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.

The Washington Publishing Company 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
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Reason Code Remark Code(s) Denial Denial Description
  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.
16 M51 | N56 Missing/Incorrect Required Claim Information
  • Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
  • 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) which is needed for adjudication.
  • 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) which is needed for adjudication.
  • 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 MA120 CLIA Certification Number - Missing/Invalid
  • Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
  • Missing/incomplete/invalid CLIA certification number
16 MA121 | MA122 Chiropractic Services – Initial Treatment Date
  • Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
  • Missing/incomplete/invalid x-ray date.
  • Missing/incomplete/invalid initial treatment date.
16 N264 | N265 Missing or Invalid Order/Referring Provider Information
  • Missing/incomplete/invalid ordering provider name
  • Missing/incomplete/invalid ordering provider primary identifier
  • Provider liable
16 N290 | N257 Missing/Incorrect Required NPI Information
  • Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
  • Missing/incomplete/invalid rendering provider primary identifier.
  • Missing/incomplete/invalid billing provider/supplier primary identifier.
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.
31 | 140   Patient Cannot Be Identified
  • Patient cannot be identified as our insured.
  • Patient/Insured health identification number and name do not match.
45   Claim Paid at Maximum Allowed Amount
  • Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: 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 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. Note: 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.
50   Medical Necessity/No Payable Diagnosis
  • 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.
96 M117 Electronic Claim Submission Requirement
  • Non-covered charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • Not covered unless submitted via electronic claim.
96 N362 MUE - Number of Days or Units of Service Exceeds Acceptable Maximum
  • Non-covered charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  • The number of Days or Units of Service exceeds our acceptable maximum.
96 N341 Non-Covered Charge
  • Non-covered charge(s). Note: 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. Note: 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 | 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. Note: 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
  • 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.
B7 N570 CLIA: Invalid Credentials
  • 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.
  • Missing/incomplete/invalid credentialing data.
B8   Alternative Services Available
  • 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   Hospice
  • Patient is enrolled in a Hospice.
B15 M80 Bundling/Not Separately Payable
  • 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.
  • Not covered when performed during the same session/date as a previously processed service for this patient.

 

 

Last Updated Jul 24, 2019