They will help tell you how the claim is processed and if there is a balance, who is responsible for it. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Item does not meet the criteria for the category under which it was billed. 65 Procedure code was incorrect. An allowance has been made for a comparable service. Procedure/service was partially or fully furnished by another provider. 25 Payment denied. Verify that ordering physician NPI is on list of physicians and other non-physician practitioners enrolled in PECOS. About Claim Adjustment Group Codes Maintenance Request Status Maintenance Request Form 11/16/2022 Filter by code: Reset Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Denial Code - 5 is "Px code/ bill type is inconsistent with the POS", The procedure code/ revenue code is inconsistent with the patient's age, The procedure code/ revenue code is inconsistent with the Patient's gender, The procedure code is inconsistent with the provider type/speciality (Taxonomy), The Diagnosis Code is inconsistent with the patient's age, The Diagnosis Code is inconsistent with the patient's gender, The Diagnosis code is inconsistent with the provider type, The Date of Death Precedes Date of Service.
Explanation of Benefits (EOB) Lookup - Washington State Department of CDT is a trademark of the ADA. 177 Patient has not met the required eligibility requirements. 1. 189 Not otherwise classified or unlisted procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. The following are the most common reasons HCFA/CMS-1500 and UB/CMS-1450 paper claims for Veteran care are rejected: Requires the 17 alpha-numeric internal control number (ICN) [format: 10 digits + "V" + 6 digits] or 9-digit social security number (SSN) with no special characters. 133 The disposition of the claim/service is pending further review. The AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. 210 Payment adjusted because pre-certification/authorization not received in a timely fashion. Select the Reason or Remark code link below to review supplier solutions to the denial and/or how to avoid the same denial in the future. Reason Code 16 | Remark Codes MA13 N265 N276 Code Description Reason Code: 16 Claim/service lacks information or has submission/billing error (s) which is needed for adjudication. 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Your Stop loss deductible has not been met. 27 Expenses incurred after coverage terminated. Benefits are not available under this dental plan. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. This service/procedure requires that a qualifying service/procedure be received and covered. The ADA does not directly or indirectly practice medicine or dispense dental services. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. PR 35 Lifetime benefit maximum has been reached. 56 Procedure/treatment has not been deemed proven to be effective by the payer.
Reason Code 16 | Remark Codes MA13 N265 N276 - JD DME 35 Lifetime benefit maximum has been reached. All rights reserved. THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. The AMA does not directly or indirectly practice medicine or dispense medical services. PR Patient Responsibility. Reproduced with permission. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. if(pathArray[4]){document.getElementById("usprov").href="/web/"+pathArray[4]+"/help/us-government-rights";} Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. 78 Non-Covered days/Room charge adjustment. End Users do not act for or on behalf of the CMS. Was beneficiary inpatient on date of service? 28 Coverage not in effect at the time the service was provided. Do not use this code for claims attachment(s)/other documentation. CPT codes, descriptions and other data only are copyright 2002-2020 American Medical Association (AMA). Main equipment is missing therefore Medicare will not pay for supplies, Item(s) billed did not have a valid ordering physician name, Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS). Any questions pertaining to the license or use of the CPT must be addressed to the AMA. These materials contain Current Dental Terminology, (CDT), copyright 2020 American Dental Association (ADA). D11 Claim lacks completed pacemaker registration form. Applications are available at the American Dental Association web site, http://www.ADA.org. CMS Disclaimer LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) Medical Billing Denial Codes are standard letters used to provide or describe the information to a patient or medical provider for why an insurance company is denying a claim. No fee schedules, basic unit, relative values or related listings are included in CPT. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. PR 31 Claim denied as patient cannot be identified as our insured. See the payer's claim submission instructions. The ADA is a third-party beneficiary to this Agreement. Procedure code billed is not correct/valid for the services billed or the date of service billed, This decision was based on a Local Coverage Determination (LCD). Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Any questions pertaining to the license or use of the CDT should be addressed to the ADA. Claim did not include patients medical record for the service. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR). 2023 Noridian Healthcare Solutions, LLC Terms & Privacy. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. Claim/service lacks information or has submission/billing error(s). CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. 207 National Provider identifier Invalid format. 39 Services denied at the time authorization/pre-certification was requested. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The scope of this license is determined by the AMA, the copyright holder. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. Non-covered charge(s). 3. 5 The procedure code/bill type is inconsistent with the place of service. Diagnosis Code: The ICD-10-CM (International Classification of Diseases) diagnosis code is a medical code that describes the condition and diagnoses of patients, whereas the ICD-10-PCS code describes inpatient procedures. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 158 Service/procedure was provided outside of the United States. An LCD provides a guide to assist in determining whether a particular item or service is covered. P2 Not a work related injury/illness and thus not the liability of the workers compensation carrier. 141 Claim spans eligible and ineligible periods of coverage. Note Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Policy frequency limits may have been reached, per LCD. Patient cannot be identified as our insured. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. 128 Newborns services are covered in the mothers Allowance. Note: The information obtained from this Noridian website application is as current as possible. Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted. California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. else{document.getElementById("usprov").href="/web/"+"jeb"+"/help/us-government-rights";}, Advance Beneficiary Notice of Noncoverage (ABN), Oral Anticancer Drugs and Oral Antiemetic Drugs, Transcutaneous Electrical Nerve Stimulators (TENS), Supplemental Medical Review Contractor (SMRC), Unified Program Integrity Contractor (UPIC), Provider Outreach and Education Advisory Group (POE AG), Healthcare Integrated General Ledger Accounting System (HIGLAS), click here to see all U.S. Government Rights Provisions, American Hospital Association Online Store, HCPCS code is inconsistent with modifier used or a required modifier is missing, Item billed was processed under DMEPOS Competitive Bidding Program and requires an appropriate competitive bid modifier, HCPCS code is inconsistent with modifier used or required modifier is missing, The procedure code/bill type is inconsistent with the place of service, Missing/incomplete/invalid place of service. 120 Patient is covered by a managed care plan. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Patient cannot be identified as our insured. PR 140 Patient/Insured health identification number and name do not match.PR 149 Lifetime benefit maximum has been reached for this service/benefit category. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. FOURTH EDITION. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. Do you have any other denial codes on these codes like an M or N denial reason. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. CO 96- Non-Covered Charges Denial (Not covered under Providers Contract) When the billed Cpt/diagnosis code not listed under the provider's contract then it called Non covered under the provider's plan. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.