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 NPI registered in PECOS

How to Avoid Future Denials

  • Verify that ordering physician NPI is on list of physicians and other non-physician practitioners enrolled in PECOS. Even if a provider has an individual NPI, it does not mean that his/her enrollment record is in PECOS and/or is active. Verification of enrollment in PECOS can be done by:
    • Checking the CMS ordering/referring provider downloadable report containing the NPI, first name, and last name of providers enrolled in PECOS.
  • Be sure name and NPI entered for ordering provider belongs to a physician or non-physician practitioner. A group NPI cannot be used as ordering NPI on a Medicare claim. In addition, be sure qualifier in electronic claim (2310A NM102 loop) is a 1 (person). Organizations (qualifier 2) cannot order and refer

 

Last Updated Dec 09 , 2023