Commercial Remittance Advice Code Descriptions

1 Exp. CodeTextCARCRARC002 This charge exceeds the maximum allowable under this member's service is limited by the member's plan. Benefits were extended by our Utilization Management charge exceeds the maximum allowable under this member's coverage 4501 DProcessing of this claim was suspended awaiting information requested from this provider or for this service are limited to two times per contract year. 273N43503 DBenefits for this service are limited to one time per three-month for this service are limited to one time per thirty-six month charge exceeds the maximum allowable under this member's Secondary Allowed Units 9s9 Change Secondary Deductible Amount HIPAA-compliant electronic Remittance Advice (ANSI-835) will not use these explanation codes. The electronic Remittance Advice (ANSI-835) uses HIPAA-compliant remark and adjustment reason codes. Where appropriate, we have included the HIPAA-compliant remark and/or adjustment reason code that corresponds to a BlueCross BlueShield of Tennessee explanation code .

2 Standardized Descriptions for the HIPAA adjustment reason and remark codes can be accessed on the Washington Publishing Company Web site at *Updates are shaded in blue. (Revised 2/21/17) The following Remittance explanation codes and Descriptions reflect those found on hardcopy (paper) Commercial Remittance Advice . These same codes and Descriptions will also apply to online Commercial Remittance advices, available on BlueAccess, the secure area of Although the provider action/information column does not appear on the Remittance Advice , we have included it on this document to assist Remittance Advice that reflect dates of service of May 1, 2008 and after, explanation codes used for BlueCare Tennessee will also appear in this Remittance Advice code Descriptions Exp. CodeTextCARCRARCu99 This claim requires configuration review.

3 133054 Services denied due to being delegated to another entity. 109N418057We are deducting this amount because of an overpayment on a previous FSA for this service have a twelve-month waiting period. 179062 These expenses are not eligible since there is no money left in your Flexible Spending is not a covered service under medical benefits. The service is eligible under the Health Reimbursement expenses are not eligible since there is no money in your Flexible Spending expenses are not eligible since there is no money in your Flexible Spending service was performed on a previously missing tooth. 272071 Your Dependent Care Flexible Spending Account funds have been exhausted. Payment may be made when additional funds are for this service are excluded under this member's plan. 96N21607 DBenefits for this service are limited to two times per twelve-month for hospital charges, hospital visits, and drugs are not for premedication and relative analgesia are not covered.

4 96N1260 DAThis is an adjustment to a previous dental claim that paid to the provider but should have paid to the member's coverage excludes benefits for the condition for which this service was for sealants and dietary instruction are not covered. 96N21611 DThe procedure code and tooth number filed do not correspond. An alternate procedure code was used for for this procedure are limited to once per lifetime, per tooth and tooth CodeTextCARCRARC13 DAppliances due to wear and services to improve bite or to correct congenital or developmental problems are for implants, TMJ (Temporomandibular Joint) Dysfunction and periodontal splinting are not Secondary Coinsurance Amount 0s1 Change Secondary Copay Amount 077 Long Term Care Hospital Override 15 DBenefits for this service are limited to one time per three-month cannot process this claim until we receive previously requested information concerning the member's other for services that are considered to be primarily cosmetic are not portion of these services is considered primarily cosmetic and will not be procedure is not covered, an allowance for a standard procedure was for this service are limited to two times per calendar year.

5 273N4351 DAThis dental claim is being adjusted due to a corrected billing submitted by the procedure has been deducted from the amount of the primary Supplementation Amount 201 Interest is being recouped. 8520 DRelines cannot be billed separately if done within six months of the primary denture and or partial for this service are limited to one time per sixty-month for this service have a twenty-four month waiting period. 17923 DThese benefits have been paid by the member's medical policy. 168 Exp. CodeTextCARCRARC24 DBenefits for this service are limited to one time per six-month category of dental benefits has a waiting period as specified in this member's dental for this service are limited to one time per five-month for this dental service are not available, per this member's for this service are limited to one time per twelve-month for this dental service are not available, per this member's Allow Amount 30 DThis charge is a duplicate of a previously processed claim for this procedure is a duplicate of a previously filed procedure.

6 18N52231 DThis service is denied based on information submitted. Participating dentist should charge only amount in 'Patient Owes'.96N10328 This claim was adjusted to provide corrected benefits. 96MA6732 DBenefits for this service are limited to one time per four-month for this service are limited to one time per two-year claim was paid to the wrong payee. 96MA67342 This claim was paid to the wrong payee. 96MA67343 This claim was paid to the wrong payee. 96MA67344 This member's coverage under this plan was not in effect on the date this service was for this service are excluded under this member's plan. 96N30346 Duplicate of previous claim. If corrected billing, please resubmit according to billing CodeTextCARCRARC347 Benefits for this service are excluded under this member's plan. 96N30348 Benefits are excluded for an on the job injury or for services eligible for Worker's Compensation claim was adjusted to provide benefits secondary to Medicare. 96MA6734 DBenefits for this service have a ninety-day waiting period.

7 179350 This is a subrogation adjustment. It will not effect previously assigned patient claim was adjusted to provide benefits secondary to this member's other insurance claim was previously processed under another member's name or ID number in claim was previously processed under another member's name or ID number in claim was adjusted to provide corrected benefits. 96MA67355 This claim was adjusted to provide corrected benefits. 96MA67356 This claim was adjusted to provide corrected benefits. 96MA6735 DBenefits for this service are limited to one time per twenty-four month claim was adjusted to provide corrected benefits. 96MA67366 This claim was adjusted to provide corrected benefits. 96MA67367 This claim was adjusted due to a change in provider information. 96MA67368 This claim was adjusted due to a change in provider information. 96MA67369 This claim was adjusted to provide benefits secondary to Medicare. 96MA6736 DThese benefits were previously paid under an incorrect provider claim was adjusted to provide corrected benefits.

8 96MA67 Exp. CodeTextCARCRARC371 This claim was adjusted to provide corrected benefits. 96MA67379 This is a subrogation adjustment. It will not effect previously assigned patient service needs to be resubmitted using current American Dental Association procedure service needs to be resubmitted using current American Dental Association procedure claim was adjusted to provide benefits secondary to Medicare. 96MA67381 Please submit a copy of the Explanation of Benefits from this member's other insurance claim was adjusted to provide benefits secondary to Medicare. 96MA67383 This claim was adjusted to provide corrected benefits. 96MA67384 This claim was adjusted to provide corrected benefits. 96MA67385 This claim was adjusted because we were notified that the provider billed for this service in claim was adjusted to provide corrected benefits . 96MA6738 DThis service has been denied due to contract limitations. 273N435390 This claim was adjusted to provide corrected benefits.

9 96MA67391 This service was previously denied as a duplicate in error. 96MA67392 This claim was adjusted to provide corrected benefits. 96MA67393 This claim was adjusted to provide corrected benefits. 96MA67394 This claim was adjusted to provide corrected benefits. 96MA67395 This claim was adjusted to provide corrected benefits. 96MA67397 ITS Inclusive Grouping Number Exp. CodeTextCARCRARC39 DBenefits for this service are limited to one time per year. 273N4353s3 Supplemental Calculation Method 40 DThis date of service is after this member's termination date. 27N3041 DThis service has been paid based on group's request. 42dMcKee Executive Dental payment reimbursement 43 DProcessing of this claim is suspended awaiting information from the charge exceeds the maximum allowable under this member's of this procedure is suspended awaiting information from this member's medical or other carrier's for adult orthodontics are only payable for TMJ diagnosis. 96N56948 DBenefits for this service are limited to one time per forty-eight month IPA is not related to member's IPA 501 Capitated entity charge amount equal 502 Prudent Layperson Override 503 Delegated Claim Entity Override 504 Capitation Indicator 505 Capitation Fund 506 Risk Indicator 507 Delegated UM Entity Override 508 Capitation Deduct Exp.

10 CodeTextCARCRARC509 Opt out override 50 DBenefits for this service are limited to three times per twelve-month Area Override 511 Reimbursable allowable amount 51 DGrace period for plan limits. 4554 DBenefits for this service are limited to one time per calendar year. 273N43555 DBenefits for this service are limited to once per lifetime. 273N43556 DBenefits for this service are limited to four times per calendar year. 273N43557 DBenefits for this service are limited to one time per three-year for this service are limited to one time per three calendar year submit a copy of the Explanation of Benefits from this member's other insurance for this service are limited to one time per five-year combination of x-ray charges submitted on this claim should not exceed the cost of a full mouth allowance is based on a less costly procedure. The disallowed amount will be the patient's procedure is non covered. An alternate standard procedure has been used to price the combination of x-ray charges submitted on this claim should not exceed the cost of a full mouth for crowns are available only when the tooth cannot be restored by any other service needs to be resubmitted using current American Dental Association procedure member or dependent is not eligible for dental benefits.