Claim Adjustment Reason Codes Crosswalk

1 EX code CARC RARC DESCRIPTIONTypeEX*1 95N584 DENY: SHP guidelines for submitting corrected Claim were not followed DENYEX*2 A1 N473 DENY: ASSESSMENT, FILLING AND/OR DME CERTIFICATION NOT ON FILE DENYEX+C 45 FOR INTERNAL PURPOSES ONLYPAYEX+O 45 LATE CLAIMS INTEREST EX code FOR ORIG YMDRCVD PAYEX+P 45 FOR INTERNAL PURPOSES ONLYPAYEX01 1 DEDUCTIBLE AMOUNTPAYEX02 2 COINSURANCE AMOUNTPAYEX03 3 COPAYMENT AMOUNTPAYEX07 7N517 DENY: THE PROCEDURE code IS INCONSISTENT WITH THE PATIENT S SEX DENYEX09 9N657 DENY: THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT S AGE OR SEX DENYEX0A 45 ADJUST: PROVIDER REFUND RECEIVED, REINSTATE RECOUPED PAYMENT AMOUNT PAYEX0B 23 ADJUST: Claim TO BE RE-PROCESSED CORRECTED UNDER NEW Claim NUMBER DENYEX0D 45 Adjustment : $ DUE IN ADDITIONAL TO ORIGINAL PAYMENT MADE FOR SERVICES PAYEX0E 193 ADJUST BASED ON APPEAL RECEIVED UPHELD ORIGINAL DENY DECISION DENYEX0F 45 ADJUST BASED ON APPEAL RECEIVED OVERTURNED ORIGINAL DENY DECISION PAYEX0G 252N232 CLM TOTAL DOES NOT MATCH TOTAL CHGS ON ITEMIZED STATEMENT FOR DOS BLD DENYEX0H 16MA67 Adjustment : PROVIDER BILLED INCORRECTLY AND SUBMITTED REIMBURSEMENT DENYEX0I A1 N172 Adjustment .

2 ADJUSTED PER CORRECTED BILLING FROM PROVIDERDENYEX0M 23 Adjustment TO PREVIOUSLY SUBMITTED Claim DENYEX0N A1 MA67 DENY: AJUSTED FOR INTERNAL PURPOSES-CORRECTION HAS BEEN GENERATED DENYEX0O 193 DENY: AUTH DENIAL UPHELD - REVIEW PER CLP0700 PEND REPORTDENYEX0P 97M15 PAY ZERO: COVERED UNDER PERDIEM PERSTAY CONTRACTUAL ARRANGEMENTS PAYEX0Q 184N767 BILLING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX0S 45 PAY: AUTH DENIAL OVERTURNED - REVIEW PER CLP0700 PEND REPORT PAYEX0U 283N767 ATTENDING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX0V 184N767 ORDERING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX0W 185N767 RENDERING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX0X 164 DENY: INELIGIBLE DUE TO UNTIMELY SUBMISSION TO PRIMARY CARRIER DENYEX0Y A1 N767 OPERATING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX0Z 183N767 REFERRING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX14 14 DENY: THE DATE OF BIRTH FOLLOWS THE DATE OF SERVICEDENYEX15 197 DENY: Claim DENIED BECAUSE THE SUBMITTED AUTH NUMBER IS INVALID DENYEX16 16M20 DENY.

3 REV code ONLY BILLED - PLEASE RESUBMIT WITH CPT HCPCS code DENYEX17 A1 N102 DENY:REQUESTED INFORMATION BY THE PROVIDER WAS NOT PROVIDED DENYEX18 18N522 DENY: DUPLICATE Claim SERVICEDENYEX19 19N418 DENY: WORK RELATED INJURY AND THE LIABILITY OF WORKER S COMP CARRIER DENYEX1a A1 N767 SERVICE FACILITY PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX1b 50M130 DENY: NON MEDICALLY NECESSARY TRANSPORT DENYEX1B A1 N767 SUPERVISING PROVIDER NOT ENROLLED WITH TX MEDICAIDDENYEX1C A1 N237 MEDICAL HOSPITAL DETAIL RECORD CANCELLED DENYEX1c A1 N767 PCP PROVIDER NOT ENROLLED WITH TX MEDICAID DENYEX1D 45 PAY IN FULL: MEMBER ELIGIBILITY VERIFIED PAYEX1e 226N258 BILLING PROVIDER ADDRESS CAN NOT BE A PO 45 PAY: THE CONTRACT IS INELIGIBLE DURING AUTHORIZED PERIODPAYEX1F A1 N255 PROVIDER TAXONOMY code INVALID, PLEASE CORRECT AND RESUBMIT.

4 DENYEX1G 45 PAY IN FULL: PARTIAL ELIGIBILTY VERIFIED PAYEX1H 45 EVV VISIT MATCHPAYEX1I 223 INFO: Provider Allowable adjusted to include ACA Parity Payment INFOEX1i 251N237 NO EVV VISIT MATCH FOR MEDICAID ID BILLED DENYEX1J 251N237 NO EVV VISIT MATCH FOR MEDICAID ID AND DATE OF SERVICE BILLED DENYEX1K 6N129 DENY: PROCEDURE code IS INCONSISTENT WITH PATIENT S AGEDENYEX1L B14M86 DENY: VISIT & PREVEN Codes ARE NOT PAYABLE ON SAME DOS W O DOCUMENTATIONDENYEX1n 251N237 NO EVV VISIT MATCH FOR MEDICAID ID AND NPI/API FOR DATE OF SVC BILLED DENYC laim Adjustment Reason Codes Crosswalk 4N657 RESUBMIT-2ND EM NOT PAYABLE W O MOD 25 & MED REC TO VERIFY SIGNIF SEP DENYEX1o 22 CONNOLLY MEDICARE DISALLOWANCE PAYEX1O 251N237 NO EVV VIST MATCH FOR MEDICAID ID AND HCPCS/MOD FOR DATE OF SVC BILLED DENYEX1p 22 CONNOLLY MEDICARE DISALLOWANCE DENYEX1P 251N237 UNITS BILLED DOES NOT MATCH TOTAL EVV VISIT UNITS DENYEX1q 45 CONNOLLY OVERPAYMENT PROJECT

5 PAYEX1R 45 PAY: PAID ACCORDING TO AUTHORIZED LEVELS OF CARE PAYEX1r 96N10 CONNOLLY OVERPAYMENT PROJECT DENYEX1s 215 RAWLINGS SUBROGATION PAYEX1U A1 N448 DENY: PROCEDURE COVERAGE NOT DEFINED BY MEDICAID DENYEX1W 45N640 PAY:30 DAY SPELL OF ILLNESS MAX MET, DO NOT BILL PATIENT PAYEX20 20 DENY: THIS INJURY IS COVERED BY THE LIABILITY CARRIER DENYEX21 21 DENY: Claim THE RESPONSIBILITY OF THE NO-FAULT CARRIER DENYEX22 22N598 DENY: THIS CARE IS COVERED BY A COORDINATION OF BENEFITS CARRIER DENYEX23 23 DENY: CHARGES HAVE BEEN PAID BY ANOTHER PARTY-COB DENYEX24 24 DENY: CHARGES COVERED UNDER CAPITATION DENYEX25 299 DENY: YOUR STOP LOSS DEDUCTIBLE HAS NOT BEEN MET DENYEX26 26N650 DENY:MEMBER NOT ELIGIBLE ON DATE OF SERVICE DENYEX27 27N650 DENY: EXPENSES INCURRED AFTER COVERAGE WAS TERMINATED DENYEX28 26N650 DENY.

6 COVERAGE NOT IN EFFECT WITH SUPERIOR AT THE TIME OF SERVICE DENYEX29 164 DENY:THE TIME LIMIT FOR FILING A Claim HAS EXPIRED DENYEX2a 45 OTHER INS CARRIER PAYMENT APPLIED PAYEX2B 16M53 DENY: OBSERVATION GREATER THAN 48 HOURS CORRECT AND RESUBMIT DENYEX2D 16 M51 DENY:ICD9 PROCEDURE code MISSING OR INVALID DENYEX2e 16MA30 DENY: NON PAYMENT BILL TYPE XX0 DENYEX2h 45 INFO: PROC Codes CONSIDERED INFORMATIONAL ONLY BY CMS PAYEX2H A1 MA41 DENY: ADMIT TYPE OR SOURCE MISSING OR INVALID DENYEX2i 45 PAYMENT ADJUSTED ACCORDING TO PAYMENT OR CLINICAL POLICY PAYEX2L 197 DENY: NO AUTH OBTAINED FOR LOCATION BILLED SUBMITTED DENYEX2m 16M50 REVENUE code NOT DEFINED DENYEX34 34 DENY: INSURED HAS NO COVERAGE FOR NEWBORNS DENYEX35 119N587 DENY: BENEFIT MAXIMUM HAS BEEN REACHED DENYEX36 45 BALANCE DOES NOT EXCEED COPAYMENT AMOUNT PAYEX37 23 DENY.

7 BALANCE DOES NOT EXCEED DEDUCTIBLE DENYEX38 242 DENY: SERVICES NOT PROVIDED OR AUTHORIZED BY OUR PROVIDERS DENYEX39 39 DENIED AT THE TIME OF AUTHORIZATION REQUEST DENYEX3C A1 M76 DENY: 2004 NEW DIAG Codes NOT BILLABLE PER STATE BEFORE 4 1 04 DENYEX3D A1 M76 DENY: NON-SPECIFIC ICD-9 DIAG PROC Codes -REQUIRES 4TH DIGIT (RESUBMIT) DENYEX3L A1 M20 DENY: PT ADMITTED-SUBMITTED SERVICES CHARGES BILLED INCLUSIVE DENYEX3P A1 N381 DENY: PAID UNDER SETTLEMENT DENYEX3Q 233 DENY: PROVIDER PREVENTABLE CONDITIONS DENYEX3V 45 PAY: NEGOTIATIED RATE PAYEX3Z A1 MA40 DENY: INTERIM BILL.

8 ADMIT DATE PT STATUS IS MISSING OR INCORRECT DENYEX40 40 DENY: CHARGES DO NOT MEET QUALIFICATIONS FOR EMERGENCY CARE OUT OF AREA DENYEX41 45 PREFERRED PROVIDER DISCOUNT PAYEX42 45 CHARGES EXCEED YOUR CONTRACTED FEE SCHEDULE PAYEX43 45 GRAMM RUDMAN REDUCTION PAYEX44 45 PROMPT PAY DISCOUNT PAYEX45 45 C21 CHARGES EXCEED REASONABLE AND CUSTOMARY AMOUNTS PAYEX46 96N216 DENY: THIS SERVICE IS NOT COVERED DENYEX47 167N30 DENY: THIS DIAGNOSIS IS NOT COVERED DENYEX48 96N216 DENY: THIS PROCEDURE IS NOT COVERED DENYEX49 49M86 DENY: THESE ARE NONCOVERED SERVICES BECAUSE THIS IS A ROUTINE EXAM DENYEX4a 16MA65 DENY: ADMITTING DIAGNOSIS MISSING OR INVALID DENYEX4A A1 MA91 DENY: Claim WAS APPEALED AND CONTINUES TO BE DENIED DENYEX4B 16M76 DENY: DIAGNOSIS code 16 MISSING OR INVALID DENYEX4b 16MA63 DENY.

9 DIAGNOSIS code 1 MISSING OR INVALID DENYEX4c 16MA63 DENY: DIAGNOSIS code 2 MISSING OR INVALID DENYEX4C A1 M76 DENY: 2005 NEW DIAGNOSIS code NOT YET BILLABLE PER STATE DENYEX4d 16M76 DENY: DIAGNOSIS code 3 MISSING OR INVALID DENYEX4D A1 M76 DENY: NON-SPECIFIC ICD-9 DIAG PROC code -REQUIRES 5TH DIGIT (RESUBMIT) DENYEX4e 16M76 DENY: DIAGNOSIS code 4 MISSING OR INVALID DENYEX4E 181N657 DENY: 2004 PROC Codes NOT ACCEPTABLE FOR DOS PRIOR TO 07 01 04 DENYEX4f 16M76 DENY: DIAGNOSIS code 5 MISSING OR INVALID DENYEX4g 16M76 DENY: DIAGNOSIS code 6 MISSING OR INVALID DENYEX4G A1 M143 DENY: MEDICAID SANCTIONED/TERMED/EXCLUDED PROVIDER DENYEX4h 16M76 DENY: DIAGNOSIS code 7 MISSING OR INVALID DENYEX4H 50N130 DENY-Breast MRI CAD not clinically proven DENYEX4i 16M76 DENY: DIAGNOSIS code 8 MISSING OR INVALID DENYEX4I 223 INFO: ACA PARITY PAYMENT MADE PREVIOUSLY VIA INTERIM CHECK INFOEX4j 16M76 DENY: DIAGNOSIS code 9 MISSING OR INVALID