. It is used when the procedure or product used was not approved by the FDA.
71. Claim Adjustment Reason Code 115
Denial code 115 indicates that the procedure was postponed, canceled, or delayed. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used when the procedure could not be completed as scheduled.
72. Claim Adjustment Reason Code 116
Denial code 116 signifies that the advance indemnification notice signed by the patient did not comply with requirements. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used when the advance notice signed by the patient does not meet the necessary requirements.
73. Claim Adjustment Reason Code 117
Denial code 117 indicates that transportation is only covered to the closest facility that can provide the necessary care. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used to specify coverage limitations for transportation services.
74. Claim Adjustment Reason Code 118
Denial code 118 signifies an ESRD network support adjustment. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used for adjustments related to End-Stage Renal Disease (ESRD) network support.
75. Claim Adjustment Reason Code 121
Denial code 121 indicates an indemnification adjustment – compensation for outstanding member responsibility. This code has been effective since 01/01/1995, with the last modification on 09/30/2007. It is used to adjust for outstanding member responsibilities that need to be compensated.
76. Claim Adjustment Reason Code 122
Denial code 122 signifies a psychiatric reduction. This code has been effective since 01/01/1995. It is used for adjustments related to psychiatric services.
77. Claim Adjustment Reason Code 128
Denial code 128 indicates that a newborn’s services are covered in the mother’s allowance. This code has been effective since 02/28/1997. It is used to specify that services for a newborn are covered under the mother’s insurance allowance.
78. Claim Adjustment Reason Code 130
Denial code 130 signifies a claim submission fee. This code has been effective since 02/28/1997, with the last modification on 06/30/2001. It is used to indicate a fee associated with the submission of a claim.
79. Claim Adjustment Reason Code 132
Denial code 132 indicates a prearranged demonstration project adjustment. This code has been effective since 02/28/1997. It is used for adjustments related to prearranged demonstration projects.
80. Claim Adjustment Reason Code 133
Denial code 133 is used when the disposition of a service line is pending further review. This code has been effective since 07/01/2014, with the last modification on 07/01/2017. It is typically used with Group Code OA and requires a reversal and correction when the service line is finalized.
81. Claim Adjustment Reason Code 134
Denial code 134 signifies technical fees removed from charges. This code has been effective since 10/31/1998. It is used when technical fees are deducted from the total charges.
82. Claim Adjustment Reason Code 135
Denial code 135 indicates that interim bills cannot be processed. This code has been effective since 10/31/1998, with the last modification on 09/30/2007. It is used when interim bills are not eligible for processing.
83. Claim Adjustment Reason Code 136
Denial code 136 is applied for failure to follow prior payer’s coverage rules. This code has been effective since 10/31/1998, with the last modification on 07/01/2013. It is typically used with Group Code OA and indicates non-compliance with the coverage rules of a previous payer.
84. Claim Adjustment Reason Code 137
Denial code 137 signifies regulatory surcharges, assessments, allowances, or health-related taxes. This code has been effective since 02/28/1999, with the last modification on 09/30/2007. It is used for adjustments related to regulatory charges or health-related taxes.
85. Claim Adjustment Reason Code 139
Denial code 139 indicates a contracted funding agreement where the subscriber is employed by the provider of services. This code has been effective since 06/30/1999, with the last modification on 05/01/2018. It is used with Group Code CO.
86. Claim Adjustment Reason Code 140
Denial code 140 signifies that the patient/insured health identification number and name do not match. This code has been effective since 06/30/1999. It is used when there is a discrepancy between the health identification number and the patient’s name.
87. Claim Adjustment Reason Code 142
Denial code 142 indicates a monthly Medicaid patient liability amount. This code has been effective since 06/30/2000, with the last modification on 09/30/2007. It is used for adjustments related to Medicaid patient liability.
88. Claim Adjustment Reason Code 143
Denial code 143 signifies a portion of payment deferred. This code has been effective since 02/28/2001. It is used when a portion of the payment is delayed or deferred for a later date.
89. Claim Adjustment Reason Code 144
Denial code 144 indicates an incentive adjustment, e.g., preferred product/service. This code has been effective since 06/30/2001. It is used for adjustments related to incentives offered for preferred products or services.
90. Claim Adjustment Reason Code 147
Denial code 147 signifies that the provider’s contracted/negotiated rate expired or is not on file. This code has been effective since 06/30/2002. It is used when the negotiated rate with the provider has expired or is not available.
91. Claim Adjustment Reason Code 148
Denial code 148 signifies that information from another provider was not provided or was insufficient/incomplete. This denial code requires at least one Remark Code to be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 148 has been effective since 06/30/2002 and was last modified on 09/20/2009.
92. Claim Adjustment Reason Code 149
Denial code 149 indicates that the lifetime benefit maximum has been reached for the specific service or benefit category. This denial is applied when the maximum benefit limit for a particular service or category has been exhausted. Denial code 149 has been effective since 10/31/2002.
93. Claim Adjustment Reason Code 150
Denial code 150 is used when the payer deems that the information submitted does not support the level of service billed. This denial is applied when the submitted information does not align with the billed level of service. Denial code 150 has been effective since 10/31/2002 and was last modified on 09/30/2007.
94. Claim Adjustment Reason Code 151
Denial code 151 is utilized when the payer determines that the information submitted does not support the frequency or quantity of services billed. This denial is applied when the submitted information does not justify the number of services billed. Denial code 151 has been effective since 10/31/2002 and was last modified on 01/27/2008.
95. Claim Adjustment Reason Code 152
Denial code 152 is used when the payer finds that the information submitted does not support the length of service provided. This denial is applied when the submitted information does not validate the duration of the service rendered. Denial code 152 has been effective since 10/31/2002 and was last modified on 07/01/2017.
96. Claim Adjustment Reason Code 153
Denial code 153 indicates that the payer deems the information submitted does not support the prescribed dosage. This denial is applied when the submitted information does not align with the prescribed dosage. Denial code 153 has been effective since 10/31/2002 and was last modified on 09/30/2007.
97. Claim Adjustment Reason Code 154
Denial code 154 is used when the payer determines that the information submitted does not support the number of days’ supply for the service or medication. This denial is applied when the submitted information does not justify the days’ supply billed. Denial code 154 has been effective since 10/31/2002 and was last modified on 09/30/2007.
98. Claim Adjustment Reason Code 155
Denial code 155 signifies that the patient refused the service or procedure. This denial is applied when the patient declines to undergo the recommended service or procedure. Denial code 155 has been effective since 06/30/2003 and was last modified on 09/30/2007.
99. Claim Adjustment Reason Code 157
Denial code 157 is used when the service or procedure was provided as a result of an act of war. This denial is applied when the service or procedure was necessitated due to an act of war. Denial code 157 has been effective since 09/30/2003 and was last modified on 09/30/2007.
100. Claim Adjustment Reason Code 158
Denial code 158 indicates that the service or procedure was provided outside of the United States. This denial is applied when the service or procedure was conducted outside the territorial boundaries of the United States. Denial code 158 has been effective since 09/30/2003 and was last modified on 09/30/2007.
101. Claim Adjustment Reason Code 159
Denial code 159 is used when the service or procedure was provided as a result of terrorism. This denial is applied when the service or procedure was necessitated due to an act of terrorism. Denial code 159 has been effective since 09/30/2003 and was last modified on 09/30/2007.
102. Claim Adjustment Reason Code 160
Denial code 160 signifies that the injury/illness was the result of an activity that is a benefit exclusion. This denial is applied when the injury or illness resulted from an activity that is excluded from coverage. Denial code 160 has been effective since 09/30/2003 and was last modified on 09/30/2007.
103. Claim Adjustment Reason Code 161
Denial code 161 indicates a provider performance bonus. This code is used to denote a bonus or incentive provided to the healthcare provider. Denial code 161 has been effective since 02/29/2004.
104. Claim Adjustment Reason Code 163
Denial code 163 is used when the attachment or other documentation referenced on the claim was not received. This denial is applied when the required documentation supporting the claim was not submitted. Denial code 163 has been effective since 06/30/2004 and was last modified on 06/02/2013.
105. Claim Adjustment Reason Code 164
Denial code 164 signifies that the attachment or other documentation referenced on the claim was not received in a timely fashion. This denial is applied when the necessary documentation was not submitted within the specified timeframe. Denial code 164 has been effective since 06/30/2004 and was last modified on 06/02/2013.
106. Claim Adjustment Reason Code 166
Denial code 166 indicates that the services were submitted after the payer’s responsibility for processing claims under the plan ended. This denial is applied when services are submitted after the payer’s obligation to process claims has ceased. Denial code 166 has been effective since 02/28/2005.
107. Claim Adjustment Reason Code 167
Denial code 167 is used when the diagnosis(es) submitted are not covered. This denial is applied when the diagnosis codes are not included in the coverage policy. Denial code 167 has been effective since 06/30/2005 and was last modified on 07/01/2017.
108. Claim Adjustment Reason Code 169
Denial code 169 signifies that an alternate benefit has been provided. This denial is applied when an alternative benefit is offered instead of the originally billed service. Denial code 169 has been effective since 06/30/2005 and was last modified on 09/30/2007.
109. Claim Adjustment Reason Code 170
Denial code 170 indicates that payment is denied when performed or billed by a specific type of provider. This denial is applied when the service is performed or billed by a provider type not covered under the plan. Denial code 170 has been effective since 06/30/2005 and was last modified on 07/01/2017.
110. Claim Adjustment Reason Code 171
Denial code 171 is used when payment is denied when performed or billed by a specific type of provider in a particular type of facility. This denial is applied when the service is provided by a specific provider type in a facility not covered under the plan. Denial code 171 has been effective since 06/30/2005 and was last modified on 07/01/2017.
111. Claim Adjustment Reason Code 172
Denial code 172 signifies that payment is adjusted when performed or billed by a provider of a specific specialty. This denial is applied when the service is provided by a provider with a specialty that triggers an adjustment. Denial code 172 has been effective since 06/30/2005 and was last modified on 07/01/2017.
112. Claim Adjustment Reason Code 173
Denial code 173 is used when the service or equipment was not prescribed by a physician. This denial is applied when the service or equipment provided was not ordered by a physician. Denial code 173 has been effective since 06/30/2005 and was last modified on 07/01/2013.
113. Claim Adjustment Reason Code 174
Denial code 174 indicates that the service was not prescribed prior to delivery. This denial is applied when the service was not ordered before it was provided. Denial code 174 has been effective since 06/30/2005 and was last modified on 09/30/2007.
114. Claim Adjustment Reason Code 175
Denial code 175 signifies that the prescription is incomplete. This denial is applied when the prescription submitted is missing essential information. Denial code 175 has been effective since 06/30/2005 and was last modified on 09/30/2007.
115. Claim Adjustment Reason Code 176
Denial code 176 is used when the prescription is not current. This denial is applied when the prescription submitted is outdated or expired. Denial code 176 has been effective since 06/30/2005 and was last modified on 09/30/2007.
116. Claim Adjustment Reason Code 177
Denial code 177 indicates that the patient has not met the required eligibility requirements. This denial is applied when the patient does not fulfill the necessary criteria for coverage. Denial code 177 has been effective since 06/30/2005 and was last modified on 09/30/2007.
117. Claim Adjustment Reason Code 178
Denial code 178 signifies that the patient has not met the required spend down requirements. This denial is applied when the patient has not met the spend down obligations as per the plan. Denial code 178 has been effective since 06/30/2005 and was last modified on 09/30/2007.
118. Claim Adjustment Reason Code 179
Denial code 179 is used when the patient has not met the required waiting requirements. This denial is applied when the patient has not fulfilled the waiting period specified in the plan. Denial code 179 has been effective since 06/30/2005 and was last modified on 03/01/2017.
119. Claim Adjustment Reason Code 180
Denial code 180 indicates that the patient has not met the required residency requirements. This denial is applied when the patient does not meet the residency criteria outlined in the plan. Denial code 180 has been effective since 06/30/2005 and was last modified on 09/30/2007.
120. Claim Adjustment Reason Code 181
Denial code 181 is used when the procedure code was invalid on the date of service. This denial is applied when the procedure code submitted is not valid for the date of service billed. Denial code 181 has been effective since 06/30/2005 and was last modified on 09/30/2007.
121. Claim Adjustment Reason Code 182
Denial code 182 signifies that the procedure modifier was invalid on the date of service. This denial is applied when the procedure modifier submitted is not valid for the date of service billed. Denial code 182 has been effective since 06/30/2005 and was last modified on 09/30/2007.
122. Claim Adjustment Reason Code 183
Denial code 183 indicates that the referring provider is not eligible to refer the service billed. This denial is applied when the referring provider is not authorized to refer the service billed. Denial code 183 has been effective since 06/30/2005 and was last modified on 07/01/2017.
123. Claim Adjustment Reason Code 184
Denial code 184 is used when the prescribing or ordering provider is not eligible to prescribe or order the service billed. This denial is applied when the provider who prescribed or ordered the service is not authorized to do so. Denial code 184 has been effective since 06/30/2005 and was last modified on 07/01/2017.
124. Claim Adjustment Reason Code 185
Denial code 185 signifies that the rendering provider is not eligible to perform the service billed. This denial is applied when the rendering provider is not qualified to perform the service billed. Denial code 185 has been effective since 06/30/2005 and was last modified on 07/01/2017.
125. Claim Adjustment Reason Code 186
Denial code 186 indicates a level of care change adjustment. This denial is applied when there is an adjustment in the level of care provided. Denial code 186 has been effective since 06/30/2005 and was last modified on 09/30/2007.
126. Claim Adjustment Reason Code 187
Denial code 187 is used for Consumer Spending Account payments, including Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc. This denial is applied when payments are related to consumer spending accounts. Denial code 187 has been effective since 06/30/2005 and was last modified on 01/25/2009.
127. Claim Adjustment Reason Code 188
Denial code 188 signifies that the product or procedure is only covered when used according to FDA recommendations. This denial is applied when the product or procedure is covered only if used as per FDA guidelines. Denial code 188 has been effective since 06/30/2005.
128. Claim Adjustment Reason Code 189
Denial code 189 is used when a ‘not otherwise classified’ or ‘unlisted’ procedure code (CPT/HCPCS) was billed when there is a specific procedure code available for the service. This denial is applied when a specific procedure code exists for the service billed. Denial code 189 has been effective since 06/30/2005.
129. Claim Adjustment Reason Code 190
Denial code 190 indicates that payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. This denial is applied when the payment is part of the allowance for an SNF qualified stay. Denial code 190 has been effective since 10/31/2005.
130. Claim Adjustment Reason Code 192
Denial code 192 is a non-standard adjustment code from paper remittance. This code is used by providers/payers for Coordination of Benefits information in the 837 transaction when a non-standard code cannot be mapped to an existing Claims Adjustment Reason Code. Denial code 192 has been effective since 10/31/2005 and was last modified on 07/01/2017.
131. Claim Adjustment Reason Code 193
Denial code 193 signifies that the original payment decision is being maintained. This denial is applied when, upon review, it is determined that the claim was processed correctly. Denial code 193 has been effective since 02/28/2006 and was last modified on 01/27/2008.
132. Claim Adjustment Reason Code 194
Denial code 194 is used when anesthesia is performed by the operating physician, the assistant surgeon, or the attending physician. This denial is applied when anesthesia services are provided by specific healthcare professionals. Denial code 194 has been effective since 02/28/2006 and was last modified on 09/30/2007.
133. Claim Adjustment Reason Code 195
Denial code 195 indicates that a refund was issued to an erroneous priority payer for the claim or service. This denial is applied when a refund is issued to a payer in error. Denial code 195 has been effective since 02/28/2006 and was last modified on 09/30/2007.
134. Claim Adjustment Reason Code 197
Denial code 197 is used when precertification, authorization, notification, or pre-treatment information is absent. This denial is applied when the required precertification or authorization is not obtained. Denial code 197 has been effective since 10/31/2006 and was last modified on 05/01/2018.
135. Claim Adjustment Reason Code 198
Denial code 198 signifies that precertification, notification, authorization, or pre-treatment requirements have been exceeded. This denial is applied when the precertification or authorization process exceeds the specified limits. Denial code 198 has been effective since 10/31/2006 and was last modified on 05/01/2018.
136. Claim Adjustment Reason Code 199
Denial code 199 indicates that the revenue code and procedure code do not match. This denial is applied when there is a discrepancy between the revenue code and procedure code submitted. Denial code 199 has been effective since 10/31/2006.
137. Claim Adjustment Reason Code 200
Denial code 200 is used when expenses are incurred during a lapse in coverage. This denial is applied when expenses are accrued when there is a gap in coverage. Denial code 200 has been effective since 10/31/2006.
138. Claim Adjustment Reason Code 201
Denial code 201 signifies that the patient is responsible for the amount of the claim or service through a ‘set aside arrangement’ or other agreement. This denial is used with Group Code PR and requires at least one Remark Code to be provided. Denial code 201 has been effective since 10/31/2006 and was last modified on 09/28/2014.
139. Claim Adjustment Reason Code 202
Denial code 202 indicates non-covered personal comfort or convenience services. This denial is applied when services are considered personal comfort or convenience and are not covered under the plan. Denial code 202 has been effective since 02/28/2007 and was last modified on 09/30/2007.
140. Claim Adjustment Reason Code 203
Denial code 203 is used when a service is discontinued or reduced. This denial is applied when a service is stopped or reduced in scope. Denial code 203 has been effective since 02/28/2007 and was last modified on 09/30/2007.
141. Claim Adjustment Reason Code 204
Denial code 204 signifies that the service, equipment, or drug is not covered under the patient’s current benefit plan. This denial is applied when the service, equipment, or drug is not included in the patient’s benefit coverage. Denial code 204 has been effective since 02/28/2007.
142. Claim Adjustment Reason Code 205
Denial code 205 indicates a pharmacy discount card processing fee. This denial is applied when a fee related to pharmacy discount card processing is not covered. Denial code 205 has been effective since 07/09/2007.
143. Claim Adjustment Reason Code 206
Denial code 206 signifies that the National Provider Identifier (NPI) is missing. This denial is applied when the NPI of the provider is not included in the claim. Denial code 206 has been effective since 07/09/2007 and was last modified on 09/30/2007.
144. Claim Adjustment Reason Code 207
Denial code 207 is used when the National Provider Identifier (NPI) is in an invalid format. This denial is applied when the format of the NPI provided is incorrect. Denial code 207 has been effective since 07/09/2007 and was last modified on 06/01/2008.
145. Claim Adjustment Reason Code 208
Denial code 208 indicates that the National Provider Identifier (NPI) is not matched. This denial is applied when the NPI provided does not match the records. Denial code 208 has been effective since 07/09/2007 and was last modified on 09/30/2007.
146. Claim Adjustment Reason Code 209
Denial code 209 signifies that, per regulatory or other agreement, the provider cannot collect the amount from the patient but may bill a subsequent payer. This denial is used with Group Code OA and requires refund to the patient if collected. Denial code 209 has been effective since 07/09/2007 and was last modified on 07/01/2013.
147. Claim Adjustment Reason Code 210
Denial code 210 is used when payment is adjusted because pre-certification or authorization was not received in a timely fashion. This denial is applied when the required pre-certification or authorization was not obtained within the specified timeframe. Denial code 210 has been effective since 07/09/2007.
148. Claim Adjustment Reason Code 211
Denial code 211 indicates that National Drug Codes (NDC) are not eligible for rebate and are not covered. This denial is applied when the NDCs submitted are not eligible for rebate and are excluded from coverage. Denial code 211 has been effective since 07/09/2007.
149. Claim Adjustment Reason Code 212
Denial code 212 signifies that administrative surcharges are not covered. This denial is applied when administrative surcharges are not included in the coverage policy. Denial code 212 has been effective since 11/05/2007.
150. Claim Adjustment Reason Code 213
Denial code 213 is used for non-compliance with the physician self-referral prohibition legislation or payer policy. This denial is applied when there is non-compliance with self-referral regulations or payer policies. Denial code 213 has been effective since 01/27/2008.
151. Claim Adjustment Reason Code 215
Denial code 215 is based on subrogation of a third-party settlement. This denial is applied when the claim is adjusted based on subrogation of a settlement from a third party. Denial code 215 has been effective since 01/27/2008.
152. Claim Adjustment Reason Code 216
Denial code 216 is based on the findings of a review organization. This denial is applied when the claim adjustment is based on the review organization’s findings. Denial code 216 has been effective since 01/27/2008.
153. Claim Adjustment Reason Code 219
Denial code 219 is based on the extent of injury. This denial is applied based on the severity or extent of the injury. Denial code 219 has been effective since 01/27/2008 and was last modified on 07/01/2017.
154. Claim Adjustment Reason Code 222
Denial code 222 indicates that the service provider has exceeded the contracted maximum number of hours, days, or units for the period. This denial is not patient-specific and is based on the provider exceeding the contracted limits. Denial code 222 has been effective since 06/01/2008 and was last modified on 07/01/2017.
155. Claim Adjustment Reason Code 223
Denial code 223 is an adjustment code for mandated federal, state, or local law/regulation that is not already covered by another code. This denial is applied when there is a requirement by law or regulation that necessitates an adjustment but does not have a specific code. Denial code 223 has been effective since 06/01/2008.
156. Claim Adjustment Reason Code 224
Denial code 224 indicates that the patient identification has been compromised by identity theft. This denial is applied when the patient’s identity has been stolen, and identity verification is required for processing current and future claims. Denial code 224 has been effective since 06/01/2008.
157. Claim Adjustment Reason Code 225
Denial code 225 signifies a penalty or interest payment by the payer, used for plan-to-plan encounter reporting within the 837 transaction. This denial is applied when a penalty or interest payment is made by the payer in specific encounter reporting scenarios. Denial code 225 has been effective since 06/01/2008.
158. Claim Adjustment Reason Code 226
Denial code 226 signifies that information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. This denial requires at least one Remark Code to be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 226 has been in effect since 09/21/2008 and was last modified on 07/01/2013.
160. Claim Adjustment Reason Code 227
Denial code 227 indicates that information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. Similar to code 226, at least one Remark Code must be provided, which may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 227 was implemented on 09/21/2008 and was last modified on 09/20/2009.
160. Claim Adjustment Reason Code 228
Denial code 228 is used when a claim is denied due to the failure of the provider, another provider, or the subscriber to supply requested information to a previous payer for their adjudication. This denial was initiated on 09/21/2008.
161. Claim Adjustment Reason Code 229
Denial code 229 signifies that the partial charge amount was not considered by Medicare due to the initial claim Type of Bill being 12X. This code is specifically 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. Denial code 229 can only be used with Group Code PR and has been effective since 01/25/2009, with the last modification on 07/01/2017.
162. Claim Adjustment Reason Code 231
Denial code 231 indicates that mutually exclusive procedures cannot be done in the same day/setting. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code 231 was introduced on 07/01/2009 and was last modified on 07/01/2017.
163. Claim Adjustment Reason Code 232
Denial code 232 relates to Institutional Transfer Amount. This code applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Denial code 232 has been in effect since 11/01/2009 and was last modified on 07/01/2017.
164. Claim Adjustment Reason Code 233
Denial code 233 pertains to services/charges related to the treatment of a hospital-acquired condition or preventable medical error. This denial was initiated on 01/24/2010.
165. Claim Adjustment Reason Code 234
Denial code 234 indicates that a specific procedure is not paid separately. At least one Remark Code must be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 234 was implemented on 01/24/2010.
166. Claim Adjustment Reason Code 235
Denial code 235 refers to Sales Tax. This denial code has been effective since 06/06/2010.
167. Claim Adjustment Reason Code 236
Denial code 236 signifies that a 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. Denial code 236 was initiated on 01/30/2011 and was last modified on 07/01/2013.
168. Claim Adjustment Reason Code 237
Denial code 237 indicates Legislated/Regulatory Penalty. At least one Remark Code must be provided, which may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 237 was introduced on 06/05/2011.
169. Claim Adjustment Reason Code 238
Denial code 238 signifies that the claim spans eligible and ineligible periods of coverage, resulting in a reduction for the ineligible period. This code is used only with Group Code PR and has been effective since 03/01/2012, with the last modification on 07/01/2013.
170. Claim Adjustment Reason Code 239
Denial code 239 indicates that the claim spans eligible and ineligible periods of coverage, requiring rebilling separate claims. This denial was implemented on 03/01/2012 and was last modified on 01/29/2012.
171. Claim Adjustment Reason Code 240
Denial code 240 signifies that the diagnosis is inconsistent with the patient’s birth weight. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code 240 has been in effect since 06/03/2012, with the last modification on 07/01/2017.
172. Claim Adjustment Reason Code 241
Denial code 241 relates to Low Income Subsidy (LIS) Co-payment Amount. This denial code has been effective since 06/03/2012.
173. Claim Adjustment Reason Code 242
Denial code 242 indicates that services were not provided by network/primary care providers. This code replaced the deactivated code 38 and has been in effect since 06/03/2012, with the last modification on 06/02/2013.
174. Claim Adjustment Reason Code 243
Denial code 243 signifies that services were not authorized by network/primary care providers. This code replaced the deactivated code 38 and has been effective since 06/03/2012, with the last modification on 06/02/2013.
175. Claim Adjustment Reason Code 245
Denial code 245 indicates a Provider performance program withhold. This denial was initiated on 09/30/2012.
176. Claim Adjustment Reason Code 246
Denial code 246 signifies that the non-payable code is for required reporting only. This denial has been effective since 09/30/2012.
177. Claim Adjustment Reason Code 247
Denial code 247 represents a Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. This denial is specifically for Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). Denial code 247 was implemented on 09/30/2012.
178. Claim Adjustment Reason Code 248
Denial code 248 indicates Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Similar to code 247, this denial is for Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). Denial code 248 has been in effect since 09/30/2012.
179. Claim Adjustment Reason Code 249
Denial code 249 signifies that the claim has been identified as a readmission. This denial should be used only with Group Code CO and was initiated on 09/30/2012.
180. Claim Adjustment Reason Code 250
Denial code 250 indicates that the attachment/other documentation received was the incorrect attachment/document, and the expected attachment/document is still missing. At least one Remark Code must be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 250 has been effective since 09/30/2012, with the last modification on 06/01/2014.
181. Claim Adjustment Reason Code 251
Denial code 251 signifies that the attachment/other documentation received was incomplete or deficient, and the necessary information is still needed to process the claim. At least one Remark Code must be provided, which may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 251 was implemented on 09/30/2012 and was last modified on 06/01/2014.
182. Claim Adjustment Reason Code 252
Denial code 252 indicates that an attachment/other documentation is required to adjudicate the claim/service. At least one Remark Code must be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 252 has been in effect since 09/30/2012, with the last modification on 06/02/2013.
183. Claim Adjustment Reason Code 253
Denial code 253 signifies Sequestration – reduction in federal payment. This denial was implemented on 06/02/2013 and was last modified on 11/01/2013.
184. Claim Adjustment Reason Code 254
Denial code 254 indicates that the claim was received by the dental plan, but benefits are not available under this plan. It advises to submit these services to the patient’s medical plan for further consideration. Denial code 254 has been effective since 06/02/2013, with the last modification on 11/01/2017.
185. Claim Adjustment Reason Code 256
Denial code 256 signifies that the service is not payable per managed care contract. This denial has been in effect since 06/02/2013.
186. Claim Adjustment Reason Code 257
Denial code 257 indicates that the disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This denial advises that the claim/service will be reversed and corrected when the grace period ends due to premium payment or lack of premium payment. It should be used only with Group Code OA and was implemented on 11/01/2013, with the last modification on 06/01/2014.
187. Claim Adjustment Reason Code 258
Denial code 258 signifies that the claim/service is not covered when the patient is in custody/incarcerated. It notes that the applicable federal, state, or local authority may cover the claim/service. Denial code 258 was initiated on 11/01/2013.
188. Claim Adjustment Reason Code 259
Denial code 259 indicates an additional payment for Dental/Vision service utilization. This denial has been effective since 01/26/2014.
189. Claim Adjustment Reason Code 260
Denial code 260 signifies that the claim was processed under Medicaid ACA Enhanced Fee Schedule. This denial was implemented on 01/26/2014.
190. Claim Adjustment Reason Code 261
Denial code 261 indicates that the procedure or service is inconsistent with the patient’s history. This denial has been in effect since 06/01/2014.
191. Claim Adjustment Reason Code 262
Denial code 262 represents an Adjustment for delivery cost. This code is to be used for pharmaceuticals only and has been effective since 11/01/2014, with the last modification on 07/01/2017.
192. Claim Adjustment Reason Code 263
Denial code 263 signifies an Adjustment for shipping cost. This code is specifically to be used for pharmaceuticals only and has been in effect since 11/01/2014, with the last modification on 07/01/2017.
193. Claim Adjustment Reason Code 264
Denial code 264 indicates an Adjustment for postage cost. Similar to code 263, this denial is to be used for pharmaceuticals only and has been effective since 11/01/2014, with the last modification on 07/01/2017.
194. Claim Adjustment Reason Code 265
Denial code 265 represents an Adjustment for administrative cost. This code is to be used for pharmaceuticals only and has been in effect since 11/01/2014, with the last modification on 07/01/2017.
195. Claim Adjustment Reason Code 266
Denial code 266 signifies an Adjustment for compound preparation cost. This code is to be used for pharmaceuticals only and has been effective since 11/01/2014, with the last modification on 07/01/2017.
196. Claim Adjustment Reason Code 267
Denial code 267 indicates that the claim/service spans multiple months. At least one Remark Code must be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code 267 has been in effect since 11/01/2014, with the last modification on 04/01/2015.
197. Claim Adjustment Reason Code 268
Denial code 268 signifies that the claim spans two calendar years and advises to resubmit one claim per calendar year. This denial was implemented on 11/01/2014.
198. Claim Adjustment Reason Code 269
Denial code 269 indicates that anesthesia is not covered for this service/procedure. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code 269 has been effective since 03/01/2015, with the last modification on 07/01/2017.
199. Claim Adjustment Reason Code 270
Denial code 270 signifies that the claim was received by the medical plan, but benefits are not available under this plan. It advises to submit these services to the patient’s dental plan for further consideration. Denial code 270 has been in effect since 07/01/2015, with the last modification on 11/01/2017.
200. Claim Adjustment Reason Code 271
Denial code 271 represents prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. This denial should be used only with Group Code OA and has been effective since 11/01/2015, with the last modification on 03/01/2018.
201. Claim Adjustment Reason Code 272
Denial code 272 indicates that coverage/program guidelines were not met. This denial was initiated on 11/01/2015.
202. Claim Adjustment Reason Code 273
Denial code 273 signifies that coverage/program guidelines were exceeded. This denial has been effective since 11/01/2015.
203. Claim Adjustment Reason Code 274
Denial code 274 indicates that the fee/service is not payable per patient Care Coordination arrangement. This denial was implemented on 11/01/2015.
204. Claim Adjustment Reason Code 275
Denial code 275 signifies that the prior payer’s (or payers’) patient responsibility (deductible, coinsurance, co-payment) is not covered. This denial should be used only with Group Code PR and has been in effect since 11/01/2015.
205. Claim Adjustment Reason Code 276
Denial code 276 indicates that services denied by the prior payer(s) are not covered by this payer. This denial was initiated on 11/01/2015.
206. Claim Adjustment Reason Code 277
Denial code 277 signifies that the disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This denial advises that the claim/service will be reversed and corrected when the grace period ends due to premium payment or lack of premium payment. It should be used during the 31-day SHOP grace period and was implemented on 11/01/2015.
207. Claim Adjustment Reason Code 278
Denial code 278 indicates that performance program proficiency requirements were not met. This denial should be used only with Group Codes CO or PI. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code 278 has been effective since 07/01/2016, with the last modification on 07/01/2017.
208. Claim Adjustment Reason Code 279
Denial code 279 signifies that services were not provided by Preferred network providers. This denial should be used when there are member network limitations, such as using contracted providers not in the member’s ‘narrow’ network. Denial code 279 has been in effect since 11/01/2016, with the last modification on 07/01/2017.
209. Claim Adjustment Reason Code 280
Denial code 280 indicates that the claim was received by the medical plan, but benefits are not available under this plan. It advises to submit these services to the patient’s Pharmacy plan for further consideration. Denial code 280 has been effective since 03/01/2017, with the last modification on 11/01/2017.
210. Claim Adjustment Reason Code 281
Denial code 281 signifies that the deductible was waived per contractual agreement. This denial should be used only with Group Code CO and has been in effect since 07/01/2017.
211. Claim Adjustment Reason Code 282
Denial code 282 indicates that the procedure/revenue code is inconsistent with the type of bill. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code 282 has been implemented on 07/01/2017.
212. Claim Adjustment Reason Code 283
Denial code 283 signifies that the attending provider is not eligible to provide direction of care. This denial was initiated on 11/01/2017.
213. Claim Adjustment Reason Code 284
Denial code 284 indicates that precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. This denial has been effective since 11/01/2017.
214. Claim Adjustment Reason Code 285
Denial code 285 represents that appeal procedures were not followed. This denial was implemented on 11/01/2017.
215. Claim Adjustment Reason Code 286
Denial code 286 signifies that appeal time limits were not met. This denial has been effective since 11/01/2017.
216. Claim Adjustment Reason Code 287
Denial code 287 indicates that the referral exceeded. This denial was initiated on 11/01/2017.
217. Claim Adjustment Reason Code 288
Denial code 288 signifies that the referral was absent. This denial has been effective since 11/01/2017.
218. Claim Adjustment Reason Code 289
Denial code 289 indicates that services were considered under the dental and medical plans, but benefits are not available. This denial advises to see also CARCs 254, 270, and 280. Denial code 289 has been in effect since 11/01/2017.
219. Claim Adjustment Reason Code 290
Denial code 290 represents that the claim was received by the dental plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s medical plan for further consideration. Denial code 290 has been effective since 11/01/2017.
220. Claim Adjustment Reason Code 291
Denial code 291 indicates that the claim was received by the medical plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s dental plan for further consideration. Denial code 291 has been in effect since 11/01/2017.
221. Claim Adjustment Reason Code 292
Denial code 292 signifies that the claim was received by the medical plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s pharmacy plan for further consideration. Denial code 292 has been implemented on 11/01/2017.
222. Claim Adjustment Reason Code 293
Denial code 293 indicates that a payment was made to the employer. This denial has been effective since 05/01/2018.
223. Claim Adjustment Reason Code 294
Denial code 294 signifies that a payment was made to the attorney. This denial was initiated on 11/01/2017.
224. Claim Adjustment Reason Code 295
Denial code 295 represents Pharmacy Direct/Indirect Remuneration (DIR). This denial has been effective since 03/01/2018.
225. Claim Adjustment Reason Code 296
Denial code 296 indicates that the precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. This denial has been in effect since 07/01/2018.
226. Claim Adjustment Reason Code 297
Denial code 297 signifies that the claim was received by the medical plan, but benefits are not available under this plan. It advises to submit these services to the patient’s vision plan for further consideration. Denial code 297 has been implemented on 03/01/2019.
227. Claim Adjustment Reason Code 298
Denial code 298 indicates that the claim was received by the medical plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s vision plan for further consideration. Denial code 298 has been effective since 03/01/2019.
228. Claim Adjustment Reason Code 299
Denial code 299 signifies that the billing provider is not eligible to receive payment for the service billed. This denial has been in effect since 07/01/2019.
229. Claim Adjustment Reason Code 300
Denial code 300 indicates that the claim was received by the Medical Plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s Behavioral Health Plan for further consideration. Denial code 300 has been implemented on 07/01/2019.
230. Claim Adjustment Reason Code 301
Denial code 301 signifies that the claim was received by the Medical Plan, but benefits are not available under this plan. It advises to submit these services to the patient’s Behavioral Health Plan for further consideration. Denial code 301 has been effective since 07/01/2019.
231. Claim Adjustment Reason Code 302
Denial code 302 indicates that the precertification/notification/authorization/pre-treatment time limit has expired. This denial was initiated on 11/01/2020.
232. Claim Adjustment Reason Code 303
Denial code 303 signifies that the prior payer’s (or payers’) patient responsibility (deductible, coinsurance, co-payment) is not covered for Qualified Medicare and Medicaid Beneficiaries. This denial should be used only with Group Code CO and has been effective since 07/01/2021.
233. Claim Adjustment Reason Code 304
Denial code 304 indicates that the claim was received by the medical plan, but benefits are not available under this plan. It advises to submit these services to the patient’s hearing plan for further consideration. Denial code 304 has been implemented on 03/01/2022.
234. Claim Adjustment Reason Code 305
Denial code 305 signifies that the claim was received by the medical plan, but benefits are not available under this plan. It advises that the claim has been forwarded to the patient’s hearing plan for further consideration. Denial code 305 has been effective since 03/01/2022.
235. Claim Adjustment Reason Code A0
Denial code A0 represents a Patient refund amount. This denial has been effective since 01/01/1995.
236. Claim Adjustment Reason Code A1
Denial code A1 indicates that the claim/service was denied. At least one Remark Code must be provided, which may consist of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT. Denial code A1 should be used when a more specific Claim Adjustment Reason Code is not available. It has been in effect since 01/01/1995, with the last modification on 11/16/2022.
237. Claim Adjustment Reason Code A5
Denial code A5 signifies Medicare Claim PPS Capital Cost Outlier Amount. This denial has been effective since 01/01/1995.
238. Claim Adjustment Reason Code A6
Denial code A6 indicates that the prior hospitalization or 30-day transfer requirement was not met. This denial has been in effect since 01/01/1995.
239. Claim Adjustment Reason Code A8
Denial code A8 represents an Ungroupable DRG. This denial has been effective since 01/01/1995, with the last modification on 09/30/2007.
240. Claim Adjustment Reason Code B1
Denial code B1 signifies Non-covered visits. This denial has been in effect since 01/01/1995.
241. Claim Adjustment Reason Code B4
Denial code B4 indicates a Late filing penalty. This denial has been effective since 01/01/1995.
242. Claim Adjustment Reason Code B7
Denial code B7 signifies that the provider was not certified/eligible to be paid for the procedure/service on the date of service. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code B7 has been in effect since 01/01/1995, with the last modification on 07/01/2017.
243. Claim Adjustment Reason Code B8
Denial code B8 indicates that alternative services were available and should have been utilized. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code B8 has been effective since 01/01/1995, with the last modification on 07/01/2017.
244. Claim Adjustment Reason Code B9
Denial code B9 signifies that the patient is enrolled in a Hospice. This denial has been in effect since 01/01/1995, with the last modification on 09/30/2007.
245. Claim Adjustment Reason Code B10
Denial code B10 indicates that the 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. This denial has been effective since 01/01/1995.
246. Claim Adjustment Reason Code B11
Denial code B11 signifies that the claim/service has been transferred to the proper payer/processor for processing. The claim/service is not covered by this payer/processor. This denial has been in effect since 01/01/1995.
247. Claim Adjustment Reason Code B12
Denial code B12 indicates that services were not documented in the patient’s medical records. This denial has been effective since 01/01/1995, with the last modification on 03/01/2018.
249. Claim Adjustment Reason Code B13
Denial code B13 signifies that the claim/service was previously paid. Payment for this claim/service may have been provided in a previous payment. This denial has been in effect since 01/01/1995.
249. Claim Adjustment Reason Code B14
Denial code B14 indicates that only one visit or consultation per physician per day is covered. This denial has been effective since 01/01/1995, with the last modification on 09/30/2007.
250. Claim Adjustment Reason Code B15
Denial code B15 signifies that the service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. It is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present. Denial code B15 has been in effect since 01/01/1995, with the last modification on 07/01/2017.
251. Claim Adjustment Reason Code B16
Denial code B16 indicates that ‘New Patient’ qualifications were not met. This denial has been effective since 01/01/1995, with the last modification on 09/30/2007.
252. Claim Adjustment Reason Code B20
Denial code B20 signifies that the procedure/service was partially or fully furnished by another provider. This denial has been effective since 01/01/1995, with the last modification on 09/30/2007.
253. Claim Adjustment Reason Code B22
Denial code B22 represents that the payment is adjusted based on the diagnosis. This denial has been effective since 01/01/1995, with the last modification on 02/28/2001.
254. Claim Adjustment Reason Code B23
Denial code B23 indicates that the procedure billed is not authorized per the Clinical Laboratory Improvement Amendment (CLIA) proficiency test. This denial has been effective since 01/01/1995, with the last modification on 09/30/2007.
255. Claim Adjustment Reason Code P1
Denial code P1 signifies a State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. This denial is to be used for Property and Casualty only. Denial code P1 has been in effect since 11/01/2013.
256. Claim Adjustment Reason Code P2
Denial code P2 indicates that it is not a work-related injury/illness and thus not the liability of the workers’ compensation carrier. This denial is to be used for Workers’ Compensation only. It has been effective since 11/01/2013, with the last modification on 07/01/2017.
257. Claim Adjustment Reason Code P3
Denial code P3 signifies that the Workers’ Compensation case has been settled. The patient is responsible for the amount of this claim/service through a WC ‘Medicare set aside arrangement’ or other agreement. This denial is to be used for Workers’ Compensation only and should be used only with Group Code PR. Denial code P3 has been effective since 11/01/2013.
258. Claim Adjustment Reason Code P4
Denial code P4 indicates that the Workers’ Compensation claim has been adjudicated as non-compensable. This payer is not liable for the claim or service/treatment. This denial is to be used for Workers’ Compensation only. It has been effective since 11/01/2013, with the last modification on 07/01/2017.
259. Claim Adjustment Reason Code P5
Denial code P5 signifies that the payment is based on payer reasonable and customary fees. There is no maximum allowable defined by a legislated fee arrangement. This denial is to be used for Property and Casualty only and has been effective since 11/01/2013.
260. Claim Adjustment Reason Code P6
Denial code P6 indicates that the payment is based on entitlement to benefits. This denial is to be used for Property and Casualty only. It has been effective since 11/01/2013, with the last modification on 07/01/2017.
261. Claim Adjustment Reason Code P7
Denial code P7 signifies that the applicable fee schedule/fee database does not contain the billed code. It advises to resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. This denial is to be used for Property and Casualty only and has been effective since 11/01/2013.
262. Claim Adjustment Reason Code P8
Denial code P8 indicates that the claim is under investigation. This denial is to be used for Property and Casualty only. It has been effective since 11/01/2013, with the last modification on 07/01/2017.
226. Claim Adjustment Reason Code P9
Denial code P9 signifies that there is no available or correlating CPT/HCPCS code to describe this service. This denial is to be used for Property and Casualty only and has been effective since 11/01/2013.
227. Claim Adjustment Reason Code P10
Denial code P10 signifies that the payment has been reduced to zero due to ongoing litigation. This code is specifically used for Property and Casualty claims. Additional information regarding the payment status will be sent once the litigation concludes. Denial code P10 has been in effect since 11/01/2013 and has replaced the previously deactivated code 244.
228. Claim Adjustment Reason Code P11
Denial code P11 indicates that the disposition of the related Property & Casualty claim, whether injury or illness, is pending due to ongoing litigation. This code is to be used exclusively for Property and Casualty claims and should only be used in conjunction with Group Code OA. Denial code P11 has been effective since 11/01/2013, replacing the deactivated code 255.
229. Claim Adjustment Reason Code P12
Denial code P12 represents a Workers’ Compensation jurisdictional fee schedule adjustment. This code is utilized when adjustments are made at either the Claim Level or Line Level, with specific instructions for both scenarios provided for payers and providers. Denial code P12 is exclusive to Workers’ Compensation claims and has been in effect since 11/01/2013, replacing the deactivated code W1.
230. Claim Adjustment Reason Code P13
Denial code P13 indicates that the payment has been reduced or denied based on workers’ compensation jurisdictional regulations or payment policies. This code should be used when no other applicable code is suitable for the adjustment. Denial code P13 is specific to Workers’ Compensation claims and has been effective since 11/01/2013, replacing the deactivated code W2.
231. Claim Adjustment Reason Code P14
Denial code P14 signifies that the benefit for a particular service is included in the payment or allowance for another service or procedure performed on the same day. This code is to be used exclusively for Property and Casualty claims and has been in effect since 11/01/2013, replacing the deactivated code W3.
232. Claim Adjustment Reason Code P15
Denial code P15 represents a Workers’ Compensation Medical Treatment Guideline Adjustment. This code is specifically designated for Workers’ Compensation claims and has been effective since 11/01/2013, replacing the deactivated code W4.
233. Claim Adjustment Reason Code P16
Denial code P16 indicates that the medical provider is not authorized or certified to provide treatment to injured workers in a particular jurisdiction. This code is exclusive to Workers’ Compensation claims and should be used with Group Code CO or OA. Denial code P16 has been in effect since 11/01/2013, replacing the deactivated code W5.
234. Claim Adjustment Reason Code P17
Denial code P17 signifies that a referral was not authorized by the attending physician as per regulatory requirements. This code is to be used solely for Property and Casualty claims and has been effective since 11/01/2013, replacing the deactivated code W6.
235. Claim Adjustment Reason Code P18
Denial code P18 indicates that a procedure is not listed in the jurisdiction fee schedule, but an allowance has been made for a comparable service. This code is specific to Property and Casualty claims and has been in effect since 11/01/2013, replacing the deactivated code W7.
236. Claim Adjustment Reason Code P19
Denial code P19 signifies that a procedure has a relative value of zero in the jurisdiction fee schedule, resulting in no payment being due. This code is to be used exclusively for Property and Casualty claims and has been effective since 11/01/2013, replacing the deactivated code W8.
237. Claim Adjustment Reason Code P20
Denial code P20 indicates that the service was not paid under the jurisdiction’s allowed outpatient facility fee schedule. This code is specific to Property and Casualty claims and has been in effect since 11/01/2013, replacing the deactivated code W9.
238. Claim Adjustment Reason Code P21
Denial code P21 represents a payment denial based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies. This code is to be used exclusively for Property and Casualty Auto claims and has been effective since 11/01/2013, with a modification last made on 03/01/2018. Denial code P21 replaces the deactivated code Y1.
239. Claim Adjustment Reason Code P22
Denial code P22 signifies that the payment has been adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies. This code is specific to Property and Casualty Auto claims and has been effective since 11/01/2013, with a modification last made on 03/01/2018. Denial code P22 replaces the deactivated code Y2.
240. Claim Adjustment Reason Code P23
Denial code P23 represents a Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. This code is exclusive to Property and Casualty Auto claims and has been in effect since 11/01/2013, with a modification last made on 07/01/2017. Denial code P23 replaces the deactivated code Y3.
241. Claim Adjustment Reason Code P24
Denial code P24 indicates that the payment has been adjusted based on a Preferred Provider Organization (PPO). This code is specific to Property and Casualty claims and should only be used with Group Code CO. Denial code P24 has been effective since 11/01/2017.
242. Claim Adjustment Reason Code P25
Denial code P25 signifies that the payment has been adjusted based on a Medical Provider Network (MPN). This code is exclusive to Property and Casualty claims and should only be used with Group Code CO. Denial code P25 has been effective since 11/01/2017.
243. Claim Adjustment Reason Code P26
Denial code P26 represents a payment adjustment based on a Voluntary Provider Network (VPN). This code is specific to Property and Casualty claims and should only be used with Group Code CO. Denial code P26 has been effective since 11/01/2017.
244. Claim Adjustment Reason Code P27
Denial code P27 signifies that the payment has been denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. This code is to be used exclusively for Property and Casualty Auto claims and has been effective since 11/01/2017.
245. Claim Adjustment Reason Code P28
Denial code P28 indicates that the payment has been adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. This code is specific to Property and Casualty Auto claims and has been effective since 11/01/2017.
246. Claim Adjustment Reason Code P29
Denial code P29 represents a Liability Benefits jurisdictional fee schedule adjustment. This code is exclusive to Property and Casualty Auto claims and has been effective since 11/01/2017.
247. Claim Adjustment Reason Code P30
Denial code P30 signifies that the payment has been denied for exacerbation when supporting documentation was incomplete. This code is specific to Property and Casualty claims and has been effective since 11/01/2020.
248. Claim Adjustment Reason Code P31
Denial code P31 indicates that the payment has been denied for exacerbation when the treatment exceeds the allowed time. This code is exclusive to Property and Casualty claims and has been effective since 11/01/2020.
249. Claim Adjustment Reason Code P32
Denial code P32 represents a payment adjustment due to Apportionment. This code has been effective since 08/01/2022.
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