Denial Code Resolution

View the most common claim submission errors below. To access a denial description, select the applicable Reason/Remark code found on Noridian's Remittance Advice. 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.

X12 publishes the CMS-approved Reason Codes and Remark Codes.

  • Claim Adjustment Reason Codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.
  • Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing
 
Reason Code Remark Code(s) Denial Denial Description
16 M51 | N56 Missing/Incorrect Required Claim Information
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid procedure code(s).
  • Procedure code billed is not correct/valid for the services billed or the date of service billed.
16 M81 Code to Highest Level of Specificity
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • You are required to code to the highest level of specificity.
16 MA04 Medicare is Secondary Payer
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.
16 MA36 | N704 Invalid Patient Name
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
  • Missing/incomplete/invalid patient name.
  • Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
16 MA120 CLIA Certification Number - Missing/Invalid
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid CLIA certification number.
16 MA121 | MA122 Chiropractic Services – Initial Treatment Date
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid x-ray date.
  • Missing/incomplete/invalid initial treatment date.
16 N264 | N265 Missing or Invalid Order/Referring Provider Information
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid ordering provider name.
  • Missing/incomplete/invalid ordering provider primary identifier.
16 N290 | N257 Missing/Incorrect Required NPI Information
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid rendering provider primary identifier.
  • Missing/incomplete/invalid billing provider/supplier primary identifier.
16 N382 | N704 Invalid Medicare Beneficiary Identifier
  • Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
  • Missing/incomplete/invalid patient identifier.
  • Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
19 N418 Medicare Secondary Payer (MSP) Work-Related Injury or Illness
  • This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier
  • Misrouted claim. See the payer's claim submission instructions
22 N598 Coordination of Benefits
  • This care may be covered by another payer per coordination of benefits.
  • Health care policy coverage is primary.
24   Medicare Advantage Plan
  • Charges are covered under a capitation agreement/managed care plan.
29 N211 Timely Filing
  • The time limit for filing has expired.
  • Alert: You may not appeal this decision
31   Patient Cannot Be Identified
  • Patient cannot be identified as our insured.
45   Claim Paid at Maximum Allowed Amount
  • Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication.
49

N111 | N429

 Routine Service
  • This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
  • Not covered when considered routine.
50 N115 Medical Necessity/No Payable Diagnosis
  • These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available on the Medicare Coverage Database or if you do not have web access, you may contact the contractor to request a copy of the LCD.
96 M117 Electronic Claim Submission Requirement
  • Non-covered charge(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Not covered unless submitted via electronic claim.
96 N431 Non-Covered Charge
  • Non-covered charge(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Not covered with this procedure
97 M15 Postoperative Care / Bundled Services
  • The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
97 M97 Pathology During Hospital Stay
  • The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.
97 | B20 N111 Duplicate Claim/Service
  • The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Procedure/service was partially or fully furnished by another provider.
  • No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
107   Related or Qualifying Claim / Service Not Identified on Claim
  • The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
151   Medical Unlikely Edit (MUE) - Number of Days or Units of Service Exceeds Acceptable Maximum
  • Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
236   Not Separately Payable/National Correct Coding Initiative
  • This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
252 M23 |
N704		 Missing Invoice
  • An attachment/other documentation is required to adjudicate this claim/service.
  • Missing invoice.
  • Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
252 N706
N704		 Missing/Invalid Molecular Diagnostic Services (MolDX) DEX Z-Code™ Identifier.
  • An attachment/other documentation is required to adjudicate this claim/service.
  • Missing documentation.
  • Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
B7 N570 CLIA: Invalid Credentials
  • This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Missing/incomplete/invalid credentialing data.
B8   Alternative Services Available
  • Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
B9   Hospice
  • Patient is enrolled in a Hospice.
OA18 N522 Exact Duplicate Claim/Service
  • Exact duplicate claim/service
  • Duplicate of a claim processed, or to be processed, as a crossover claim
OA258 N103 Incarcerated Beneficiary
  • Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.
  • Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.

 

 

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