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ADJUSTMENT REASON CODES REASON CODE DESCRIPTION
1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount
4
The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
5 The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
6 The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
7 The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
9
The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
10
The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
11
The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
12
The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 13 The date of death precedes the date of service. 14 The date of birth follows the date of service. (^15) The authorization number is missing, invalid, or does not apply to the billed services or provider.
Claim/service lacks information which is needed for adjudication. 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.)
Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
18
Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use only with Group Code OA)
(^19) This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20 This injury/illness is covered by the liability carrier. 21 This injury/illness is the liability of the no-fault carrier. 22 This care may be covered by another payer per coordination of benefits.
23 The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
24 Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your Stop loss deductible has not been met. 26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated. 28 Coverage not in effect at the time the service was provided. 29 The time limit for filing has expired.
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
31 Patient cannot be identified as our insured. 32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Insured has no dependent coverage. 34 Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached. 36 Balance does not exceed co-payment amount. 37 Balance does not exceed deductible.
38 Services not provided or authorized by designated (network/primary care) providers. 39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
41 Discount agreed to in Preferred Provider contract. 42 Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
43 Gramm-Rudman reduction. 44 Prompt-pay discount.
45
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
46 This (these) service(s) is (are) not covered. 47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48 This (these) procedure(s) is (are) not covered.
49
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
51 These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
55 Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
94 Processed in Excess of charges. 95 Plan procedures not followed.
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 98 The hospital must file the Medicare claim for this inpatient non-physician service. 99 Medicare Secondary Payer Adjustment Amount. 100 Payment made to patient/insured/responsible party/employer.
(^101) Predetermination: anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment. 103 Provider promotional discount (e.g., Senior citizen discount).
104 Managed care withholding. 105 Tax withholding. 106 Patient payment option/election not in effect.
107 The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
108
Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
109
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
110 Billing date predates service date. 111 Not covered unless the provider accepts assignment.
112 Service not furnished directly to the patient and/or not documented.
113
Payment denied because service/procedure was provided outside the United States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Procedure postponed, canceled, or delayed.
(^116) The advance indemnification notice signed by the patient did not comply with requirements.
117 Transportation is only covered to the closest facility that can provide the necessary care.
118 ESRD network support adjustment. 119 Benefit maximum for this time period or occurrence has been reached. 120 Patient is covered by a managed care plan.
121 Indemnification adjustment - compensation for outstanding member responsibility. 122 Psychiatric reduction.
123 Payer refund due to overpayment. 124 Payer refund amount - not our patient.
125 Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
126 Deductible -- Major Medical 127 Coinsurance -- Major Medical
128 Newborn's services are covered in the mother's Allowance.
Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
130 Claim submission fee.
131 Claim specific negotiated discount. 132 Prearranged demonstration project adjustment.
The disposition of the claim/service is pending further review. (Use only with Group Code OA). Note: Use of this code requires a reversal and correction when the service line is finalized ( use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).
134 Technical fees removed from charges.
135 Interim bills cannot be processed.
136
Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective 7/1/2013: Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 Appeal procedures not followed or time limits not met. 139 Contracted funding agreement - Subscriber is employed by the provider of services.
140 Patient/Insured health identification number and name do not match. 141 Claim spans eligible and ineligible periods of coverage. 142 Monthly Medicaid patient liability amount.
143 Portion of payment deferred. 144 Incentive adjustment, e.g. preferred product/service.
145 Premium payment withholding 146 Diagnosis was invalid for the date(s) of service reported. 147 Provider contracted/negotiated rate expired or not on file.
Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
149 Lifetime benefit maximum has been reached for this service/benefit category. 150 Payer deems the information submitted does not support this level of service.
151
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
153 Payer deems the information submitted does not support this dosage. 154 Payer deems the information submitted does not support this day's supply.
155 Patient refused the service/procedure. 156 Flexible spending account payments. Note: Use code 187. 157 Service/procedure was provided as a result of an act of war.
158 Service/procedure was provided outside of the United States. 159 Service/procedure was provided as a result of terrorism.
160 Injury/illness was the result of an activity that is a benefit exclusion. 161 Provider performance bonus
162
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
163 Attachment referenced on the claim was not received. 164 Attachment referenced on the claim was not received in a timely fashion.
Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
193 Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
(^194) Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
195 Refund issued to an erroneous priority payer for this claim/service. 196 Claim/service denied based on prior payer's coverage determination. 197 Precertification/authorization/notification absent.
198 Precertification/authorization exceeded. 199 Revenue code and Procedure code do not match.
200 Expenses incurred during lapse in coverage
Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. ( Use only with Group Code PR) At least on remark code must be provider (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an alert.)
202 Non-covered personal comfort or convenience services. 203 Discontinued or reduced service.
204 This service/equipment/drug is not covered under the patients current benefit plan 205 Pharmacy discount card processing fee
206 National Provider Identifier - missing. 207 National Provider identifier - Invalid format 208 National Provider Identifier - Not matched.
Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)
(^210) Payment adjusted because pre-certification/authorization not received in a timely fashion
211 National Drug Codes (NDC) not eligible for rebate, are not covered.
212 Administrative surcharges are not covered 213 Non-compliance with the physician self referral prohibition legislation or payer policy.
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
215 Based on subrogation of a third party settlement 216 Based on the findings of a review organization
217 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)
Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This change effective 7/1/2013: Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)
Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
223
Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
224
Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
(^225) Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) This change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
228 Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an alert.
The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an Alert).
An attachment is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
253 Sequestration - reduction in federal payment
254
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
255
The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
256 Service not payable per managed care contract.
The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lace of premium payment). (Use only with Group Code OA)
258
Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
259 Additional payment for Dental/Vision service utilization 260 Processed under Medicaid ACA Enhance Fee Schedule
261 The procedure or service is inconsistent with the patient's history. 262 Adjustment for delivery cost. Note: to be used for pharmaceuticals only. 263 Adjustment for shipping cost. Note: To be used for pharmaceuticals only.
264 Adjustment for postage cost. Note: To be used for pharmaceuticals only. 265 Adjustment for administrative cost. Note: To be used for pharmaceuticals only.
266 Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only. 267 Claim/service spans multiple months. Rebill as a separate claim/service.
268 The Claim spans two calendar years. Please resubmit on claim per calendar year. A0 Patient refund amount.
A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) A2 Contractual adjustment. A3 Medicare Secondary Payer liability met. A4 Medicare Claim PPS Capital Day Outlier Amount. A5 Medicare Claim PPS Capital Cost Outlier Amount. A6 Prior hospitalization or 30 day transfer requirement not met. A7 Presumptive Payment Adjustment A8 Ungroupable DRG. B1 Non-covered visits.
B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
B
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. B12 Services not documented in patients' medical records.
B13 (^) Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Only one visit or consultation per physician per day is covered.
B
This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B16 'New Patient' qualifications were not met.
B
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B18 This procedure code and modifier were invalid on the date of service. B19 Claim/service adjusted because of the finding of a Review Organization. B2 Covered visits. B20 Procedure/service was partially or fully furnished by another provider.
B21 (^) The charges were reduced because the service/care was partially furnished by another physician. B22 This payment is adjusted based on the diagnosis.
B
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. B3 Covered charges. B4 Late filing penalty. B5 Coverage/program guidelines were not met or were exceeded.
B
This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B8 Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B9 Patient is enrolled in a Hospice. D1 Claim/service denied. Level of subluxation is missing or inadequate.
D10 Claim/service denied. Completed physician financial relationship form not on file. D11 Claim lacks completed pacemaker registration form.
D
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
D
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
D14 Claim lacks indication that plan of treatment is on file. D15 Claim lacks indication that service was supervised or evaluated by a physician.
D16 Claim lacks prior payer payment information. D17 Claim/Service has invalid non-covered days. D18 Claim/Service has missing diagnosis information.
D19 Claim/Service lacks Physician/Operative or other supporting documentation D2 Claim lacks the name, strength, or dosage of the drug furnished.
D20 Claim/Service missing service/product information. D21 This (these) diagnosis(es) is (are) missing or are invalid
P
Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.
P
Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.
P
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
P
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
P
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
P
Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)
P
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
P
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.
P
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
P
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.
P
Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
P
No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.
W
Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
W
Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.
W
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
W4 Workers' Compensation Medical Treatment Guideline Adjustment.
W
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction (Use with Group Code CO or OA)
W6 Referral not authorized by attending physician per regulatory requirement
W
Procedure is not listed in the jurisdiction fee schedule. A allowance has been made for a comparable service.
W8 (^) Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
W9 Service not paid under jurisdiction allowed outpatient facility fee schedule.
Y
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only.
Y
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only.
