| Alternative Services Available | - PR-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.
|
| Bundling/Not Separately Payable | - CO-B15: 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.
- M80: Not covered when performed during the same session/date as a previously processed service for this patient.
|
| Chiropractic Services – Initial Treatment Date | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- MA121: Missing/incomplete/invalid x-ray date.
- MA122: Missing/incomplete/invalid initial treatment date.
|
| Claim Paid at Maximum Allowed Amount | - CO-45: 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.
- PR-45: 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.
|
| CLIA Certification Number - Missing/Invalid | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- MA120: Missing/incomplete/invalid CLIA certification number
|
| CLIA: Invalid Credentials | - CO-B7: 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.
- N570: Missing/incomplete/invalid credentialing data.
|
| Code to Highest Level of Specificity | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- M81: You are required to code to the highest level of specificity.
|
| Coordination of Benefits | - CO-22: This care may be covered by another payer per coordination of benefits.
- N598: Health care policy coverage is primary.
|
| Duplicate Claim/Service | - CO-97: 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.
- CO-B20: Procedure/service was partially or fully furnished by another provider.
- N111: No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
|
| Electronic Claim Submission Requirement | - CO-96: Non-covered charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
- M117: Not covered unless submitted via electronic claim.
|
| Hospice | - PR-B9: Patient is enrolled in a Hospice.
|
| Incarcerated Beneficiary | - N103: Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered.
|
| Medical Necessity/No Payable Diagnosis | - CO-50: 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.
|
| Medicare Advantage Plan | - CO-24: Charges are covered under a capitation agreement/managed care plan.
|
| Medicare is Secondary Payer | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- MA04: 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.
|
| Missing/Incorrect Required Claim Information | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- M51: Missing/incomplete/invalid procedure code(s).
- N56: Procedure code billed is not correct/valid for the services billed or the date of service billed.
|
| Missing/Incorrect Required NPI Information | - CO-16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- N290: Missing/incomplete/invalid rendering provider primary identifier.
- N257: Missing/incomplete/invalid billing provider/supplier primary identifier.
|
| Missing or Invalid Order/Referring Provider Information | - N264: Missing/incomplete/invalid ordering provider name
- N265: Missing/incomplete/invalid ordering provider primary identifier
- CO-16: Provider liable
|
| MUE - Number of Days or Units of Service Exceeds Acceptable Maximum | - CO-96: Non-covered charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
- N362: The number of Days or Units of Service exceeds our acceptable maximum.
|
| Non-Covered Charge | - CO-96: Non-covered charge(s). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
- N431: Not covered with this procedure.
|
| Patient Cannot Be Identified | - CO-31: Patient cannot be identified as our insured.
- PR-31: Patient cannot be identified as our insured.
- CO-140: Patient/Insured health identification number and name do not match.
|
| Postoperative Care / Bundled Services | - CO-97: 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.
- M15: Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
|
| Related or Qualifying Claim / Service Not Identified on Claim | - CO-107: 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.
|
| Routine Service | - PR-49: 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.
- N111: No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
|
- 03/07/2019