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Reason Code Guidance

Below are the most common claim submission error codes, descriptions of the issues and potential solutions.

Watch the below list continue to expand as reason codes are added and updates made.

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Denial Claim Adjustment Reason Code (CARC)/ Remittance Advice Remark Code (RARC) and Description
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.

 

Last Updated Jan 10, 2017