Claim Adjustment Reason Codes - All

1 Help | My Account | CheckoutHomeHIPAAEDI PublicationsEDI StandardsEDI Table DataCode ListsClaim AdjustmentReason Codes All To Be Deactivated Deactivated CurrentChange Request FormOn-Line Conference FAQsLAST UPDATE 7/1/2011 - ALLC laim Adjustment Reason Codes - AllClaim Adjustment Reason Codes communicate an Adjustment , meaning that theymust communicate why a Claim or service line was paid differently than it wasbilled. If there is no Adjustment to a Claim /line, then there is no Adjustment AmountStart: 01/01/19952 Coinsurance AmountStart: 01/01/19953Co-payment AmountStart: 01/01/19954 The procedure code is inconsistent with the modifier used or a required modifier ismissing.

2 Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if the code ListsElectronic FilePrinted DocumentUpdate Alert ServiceWashington Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PMStart: 01/01/1995 | Last Modified: 09/20/20095 The procedure code /bill type is inconsistent with the place of service. Note: Refer tothe 835 Healthcare Policy Identification Segment (loop 2110 Service PaymentInformation REF), if : 01/01/1995 | Last Modified: 09/20/20096 The procedure/revenue code is inconsistent with the patient's age. Note: Refer tothe 835 Healthcare Policy Identification Segment (loop 2110 Service PaymentInformation REF), if : 01/01/1995 | Last Modified: 09/20/20097 The procedure/revenue code is inconsistent with the patient's gender.

3 Note: Referto the 835 Healthcare Policy Identification Segment (loop 2110 Service PaymentInformation REF), if : 01/01/1995 | Last Modified: 09/20/20098 The procedure code is inconsistent with the provider type/specialty (taxonomy).Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 ServicePayment Information REF), if : 01/01/1995 | Last Modified: 09/20/20099 The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationREF), if : 01/01/1995 | Last Modified: 09/20/200910 The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationAARP MedicareOptionsAARP-brandedinsurance & BillingClassesAdvance YourCareer - FindLocal & Free Info!)

4 Coveragepre-service, createABNs. Hospitals,physicians, Fill & PrintNPIUB-04 Form FillerSoftwareDownload Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PMREF), if : 01/01/1995 | Last Modified: 09/20/200911 The diagnosis is inconsistent with the procedure. Note: Refer to the 835 HealthcarePolicy Identification Segment (loop 2110 Service Payment Information REF), : 01/01/1995 | Last Modified: 09/20/200912 The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationREF), if : 01/01/1995 | Last Modified: 09/20/200913 The date of death precedes the date of : 01/01/199514 The date of birth follows the date of : 01/01/199515 The authorization number is missing, invalid, or does not apply to the billedservices or : 01/01/1995 | Last Modified: 09/30/200716 Claim /service lacks information which is needed for adjudication.

5 At least oneRemark code must be provided (may be comprised of either the NCPDP RejectReason code , or Remittance Advice Remark code that is not an ALERT.)Start: 01/01/1995 | Last Modified: 09/20/200917 Requested information was not provided or was insufficient/incomplete. At leastone Remark code must be provided (may be comprised of either the RemittanceWashington Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PMAdvice Remark code or NCPDP Reject Reason code .)Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/200918 Duplicate : 01/01/199519 This is a work-related injury/illness and thus the liability of the Worker'sCompensation : 01/01/1995 | Last Modified: 09/30/200720 This injury/illness is covered by the liability : 01/01/1995 | Last Modified: 09/30/200721 This injury/illness is the liability of the no-fault : 01/01/1995 | Last Modified: 09/30/200722 This care may be covered by another payer per coordination of : 01/01/1995 | Last Modified: 09/30/200723 The impact of prior payer(s) adjudication including payments and/or : 01/01/1995 | Last Modified.

6 09/30/200724 Charges are covered under a capitation agreement/managed care : 01/01/1995 | Last Modified: 09/30/200725 Payment denied. Your Stop loss deductible has not been : 01/01/1995 | Stop: 04/01/200826 Expenses incurred prior to : 01/01/1995 Washington Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PM27 Expenses incurred after coverage : 01/01/199528 Coverage not in effect at the time the service was : 01/01/1995 | Stop: 10/16/2003 Notes: Redundant to Codes 26& time limit for filing has : 01/01/199530 Payment adjusted because the patient has not met the required eligibility, spenddown, waiting, or residency : 01/01/1995 | Stop: 02/01/200631 Patient cannot be identified as our : 01/01/1995 | Last Modified.

7 09/30/200732 Our records indicate that this dependent is not an eligible dependent as : 01/01/199533 Insured has no dependent : 01/01/1995 | Last Modified: 09/30/200734 Insured has no coverage for : 01/01/1995 | Last Modified: 09/30/200735 Lifetime benefit maximum has been : 01/01/1995 | Last Modified: 10/31/200236 Balance does not exceed co-payment : 01/01/1995 | Stop: 10/16/2003 Washington Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PM37 Balance does not exceed : 01/01/1995 | Stop: 10/16/200338 Services not provided or authorized by designated (network/primary care) : 01/01/1995 | Last Modified: 06/30/200339 Services denied at the time authorization/pre-certification was : 01/01/199540 Charges do not meet qualifications for emergent/urgent care.

8 Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationREF), if : 01/01/1995 | Last Modified: 09/20/200941 Discount agreed to in Preferred Provider : 01/01/1995 | Stop: 10/16/200342 Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/200743 Gramm-Rudman : 01/01/1995 | Stop: 07/01/200644 Prompt-pay : 01/01/199545 Charge exceeds fee schedule/maximum allowable or contracted/legislated feearrangement. (Use Group Codes PR or CO depending upon liability).Start: 01/01/1995 | Last Modified: 10/31/2006 Washington Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PM46 This (these) service(s) is (are) not : 01/01/1995 | Stop: 10/16/2003 Notes: Use code (these) diagnosis(es) is (are) not covered, missing, or are : 01/01/1995 | Stop: 02/01/200648 This (these) procedure(s) is (are) not : 01/01/1995 | Stop: 10/16/2003 Notes: Use code are non-covered services because this is a routine exam or screeningprocedure done in conjunction with a routine exam.

9 Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationREF), if : 01/01/1995 | Last Modified: 09/20/200950 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 (loop2110 Service Payment Information REF), if : 01/01/1995 | Last Modified: 09/20/200951 These are non-covered services because this is a pre-existing condition. Note:Refer to the 835 Healthcare Policy Identification Segment (loop 2110 ServicePayment Information REF), if : 01/01/1995 | Last Modified: 09/20/200952 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service Publishing Company | EDI | HIPAA | of 398/10/2011 4:44 PMStart: 01/01/1995 | Stop: 02/01/200653 Services by an immediate relative or a member of the same household are : 01/01/199554 Multiple physicians/assistants are not covered in this case.

10 Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment InformationREF), if : 01/01/1995 | Last Modified: 09/20/200955 Procedure/treatment is deemed experimental/investigational by the payer. Note:Refer to the 835 Healthcare Policy Identification Segment (loop 2110 ServicePayment Information REF), if : 01/01/1995 | Last Modified: 09/20/200956 Procedure/treatment has not been deemed 'proven to be effective' by the : Refer to the 835 Healthcare Policy Identification Segment (loop 2110 ServicePayment Information REF), if : 01/01/1995 | Last Modified: 09/20/200957 Payment denied/reduced because the payer deems the information submitted doesnot support this level of service, this many services, this length of service, thisdosage, or this day's : 01/01/1995 | Stop: 06/30/2007 Notes.