Reason Code 16 | Remark Codes MA13 N264 N575

Code Description
Reason Code: 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. 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.
Remark Codes:
MA13, N264 and N575

Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

Missing/incomplete/invalid ordering provider name.

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

 

Common Reasons for Denial

  • Item(s) billed did not have a valid ordering physician name

Next Step

  • Resubmit claim with a valid ordering physician name

How to Avoid Future Denials

  • Report first and last name of ordering physician
    • Paper claim: Report ordering physician name as first name, followed by last name in Item 17 on CMS-1500 claim form, e.g., John Smith. Do not include credentials or initials in name
    • Electronic claim: Be sure first and last names are submitted in correct field. Do not reverse order
  • Report first and last name of ordering physician exactly as listed on CMS Provider Enrollment, Chain and Ownership System (PECOS) files. Can be found in below sources.
    • CMS: Check CMS ordering/referring provider downloadable report which contains NPI, first name, and last name of providers enrolled in PECOS
    • Noridian Interactive Voice Response (IVR): Call Noridian IVR and select Option 6 to enter NPI and name of referring provider. IVR will respond if individual is or is not enrolled in PECOS

 

Last Updated Apr 18, 2018