(Use only with Group Code OA). No current requests. The EDI Standard is published onceper year in January. Want to know what is the exact reason? Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Service(s) have been considered under the patient's medical plan. The procedure/revenue code is inconsistent with the patient's gender. Reason Code 91: Processed in Excess of charges. Claim/service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). NULL CO A1 M62, N612 028 X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. However, this amount may be billed to subsequent payer. To be used for Property & Casualty only. It will not be updated until there are new requests. Reason Code 132: Interim bills cannot be processed. CO/200/ CO/26/N30. The Claim Adjustment Group Codes are internal to the X12 standard. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Patient cannot be identified as our insured. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Reason Code 218: Workers' Compensation claim is under investigation. Explanation. Requested information was not provided or was insufficient/incomplete. ), Reason Code 15: Duplicate claim/service. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Reason Code 44: This (these) diagnosis (es) is (are) not covered, missing, or are invalid. X12 maintains policies and procedures that govern its corporate, committee, and subordinate group activities and posts them online to ensure they are easily accessible to members and other materially-interested parties. Note: Refer to the835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The attachment/other documentation that was received was incomplete or deficient. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. CO : Contractual Obligations Denial based on the contract and as per the fee schedule amount. Alphabetized listing of current X12 members organizations. The expected attachment/document is still missing. Claim/service denied. Our records indicate that this dependent is not an eligible dependent as defined. An attachment is required to adjudicate this claim/service. Legislated/Regulatory Penalty. You see, CO 4 is one of the most common types of denials and you can see how it adds up. Service(s) have been considered under the patient's medical plan. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). Denial Code (Remarks): CO 96 Denial reason: Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Denial Action: : Correct the diagnosis codes What other Remark Code is she receiving? Is there an issue with the DOS or dx? Service not furnished directly to the patient and/or not documented. Monday, April 25, 2016 Denial Action on Medicare code MA61, MA27, N256, MA112 AND M79 Beneficiary name and/or Medicare number MA61: Missing/incomplete/invalid Social Security number or health insurance claim number (HICN). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Denial Code Resolution - JE Part B - Noridian Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Reason Code 113: The advance indemnification notice signed by the patient did not comply with requirements. Services not provided or authorized by designated (network/primary care) providers. Denial codes are codes assigned by health care insurance companies to faulty insurance claims. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. Join other member organizations in continuously adapting the expansive vocabulary and languageused by millions of organizationswhileleveraging more than 40 years of cross-industry standards development knowledge. Reason Code 240: Services not authorized by network/primary care providers. Procedure code was invalid on the date of service. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. The format is always two alpha characters. Reason Code 258: The procedure or service is inconsistent with the patient's history. Reason Code 58: Penalty for failure to obtain second surgical opinion. (Use only with Group Code OA). Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. (Use CARC 45). The related or qualifying claim/service was not identified on this claim. Low Income Subsidy (LIS) Co-payment Amount. co 256 denial code descriptions . Reason Code 94: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Contact our Account Receivables Specialist today! Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. (Use only with Group Code CO). Reason/Remark Code Lookup

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