Blue Cross Blue Shield denial codes or BCBS Commercial insurance denials codes list is prepared for the help of executives who are working in denials and AR follow-up. Most of the time when people work on denials they face difficulties to find out the exact reason of denials, so this Blue Cross Blue Shield denial codes or Commercial insurance denials codes list will help you.
Blue Cross Blue Shield Denial Codes List
Denial Codes | Description | CARC | RARC |
2 | Charge exceeds the maximum allowable under member’s coverage. | 45 | |
8 | Service is limited by the member’s plan. Benefits were extended by our Utilization Management department. | 119 | |
18 | Charge exceeds the maximum allowable under member’s coverage | 45 | |
01D | Processing of Claim was suspended awaiting information requested from provider or subscriber. | 133 | |
02D | Benefits for service are limited to two times per contract year. | 273 | N435 |
03D | Benefits for service are limited to one time per three-month period. | 273 | N435 |
04D | Benefits for service are limited to one time per thirty-six month period. | 273 | N435 |
50 | Charge exceeds the maximum allowable under member’s coverage. | 59 | N644 |
54 | Services denied due to being delegated to another entity. | 109 | N418 |
57 | We are deducting amount because of an overpayment on a previous FSA Claim. | ||
05D | Benefits for service have a twelve-month waiting period. | 179 | |
62 | These expenses are not eligible since there is no money left in your Flexible Spending Account. | 187 | |
66 | Service is not a covered under medical benefits. The service is eligible under the Health Reimbursement Account. | 96 | N30 |
68 | These expenses are not eligible since there is no money in your Flexible Spending Account. | 187 | |
69 | These expenses are not eligible since there is no money in your Flexible Spending Account. | 187 | |
06D | Service was performed on a previously missing tooth. | 272 | |
71 | Your Dependent Care Flexible Spending Account funds have been exhausted. Payment may be made when additional funds are available. | 187 | |
73 | Benefits for service are excluded under member’s plan. | 96 | N216 |
77 | Long Term Care Hospital Override | ||
79 | Line Item Denial Override | ||
07D | Benefits for service are limited to two times per twelve-month period. | 273 | N412 |
08D | Services for hospital charges, hospital visits, and drugs are not covered. | 96 | N216 |
09D | Services for premedication and relative analgesia are not covered. | 96 | N126 |
0DA | This is an adjustment to a previous dental Claim that paid to the provider but should have paid to the subscriber. | 96 | MA67 |
0s0 | Change Secondary Coinsurance Amount | ||
0s1 | Change Secondary Copay Amount | ||
104 | Member’s coverage excludes benefits for the condition for which service was rendered. | 96 | N216 |
10D | Benefits for sealants and dietary instruction are not covered. | 96 | N216 |
11D | The Procedure code and tooth number filed do not correspond. An alternate Procedure code was used for pricing. | 169 | |
12D | Benefits for Procedure are limited to once per lifetime, per tooth and tooth surface. | 119 | N587 |
13D | Appliances due to wear and services to improve bite or to correct congenital or developmental problems are non-covered. | 96 | N216 |
14D | Benefits for implants, TMJ (Temporomandibular Joint) Dysfunction and periodontal splinting are not covered. | 96 | N216 |
15D | Benefits for service are limited to one time per three-month period. | 273 | N435 |
16D | We cannot process Claim until we receive previously requested information concerning the member’s other insurance. | 22 | |
17D | Benefits for services that are considered to be primarily cosmetic are not covered. | 96 | N383 |
17d | A portion of these services is considered primarily cosmetic and will not be covered. | 96 | N383 |
18D | Procedure is not covered, an allowance for a standard Procedure was paid. | 169 | |
19D | Benefits for service are limited to two times per calendar year. | 273 | N435 |
1DA | Dental Claim is being adjusted due to a corrected billing submitted by the provider. | 96 | MA67 |
1DO | Temporary Procedure has been deducted from the amount of the primary Procedure. | 169 | |
1s1 | Secondary Supplementation Amount | ||
201 | Interest is being recouped. | 85 | |
20D | Relines cannot be billed separately if done within six months of the primary denture and or partial Procedure. | 273 | N435 |
217 | Paid Limit Accumulator Has Been Altered by Med Supp Sequestration Reduced from the Paid Amount | ||
21D | Benefits for service are limited to one time per sixty-month period. | 273 | N435 |
22D | Benefits for service have a twenty-four month waiting period. | 179 | |
23D | These benefits have been paid by the member’s medical policy. | 168 | |
24D | Benefits for service are limited to one time per six-month period. | 273 | N435 |
25D | Category of dental benefits has a waiting period as specified in member’s dental contract. | 179 | |
26D | Benefits for service are limited to one time per five-month period. | 273 | N435 |
27D | Benefits for dental service are not available, per member’s contract. | 96 | N216 |
28D | Benefits for service are limited to one time per twelve-month period. | 273 | N435 |
29D | Benefits for dental service are not available, per member’s contract. | 96 | N216 |
2s2 | Secondary Allow Amount | ||
30D | Charge is a duplicate of a previously processed Claim for member. | 18 | N702 |
30d | Procedure is a duplicate of a previously filed Procedure. | 18 | N522 |
31D | Service is denied based on information submitted. Participating dentist should charge only amount in ‘Patient Owes’. | 96 | N10 |
328 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
32D | Benefits for service are limited to one time per four-month period. | 273 | N435 |
33D | Benefits for service are limited to one time per two-year period. | 273 | N435 |
341 | Claim was paid to the wrong payee. | 96 | MA67 |
342 | Claim was paid to the wrong payee. | 96 | MA67 |
343 | Claim was paid to the wrong payee. | 96 | MA67 |
344 | Member’s coverage under plan was not in effect on the date service was provided. | 27 | N30 |
345 | Benefits for service are excluded under member’s plan. | 96 | N30 |
346 | Duplicate of previous Claim. If corrected billing, please resubmit according to billing guidelines. | 18 | N702 |
347 | Benefits for service are excluded under member’s plan. | 96 | N30 |
348 | Benefits are excluded for an on the job injury or for services eligible for Worker’s Compensation benefits. | 19 | N418 |
349 | Claim was adjusted to provide benefits secondary to Medicare. | 96 | MA67 |
34D | Benefits for service have a ninety-day waiting period. | 179 | |
350 | It is a subrogation adjustment. It will not effect previously assigned patient liability. | 215 | |
351 | Claim was adjusted to provide benefits secondary to member’s other insurance coverage. | 96 | MA67 |
352 | Claim was previously processed under another member’s name or ID number in error. | 96 | MA67 |
353 | Claim was previously processed under another member’s name or ID number in error. | 96 | MA67 |
354 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
355 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
356 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
35D | Benefits for service are limited to one time per twenty-four month period. | 273 | N435 |
365 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
366 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
367 | Claim was adjusted due to a change in provider information. | 96 | MA67 |
368 | Claim was adjusted due to a change in provider information. | 96 | MA67 |
369 | Claim was adjusted to provide benefits secondary to Medicare. | 96 | MA67 |
36D | These benefits were previously paid under an incorrect provider status. | 170 | N95 |
370 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
371 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
379 | It is a subrogation adjustment. It will not effect previously assigned patient liability. | 215 | |
37D | Service needs to be resubmitted using current American Dental Association Procedure codes. | 181 | M20 |
37d | Service needs to be resubmitted using current American Dental Association Procedure codes. | 181 | M20 |
380 | Claim was adjusted to provide benefits secondary to Medicare. | 96 | MA67 |
381 | Please submit a copy of the Explanation of Benefits from member’s other insurance carrier. | 22 | MA92 |
382 | Claim was adjusted to provide benefits secondary to Medicare. | 96 | MA67 |
383 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
384 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
385 | Claim was adjusted because we were notified that the provider billed for service in error. | 96 | MA67 |
389 | Claim was adjusted to provide corrected benefits . | 96 | MA67 |
38D | Service has been denied due to contract limitations. | 273 | N435 |
390 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
391 | Service was previously denied as a duplicate in error. | 96 | MA67 |
392 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
393 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
394 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
395 | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
397 | ITS Inclusive Grouping Number | ||
39D | Benefits for service are limited to one time per year. | 273 | N435 |
3s3 | Supplemental Calculation Method | ||
40D | Date of service is after member’s termination date. | 27 | N30 |
41D | Service has been paid based on group’s request. | ||
42d | McKee Executive Dental payment reimbursement | ||
43D | Processing of Claim is suspended awaiting information from the provider. | 163 | N686 |
44D | Charge exceeds the maximum allowable under member’s contract. | 45 | |
46D | Processing of Procedure is suspended awaiting information from member’s medical or other carrier’s policy. | 168 | |
47D | Benefits for adult orthodontics are only payable for TMJ Diagnosis. | 96 | N569 |
48D | Benefits for service are limited to one time per forty-eight month period. | 273 | N435 |
4s4 | Change Secondary Service Rule | ||
500 | Submitting IPA is not related to member’s IPA | ||
501 | Capitated entity charge amount equal 0.00 | ||
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 | ||
509 | Opt out override | ||
50D | Benefits for service are limited to three times per twelve-month period. | 273 | N435 |
510 | Service Area Override | ||
511 | Reimbursable allowable amount | ||
51D | Grace period for plan limits. | 45 | |
54D | Benefits for service are limited to one time per calendar year. | 273 | N435 |
55D | Benefits for service are limited to once per lifetime. | 273 | N435 |
56D | Benefits for service are limited to four times per calendar year. | 273 | N435 |
57D | Benefits for service are limited to one time per three-year period. | 96 | N130 |
57d | Benefits for service are limited to one time per three calendar year period. | 273 | N435 |
58D | Please submit a copy of the Explanation of Benefits from member’s other insurance carrier. | 22 | N4 |
59D | Benefits for service are limited to one time per five-year period. | 273 | N435 |
5s5 | Bypass Secondary Plan Limits | ||
60D | The combination of x-ray charges submitted on Claim should not exceed the cost of a full mouth series. | 169 | |
61D | Allowance is based on a less costly Procedure. The disallowed amount will be the patient’s responsibility. | 169 | |
61d | Procedure is non covered. An alternate standard Procedure has been used to price the allowed. | 169 | |
62D | The combination of x-ray charges submitted on Claim should not exceed the cost of a full mouth series. | 169 | |
63D | Benefits for crowns are available only when the tooth cannot be restored by any other material. | 96 | M25 |
6s6 | Change Secondary Allow per Unit | ||
704 | Service needs to be resubmitted using current American Dental Association Procedure codes. | ||
7s7 | Change Secondary Allowed Units | ||
82D | Member or dependent is not eligible for dental benefits. | ||
83D | Member is not eligible for dental benefits. | 96 | N216 |
84D | Member is not eligible for dental benefits. | 96 | N216 |
85D | Patient has met his or her annual or lifetime maximum benefits. | 119 | N587 |
89D | Dental Claim was processed in error. | ||
8s8 | Change Secondary Disallow Amount | ||
90D | Member’s contract does not allow for crown coverage. An allowance has been made for a stainless steel crown. | 169 | |
95D | Temporary partials are only covered for the anterior front teeth. | 96 | N130 |
97D | Charge is considered part of the total cost. Please do not bill separately. | 169 | |
98D | Dental Claim was processed in error. | B11 | N216 |
9s9 | Change Secondary Deductible Amount | ||
A01 | Provider is not eligible under member’s coverage. | 170 | N348 |
AB0 | Call 1-800-924-7141 for Claim detail if needed. | ||
AD3 | It is a subrogation adjustment. It will not affect previously assigned patient liability. | 215 | |
AD4 | It is the disallowed amount prior to subrogation adjustment. | 215 | MA67 |
ADP | Amount was previously paid to the wrong payee. A corrected payment has been made. | 96 | MA67 |
ADT | It is an adjustment of a previously processed Claim due to a BCBST change to the provider assignment. | 96 | MA67 |
ADX | Claim was adjusted due to a change in provider information. | 96 | MA67 |
AUT | Benefits cannot be provided for service because the required authorization is not on file. | 197 | |
AY1 | Outside Year Period Override | ||
AZP | Medication is to be dispensed by CVS Specialty at 1-888-265-7990. A one time exception was allowed under your medical plan. | N189 | |
B01 | Procedure is not covered per contract limitations. Alternate Procedure pricing was used. | 169 | |
B02 | Number of services exceeds contract limitations. An alternate Procedure was used. | 169 | |
B03 | Benefits for service are limited to one time per seven year period. | 273 | N435 |
B08 | Member’s coverage does not provide benefits for TMJ (Temporomandibular Joint) Dysfunction and occlusion. | 96 | N216 |
B09 | Member’s coverage does not provide benefits for implants and periodontal splinting. | 96 | N216 |
B10 | Member’s coverage does not provide benefits for basic restorative dentistry. | 96 | N216 |
B11 | Member’s coverage does not provide benefits for crown and prosthetic dentistry. | 96 | N216 |
B12 | Member’s coverage does not provide benefits for orthodontic dentistry. | 96 | N216 |
B13 | Member’s coverage does not provide benefits for gold foil restorations. | 96 | N216 |
B14 | Member’s coverage does not provide benefits for dental care that is elective or a special technique. | 96 | N216 |
B15 | Member’s coverage does not provide benefits for replacement services due to loss or theft. | 96 | N216 |
B16 | Member’s coverage does not provide benefits for desensitizing teeth. | 96 | N216 |
B17 | service is primarily considered medical. Please file with member’s medical policy. | 168 | |
B18 | Member’s coverage does not provide benefits for adult orthodontics. | 96 | N216 |
B19 | Member’s coverage does not provide benefits for prescribed drugs and other medications. | 96 | N216 |
B20 | Member’s coverage does not provide benefits for congenital, cosmetic or aesthetic services. | 96 | N216 |
B21 | Member’s coverage only allows for sealants on the occlusal biting surface of a tooth. | 96 | N216 |
B22 | Service is primarily considered medical. Please file with Member’s medical policy. | 168 | |
B23 | Provider is not eligible under Member’s coverage. | 185 | |
B24 | Patient has met his or her annual or lifetime maximum benefits. | 119 | N587 |
B25 | Benefits for service have a twelve-month waiting period. | 273 | N435 |
B26 | Benefits for service have a twenty-four month waiting period. | 273 | N435 |
B27 | Benefits for service have a ninety-day waiting period. | 179 | |
B28 | Service is not covered when performed on the same day as a related Procedure. | 273 | N435 |
B29 | Benefits cannot be provided for a prosthetic device that replaces one or more teeth that were missing prior to the policy effective date. | 96 | N130 |
B30 | Service is not covered unless specific Services are performed in conjunction with or prior to Service. | 96 | N130 |
B31 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
B32 | Service is not covered when performed within 90 days of another active surgical or non-surgical Procedure. | 273 | N435 |
B33 | Benefits cannot be provided until we receive information about Member’s eligibility. | 252 | N375 |
B34 | Benefits for Service are limited to one time per ten year period. | ||
B35 | Benefits payable for Member’s orthodontic treatment has been provided. | 96 | N130 |
B36 | Patient has met his or her dental quarterly maximum benefits. | 119 | N640 |
B37 | Benefits for Service are limited to four times per twelve-month period. | 273 | N435 |
B51 | Service does not meet BlueCross BlueShield of Tennessee clinical criteria and will not be considered for payment. | 96 | N130 |
B52 | Recementing or repairs cannot be billed separately if done within twelve months of the initial placement Procedure. | 273 | N435 |
B53 | A deleted Procedure code was filed. code was replaced with a current Procedure code. | 181 | M20 |
B54 | Recementing or repairs cannot be billed separately if done within six months of the initial placement Procedure. | 273 | N435 |
B59 | Service is considered part of the primary Procedure. Please do not bill separately. | 97 | N19 |
B61 | The servicing provider has billed Claim under the incorrect patient. | 96 | N10 |
B62 | Claim must be filed by the provider who actually rendered the Service. | 96 | N32 |
B63 | Claim was adjusted because it was previously processed under a different patient. | B13 | |
B64 | Charge was adjusted because we were notified that the provider billed for Service in error. | 96 | N10 |
B65 | Claim was paid to the wrong payee. | 96 | N10 |
CBM | Member’s primary insurance carrier already paid amount. | 23 | |
CCC | The payment for Service is to reimburse the provider for patient care coordination. | 24 | M112 |
CDD | Claim is a duplicate of a previously submitted Claim for member. | 18 | N522 |
CG0 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CG1 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CG2 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CG3 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CG4 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CG5 | Service falls into a category that is not covered under Member’s dental plan. | 96 | N216 |
CM1 | charge exceeds the previous carrier’s allowed amount. Provider has agreed not to bill the patient for amount. | 45 | |
CM2 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
CMS | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
CO1 | payment was secondary to primary benefits provided by Member’s other health insurance. | 23 | |
CO2 | amount includes the benefits provided by Member’s other insurance carrier. | 23 | |
COB | Benefits cannot be provided until we receive previously requested information concerning Member’s other insurance. | 252 | N686 |
COS | Procedure is not eligible for benefits under Member’s coverage because it was performed for cosmetic purposes. | 96 | N383 |
CPY | The original Copay amount has been reduced to a percentage of the allowable amount | ||
CR | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
CRT | CREdit-ADJUSTMENT-OVERPAYMENT TO BE DEDUCTED FROM PAID AMOUNT. Message appears on RA when auto deduct of overpayment. | ||
CVX | Coverage Exclusion | 96 | N30 |
D01 | The dental allowable amount was increased. | 45 | |
D02 | The dental allowable amount was decreased. | 45 | |
D11 | The dental allowable amount per unit was increased. | 45 | |
D12 | The dental allowable amount per unit was decreased. | 45 | |
D13 | The dental allowable units were increased. | 45 | |
D14 | The dental allowable units were decreased. | 45 | |
D15 | It is dental disallowed amount. | 96 | N130 |
D21 | Please submit the date orthodontic treatment started. | ||
D22 | Please submit accompanying x-rays for dental Procedure. | 16 | M129 |
DA0 | dental Claim is being adjusted since we have been notified that the provider billed for Service in error. | 96 | MA67 |
DA1 | Claim was previously paid to the wrong provider. A payment has been made to the correct provider. | 96 | MA67 |
DA2 | Claim was previously processed correctly under another ID number or patient’s name. No additional payment is due. | 96 | MA67 |
DA3 | Disallowed amount is the ortho extended treatment and has been moved to another Claim. | 172 | |
DA4 | it is an adjustment to a previous dental Claim that paid to the subscriber but should have paid to the provider. | 96 | MA67 |
DA6 | A dental adjustment is in process for Claim, which will be reprocessed on a future date. | 96 | MA67 |
DA7 | It is an adjustment to a previously paid dental Claim. The payable amount is less than the amount originally paid. | 96 | MA67 |
DA8 | It is money reimbursed due to another party’s payment. Refer to Patient Owes column for any liability charges. | 215 | |
DA9 | Dental Claim was previously processed with an incorrect date of Service. | 96 | MA67 |
DAC | Other insurance information has been received and Member’s records updated. Claim has been adjusted. | 96 | MA67 |
DAD | Full or partial dental benefits were denied in error. | 96 | MA67 |
DAL | It is a dental adjustment. The provider was corrected and or subscriber payment liability. | 96 | MA67 |
DAP | The originally submitted Procedure was replaced due to benefit plan restrictions. | 169 | |
DB0 | Dental Claim has been adjusted due to an incorrect tooth and or surface. | 96 | MA67 |
DB1 | Dental Claim was adjusted due to an incorrect Procedure code. | 96 | MA67 |
DB2 | Claim was denied for an Explanation of Benefits. | ||
DB3 | Claim paid secondary to another insurance carrier. | ||
DB4 | Dental Claim was denied requesting additional information from the provider. | ||
DB5 | A dental adjustment has been completed and has resulted in a statistical change. | 96 | MA67 |
DB6 | Claim was adjusted because the Member’s eligibility has been updated. | 96 | MA67 |
DCG | Override Dental Category | ||
DEN | Dental Service is not eligible for benefits under Member’s coverage. | 96 | N216 |
DG2 | The allowable is a discounted DRG amount. | 45 | |
DGE | Override Age Limitation | ||
Dis | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
DMD | Oral surgery Service does not meet the requirements of Member’s program for coverage. | 96 | N216 |
DOP | We are deducting amount because of an overpayment on a previous Claim. | 172 | |
DP0 | Patient’s age is not within the normal range established for dental Procedure. | 96 | N130 |
DP1 | Pental Procedure is not a covered Service for tooth/teeth numbers. | 96 | N130 |
DP2 | The charge or number of occurrences Procedure was performed has exceeded the contract limits. | 273 | N435 |
DP3 | The charge or number of occurrences Procedure was performed has exceeded the contract limits. | 273 | N435 |
DP4 | The charge or number of occurrences Procedure was performed has exceeded the contract limits. | 273 | N435 |
DP5 | The number of occurrences Procedure was performed has exceeded the contract limits. | 273 | N435 |
DPX | Your group’s contract requires a period of membership before benefits are available for Service. | 51 | N607 |
DRC | The dental runout time limit has been exceeded. | 29 | |
DRE | Claim is prior to effective date of the coverage. | 26 | N30 |
DRQ | Date of Service (DOS) is after the termination of coverage. | 27 | N30 |
DRT | Timely filing has been exceeded. | 29 | |
DSR | Your Claim has been received and is currently under special review. | 216 | |
DUP | Duplicate of previous Claim. If corrected billing, please resubmit according to billing guidelines. | 18 | N522 |
DWP | Override Dental Category Waiting Period | ||
ECT | ECT single or multiple is not a billable Service for discipline level. | 185 | N684 |
EMR | Amount was previously reimbursed and is not included in the Executive Medical Reimbursement. | 96 | M86 |
EMr | Amount is for Executive Medical Reimbursement. | 96 | M86 |
EOB | Please submit a copy of the Explanation of Benefits from Member’s other insurance carrier. | 22 | MA04 |
EXC | Claim was paid as an exception. Future Claims without a referral from the Member’s PCP will be denied. | 45 | N189 |
FTP | Family therapy is a non-covered Service. | 96 | N30 |
FYI | RECALCULATED PAYMENT – EXCLUDED FROM AMOUNT PAID. (Message appears on RA when auto deduct of overpayment.) | ||
G44 | Check amount is the outstanding balance (minus deductible and coinsurance) that the provider may bill. | 96 | N30 |
GAR | Execution Of Garnishment | ||
GLB | Claim is disallowed because it is included in the global case payment. | 97 | N525 |
GNS | The provider must file Claim with Magellan, P.O. BOX 5190, Columbia, MD 21046. | 109 | N418 |
GRP | The Member’s group has already paid for Claim. We are reimbursing the Member’s group by manual check. | 96 | N30 |
HLD | There is a hold on payment of Claim. | 96 | N30 |
HM0 | Call 1-800-924-7141 for Claim detail if needed. | ||
HRA | amount was paid from the Member’s Health Reimbursement Account. | 187 | |
INF | Medical records have been requested from the provider. | 252 | M127 |
INH | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
INV | Procedure is considered investigative and is not covered under Member’s plan. | 55 | N623 |
IPM | Individual Psychotherapy with Medical Management is non-covered. | 96 | N30 |
IRS | Execution of IRS Levy | ||
is1 | It is the State surcharge amount which is payable to the provider. | 96 | N30 |
isS | Service is not covered per the information submitted. The provider should verify coding and resubmit if incorrect. | 16 | MA39 |
ITA | Benefits cannot be provided for Service because the required authorization is not on file. | 197 | |
ITD | The provider must file Claim with his or her local BlueCross BlueShield plan for processing. | 109 | N418 |
LAB | Lab charge was already paid to the lab that performed the Service. The patient should not be billed. | 24 | |
LB1 | Lab charge was already paid to Member’s physician. The patient should not be billed. | 24 | |
LET | Benefits cannot be provided for Service. We are sending the member additional correspondence to explain. | 96 | N179 |
LOV | Charge exceeds the maximum allowed under Member’s coverage. | 45 | |
M09 | The provider has not contracted to provide Service. | 96 | N448 |
MAD | Portion of your Medicare Part A deductible is not covered under your supplemental policy. | 96 | N30 |
MAR | Call 1-800-924-7141 for Claim detail if needed. | ||
MAT | A portion of Claim is denied because member was not eligible for benefits for the entire term of the pregnancy. | 179 | |
MBD | Member’s plan does not cover the Medicare Part B deductible. | 96 | N30 |
MCC | We cannot pay benefits until Member’s out-of-pocket amount has been satisfied. | 96 | N30 |
MCD | Charge was denied by Medicare and is not covered on plan. The provider can bill the patient. | 96 | N30 |
MDC | Amount exceeds the reimbursement due to Medicaid. | 45 | |
MED | Please submit a copy of the Medicare Explanation of Benefits (EOB) so we can determine benefits. | 22 | MA04 |
MLN | The provider must submit the primary Diagnosis. | 11 | N657 |
MPF | Medicare paid Service in full. | 23 | |
MPf | Medicare paid Service in full. | 23 | |
MR1 | Medicare denied charge and the provider cannot bill you for it. | 45 | |
MR3 | The provider agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
MSD | The allowable amount for Service has been reduced according to multiple same day surgery guidelines. | 59 | N644 |
MSP | Payment is secondary to benefits provided by Medicare. | 23 | |
MTN | Service was prepaid by Middle Tennessee IPA. | 24 | |
MXC | The provider’s charge exceeds the amount allowed by Medicare. The member is not responsible for amount. | 45 | |
Mds | It is a non-participating facility. The Medicare Part A deductible/coinsurance is not covered under Member’s plan. | 242 | M115 |
Mrx | These benefits are reduced because a non-participating pharmacy was used. | 242 | |
N01 | Procedure is considered subset or redundant to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
N02 | The Procedure is considered subset or redundant to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
N03 | Procedure is secondary to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
N04 | Service is a part of the original surgical Procedure and is limited by Member’s plan. | 97 | M144 |
N05 | Service is not covered when performed on the same day as a surgical Procedure. | 97 | N20 |
N06 | Procedure does not normally require the Services of an assistant surgeon. | 54 | N646 |
N09 | Procedure is not eligible for benefits under Member’s coverage because it was performed for cosmetic purposes. | 96 | N383 |
N10 | Procedure is considered investigative and is not a covered Service under Member’s plan. | 55 | N623 |
N11 | Procedure is no longer considered clinically effective and is not eligible for benefits. | 56 | N623 |
N13 | It is a deleted/invalid code or modifier for date of Service. The provider should submit the proper code. | 182 | N657 |
N14 | Service is not covered for member. The provider should submit the proper code or medical documentation. | 16 | MA39 |
N15 | Service is not normally performed for members in age range. | 6 | N129 |
N16 | Service is not normally performed for members in age range. | 6 | N129 |
N17 | Service is not covered when performed in setting. | 96 | N428 |
N19 | Service is not covered when performed for the reported Diagnosis. | 11 | N657 |
N25 | The charge for Service has been combined with the primary Procedure. | 234 | M15 |
N26 | Service is a part of the original surgical Procedure and is limited by Member’s plan. | 97 | M144 |
N29 | Procedure is redundant to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
N30 | The maximum amount allowable for equipment has been reached. | 45 | |
NB | These benefits are for an eligible newborn who has not been added to subscriber’s plan. | 96 | N30 |
NCC | Member’s coverage excludes benefits for the condition for which service was rendered. | 96 | N216 |
NCP | Benefits for Service are excluded under Member’s plan. | 96 | N216 |
NEC | Benefits cannot be provided for Services that have been determined not to be medically necessary. | 50 | N130 |
NER | Benefits cannot be provided for Services not considered a medical emergency. | 40 | |
NRT | It is a non-contracted room type. The room type is disallowed. | 45 | |
O25 | The charge for Service has been combined with the primary Procedure. | 169 | |
OAS | Service is not normally covered for members in age range. | 6 | N129 |
OJI | These Services are related to an on-the-job injury. | 19 | |
OOA | Claim was filed by an out of area dental provider. | ||
OPC | Override PCA Disallow | ||
OTC | Drugs that can be purchased without a prescription are not an eligible expense. | 96 | N30 |
OTc | Drugs that can be purchased without a prescription are not an eligible expense. | 96 | N30 |
OUT | These benefits have been reduced because a non-participating provider was used. | 242 | N130 |
OVP | We are deducting amount because of an overpayment on a previous Claim. | 96 | N10 |
P50 | Present On Admission indicator required but is not valid. | ||
P59 | There are one or more Edits present that cause the whole Claim to be rejected. | 96 | N56 |
P60 | There are one or more Edits present that cause the whole Claim to be returned to the provider. | 96 | N56 |
P61 | There are one or more Edits present that cause the whole Claim to be rejected. | 96 | N56 |
P62 | There are one or more Edits present that cause the whole Claim to be denied. | 96 | N56 |
PAA | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAC | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAH | APC Rate | ||
PAI | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAK | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAL | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAP | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PAR | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PCD | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PCP | member has not chosen a PCP or has selected a PCP who is not participating in the plan. | 242 | N130 |
PCS | prescription requires prior authorization through your pharmacy. | 197 | |
PDA | Charge has been reduced based on a discount arrangement with provider. | 45 | |
PDC | Charge has been reduced based on a discount arrangement with provider. | 45 | |
PDD | Charge has been reduced based on a discount arrangement with the provider of Service. | 45 | |
PDP | Charge has been reduced based on a discount arrangement with provider. | 45 | |
PE0 | Charge exceeds the maximum allowable for Service. | 45 | |
PED | Routine nursery or pediatric care of a newborn is not eligible for benefits. | 96 | N30 |
PEN | Benefits for Service have been reduced due to lack of compliance with plan requirements. | 197 | |
PEO | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PEX | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PFC | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PFS | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PFU | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PFV | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PFW | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PGA | Charge is not reimbursed according to your DRG contract. Please see the provider manual. | 45 | |
PGD | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PGE | Charge exceeds the DRG rate for confinement. | 45 | |
PGO | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PGP | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PGR | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PHA | Pharmacological Management is non-covered. | 96 | N30 |
PHH | Hold Harmless Payment Applied | ||
PHY | Physician fees should be filed separately from the hospital Claim. The provider should rebill on the proper form. | 89 | N200 |
PI | Personal items cannot be considered for benefits. | 96 | N30 |
PLC | The Medicare limiting Charge was applied. | 96 | N30 |
PLP | Percent Threshold Stoploss Met | 119 | |
PPD | Service is included in the ordering physician’s agreement. It should be billed to the ordering physician. | 24 | |
PRO | Professional Pricer Reduction | ||
PS | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PS0 | Benefits for Service are excluded under Member’s plan. | 96 | N30 |
PS1 | The maximum amount payable under Member’s coverage for Service has been provided. | 119 | N587 |
PS2 | The maximum number of Services payable under Member’s coverage has been provided. | 119 | N362 |
PS3 | Drugs that can be purchased without a prescription or other non-covered drugs are excluded under Member’s plan. | 96 | N30 |
PS4 | Maximum benefits payable under Member’s coverage have been provided. | 119 | N587 |
PSB | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSC | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSM | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSN | Charge Exceeds SNF amount for Services | ||
PSR | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSS | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSU | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSV | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PSW | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
PT1 | Bypass Provider Termination Date Override | ||
PTR | The maximum number of units allowed for Service under Member’s coverage has been provided. | 119 | N362 |
PU4 | Milliliters | ||
PU5 | Units | ||
PX | Charges for a pre-existing condition are not eligible for benefits. | 51 | |
PXN | NetworX Std Fee Schedule | 45 | |
RB | These Charges exceed the maximum room and board allowance under Member’s coverage. | 78 | |
RDP | Procedure is considered subset or redundant to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
REC | MONEY RECEIVED – NO DEDUCTION FROM AMOUNT PAID. (Message appears on RA when auto recovery bypassed). | ||
REF | These Services were provided after the time limit specified in the referral from the PCP or Member’s plan. | 95 | N630 |
REJ | Service is not covered under Member’s plan. | 96 | N30 |
REX | Routine examinations are not eligible for benefits under Member’s plan. | 49 | N429 |
RFD | The referral for these Services was denied and benefits cannot be provided under Member’s plan. | 16 | N335 |
RFN | Benefits cannot be provided for these Services because we have no record of a referral from Member’s PCP. | 16 | N335 |
ROU | Routine Services are not covered under Member’s plan. | 49 | N429 |
RPC | Charges cannot be considered if the referring provider’s National Provider Identifier is not present on the Claim. | 16 | N286 |
RWC | Recoup due to Subrogation/Workers Comp Third Party Liability overpayment. | ||
RWD | A risk withhold has been applied to Service. The member is not responsible for amount. | 104 | |
RXD | Amount was applied to your prescription deductible. | 1 | |
RXI | Save $$ on drug cost. Show your BlueCross BlueShield ID card and use a member pharmacy when buying prescription drugs. | 96 | N30 |
RY1 | We have paid the annual maximum allowable for these Services for member. | 119 | N362 |
RY2 | The maximum days allowed for these Services have been used for member. | 119 | N362 |
S10 | Member’s coverage ended before the date these Services were provided. | 27 | N30 |
S11 | Member’s coverage was not in effect on the date Service was provided. | 26 | N30 |
S12 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S13 | Member’s coverage was not in effect on the date Service was provided. | 26 | N30 |
S14 | Member’s coverage did not take effect until after the date Service was provided. | 26 | N30 |
S16 | Member’s coverage was not in effect on the date Service was provided. | 26 | N30 |
S17 | Member’s coverage was not in effect on the date Service was provided. | 27 | N619 |
S1A | Member’s coverage was not in effect on the date Service was provided. | 26 | N30 |
S1B | Member’s coverage was not in effect on the date Service was provided. | 26 | N30 |
S1C | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S1D | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S1E | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S1F | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S2 | Member’s coverage was not in effect on the date Service was provided. | 14 | |
S20 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S21 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S22 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S23 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S24 | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
S25 | We have placed a hold on all Claims administration for subscriber and related members. | 26 | N30 |
S3 | Member’s coverage was not in effect on the date Service was provided. | 14 | |
S4 | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S5 | Member’s eligibility does not include coverage for type of Service. | 31 | |
S6 | Member’s age is beyond the limiting age for the plan. | 32 | N129 |
S61 | member is older than the plan’s age limit for coverage of Service. | 32 | N129 |
S7 | Member’s age is beyond the limiting age for the plan. | 27 | N30 |
S8 | Member’s age is beyond the limiting age for the plan. | 27 | N30 |
S9 | Member’s coverage was not in effect on the date Service was provided. | 27 | N30 |
S? | member was not eligible for coverage on the date Service was provided. | 27 | N30 |
SB | Patient is not a covered member under the plan. | 33 | |
SC | Patient is not a covered member under the plan. | 33 | |
SD | Patient is not a covered member under the plan. | 33 | |
SDP | Service is not covered when performed on the same day as a surgical Procedure. | 97 | N20 |
SE | Patient is not a covered member under the plan. | 33 | |
SF | Patient is not a covered member under the plan. | 33 | |
SG | Patient is not a covered member under the plan. | 33 | |
SH1 | Charge is a duplicate of a previously processed Claim. | 18 | N522 |
SHD | Charge is a duplicate of a previously submitted Charge for member. | 18 | N522 |
SL | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SL2 | Charge was discounted under the provider agreement. You have saved amount by using a participating provider. | 45 | |
SM | Member’s coverage under plan was not in effect on the date Service was provided. | 13 | |
SN | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SN1 | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SNF | The level of care billed does not match the level authorized. The provider must submit a corrected billing. | 197 | |
SO | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SO1 | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SP | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N619 |
SPD | Supplemental Discount | 45 | |
SPL | Patients stop-loss limit has been reached. Benefits are payable at 100%. | 119 | |
SPT | Member’s coverage has terminated. | 27 | N30 |
SQ | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SS | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
ST | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
STN | Claim is pended due to non-payment of premiums. The member should contact his or her State Group Representative. | 27 | N30 |
STP | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
STU | Benefits cannot be provided until we receive information about Member’s eligibility. | 252 | N375 |
SW | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
SW2 | It is a non-billable Service for the discipline level. | 185 | N684 |
TF0 | The Claim for these Services was received after the time limit specified in Member’s benefit plan. | 29 | |
TF1 | The Claim for these Services was received after the time limit specified in the provider’s agreement. | 29 | |
TMF | The Claim for these Services was filed after the time limit for filing specified in Member’s plan. | 29 | |
TPS | Payments have been suspended at the direction of the Bureau of TennCare. | B7 | |
TR0 | Benefits cannot be provided because there was no authorization and/or referral for Service. | 197 | |
TR1 | It is not a covered Service. | 96 | N30 |
TR2 | The maximum amount payable under Member’s coverage for Service has been provided. | 119 | N587 |
TR3 | The maximum amount payable under Member’s coverage for Service has been provided. | 119 | N587 |
TR4 | The maximum number of Services payable under Member’s coverage has been provided. | 119 | N362 |
TR5 | The maximum number of Services payable under Member’s coverage has been provided. | 119 | N362 |
TR6 | The payment is reduced by the amount paid by your primary insurance carrier. | 23 | |
Th | Member’s coverage was not in effect on the date these Services were provided. | 26 | N30 |
Trx | Your annual prescription drug maximum has been met. | 119 | N587 |
UAS | Member was not covered under the plan on the date Service was provided. | 26 | N30 |
UCR | Charge exceeds the maximum allowed under Member’s coverage. | 45 | |
UD | These Charges have been disallowed by Utilization Management. | 39 | |
UM0 | These Services were disallowed by Utilization Management. | 39 | |
UM1 | The number of Services provided exceeds the number approved in the Utilization Management authorization. | 198 | N351 |
UM2 | These Services were limited by a Utilization Management authorization. | 198 | N351 |
UM3 | Benefits cannot be provided because there was no authorization and/or referral for Service. | 197 | |
VBB | An enhanced medical benefit has been applied to a Service on Claim. | ||
VEX | Member’s coverage does not provide benefits for routine vision examinations. | 96 | N30 |
VGC | Member’s coverage does not provide benefits for glasses or contact lens. | 96 | N30 |
Vis | Charge exceeds the maximum allowed for vision Services. | 119 | N587 |
VNC | Service is not an eligible vision expense under Member’s coverage. | 96 | N30 |
W01 | The maximum amount allowable for equipment has been reached. | 45 | |
W02 | Charge is more than Medicare allows for Service. The member is not responsible for amount. | 45 | |
W03 | Benefits cannot be provided until a special review is completed. | 133 | |
W04 | The provider must submit the NDC, drug name, RX number, strength, day supply and quantity before benefits can be provided. | 16 | M123 |
W05 | The provider must submit a copy of the manufacturer’s invoice before benefits can be provided. | 252 | M23 |
W06 | The provider must submit the operative report or office notes before benefits can be provided. | 252 | M29 |
W07 | The provider must submit a Procedure code before benefits can be provided. | 16 | M51 |
W08 | The information on Claim does not match the medical records submitted. | 250 | M127 |
W09 | The provider has not contracted to provide Service. | 96 | N448 |
W0L | The Ambulatory Code Editor detected one or more errors for Claim line. | 16 | M50 |
W10 | Procedure is not eligible for benefits when performed in a hospital setting. | 96 | N428 |
W11 | A copy of the Anesthesia Flow sheet is needed to process Claim. The provider should submit information to us. | 252 | N439 |
W12 | The provider has not contracted to provide Service. | 45 | |
W13 | Service is not paid in addition to or separately from the primary Service. | 234 | N20 |
W14 | Service should not be billed separately from the room and board. | 234 | M2 |
W15 | Revenue code is not valid for place of Service billed. | 16 | M50 |
W16 | It is a non-covered Service. | 16 | M12 |
W17 | Service requires a detailed revenue code. The provider should refer to billing guidelines locator form 44. | 16 | M12 |
W18 | Requires Case Management approval prior to rendering Services. | 197 | |
W19 | The provider must submit a hard copy of Claim with outpatient medical records. | 50 | M127 |
W1L | The Claim line contains revenue code 058x, 059x,0275,0276,0277,or 0278 with Charges greater than zero or it has revenue code 0624. | 16 | M50 |
W1T | Benefits cannot be provided until the doctor submits additional information for the Abortion, Sterilization or Hysterectomy review. | 252 | M127 |
W21 | The provider must submit the appropriate CDT/CPT/HCPCS code for Service. | 189 | M81 |
W22 | It is not a valid revenue code for provider. The provider should refer to billing guidelines. | 16 | M50 |
W23 | It is an inactive revenue code. The provider should refile with a valid code. | 16 | M50 |
W24 | Service requires a detailed revenue code. The provider should refer to billing guidelines locator form 42. | 16 | M50 |
W25 | The revenue code is invalid for the place of Service billed. The provider should verify code. | 16 | M50 |
W26 | The provider must refer to the billing guidelines for proper billing. | 16 | N657 |
W27 | The facility has a separate contract for lithotripsy. When billing, the provider must use revenue code 790. | 96 | N56 |
W29 | The facility did not contract for lithotripsy, revenue code 790. The provider must bill using revenue code 490 or 360. | 96 | N56 |
W2A | The provider must refer to the billing guidelines for proper billing. | 96 | N56 |
W2L | Claim contains injectable osteoporosis drugs that are not payable because the Claim does not meet all of the required criteria. | 50 | N130 |
W30 | It is a bundled Service. The payment is included in the Service to which item/Service is incident. | 97 | M80 |
W31 | Only the initial visit is eligible. | 96 | N113 |
W33 | These Charges were included in the reimbursement for the mother’s room and board. | 128 | |
W34 | It is a deleted/invalid code or modifier for date of Service. The provider should submit the proper code. | 182 | N657 |
W35 | These DRG outlier days were denied by Utilization Management. | 69 | |
W36 | These DRG inlier days were approved by Utilization Management. | 69 | |
W37 | per diem rate was approved for DRG facility transfer. | 232 | |
W38 | The amount was disallowed for DRG facility transfer. | 232 | |
W39 | DRG code is no longer valid. | A8 | N657 |
W3L | ESRD Claim was billed with another bill type than 72x. | 16 | MA30 |
W40 | A valid DRG code could not be assigned for the coding that was submitted. The provider must submit valid codes. | A8 | N657 |
W41 | Medical Direction of four or more concurrent Procedures is not eligible for reimbursement. | B15 | M80 |
W42 | For dates of Service prior to 1/1/01, please submit the Claim to Magellan. | 109 | N418 |
W43 | Procedure is considered investigative and is not a covered Service. | 55 | N623 |
W44 | Benefits cannot be provided for Services that have been determined not to be medically necessary. | 96 | N30 |
W45 | The Claim for these Services was filed after the time limit for filing specified in Member’s plan. | 29 | |
W46 | The organ acquisition cost is included in the kidney transplant case rate. | 97 | N525 |
W47 | It is a non-covered chiropractic Service. | 185 | N684 |
W48 | Benefits for maintenance or servicing of durable medical equipment within six months of purchase date are not available. | 96 | N30 |
W49 | Benefits cannot be provided for Service because the required authorization is not on file. | 197 | |
W4L | ESRD Claims must contain condition codes 59,71,72,73,74,76 or 80. Condition codes 73 and 74 cannot appear on the same Claim. | 16 | M44 |
W50 | Benefits cannot be provided for Services that have been determined not to be medically necessary. | 50 | N130 |
W51 | CPT code, modifier, or provider type is invalid. The provider should refer to billing guidelines. | 96 | N56 |
W52 | The provider must submit patient’s complete medical history before benefits can be provided for Service. | 252 | M127 |
W53 | Facility number is used only for Signature members. The provider must refile under the correct provider number. | 16 | N77 |
W54 | The provider must submit patient’s medical records. Please reference Claim number and member id when you submit the records. | 252 | M127 |
W55 | Benefits are unavailable until we receive the information we requested in a recent letter to the provider’s office. | 252 | M143 |
W56 | The provider must submit a letter of medical necessity and plan of treatment for patient. | 50 | M135 |
W57 | Information has been requested from another provider to completed a pre-existing review. Not action is required. | 252 | N204 |
W58 | Interim bills should only be submitted once every thirty days for the same hospital stay. | 16 | M53 |
W59 | Claim was filed under the BlueCare provider number. Please resubmit using the Commercial provider number. | 16 | N77 |
W5L | An ESRD Claim must contain a Diagnosis of End Stage Renal Disease. | 16 | M64 |
W60 | Benefits cannot be provided until the provider submits a manufacturer name, product name, product number, and quantity. | 252 | M23 |
W61 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
W62 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
W63 | The provider has agreed to waive the Medicare Part A deductible and coinsurance. | 45 | N364 |
W64 | Measurement/Reporting Codes No Fee – Charge is incidental to the primary Service. | 97 | M80 |
W65 | Charge is more than Medicare allows for Service. The member is not responsible for amount. | 45 | |
W66 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
W67 | Service is not covered since it is supplied by the government. | 212 | N658 |
W6L | An ESRD Claim must contain a valid weight and height passed through value codes A8 and A9. | 16 | N207 |
W71 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
W72 | The rendering provider is not eligible to perform the Service billed. | 185 | N570 |
W73 | Claim was adjusted following a provider audit. | 96 | MA67 |
W74 | Medical information is needed to complete a pre-existing review. Correspondence to the provider will follow. | 252 | N204 |
W75 | Charge exceeds the maximum allowable under the group practice agreement. | 45 | |
W76 | Charge is included in the facility or physician fee that contracted for Service. | 234 | M80 |
W77 | Claim was processed under continuity of care guidelines. | 131 | |
W78 | Charges do not meet qualifications for emergent/urgent care. | 40 | |
W79 | The provider must file Claim with CMS. The Medicare contractor to process Claim can be identified through the CMS website. | 109 | N104 |
W7L | Automated Multi-Channel Chemistry HCPCS component codes must be billed separately. | 16 | M126 |
W80 | Member’s benefits are based on Medicare’s allowed amount. | 23 | |
W8L | ESRD Claim has an invalid modifier for pricing or is missing the required combination of modifier codes | 4 | N519 |
W9L | The incorrect number of units billed for revenue code 0634 or 0635 or a dialysis code was billed with units greater than 1. | 16 | M53 |
WA0 | Charge was adjusted because we were notified that the provider billed for Service in error. | 96 | N10 |
WA1 | We cannot provide benefits for Services that have been determined not to be a standard medical Procedure. | 56 | N623 |
WA2 | Claim must be filed by the provider who actually rendered the Service. | 96 | N32 |
WA3 | Procedure is not covered when rendered in place of Service. | 96 | N428 |
WA4 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
WA5 | Benefits for Charge must be determined by filing through Member’s appropriate pharmacy network. | 109 | N418 |
WA7 | For dates of Service prior to 1/1/01, please submit the Claim to Magellan. | 109 | N418 |
WA8 | The provider who rendered these Services is not eligible to assist during surgery. | 185 | N684 |
WB0 | A completed consent form is required from the provider before Service can be considered for benefits. | 252 | N28 |
WB1 | Benefits cannot be provided until a Behavioral Health provider number and/or taxonomy code is submitted with a corrected Claim. | 96 | N30 |
WB2 | The provider must file Claim with Tennessee Bureau of Medicaid PO Box 460, Nashville, TN 67202-0460. 1-800-852-2683 | 109 | N418 |
WB3 | The provider must file Claim with Magellan Health Services, PO Box 85042 Richmond, VA 23261. 1-866-434-5524 | 109 | N418 |
WB4 | Claim is paid according to the State Medicaid Rates due to the Deficit Reduction Act. | 45 | |
WB5 | Benefits are provided under the Vaccines for Children Program for the handling/administration of the vaccine only. | 45 | |
WB6 | Benefits can not be provided for out of network Services because the required authorization is not on file. | 243 | M115 |
WB7 | A completed consent form is required from the provider before Service can be considered for benefits. | 252 | N28 |
WB8 | The number of administration Services for these injections must equal injections billed. The provider may need to file a corrected bill. | 45 | |
WB9 | The provider must submit a valid National Drug Code, unites and quantity qualifier before benefits can be provided. | 16 | M119 |
WC | Benefits are excluded for an on the job injury or for Services eligible for Worker’s Compensation benefits. | 19 | N418 |
WC1 | Benefits are excluded for an on the job injury or for Services eligible for Worker’s Compensation benefits. | 19 | N418 |
WCS | Benefits are excluded for an on the job injury or for Services eligible for Worker’s Compensation benefits. | 19 | N418 |
WD1 | Service is not eligible since it was not filed according to the corrected billing guidelines. Please submit a corrected Claim. | 96 | N56 |
WD2 | We are adjusting Claim because the Procedure was billed in error. | 96 | MA67 |
WD3 | The provider must refer to billing guidelines for BlueCare or TennCare Select. | 96 | N56 |
WD4 | is not a valid revenue code for type of provider. The provider should refer to billing guidelines. | 170 | N95 |
WD5 | The provider must file Claim with OPTUM HEALTH ServiceS 1-855-437-3486 (1-855-Here4TN) | 109 | N418 |
WD6 | The provider must file Claim with Beacon Health Options 1-888-474-0929 | 109 | N418 |
WE0 | Service is not a covered benefit under the Member’s plan. | 96 | N30 |
WE1 | Claim was paid to the wrong payee. | 96 | N10 |
WE2 | The provider must submit Room and Board Charges correctly before benefits can be provided. | 16 | MA30 |
WE3 | The servicing provider has billed Claim under the incorrect patient. | 16 | MA36 |
WE4 | Charge was adjusted because we were notified that the provider billed for Service in error. | 96 | N10 |
WE5 | Claim must be filed by the provider who actually rendered the Service. | 96 | N32 |
WE6 | Claim was paid to the wrong payee. | 129 | MA130 |
WE7 | Charge has been forwarded to the Member’s appropriate pharmacy network to determine benefits. | 109 | N216 |
WE8 | Benefits have been provided at the PCP Enhancement Rate. | 45 | |
WE9 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 45 | |
WEL | Member’s coverage does not provide benefits for physical examinations and related Services. | 49 | N429 |
WF0 | Service is not eligible since it was not filed according to the corrected billing guidelines. Please submit a corrected Claim. | 96 | N56 |
WF1 | Procedure or related Procedure code cannot be billed on the same or different Claim within ten months. | 119 | N435 |
WF2 | The provider must submit a valid National Provider Identifier before benefits can be provided. | 208 | |
WF4 | Payment of Claim is pending receipt of State of Medicaid number or Need Medicaid number and/or Disclosure Form. | 16 | MA112 |
WG0 | The Claim for these Services was received after the time limit specified in the provider’s agreement | 29 | |
WG1 | These Services were disallowed by Utilization Management. | 39 | MA67 |
WG2 | Medical Records are required before outlier days will be reviewed for medical appropriateness. | 252 | M127 |
WG3 | No approved authorization. Specialty Pharmacy Drug authorizations are handled through PBM Vendor. Please contact CVS/Caremark. | 243 | |
WG4 | No approved authorization. Specialty Pharmacy Drug authorizations are handled through PBM Vendor. Please contact CVS/Caremark. | 243 | |
WGB | These Services should be filed and paid by the behavioral health carrier at ComPsych Claims, PO Box 8379, Chicago, IL 60680-8379. | 109 | N418 |
WH0 | Claim was adjusted because it was previously processed under a different patient. | B13 | |
WH1 | Exceeds maximum units considered medically appropriate. | 119 | N435 |
WH2 | Service was included in the Bundled Episode Payment. | 97 | N525 |
WH3 | The maximum amount payable under Member’s coverage for bundled episode. | 45 | |
WH4 | Benefits cannot be provided until the provider submits a brand name, manufacturer name, model and description. | 252 | M23 |
WH5 | The information on Claim does not match the medical records submitted | B12 | |
WH6 | The provider must submit an itemized or detailed billing before benefits can be provided for Service. | 16 | N260 |
WH7 | The provider must submit the NDC, drug name, Rx number, strength, day supply and quantity before benefits can be provided. | 16 | M123 |
WH8 | Care Coordination fees are not payable. | 96 | N30 |
WH9 | Care Coordination fees are not payable. | 96 | N30 |
WK0 | Lab Service is required to be performed by Quest Diagnostics or Solstas Lab Partners. | 185 | |
WK1 | The provider must file Claim with his or her local BlueCross BlueShield plan for processing. | 109 | N418 |
WK2 | Corrected Bill was received after the time limit for submission. | 29 | |
WK3 | Corrected Bill was received after the time limit for submission. | 29 | |
WK4 | The provider must submit a correct Procedure code before benefits can be provided. | 16 | M51 |
WK5 | Statement begin and end dates can’t span calendar months TOB 89X and 66X. | 273 | N435 |
WK6 | The provider must submit a correct occurrence code before benefits can be provided. | 16 | M46 |
WK7 | The provider must submit a correct value code before benefits can be provided. | 16 | M49 |
WK8 | The provider must submit a correct condition code before benefits can provided. | 16 | M44 |
WK9 | Revenue codes not keyed in date of Service order. | 16 | M50 |
WL0 | Home Health Claim has a UB04 bill type other than 0322, 0327, 0329, 0332, 0337, 0339, or 034x. | 16 | MA30 |
WL1 | Home Health Claim has an invalid Service date, from -thru dates or admission date. | 16 | MA31 |
WL2 | The length of stay for Home Health Claim is greater than 60 days | 16 | MA31 |
WL3 | The Home Health Claim has more than one Claim line with a HIPPS code and revenue code 0023. | 16 | N471 |
WL4 | The Home Health Claim indicates non-routine supplies were provided during the episode, without revenue code 027x or 0623. | 16 | M20 |
WL5 | Home Health Claim is missing the Core Based Statistical Area in the UB-04 Value Amount with UB-04 Value Code 61. | 16 | M49 |
WL6 | Claim must have at least on Home Health visit related revenue code | 16 | M50 |
WL7 | A weight/rate record cannot be found for particular facility ID, payer ID, effective date and Home Health Resource Group. | 16 | N471 |
WL8 | Therapy Services billed with revenue codes 042x, 043x and 044x must be billed with the applicable modifier codes. | 182 | N657 |
WL9 | Service is not found on the fee schedule because it may be covered under the HHA episode rate, so it is not separately payable. | 16 | N471 |
WM0 | The provider must submit a correct type of admission code before benefits can be provided. | 16 | MA41 |
WM1 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
WM2 | It is a subrogation adjustment. It will not affect previously assigned patient liability. | 215 | |
WM3 | The provider must submit a correct disCharge status before benefits can be provided. | 16 | N50 |
WM4 | The provider must submit a correct admission status before benefits can be provided. | 16 | MA43 |
WM5 | Statement from/thru dates must correspond Service line dates of Service before benefits can be provided. | 16 | MA31 |
WM6 | Duplicate data not allowed in 5010 formatted Claim. | 18 | N522 |
WM7 | Member has other insurance; please bill the primary carrier. Claim is paid due to the Services being under the pay and chase option. | 22 | N598 |
WM8 | Modifier code or Procedure code is not valid for the date of Service on the Claim. | 4 | N519 |
WM9 | Service is not covered when performed with an invalid Diagnosis code. | 11 | N657 |
WMN | Payment of Claim is pending receipt of Medicaid registration. | 16 | MA112 |
WMT | Claim is on hold based on current premium information. The member should contact his or her Human Resource office. | 27 | N30 |
WN1 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 45 | |
WN2 | The only appropriate bill types for SNF Claims are 18X, 21X, 22X, and 23X. | 16 | MA30 |
WN3 | Claim contains Service dates that are invalid or out of range. | 16 | MA31 |
WN4 | Only one Resource Utilization Group can be billed per individual date of Service. | 16 | N471 |
WN5 | SNF Part B Claims are not allowed to cross the calendar year boundary. | 16 | M52 |
WN6 | Part B therapy Services billed with revenue codes 042x, 043x and 044x must be billed with the applicable modifier codes. | 182 | N657 |
WN7 | Service is non-covered because authorization guidelines were not followed for Service. | 197 | |
WN8 | Claim was adjusted following an HDI provider Audit | 50 | N10 |
WN9 | The Claim was adjusted following an HDI provider Audit | 50 | N10 |
WOD | Payment of Claim is pending the receipt of a ownership and disclosure form from the rendering provider or group billing entity. | 16 | MA112 |
WP0 | Call 1-800-924-7141 for Claim detail if needed. | ||
WP1 | Charge is being discounted in accordance with NPPN agreement. The member is not responsible for amount. | 45 | |
WP2 | Charge is being discounted in accordance with URN agreement. The member is not responsible for amount. | 45 | |
WP3 | Charge is discounted in accordance with MultiPlan Inc. agreement. The member is not responsible for amount. | 45 | |
WP4 | Benefits cannot be provided until the provider submits complete medical records for inpatient admission. | 252 | N451 |
WPX | Charges for a pre-existing condition are not eligible for benefits. | 51 | N607 |
WQ0 | The number of units on line is considered Medically Unlikely. | 96 | N362 |
WQ1 | Automated Multi Channel Chemistry HCPCS component codes must have only one occurrence of a CD, CE or CF modifier on each line. | 16 | M53 |
WQ2 | Automated Multi-Channel Chemistry Service is not paid because less than 50% of these Services are separately payable. | 234 | M15 |
WQ3 | Telehealth originating site fee, HCPCS code Q3014, is billed incorrectly. | 16 | M20 |
WQ4 | Service has been paid at a user-defined percent of Charges. | 169 | |
WQ5 | Claim lines for EPO and Aranesp must be billed with the proper revenue codes. | 16 | M50 |
WQ6 | The HCT or HGB exceeds monitoring threshold without the appropriate modifier code. | 4 | N519 |
WQ7 | Part A SNF Claims must contain at least one Resource Utilization Group Codes. | 16 | N471 |
WQ8 | Part B ambulance Services must have the zip code of the location of pick-up present on the Claim. | 16 | N53 |
WQ9 | Revenue code is not covered for type of bill 22x. | 16 | M50 |
WR0 | Service is not covered when performed for the reported Diagnosis. | 11 | N657 |
WR1 | Procedure is redundant to the primary Procedure and is limited by Member’s plan. | 234 | M15 |
WR2 | Service is not eligible since it was not filed according to the corrected billing guidelines. Please submit a corrected Claim. | 18 | N522 |
WR3 | Services performed in a school setting requires an Individualized Educational Plan. | 252 | M135 |
WR4 | Medial Branch Block Injection Certification form invalid or incomplete | 252 | N473 |
WR5 | The provider must file Claim to the non-emergency transportation broker for processing. | 96 | N61 |
WR6 | The provide must submit a corrected EOB from the primary insurance before benefits can be provided. | 16 | N4 |
WR7 | Claim was pended due to non-payment of premium and will be denied if the premium is not pad by the end of the grace period. | 200 | N619 |
WR8 | The provider must submit a corrected EOB from the primary insurance before benefits can be provided. | 16 | N4 |
WR9 | is a subrogation adjustment. It will not affect previously assigned patient liability. | 215 | |
WS0 | revenue code is not valid with the Diagnosis on the Claim. The provider should refer to billing guidelines. | 96 | N95 |
WS1 | Submit dental Claims to DentaQuest, 11100 W Liberty Drive, Milwaukee, WI 53224. | 109 | N418 |
WS2 | Claim needs to be submitted to Magellan Rx | 109 | N418 |
WS3 | Claim should be submitted to Department of Medical Assistance Services. | 109 | N418 |
WS4 | Consumer Directed Services are not payable for the submitted Claim. Please contact Public Partnerships, LLC, at 1-866-3009. | 109 | N418 |
WS5 | These Services will need to be billed to Vision Services Plan. Please contact the vendor at 1-800-877-7195. | 109 | N418 |
WS6 | Service will need to be billed to the Member’s non emergent transportation provider. | 109 | N418 |
WS8 | Medical review on these DRG outlier days has been completed. The outlier days have been denied. | 69 | |
WS9 | Medical records are required before outlier days will be reviewed for medical appropriateness. | 252 | M127 |
WSH | is an excluded benefit under the member’s coverage. | 96 | N30 |
WSP | specialist does not participate in your network. Please contact your PCP for a new referral. | 242 | N130 |
WT0 | Benefits for abortion, sterilization or hysterectomy Services are excluded due to not meeting State or Federal requirements. | 272 | N584 |
WT1 | Benefits for abortion, sterilization or hysterectomy Services are excluded due to not meeting State or Federal requirements. | 272 | N584 |
WT2 | ancillary Service is not eligible for reimbursement when billed with a triage visit. | 97 | M86 |
WT3 | Benefits can not be provided since the dates of Service must equal the number of units billed. The provider may file a corrected bill. | 16 | M53 |
WT4 | The provider must submit a valid National Provider Identifier before benefits can be provided. | 208 | |
WT5 | Emergency room Service is included in the reimbursement for the observation room. | 45 | |
WT6 | Payment has already been made by another TennCare coverage for these Services. No additional reimbursement will be provided. | 129 | MA36 |
WT7 | Service must be billed with a Category II code before benefits can be provided. The provider needs to file a corrected bill. | 16 | M51 |
WT8 | It is not a covered Service since the primary carrier payment policies were not followed for member. | 136 | N23 |
WTA | It is not a covered Service since the primary carrier payment policies were not followed for member. | 136 | N23 |
WU0 | Provider timely filing has been exceeded. | 29 | |
WU1 | Provider timely filing has been exceeded. | 29 | |
WU2 | Contracted funding agreement – Subscriber is employed by the provider of Services. | 139 | |
WU3 | Contracted funding agreement – Subscriber is employed by the provider of Services. | 139 | |
WU4 | Charges are eligible for Crossover or Do not match EOMB. | 250 | N479 |
WU6 | The date of death precedes the date of Service. | 13 | |
WU7 | The date of death precedes the date of Service. | 13 | |
WU8 | Charges are eligible for processing via existing crossover arrangements. | B11 | |
WU9 | Charges are eligible for processing via existing crossover arrangements. | B11 | |
WV0 | It is a subrogation adjustment. It will not affect previously assigned patient liability. | 215 | |
WV1 | Provider changed data from original Claim related to COB. | 96 | MA67 |
WV2 | Line item units cannot contain a decimal. | 16 | M53 |
WV3 | The provider must submit a correct occurrence code before benefits can provided. | 16 | M46 |
WV4 | Claim is considered a duplicate due to a previous settlement for Medicaid Provider. | B13 | |
WV5 | Claim was adjusted following a provider audit. | 50 | N10 |
WV6 | The provider must submit patient’s medical records. Please reference Claim number and member id when you submit the records. | 252 | M127 |
WV7 | Surgical ICD Dates can’t be more than three day prior to the Statement From Date or should not be greater than the Statement To Date. | 16 | N301 |
WV8 | The provider must submit appropriate Attending Physician information before benefits can be provided. | 206 | N253 |
WV9 | Medical Records need to be submitted to HDI in Las Vegas for reconsideration. | 50 | M127 |
WVA | The provider must file Claim with VA Health Administration Ctr. CHAMPVA, PO Box 65024 Denver, CO 80206-9024. | 109 | N36 |
WW0 | Medical Records need to be submitted to HDI in Las Vegas for reconsideration. | 50 | N10 |
WW1 | Lab Service is required to be performed by Quest Diagnostics. | 242 | N95 |
WW2 | The servicing provider has billed Claim under the incorrect patient. | 96 | N10 |
WW3 | These Services are only covered when performed by the primary care provider or designee after the network discounts. | 242 | N450 |
WW4 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
WW5 | Benefits for Service cannot be reimbursed until the correct provider indicator number is billed. | 16 | MA134 |
WW6 | Provider must submit medical records to better support Claim. Please reference Claim number and member id when you submit the records. | 252 | M127 |
WW7 | Provider must submit medical records to better support Claim. Please reference Claim number and member id when you submit the records. | 252 | M127 |
WW8 | Claim contains one or more duplicate line items to the current Claim. Please resubmit according to billing guidelines. | 18 | N111 |
WW9 | Claim contains one or more duplicate line items to the current Claim. Please resubmit according to billing guidelines. | 18 | N111 |
WX0 | Member incarcerated medical necessity review required. | 16 | M60 |
WX1 | Line item units cannot contain a decimal. | 16 | M53 |
WX2 | Claim rejected due to Member’s Medicare eligibility status; unable to apply surCharge. | 137 | N733 |
WX3 | The ICD code version submitted by the provider is not compliant with Federal Regulation for Service/disCharge date. | 16 | M76 |
WX4 | Benefits for Service cannot be reimbursed until the correct provider indicator number is billed. | 16 | MA134 |
WX5 | Service is not paid in addition to or separately from the denied Service. | 234 | N20 |
WX6 | The provider has not contracted to provide Service. | 45 | |
WX7 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
WX8 | The provider must submit a valid pick up location zip code before benefits can be provided. | 16 | N53 |
WX9 | Claim was pended due to non-payment of premium and will be denied if the premium is not paid by the end of the grace period. | 200 | N619 |
WY0 | A corrected bill has been received. Any previous payment from is being recouped. | 96 | MA67 |
WY1 | The units of Service billed for the Procedure code exceeds the allowed number of units. | 50 | N362 |
WY2 | Benefits cannot be provided until a special review is completed. | 133 | M127 |
WY3 | Edit occurred because a submitted Procedure code is not valid for the Service dates on the Claim. | 181 | M20 |
WY4 | Benefits cannot be provided until a special review is completed. | 133 | M127 |
WY5 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
WY6 | The patient is not liable for these Charges. | 133 | |
WY7 | Provider is required to enroll in the Medicaid Program where the member resides. | B7 | N570 |
WY8 | Provider is required to enroll in the Medicaid Program where the member resides. | B7 | N570 |
WY9 | Medicaid Data Elements are Missing. | 252 | M127 |
WZ0 | Provider has been termed per special review completed by BlueCross BlueShield of Tennessee. | 170 | |
WZ1 | Payment of Claim is pending receipt of Disclosure Form from the rendering provider or group billing entity. | 16 | MA112 |
WZ2 | Claim did not meet the Tennessee Perinatal Care System for Guidelines for Regionalization, Hospital Care Levels, Staffing and Facilities. | 272 | N584 |
WZ3 | Exceeds maximum units considered medically appropriate. | 119 | N435 |
WZ4 | Medicare Advantage requires a completed CMS-2728-U3 form to be on file prior to adjudicating Claim. | 252 | M127 |
WZ5 | Medicare Advantage requires a completed CMS-2728-U3 form to be on file prior to adjudicating Claim. | 252 | M127 |
WZ6 | Statement from/thru dates must correspond Service line date of Service before benefits can be provided. | 16 | MA31 |
WZ7 | A maximum of one Patient Assessment Form is payable each calendar year under Member’s coverage. | 119 | N362 |
WZ8 | Delivery Charges for mother and baby must be billed separately. | 16 | MA36 |
WZ9 | revenue code is not valid with the Diagnosis on the Claim. The provider should refer to billing guidelines. | 96 | N95 |
WZA | Below minimum units considered medically appropriate | 16 | N430 |
WZB | Claim is being reviewed to determine if a third party payer, subrogation has liability on Claim. Questionnaire to follow. | 252 | N686 |
WZD | Improper or inappropriate use of the modifier billed with Procedure. | 236 | |
WZE | Routine vision Services should be filed to Eyemed for payment. Contact Eyemed for filing instructions at 1-844-261-9034. | 109 | N418 |
WZF | CMHRS Services are only billable through Magellan BH of VA. Re-submit to PO Box 1099; Maryland Heights, MO 63043. | 109 | N418 |
WZG | The Member’s Individualized Family Service Plan (IFSP) is not found or does not include Service. | 15 | M62 |
WZH | The Member’s Individualized Family Service Plan (IFSP) is not found or does not include Service. | 15 | MA62 |
WZI | Service can only be billed with a professional modifier code and will not be reimbursed at the global or technical rate. | 234 | M15 |
WZJ | CMHRS Services are only billable through Magellan BH of VA through 12/31/17. Re-submit to PO Box 1099; Maryland Heights, MO 63043 | 109 | N418 |
WZK | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
WZL | Service was billed on the incorrect Claim form type. | 16 | N34 |
WZM | Service was billed on the incorrect Claim form type. | 16 | N34 |
X01 | The actual date of Service is needed for Charge. | 16 | M52 |
X02 | Charge should be filed at the time of delivery. | 96 | N56 |
X04 | Charge has been applied to the maximum for routine Services. | 96 | N30 |
X05 | The provider must submit an itemized or detailed billing before benefits can be provided for Service. | 252 | N26 |
X06 | The provider must submit the anesthesia time before benefits can be provided for Service. | 16 | N203 |
X07 | The provider must submit the name and title of the individual who rendered Service before benefits can be provided. | 16 | N289 |
X08 | The provider must submit a description of Services rendered before benefits can be provided. | 252 | N350 |
X09 | principal Diagnosis code is invalid. The provider must submit a valid code. | 16 | MA63 |
X10 | DRG is not paid under the Acute Care Hospital Agreement. | 45 | |
X11 | Charge exceeds the maximum allowable under Member’s coverage. | 59 | N644 |
X12 | The provider has not contracted to provide Service. | 185 | N684 |
X13 | Service is not paid in addition to or separately from the primary Service. | 234 | N20 |
X14 | Service is not covered for member. The provider should submit the proper code or medical documentation. | 16 | MA39 |
X15 | A valid DRG code could not be assigned for the coding that was submitted. The provider must submit valid codes. | 236 | N657 |
X16 | The reimbursement for re-admission is included in the DRG allowance on a previous Claim. | 97 | N525 |
X17 | The provider must submit a correct Procedure and revenue code combination before benefits can be provided. | 199 | N657 |
X18 | Service is not normally performed for members in age range. | 6 | N129 |
X19 | Benefits have been reduced since the required authorization for Service was not obtained. | 197 | |
X20 | Benefits have been reduced since the required authorization for Service was not obtained. | 197 | |
X29 | modifier is not compatible with Procedure code. The provider should submit the proper code. | 4 | N519 |
X30 | Benefits cannot be determined until the provider submits the first date of dialysis. | 16 | MA122 |
X31 | A split billing is needed for confinement. The hospital must rebill according to the letter being sent to them. | 96 | N61 |
X32 | The provider should refer to billing guidelines on filing days or units for Durable Medical Equipment Claims. | 108 | N130 |
X33 | The Diagnosis code or Procedure code is not valid for the date of Service on the Claim. | 146 | M76 |
X34 | The provider must submit the x-ray report before benefits can be provided for Service. | 252 | M31 |
X35 | The provider must file Claim with Magellan Health Services, PO Box 2154, Maryland Heights, MO 63043 (1-800-308-4934). | 109 | N418 |
X36 | The provider must refer to the billing guidelines for proper billing of patient Services. | 96 | N56 |
X37 | Medical information is needed to complete a pre-existing review. Correspondence to the provider will follow. | 252 | N204 |
X38 | Information has been requested from another provider to complete a pre-existing review. No action is required. | 252 | N204 |
X39 | Pricing is based on a prior year agreement. The member is not liable for the amount that exceeds pricing. | 45 | |
X40 | The amount represents your Medicare savings. | 23 | |
X49 | Medical records have been requested for a provider audit reconsideration. | 252 | M127 |
X50 | The amount was paid by your dental policy. | 23 | |
X51 | Vanderbilt employee PPO Claims must be filed with Signature Health Alliance. | 109 | N418 |
X53 | Benefits cannot be provided for Services that have been determined not to be medically necessary. | 50 | N130 |
X54 | Service in non-covered because authorization guidelines were not followed for Service. | 197 | |
X55 | The provider must file the Claim with CareCentrix, PO Box 277947 Atlanta, GA 30384. | 109 | N418 |
X56 | Medical records have been requested for a provider audit reconsideration. | 252 | M127 |
X57 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
X58 | Medicaid Data Elements are Missing. | 252 | M127 |
X60 | Benefits for Services related to obesity, including surgical Procedures, are not covered under Member’s plan. | 96 | N30 |
X76 | Medical records have been requested from the provider. | 252 | M127 |
X77 | The provider must submit the NDC, drug name, RX number, strength, day supply and quantity before benefits can be provided. | 16 | M123 |
X78 | The provider must refer to the billing guidelines for Home Infusion Therapy. A separate line must be billed for each date of Service. | 16 | N61 |
X79 | The provider must submit the appropriate CDT/CPT/HCPCS code for Service. | 189 | M81 |
X80 | Procedure requires an Origin and Destination modifier be billed. The provider should submit the proper code and modifier. | 4 | N519 |
X83 | The provider must submit the proper code. No medication currently manufactured matching the code billed. | 16 | M119 |
X84 | The date of birth follows the date of Service. | 14 | |
X85 | The date of birth follows the date of Service. | 14 | |
X86 | The provider must submit a correct Procedure and revenue code combination before benefits can be provided. | 199 | N657 |
X87 | The provider must submit a correct Type of Bill and revenue code combination before benefits can be provided. | 16 | MA30 |
X88 | The provider must submit a correct Procedure and place of Service combination before benefits can be provided. | 5 | M77 |
X89 | The submitted Procedure is disallowed because an add on code was billed without the presence of the related primary Service/Procedure. | 97 | N122 |
X90 | modifier code or Procedure code is not valid for the date of Service on the Claim. | 4 | N519 |
X91 | Each per diem must be filed with any medication/injection. | 16 | M123 |
X92 | Date span is not within HHA benefit week. HHA benefit week. | 199 | N657 |
X93 | Date span is not within HHA benefit week. benefit week. | 96 | N56 |
X94 | Each per diem must be filed with any medication/injection. | 50 | M51 |
XA1 | Member’s maternity benefits include a twelve-month waiting period before benefits can be provided. | 179 | |
XA2 | Completed questionnaire is needed from the member before the Claim can be processed. | 133 | |
XA3 | dental Service is not eligible for benefits under Member’s coverage. | 96 | N130 |
XA4 | Service is not eligible because it was not rendered by Member’s PCP. | 185 | N684 |
XA5 | Procedure is considered investigative and is not covered under Member’s plan. | 55 | N623 |
XA6 | These Charges will be considered if a referral is submitted. | 16 | N335 |
XA7 | Routine examinations are not eligible for benefits under Member’s plan. | 49 | N567 |
XA8 | Member’s coverage was not in effect on the date these Services were provided. | 27 | N30 |
XA9 | Charges for a pre-existing condition are not eligible for benefits. | 51 | N10 |
XAC | Information concerning other insurance has been received and your records updated. Claim has been adjusted. | 96 | MA67 |
XAD | The accident date or onset date is needed from the provider before benefits can be provided for these Services. | 16 | N305 |
XAT | Provider Audit Rec. – Call 423-755-5891 | ||
XAX | Self-administered drugs not covered Services under your plan. | 96 | N426 |
XB0 | newborns date of birth and effective date are different, please contact the Department of Human Services. | 26 | N30 |
XB1 | Member’s plan does not cover a portion of the Medicare Part B deductible. | 96 | N30 |
XB2 | Benefits for Service are excluded under Member’s plan. | 96 | N30 |
XB3 | Services for prenatal and postnatal care are not covered by plan. Please re-file the labor and delivery Charges only. | 96 | N188 |
XB4 | We are deducting amount because of an overpayment on a previous Claim. | 96 | N10 |
XB5 | Please submit a copy of the Medicare Explanation of Benefits so we can determine benefits. | 252 | MA04 |
XB6 | Please submit a copy of the Explanation of Benefits from Member’s other insurance carrier. | 252 | MA04 |
XB7 | Benefits are excluded for an on the job injury or for Services eligible for Worker’s Compensation benefits. | 19 | N418 |
XB8 | Your plan does not provide benefits for Services by an out of network provider. | 242 | M115 |
XB9 | Benefits cannot be provided for Services not considered a medical emergency. | 40 | |
XBG | The blood gases report is needed from the provider before benefits can be provided for these Services. | 252 | N749 |
XC1 | Benefits for compound drugs purchased from a non-participating pharmacy are not covered under Member’s plan. | 96 | N30 |
XC2 | The provider must file Claim with the members home BlueCross BlueShield plan for processing. | 109 | N418 |
XC3 | Please refile Claim with the correct Explanation of Benefits from the other insurance carrier. | 16 | N4 |
XC4 | Your plan does not provide benefits for Services by an out of network provider. | 242 | M115 |
XC5 | The amount includes the benefits provided by Member’s other insurance carrier. | 23 | |
XCB | Please refile Claim with the correct Explanation of Benefits from the other insurance carrier. | 16 | N4 |
XCC | Benefits for Services related to custodial care are not provided under Member’s plan. | 96 | N30 |
XCD | Benefits cannot be provided until we receive previously requested information concerning Member’s other insurance. | 252 | N686 |
XCK | Reimbursement amount applying is due to the Service not meeting medical emergency guidelines. | 45 | |
XCM | Benefits cannot be provided until the provider submits a Certificate of Medical Necessity. | 252 | N170 |
XCO | Benefits cannot be provided until we receive previously requested information concerning Member’s other insurance. | 252 | N4 |
XCP | Benefits for a compound prescription cannot be provided until the pharmacy supplies additional information. | 16 | M123 |
XCU | COU-Charges were reduced due to a coupon or discount applied at point of sale. | 246 | |
XD1 | Charge is a duplicate of a previously submitted Charge for member. | 18 | N702 |
XD2 | We are deducting amount because of an overpayment on a previous Claim. | 96 | N10 |
XD3 | The provider must file Claim with the members home BlueCross BlueShield plan for processing. | 109 | N418 |
XD4 | Maximum benefits payable under Member’s coverage have been provided. | 119 | N640 |
XD5 | The maximum amount allowable for equipment has been reached. | 119 | N640 |
XD6 | We have paid the annual maximum allowable for these Services for member. | 119 | N640 |
XD7 | provider is not eligible under Member’s coverage. | 170 | |
XDC | Dental Service is not eligible for benefits under Member’s coverage. | 96 | N30 |
XDD | Member is not eligible to receive pharmacy benefits since they have Medicare Part D. | 96 | N30 |
XDE | The provider must file Claim with DentaQuest. 12121 N. Corporate Pkwy; Mequon, WI 53092 – 1-855-418-1623. | 109 | N418 |
XDF | Expense is a duplicate of a previously submitted expense for member. | 18 | N522 |
XDN | Newborn Charges have been denied under the subscriber’s name. newborn is not eligible for benefits. | 34 | |
XDP | Please submit the original Medicare Explanation of Benefits showing the amount Medicare paid on Charge. | 252 | MA04 |
XDR | A copy of all diagnostic reports for the patient is needed before the Claim can be considered. | 252 | N457 |
XDU | Duplicate of previous Claim. If corrected billing, please resubmit according to billing guidelines. | 18 | N522 |
XE1 | The Charges for the 2004 dates of Service were forwarded to another BlueCross BlueShield plan for processing. | B11 | |
XED | Please submit a copy of the Explanation of Benefits from Member’s other insurance carrier. | 252 | MA04 |
XEG | A copy of the EEG report with analysis is needed before the Claim can be considered. | 252 | M31 |
XEP | Service must be approved by your EAP. | 197 | |
XF0 | Service is non-covered when billed by a practitioner with specialty. | 170 | N95 |
XF1 | The Claim was adjusted due to Maternity Incentive requirements were not met. | 50 | N10 |
XF2 | Multiple transitional care management codes have been filed within a specific time period. | 96 | M86 |
XF3 | The required modifier is missing or the modifier is invalid for the Procedure code. | 16 | N519 |
XF4 | Procedure is considered a part of the global package previously paid on another Claim. | 97 | N525 |
XF5 | The units billed on Claim fall outside the range of units that are considered medically appropriate. | 151 | N362 |
XF6 | The Claim was adjusted to reflect your payment to the Division of TennCare. | 131 | |
XF7 | A Charge in history relating to Procedure has been paid. Please re-file corrected bill with all necessary Charges on one Claim. | 97 | M15 |
XF8 | The ambulance report is needed from the provider before benefits can be provided for these Services. | 252 | N745 |
XFB | Service is not covered because benefits for the related condition are limited by a rider to Member’s contract. | 51 | N607 |
XFD | Contract does not provide benefits for Services intended to create a pregnancy. | 96 | N30 |
XFO | Service ordered by provider sanctioned by HHS. Federal law mandates no payment when insured by federally funded program. | 185 | |
XFS | Provider sanctioned by HHS. Patient insured by federally funded healthcare plan. Federal law mandates no payment. | 185 | |
XFT | contract does not cover infertility treatment, Services to create a pregnancy, or any resulting complications. | 96 | N30 |
XFW | It is a subrogation adjustment. It will not affect previously assigned patient liability. | 215 | |
XG0 | Maximum benefits payable under Member’s coverage have been provided. | 119 | N587 |
XH0 | An intermediary handles Service. The Claim should be filed to the intermediary. | 16 | N8 |
XH1 | Charges for outpatient Services with proximity to inpatient Services are not covered. | 60 | N676 |
XH2 | It is not a covered Service unless the provider accepts assignment. | 111 | |
XH3 | It is not a covered Service since appeal Procedures were not followed or time limits were not met. | 138 | N584 |
XH4 | It is not a covered Service since the patient It is enrolled in Hospice. | B9 | |
XH5 | It is not a covered Service since new patient qualifications were not met. | B16 | |
XH6 | It is not a covered Service since the DiagnosIt is It is inconsIt istent with the provider type. | 12 | N657 |
XH7 | Information has been requested from the member. | 95 | |
XH8 | It is not a covered Service since there was a lapse in coverage. | 200 | N650 |
XH9 | It is not a covered Service since prior hospitalization or thirty day transfer requirement was not met. | A6 | |
XHA | Claim has been paid up to the Member’s local plan’s allowance. | 45 | |
XHB | is a Medicare Advantage Type Claim. Medicare Charge limitations may apply. | ||
XHC | The payment on Claim includes a Personal Savings Account or Health Reimbursement Account payment. | 187 | |
XHD | The Payment Direction has been changed on Claim. | ||
XHE | Claim is being paid in full up to the Charged amount. | ||
XHH | The maximum home health Services under Member’s coverage has been provided. | 119 | N362 |
XHI | The provider must submit patient’s progress notes or progress report before benefits can be provided for Service. | 252 | N393 |
XHJ | The provider must submit a photo or copy of patient’s X-rays before benefits can be provided for Service. | 252 | N40 |
XHK | The provider must submit the plan of treatment for patient before benefits can be provided for Service. | 50 | M132 |
XHL | The provider must submit the psychiatric testing results before benefits can be provided for Service. | 252 | N467 |
XHM | Claim is a duplicate to a Medicare cross over Claim which was processed directly by the Member’s plan. | 18 | N522 |
XHN | The provider must submit the tooth number before benefits can be provided for Service. | 16 | N37 |
XHO | Your plan does not provide benefits for Services by an out of network provider. | 242 | M115 |
XHP | Claim was closed without processing by the Member’s Plan. | 227 | |
XHR | Your plan does not provide benefits for Services by an out of network provider. | 242 | M115 |
XHS | Claim is a duplicate to a Medicare cross over Claim which was processed directly by the Member’s plan. | 18 | N522 |
XHT | A copy of the PET/MRI/CT Scan reports for the patient is needed before the Claim can be considered. | 252 | M31 |
XID | The contract does not cover infertility treatment, Services to create a pregnancy, or any resulting complications. | 96 | N30 |
XIF | The contract does not provide benefits for Services intended to create a pregnancy. | 96 | N30 |
XJ0 | Claim needs to be filed to the Plan in whose Service area the DME equipment was shipped to or purchased at a retail store. | 96 | N30 |
XJ1 | Claim needs to be filed to the Plan in whose Service area the specimen was drawn. | 109 | N557 |
XJ2 | Specialty Pharmacy Claim needs to be filed to the Plan in whose Service area the ordering physician is located. | 96 | N30 |
XJ3 | Claim needs to be filed to the Plan in whose Service area the DME equipment was shipped to or purchased at a retail store. | 96 | N30 |
XJ4 | Claim needs to be filed to the Plan in whose Service area the specimen was drawn. | 109 | N557 |
XJ5 | Specialty Pharmacy Claim needs to be filed to the Plan in whose Service area the ordering physician is located. | 96 | N30 |
XK0 | is an inactive revenue code. The provider should refile with a valid code. | 16 | M50 |
XK1 | The provider must submit a correct Procedure and revenue code combination before benefits can be provided. | 199 | N657 |
XK2 | Medicare considered amount as a contractual write-off and the provider cannot bill you for it. | 96 | M41 |
XK3 | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
XK4 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
XK5 | The provider has not contracted to provide Service. | 96 | N448 |
XK6 | Service is not paid in addition to or separately from the primary Service. | 234 | N20 |
XK7 | A maximum of one DME maintenance Service is payable every 6 months. | 119 | N362 |
XK8 | The provider has agreed to accept the amount allowed under Member’s contract for Service. | 131 | |
XK9 | Claim contains DOS that span patient’s hospice benefit election date. Please reference applicable billing guidelines. | 96 | N143 |
XKA | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
XL1 | The maximum annual benefits payable under Member’s coverage have been provided. | 119 | N587 |
XL2 | The maximum number of Services payable under Member’s coverage has either been met or exceeded on Claim. | 119 | N362 |
XL3 | The maximum annual benefits payable under Member’s coverage have been provided. | 119 | N587 |
XLT | The maximum lifetime benefits payable under Member’s coverage have been provided. | 119 | N587 |
XM1 | A new Claim is being requested that meets Medicare payment guidelines. No action is required by the member. | 96 | N386 |
XM2 | Member’s coverage allows hearing aids for the subscriber and dependent children only. | 96 | N30 |
XM3 | Services are eligible for processing under the Medicare crossover arrangement. | 22 | N479 |
XM4 | Charge is more than Medicare allows for Service. The member is liable for amount. | 45 | |
XMA | These Services are not covered for a dependent child under your plan. | 96 | N30 |
XMB | Please refile Claim with the correct Medicare Explanation of Benefits. | 252 | MA04 |
XMC | Medicare coinsurance is not covered by policy. | 96 | N30 |
XMD | Please submit a copy of the Medicare Explanation of Benefits so we can determine benefits. | 252 | MA04 |
XMF | Provider is not eligible under Member’s coverage. | 170 | |
XMH | Policy does not provide secondary benefits when Medicare is an HMO or Choice Plan. | 96 | N30 |
XMI | Benefits cannot be provided until the provider submits additional information to complete a pre-existing review. | 252 | N204 |
XMK | Date of Service (DOS) is prior to the effective date. The provider must file with the prior carrier. | 26 | N30 |
XMP | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
XMS | Member’s coverage was not in effect at the time of Service. | 27 | N30 |
XMT | The timely filing limit as outlined in the Member’s contract/benefit has expired. | 29 | |
XN1 | The member failed to comply with the Mandatory Case Management requirement. | 272 | N584 |
XNC | The difference between the Medicare allowance and benefit maximum is not eligible under your contract. | 122 | |
XNE | Service is being reimbursed based on the non emergency fee schedule. | 45 | |
XNF | Information is needed from the Member to complete a pre-existing review. Correspondence to the member will follow. | 96 | N204 |
XNM | Non maternity Service not covered. Maternity Only Policy. For a list of eligible maternity codes see BCBST.com | 96 | N30 |
XNN | Benefits for Service are excluded under Member’s plan. | 96 | N30 |
XNP | Charge exceeds the maximum allowable under Member’s contract for a non-participating provider. | 45 | |
XNR | Benefits cannot be provided until we receive previously requested information concerning another party’s liability. | 20 | |
XOB | Your contract provides benefits for maternity Services only at facility. | 242 | N130 |
XON | Your plan does not provide benefits for Services by an out of network provider. | 242 | M115 |
XOV | Please submit dates of Service beginning 7/1/2015 to TRH/Farm Bureau Health Plans. | 27 | N30 |
XP1 | Service is denied as a pre-existing condition because symptoms existed prior to Member’s effective date. | 51 | N607 |
XP2 | Service is denied as a pre-existing condition because treatment was recommended prior to Member’s enrollment date. | 51 | N607 |
XP3 | Service is denied as a pre-existing condition because treatment as received prior to Member’s enrollment date. | 51 | N607 |
XP4 | Service is denied as pre-existing because treatment was recommended prior to Member’s effective date. | 51 | N607 |
XP5 | Service is denied as pre-existing because treatment was received prior to Member’s effective date. | 51 | N607 |
XP6 | Member’s coverage does not include benefits for congenital malformations that do not meet medical policy criteria. | 96 | N30 |
XP7 | Service is not covered because benefits for the related condition are limited by a rider to Member’s contract. | 51 | N607 |
XPA | Provider is not eligible under Member’s coverage. | 185 | N684 |
XPB | Service is denied as a pre-existing condition because treatment prior to Member’s enrollment date. | 26 | N30 |
XPC | Service is not eligible because it was not rendered by Member’s PCP. | 242 | M115 |
XPD | Member’s age is beyond the limiting age for these benefits. | 96 | N129 |
XPH | Physician Services must be billed separately from the hospital Claim. | 89 | N200 |
XPI | Benefits are not provided for personal convenience items. | 96 | N30 |
XPR | A non-participating provider has been used. | 242 | M115 |
XPW | Benefits for Service have a ninety-day waiting period. | 179 | |
XPX | Your coverage has a one-year waiting period before benefits are available for Service. | 179 | |
XR0 | Benefits cannot be provided since an authorization was not obtained for Service. | 197 | |
XR1 | Provider is ineligible to provide pharmacy Service. | 185 | N684 |
XR2 | Diabetic Testing Supplies should be provided through Pharmacy. | 109 | N418 |
XR3 | Medication is not covered under the Member’s medical plan. Please contact CVS Specialty at 1-888-265-7790 for pharmacy benefits. | 185 | N684 |
XRU | BlueCross BlueShield of Tennessee no longer administers Claims for group. Please contact employer for information. | 27 | N30 |
XRX | Member’s coverage does not provide benefits for prescribed drugs and other medications. | 96 | N30 |
XS1 | Secondary benefits will be paid until day one hundred of confinement. Benefits will then be based on medical necessity. | 96 | N30 |
XSA | is money reimbursed due to another party’s payment. Refer to Patient Owes column for any liability changes. | 215 | |
XSB | The amount exceeds the Member’s liability per Health Care Financing Administration guidelines. | 45 | |
XSD | We are providing secondary benefits to your prescription drug card. | 23 | |
XSF | coverage does not provide benefits for the treatment of self inflicted injuries. | 96 | N30 |
XSH | The amount was applied to the member’s monthly patient pay. | ||
XSI | Coverage does not provide benefits for the treatment of self inflicted injuries. | 96 | N30 |
XSM | For Services after 1/1/2000, Claim is administered by United Behavioral Health 1-877-237-8574. | 27 | N30 |
XSN | Non-skilled nursing home visits are not a covered benefit under plan. | B1 | N30 |
XSR | Benefits have been reduced because a non-participating provider was used. | 45 | |
XSS | Your supplemental BlueCross BlueShield coverage does not provide benefits for these Charges. | 96 | N30 |
XSm | These Services are handled by your Behavioral Health Provider. Please have your provider refile Claim with the appropriate carrier. | 96 | N30 |
XT1 | Member’s contract does not provide benefits for contraceptives. | 96 | N30 |
XT2 | Member’s contract does not provide benefits for routine maternity Services. | 96 | N30 |
XT3 | Member’s coverage does not provide benefits for Temporomandibular Joint Dysfunction – TMJ. | 96 | N30 |
XTB | We have provided extended benefits for a condition that was diagnosed and treated before Member’s policy expired. | 96 | N30 |
XTF | The timely filing limit as outlined in the Member’s contract/benefit has expired. | 29 | |
XTH | Services not eligible for Telehealth. | 96 | N776 |
XTP | Service has been reimbursed by a third party liability carrier. | 20 | |
XUC | Charge exceeds the maximum allowable under Member’s coverage. | 45 | |
XUN | Claim was for date of Service July 1, 2015, or after, please submit to new Claims Administrator. | 27 | N30 |
XV1 | Benefits for Service are limited to one time per twelve-month period. | 119 | M90 |
XV2 | Benefits for Service are limited to one time per twenty-four month period. | 119 | N435 |
XVS | The vein study report is needed from the provider before benefits can be provided for these Services. | 252 | N739 |
XW1 | Benefits for Service have a six-month waiting period. | 179 | |
XW2 | Benefits for Service have a six-month waiting period. | 179 | |
XW3 | Benefits for Service have a sixty-day waiting period. | 179 | |
XWP | Member’s maternity rider includes a ten-month waiting period before benefits can be provided. | 179 | |
XZA | Paid according to the USA MCO/USA Senior Care Network contractual agreement. | 1 | N364 |
YAB | Claim was adjusted because the Service is eligible for benefits under the Member’s coverage. | 96 | MA67 |
YAI | Claim was adjusted because additional information was received. | 96 | MA67 |
YBC | Claim was adjusted because the provider submitted a corrected billing. | 96 | MA67 |
YBE | Claim was adjusted because we were notified that the provider billed for Service in error. | 96 | MA67 |
YBI | Claim was adjusted to include the additional billing from the provider. | 96 | MA67 |
YCA | Cost Share – Corrected – DO NOT ADJUST. | ||
YCB | Claim not handled as a corrected bill due to original Claim was denied | 96 | MA67 |
YCC | Claim was adjusted to correct the deductible, copay or coinsurance. | 96 | MA67 |
YCM | Claim was adjusted to provide benefits secondary to Medicare. | 96 | MA67 |
YCO | Cost Share – Corrected – Additional Payment Made. | ||
YCP | Claim was adjusted because the Member’s BlueCross BlueShield coverage is primary. | 96 | MA67 |
YCS | Claim was adjusted to provide benefits secondary to Member’s other insurance coverage. | 96 | MA67 |
YDD | Claim was adjusted because Service was processed on a previous Claim. | 96 | MA67 |
YDP | Service was previously denied as a duplicate in error. | 96 | MA67 |
YEU | Claim was adjusted because the Member’s eligibility has been updated. | 96 | MA67 |
YGO | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
YHC | Member has been enrolled in Contraceptive coverage. Please note new contraceptive Only identification number. | ||
YM1 | Your Claim for date of Service is being adjusted due to an increase in Medicare’s allowed amount. | 96 | MA67 |
YM2 | Claim was adjusted because Member’s coverage has been terminated. | 96 | MA67 |
YMP | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
YMR | Claim was adjusted because Member’s coverage has been terminated. | 96 | MA67 |
YNI | Claim was adjusted to provide corrected benefits. | 96 | MA67 |
YPD | Claim was adjusted because Service is related to a pre-existing condition. | 96 | MA67 |
YPP | Claim was adjusted because it was determined that Service is not related to a pre-existing condition. | 96 | MA67 |
YRB | Claim was adjusted because the Service is not eligible for benefits under the Member’s coverage. | 96 | MA67 |
YRD | Claim was adjusted because Service is related to a condition limited by a rider to Member’s contract. | 96 | MA67 |
YSC | Claim was adjusted to provide corrected benefits under Member’s coverage. | 96 | MA67 |
YSD | Claim was adjusted because Service is not eligible for benefits under the Member’s coverage. | 96 | MA67 |
YSP | Claim was adjusted because Service is eligible for benefits under Member’s coverage. | 96 | MA67 |
YTH | Although Member’s benefit limit has been met, Claim has been reconsidered and adjusted pursuant to your separate mailing. | 96 | MA67 |
YUM | Claim was adjusted because the authorization for Service has been updated. | 96 | MA67 |
YWI | Claim was previously processed under another Member’s name or ID number in error. | ||
Z02 | Agreement Discount Off Charges | 45 | |
Z05 | CoverKids – Claim to apply Network S rates. | ||
Z19 | Call 1-800-276-1978 for Claim detail if needed. | MR | |
Z21 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
Z2B | Claim is being processed under your secondary coverage. | B11 | N418 |
Z44 | Call 1-800-468-9736 for Claim detail if needed. | ||
Z55 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
Z57 | We are investigation to determine if condition is pre-existing. If found to be pre-existing we may seek a refund. | ||
Z66 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
Z8A | HIPAA 835 Runbook setting CapitatedPayment | 24 | |
Z8C | HIPAA 835 Runbook setting RishWhAmt | 104 | |
Z8D | HIPAA 835 Runbook setting DentalPreDeterminationAmt | 101 | |
Z8E | HIPAA 835 Runbook setting CalculatedCdcbAdjAmt | 22 | N598 |
Z8F | HIPAA 835 Runbook setting OffsetCdcbAdjAmt | 22 | N598 |
Z8G | HIPAA 835 Runbook setting SbPymAmt | 100 | |
Z8H | HIPAA 835 Runbook setting CdcbCobAmt | 23 | |
Z8I | HIPAA 835 Runbook setting ConsiderChg | 94 | |
Z8J | HIPAA 835 Runbook setting CoinsAmt | 2 | |
Z8K | HIPAA 835 Runbook setting CopayAmt | 3 | |
Z8L | HIPAA 835 Runbook Setting DedAmt | 1 | |
Z8M | HIPAA 835 Runbook setting Inclusive | A1 | |
Z8N | HIPAA 835 Runbook setting BundleOrigSubmChg | 97 | M15 |
Z8O | HIPAA 835 Runbook setting BundleChgsAdjustedUp | 94 | |
Z8P | HIPAA 835 Runbook setting Hra | 187 | |
ZA4 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
ZA5 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
ZA6 | Call 1-800-468-9736 for Claim if needed. | MR | |
ZA7 | Call 1-800-276-1978 for Claim detail if needed. | MR | |
ZA8 | Call 1-800-468-9736 for Claim detail if needed. | MR | |
ZAS | A reduction was applied to provider Claim paid amount due to CMS Sequestration. | ||
ZB1 | Call 1-800-705-0391 if you need assistance or Claim detail. | ||
ZCB | IT is TIME TO UPDATE INFORMATION REGARDING OTHER INSURANCE. PLEASE CALL 1-800-200-3704. | 252 | N686 |
ZCD | IT is TIME TO UPDATE INFORMATION REGARDING OTHER INSURANCE. PLEASE CALL 1-800-200-3704. | 252 | N686 |
ZCN | Payment was recommended by NCN Data isight. For questions contact www.dataisight.com or 1-800-499-9708 and select option 2. | 96 | N30 |
ZD1 | These Services were not approved by your EAP. | ||
ZD2 | These Services were approved by your EAP. | ||
ZD3 | Benefits are being provided for Claim; however, future Claims for Diagnosis should be submitted to your EAP. | ||
ZD5 | Benefits were provided for Claim since a free cleaning coupon was redeemed. Service did not apply toward any annual maximum. | ||
ZDA | Your contract provides alternate courses of treatment that must meet accepted dental standards. Benefits are reduced. | ||
ZDK | Claim has been approved based on information provided by Duke EAP. Call 800-336-DUKE (3853) if you have any questions. | ||
ZDN | Call 1-800-924-7141 for Claim detail if needed. | ||
ZE1 | Member’s Claim has been separated for processing. No action is required. | B11 | MA15 |
ZF5 | Manual Recovery – Call 1-800-572-1003 for details | MR | |
ZHF | Member’s coverage under plan was not in effect on the date Service was provided. | 27 | N30 |
ZMB | You may not be liable for the amount indicated in the Amount You Owe Provider field. Please verify with your provider or primary carrier. | 96 | N30 |
ZMG | Call 1-800-924-7141 for Claim detail if needed. | ||
ZMP | The Maintenance of Benefits provision in Member’s contract may affect liability. Please see primary carrier’s remittance for details. | 96 | N30 |
ZMR | Call 1-800-924-7141 for Claim detail if needed. | ||
ZMS | payment is secondary to benefits provided by Medicare. In network benefits have been applied. | ||
ZNN | In-Network benefits have been applied to Out-of-Network Provider. You may be subject to balance billing. | ||
ZON | In-Network benefits have been applied to Out-of-Network Provider. You may be subject to balance billing. | ||
ZOO | In-Network benefits have been applied to Out-of-Network Provider. You may be subject to balance billing. | ||
ZP1 | Failure to obtain a prior authorization for Service will result in a $250.00 copay. | 96 | N30 |
ZP2 | Our records indicate that you have overpaid at the pharmacy for date of Service. | ||
ZP3 | Benefits are not payable when Medicare’s primary benefit exceeds plan’s maximum payment. The amount owed is shown as patient liability. | 96 | N30 |
ZPA | Provider Advance Recovery | ||
ZPS | Part D medications that are otherwise covered under the ESRD PPS bundled payment are not eligible for a separate Part D benefit payment | 96 | MA67 |
ZPX | Charges not shown on the Explanation of Benefits are in pre-existing review. No action is required. | B11 | MA15 |
ZR1 | Claim was adjusted because additional information was received. | 96 | MA67 |
ZRA | Claim was combined with a related Claim and considered as one confinement. | 96 | MA67 |
ZRB | Medical chart was not submitted for review within the required time frame. | 96 | MA67 |
ZRC | Approved orders for inpatient stay were not included in the medical records. | 96 | MA67 |
ZRD | Charge was combined with an inpatient Claim of an affiliated hospital. | 96 | MA67 |
ZRE | A provider audit determined that CPT code is not appropriate for the Service rendered. | 96 | MA67 |
ZRF | CPT code was added due to appropriateness. | 96 | MA67 |
ZRG | A provider audit determined that code is a component of a more comprehensive code filed on a different Claim. | 96 | MA67 |
ZRH | Pre-admission and post-disCharge Services were combined with the inpatient Claim. | 96 | MA67 |
ZRI | A provider audit determined that Service is considered to be part of Member’s inpatient confinement. | 96 | MA67 |
ZRJ | Payment for pre-admission testing is included in the ambulatory surgery global fee. | 96 | MA67 |
ZRK | The medical chart indicates that a twenty-three hour observation stay was rendered instead of an inpatient stay. | 96 | MA67 |
ZRL | A provider audit determined that code is a component of a more comprehensive code filed on the same Claim. | 96 | MA67 |
ZRM | A provider audit determined that Service is a duplicate of another CPT code filed on the same Claim. | 96 | MA67 |
ZRN | A provider audit determined that Service should be included in the global case payment. | 96 | MA67 |
ZS0 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS1 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS2 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS3 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS4 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS5 | Call 1-800-558-6213 if Claim detail is required. | MR | |
ZS6 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS7 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS8 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZS9 | Call 1-800-558-6213 for Claim detail if required. | MR | |
ZSB | Call 1-800-924-7141 for Claim detail if required. | MR | |
ZSC | Call 1-800-468-9736 for Claim detail if required. | MR | |
ZSP | Call 1-800-924-7141 for Claim detail if required. | MR | |
ZST | Call 1-800-276-1978 for Claim detail if required. | MR | |
ZTB | The Claim was adjusted to reflect your payment to the Bureau of TennCare. | ||
ZTC | Due to TennCare RAC Recovery your payment has been applied to the Claim. | ||
ZTD | The Claim was adjusted to reflect your payment to the Bureau of TennCare. | ||
ZTH | THCII – Review Episode of Care Report in BlueAccess. | ||
ZTM | Previous payment. | MR | |
ZY1 | Procedure is not covered under the Member’s current benefit plan. | 204 | |
ZYP | The required modifier is missing or the modifier is invalid for the Procedure code. | 4 | N519 |
ZYQ | Charge was denied by Medicare and is not covered on plan. The provider can bill the patient. | 96 | N30 |
ZYR | Service is not covered when performed in setting. | 96 | N428 |
ZYS | Procedure code is not a billable Service under plan. | 96 | N431 |
ZYT | The benefit for Service is included in the allowance for another Service that has already been adjudicated. | 97 | |
ZYU | The date of Service is past timely filing guidelines. | 29 | |
ZYV | Procedure was denied because it was billed by a provider with an invalid or inactive NPI number. | 16 | N433 |
ZYW | Cosurgeons need to be of a different subspecialty. | 54 | N646 |
ZYX | Each provider is reimbursed according to the portion of surgical care they provided during Procedure(s). | B20 | M86 |
ZYY | Procedure denied due to multiple submissions for the technical or professional component of the same Procedure. | B13 | M86 |
ZYZ | Contracted amount for Procedure is greater than submitted Charge. Payment reduced to the submitted Charge. | 16 | M54 |
ZZ1 | CPT code has been denied because a more appropriate CPT code that better describes the Services rendered should be billed. | 96 | N56 |
ZZ2 | Charge is a duplicate of a previously submitted Charge for member. | 18 | N522 |
ZZ3 | Procedure is considered subset or redundant to the primary Procedure and is limited by Member’s plan. | 97 | M80 |
ZZ4 | principle Diagnosis code is invalid. The provider must submit a valid code. | 16 | MA63 |
ZZ5 | Service is not normally performed for members in age range. | 6 | N129 |
ZZ6 | Service is considered part of the primary Procedure. Please do not bill separately. | 97 | N19 |
ZZ7 | Service is not covered when performed on the same day as a related Procedure. | 273 | N435 |
ZZ8 | Edit occurred because a submitted Procedure code is not valid for the Service dates on the Claim. | 181 | M20 |
ZZ9 | A history Procedure code is within the global period of the Procedure code on line. | 96 | M86 |
ZZA | is a bundled Service. The payment is included in the Service to which item/Service is incident. | 97 | M80 |
ZZD | There is one or more Edits present that cause the whole Claim to be denied. | 96 | N56 |
ZZE | The billed Service has been denied since the maximum units of Service allowed has been exceeded. | 119 | N362 |
ZZF | is a bundled Service. The payment is included in the Service to which item or Service is incident. | 234 | M15 |
ZZG | Price adjusted due to additional line item modifiers. | ||
ZZH | Submitted Procedure is disallowed, mutually exclusive to other Procedure. | 96 | N20 |
ZZI | Service is a part of the original surgical Procedure and is limited by Member’s plan. | 97 | M144 |
ZZJ | A potential overpayment has been identified on Claim. | 45 | |
ZZL | Only postoperative portion of global payment is allowed. | 45 | |
ZZM | The single/unilateral code disallowed – billed more than once on a single date of Service. Replaced with Bilateral code. | ||
ZZN | Non-physician assistant at surgery Services are included in the physician/facility payment. | 54 | N646 |
ZZO | The submitted Procedure is disallowed because it does not typically require a co-surgeon according to CMS Medicare guidelines. | 54 | N646 |
ZZP | The submitted Procedure is disallowed because it does not typically require a team of surgeons according to CMS Medicare guidelines. | 54 | N646 |
ZZQ | Procedure qualifies for multiple endoscopy reduction and payment should be reduced. RVU value for line should be reduced. | ||
ZZU | Multiple Procedures billed for the same Service date in which a reduction is applicable, per CMS guidelines. | 45 | |
ZZV | The Procedure code describes a physician interpretation for Service and is not appropriate in place of Service. | 96 | M97 |
ZZW | Claim line is being disallowed because and E and M code is within the global period with a same Diagnosis category by same provider. | 97 | N525 |
ZZX | Service is not paid in addition to or separately from the primary Service. | 234 | N20 |
ZZY | The health Service code was denied as it is not a covered Service when billed with the submitted Diagnosis code. | 11 | N657 |
E01 | The submitted line is disallowed because it was previously billed. | ||
E02 | The submitted line was submitted after the filing deadline. | ||
E03 | The submitted code is disallowed because of an invalid Procedure code. | ||
E04 | The submitted line item is disallowed because it was received after the code deletion date. | ||
E05 | The submitted code is disallowed because the Procedure is not covered. | ||
E06 | The line item is disallowed because the payment modifier and Procedure code combination is invalid. | ||
E07 | The submitted Procedure code and nonpayment modifier are disallowed because the payment modifier and Procedure code combination is invalid | ||
E08 | The submitted code is disallowed because the Procedure code is unlisted. | ||
E09 | The submitted office consultation is disallowed because it was submitted by a provider who is classified as a primary care provider. | ||
E10 | The submitted Procedure is disallowed because it does not typically require an assistant surgeon. | ||
E11 | The submitted non-anesthesia Procedure is disallowed because is not eligible to be crosswalked to an anesthesia Procedure. | ||
E12 | The submitted Procedure is disallowed because is inconsistent with the patient’s age. | ||
E13 | The submitted Procedure is disallowed because is inconsistent with the patient’s gender. | ||
E14 | The submitted Procedure is disallowed because an add on code was billed without the presence of the related primary Service/Procedure. | ||
E15 | The submitted line item is disallowed because the Diagnoses are inconsistent with the male gender. | ||
E16 | The submitted line item is being disallowed because the Diagnoses are inconsistent with the female gender. | ||
E17 | The submitted line item is being disallowed because of incomplete Diagnosis codes. | ||
E18 | The submitted line item is disallowed because of invalid Diagnosis code(s). | ||
E19 | A surgical code is billed rather anesthesia code Service disallowed. Replaced anesthesia code. | ||
E20 | A surgical code is billed rather anesthesia code Service disallowed. Replaced anesthesia code. | ||
E21 | Submitted quantity corrected to reflect submitted date range. The submitted quantity exceeded the date rage with previous Claims. | ||
E22 | The submitted Procedure is disallowed because is inconsistent with the patient’s gender. | ||
E23 | The submitted Procedure is disallowed because is inconsistent with the patient’s age. | ||
E24 | Submitted Procedure is disallowed since the total Procedure was previously billed. Cannot submit the professional or tech component. | ||
E25 | Submitted Procedure is disallowed, total Procedure was previously billed by another provider. Cannot submit the prof or tech component. | ||
E26 | The submitted Procedure is disallowed because CMS indicates that Procedure is always bundled when billed with any other Procedure. | ||
E27 | Submitted Procedure is disallowed, incidental to other Procedures. | ||
E28 | Submitted Procedure is disallowed, mutually exclusive to other Procedures. | ||
E29 | Submitted Procedure is disallowed, component to other Procedures. | ||
E30 | The visis disallowed because it was billed by the same provider on the same date of Service as a code within the global period. | ||
E31 | The submitted line is disallowed because code pairs found to be unbundled according to CMS National Correct Coding Initiative. | ||
E32 | The submitted line is disallowed because the supply was submitted for the same date as a surgical Procedure. | ||
E33 | The submitted line is disallowed because code pairs found to be unbundled according to CMS Outpatient Code Editor. | ||
E34 | The submitted line is disallowed because the visit was billed by the same provider within the Procedure’s preoperative period. | ||
E35 | The submitted line is disallowed because the visit was billed by the same provider within the Procedure’s postoperative period. | ||
E36 | The submitted line is disallowed, primary Service billed with a quantity greater than one, rather than appropriate addon code. | ||
E37 | The submitted Procedure is disallowed because it was submitted more than once per date of Service. | ||
E38 | The submitted Procedure is disallowed because it was submitted more than once per date of Service. | ||
E39 | The submitted quantity is replaced since it exceeded the maximum number of times allowed on a single date of Service. | ||
E40 | The submitted Procedure is disallowed because the Procedure has already been billed with a modifier 50 for the same date of Service. | ||
E41 | The submitted Procedure is disallowed because the Procedure is not payable without immunization code billed on the same date of Service. | ||
E42 | The payment for Procedure was reduced based on CMS multiple radiology Procedure cutback guidelines. | ||
E43 | The submitted Procedure is disallowed; a single more comprehensive code that more accurately represents the Service performed was added. | ||
E44 | The single/unilateral code disallowed – billed more than once on a single date of Service. Replaced with Bilateral code. | ||
E45 | The visit/outpatient consultation code is disallowed – billed at an inappropriate level. Replaced with Unlisted E and M. | ||
E46 | The inpatient consultation code is disallowed – billed at an inappropriate level. Replaced with Unlisted E and M. | ||
E47 | The submitted new patient Procedure is disallowed for an established patient.. Replaced with Established code | ||
E48 | Multiple surgical Procedures identified. Modifier 51 added. | ||
E49 | The submitted line modified to include modifier 26, denoting professional component performed at noted place of Service. | ||
E50 | Pay percent cutback applied | ||
E51 | The submitted Procedure is disallowed based on CMS Status Code Payment guidelines. | ||
E52 | The submitted Procedure is disallowed based on CMS Medicare Status Code Guidelines | ||
E53 | The submitted Procedure is disallowed because it does not typically require an assistant surgeon according to CMS. | ||
E54 | The submitted Procedure is disallowed because it does not typically require an co-surgeon according to CMS Medicare guidelines. | ||
E55 | The submitted Procedure is disallowed because it does not typically require a team of surgeons according to CMS Medicare guidelines. | ||
E56 | The DME Service is disallowed because it classified as Frequently Serviced in the DMEPOS fee. | ||
E57 | The DME replacement is disallowed because it classified as Frequently Serviced in the DMEPOS fee. | ||
E58 | The item is classified as rented and the Service is included in the rental fee. | ||
E59 | The DME Service disallowed. Special CMS coverage instructions apply. | ||
E60 | The submitted modifier is not a valid CPT or HCPCS modifier. | ||
E61 | The line item is disallowed because the modifier and Procedure code combination is invalid according to CMS. | ||
E62 | The submitted Procedure is disallowed because it is not recommended for payment based on CMS National Coverage Lab Policy. | ||
E63 | The submitted Procedure is disallowed because it is not recommended for payment based on CMS National Coverage Lab Policy. | ||
E64 | The Claim line is disallowed because the Diagnosis is inconsistent with the patient’s age. | ||
E65 | Procedure is disallowed because other payable Services under the physician fee schedule are billed on same date by same provider | ||
E66 | The DME item is disallowed because it was submitted for maintenance and servicing and is currently rented or beneficiary owned | ||
E67 | The DME item is disallowed because it was submitted for maintenance | ||
E68 | The DME item is disallowed because it was submitted for maintenance and servicing and is currently rented or beneficiary owned | ||
E69 | The DME item is disallowed because the item was purchased new and is beneficiary owned. Rental payments should not be submitted. | ||
E70 | The DME item disallowed because the item was purchased new and is beneficiary owned. Payments should not be submitted for owned DME item | ||
E71 | The DME item is disallowed because the maximum payment for the DME item was exceeded | ||
E72 | Allowed Procedure represents remaining MUE amount that can be paid. The submitted Procedure disallowed.Quantity billed was over MUE limit | ||
E73 | Allowed Procedure represents remaining MUE amount that can be paid. Multiple Procedures disallowed. Quantity billed was over MUE limit | ||
E74 | The submitted facility code is disallowed because the Procedure is not covered. | ||
E75 | The submitted revenue code is an invalid revenue code. | ||
E76 | Represents more appropriate code for the patient’s age than submitted Procedure code. Submitted code denied. | ||
E77 | Procedure is disallowed because component was previously billed. | ||
E78 | Submitted payment modifier and Procedure code combination is invalid. Line disallowed. | ||
E79 | Submitted non-payment modifier and Procedure code combination is invalid.Line disallowed. | ||
E80 | The DME item is disallowed because the maximum payment amount for the item has been exceeded in history or on the current Claim. | ||
E81 | The submitted Procedure is disallowed because it was submitted more than once per date of Service. | ||
E82 | The submitted quantity is replaced since it exceeded the maximum number of times allowed on a single date of Service. | ||
E83 | The single/unilateral code disallowed – billed more that once on a single date of Service. | ||
E84 | Revenue code is disallowed because a required HCPCS code was not submitted. | ||
E85 | Observation revenue code is disallowed because a required HCPCS code was not submitted. | ||
E86 | Procedure is disallowed because a E code was submitted as the primary Diagnosis. | ||
E87 | Submitted quantity greater than 1 on bilateral Procedure with history with history Claims. Replaced with quantity of one | ||
E88 | Submitted quantity exceeds MUE limit. Remaining allowed MUE quantity shown. | ||
E89 | Remaining MUE allowed amount. One or more submitted Claim lines were disallowed because the quantity billed was over the MUE limit. | ||
E90 | Submitted Procedure is disallowed because it was submitted without modifier -27. | ||
E91 | Submitted facility Procedure is disallowed because it is incidental to another submitted. | ||
E92 | Submitted Procedure is disallowed because it was submitted without modifier CA or exceeds quantities allowed. | ||
E93 | Submitted Procedure is disallowed because it was submitted submitted without modifier 91 | ||
E94 | Submitted quantity corrected to reflect submitted date range. The submitted quantity exceeded the date range. | ||
E95 | Submitted quantity corrected to reflect submitted date range. The submitted quantity exceeded the date range. | ||
E96 | Submitted Procedure is disallowed because it is considered to be non-covered based on health plan medical and /or payment policy. | ||
E97 | Submitted Procedure is disallowed because related Services were previously also disallowed. | ||
E98 | Submitted Procedure is disallowed because it is not listed on the CMS NCD covered list for the submitted Diagnosis. | ||
E99 | Submitted Procedure is disallowed because it is listed on the CMS NCD not-covered list for the submitted Diagnosis. | ||
P01 | A required Procedure code or modifier is missing or invalid on the current line or an associated Claim line | 16 | M67 |
P02 | The patient’s age or gender conflicts with the Procedure and/or Diagnosis code. | 16 | M51 |
P03 | A Diagnosis code which meets medical necessity for Procedure code is missing or invalid | 16 | M76 |
P04 | Documentation or authorization is required to be submitted and/or reviewed. | 197 | |
P05 | is a possible duplicate Claim line of another Claim line in history | 18 | N111 |
P06 | E/M Procedure code is inappropriately reported for an established or new patient. | 16 | N657 |
P07 | The units have exceeded the allowable maximum frequency per time span | 119 | N640 |
P08 | The required modifier is missing or the modifier is invalid for the Procedure code | 4 | |
P09 | is a non-covered, restricted, reporting only or bundled Procedure code or Service | 96 | N130 |
P10 | The place of Service code is missing or invalid for the Procedure code | 16 | M77 |
P11 | The provider specialty is missing or invalid for the place of Service or Procedure code | 8 | |
P12 | A Procedure reduction should be applied to Claim line based on the Procedure code or modifier submitted | 59 | |
P13 | The type of bill, Procedure code, or revenue code are conflicting | 16 | N657 |
P14 | The Procedure code has an unbundle relationship with another Procedure on Claim or on a Claim in history | 97 | M15 |
P15 | Claim or Claim line is missing information which is needed for Editing | 16 | M84 |
P16 | There is a conflict with the occurrence, value or condition code and the Procedure, revenue code or TOB on the Claim | 16 | N657 |
P17 | A potential overpayment has been identified on Claim | 97 | |
S01 | The patient status is not valid. | 16 | MA43 |
S02 | The patient status code is missing. | 16 | MA43 |
S03 | Procedure code is limited coverage code. | 16 | N657 |
S04 | Procedure code is limited coverage since there is an associated limited Diagnosis code on the Claim. | 16 | N657 |
S05 | Procedure codes 02RK0JZ and 02RL0JZ are limited coverage when Z006 Diagnosis code is present. | 16 | N657 |
S06 | The Other Diagnosis code indicates that a wrong Procedure was performed. | 11 | MA63 |
S07 | The Principal Diagnosis code indicates that a wrong Procedure was performed. | 11 | MA63 |
S08 | Procedure code 9672 should not be reported when the patient’s length of stay is less than four days | 16 | N657 |
S09 | Non-exempt facility submitted admission Diagnosis with Hospital Acquired Condition | 233 | |
S10 | Non-exempt facility submitted principle Diagnosis code with Hospital Acquired Condition | 233 | |
S11 | Non-exempt facility submitted Non-exempt Diagnosis w/POA of 1 or X | 16 | N434 |
S12 | The Principal Diagnosis code requires a non-exempt POA indicator of 1 or X | 16 | N434 |
S13 | The Other Diagnosis code requires a non-exempt POA indicator of 1 or X | 16 | N434 |
S14 | Non-exempt facility submitted other Diagnosis code with Hospital Acquired Condition | 233 | |
T01 | Edit occurred because the Procedure code requires a specific modifier when billed at place of Service. | ||
T02 | The required Procedure code is missing according to a Local Coverage Determination. | 16 | M51 |
T03 | The provider specialty does not meet criteria for the Procedure code according to a Local Coverage Determination. | 8 | MA130 |
T04 | Add-on Procedure code billed with primary Procedure on Claim-Id Line. | 16 | MA66 |
T05 | History Procedure Code has incidental relationship with Procedure code. | 97 | M80 |
T06 | LCD/NCD – Policy requirements are not met for Procedure code. | ||
T07 | The Diagnosis on the line is inconsistent with the Procedure according to a Local Coverage Determination. | 11 | N657 |
T08 | Edit occurred because the Procedure has a profile relationship according to the Local or National Coverage Determination. | 96 | N386 |
T09 | Procedure requires documentation according to a Local Coverage Determination. | 252 | M127 |
T10 | Add-on Procedure is not eligible when the primary Procedure is not eligible. | B15 | N674 |
T11 | Bilateral Procedure reduction. | 59 | N670 |
T12 | Procedure code and history Procedure code indicate multiple imaging Services. A 25% reduction of the technical component applies. | 59 | |
T13 | Procedure code and history Procedure code indicate multiple imaging. 25% reduction of the technical component applies. | 59 | |
T14 | Procedure is missing an appropriate modifier when related to an evaluation and management visit in patient history. | 4 | N519 |
T15 | Procedure is missing an appropriate modifier when billed with an evaluation and management code. | 4 | N519 |
T16 | Procedure qualifies for multiple endoscopy reduction and payment should be reduced. RVU value for line should be reduced. | ||
T17 | For Procedure code and history code a multiple endoscopy reduction applies to the history Claim and payment should have been reduced. | ||
T18 | The maximum frequency for Procedure code has been exceeded. | 119 | N362 |
T19 | A multiple Procedure reduction of 50 percent of the allowed amount should be applied to Claim line. | 59 | N670 |
T20 | An operative report must be reviewed when more than 5 Procedures have been performed on the same date of Service. | 252 | M29 |
T21 | A multiple Procedure reduction of 50% of the allowed amount should be applied to History Claim. | 59 | |
T22 | An add on Procedure code has been submitted without the appropriate primary Procedure. | B15 | N122 |
T23 | Procedure code is a non-covered Service per the Non-covered Service list. | ||
T24 | Add-on Procedure code has been submitted without an appropriate primacy Procedure code. | B15 | N122 |
T25 | Procedure Code has an incidental relationship with another Procedure code. | 97 | M80 |
T26 | Only intraoperative portion of global payment is allowed. | 59 | |
T27 | Only postoperative portion of global payment is allowed. | 59 | |
T28 | Only preoperative portion of global payment is allowed. | 59 | |
T29 | Only intraoperative portion of global payment is allowed. | 59 | |
T30 | Per Medically Unlikely Edits, the units of Service billed for Procedure code exceeds the allowed units. | 96 | N362 |
T31 | The presence of an anesthesia modifier indicates a reduction in payment. | 59 | |
T32 | Anesthesia code on line requires an appropriate modifier. | 4 | N519 |
T33 | Edit occurred because a professional component modifier is needed for place of Service for diagnostic Procedure code. | 4 | N519 |
T34 | The Procedure code describes the physician Service. Use of modifier ZY is not appropriate. | 4 | N519 |
T35 | Procedure code describes only the technical portion of a Service or diagnostic test. Modifier ZY is not appropriate. | 4 | N519 |
T36 | The Procedure code describes the global code of a Service or diagnostic test. Modifier ZY is not appropriate. | 4 | N519 |
T37 | The Procedure code describes a physician interpretation for Service and is not appropriate in place of Service. | 96 | M97 |
T38 | The Procedure code is a Service covered incident to a physician’s Service and modifier XY is not appropriate. | 4 | N519 |
T39 | The Procedure code is a Service covered incident to a physician’s Service and modifier YZ is not appropriate. | 4 | N519 |
T40 | The use of a modifier is not typical for the billed Procedure. | 4 | N519 |
T41 | Procedure was performed on the same day of a history Procedure by the same provider. The Diagnosis indicates same condition. | 96 | M86 |
T42 | Items that do not have a physician order or prescription are not covered. | 173 | N667 |
T43 | The ESRD Supply HCPCS code billed is not Payable to DME Suppliers. | 96 | N95 |
T44 | The maximum frequency for the DME Procedure code has been exceeded | 96 | N435 |
T45 | The Procedure was performed on the same day of a history Procedure by the same provider. The Diagnosis indicates condition | 96 | M86 |
T46 | A Diagnosis code or codes which meets medical necessity for the Procedure code is missing or invalid. | 146 | M76 |
T47 | A history Procedure code by the same provider is in the global period of the Procedure code for the same condition | 96 | M86 |
T48 | A Diagnosis code, which meets medical necessity for the Procedure code is missing or invalid. | 146 | M76 |
T49 | All Claim lines on the same Claim must contain the modifier EY. | 4 | N519 |
T50 | Modifier GK cannot be submitted alone, another line with GA or GZ must be present on the same Claim. | 4 | N519 |
T51 | Item or Service statutorily excluded or does not meet the definition of any Medicare benefit. | 4 | N519 |
T52 | The Procedure code is a non covered code or the modifier is a non covered modifier. | 16 | N657 |
T53 | These are non-covered Services because is not deemed a medical necessity by the payer. | 50 | |
T54 | A Diagnosis code, which meets medical necessity for the Procedure code is missing or invalid. | 146 | M76 |
T55 | In the absence of injury or direct exposure, preventive immunization and its administration is not covered. | 50 | N130 |
T56 | A history Procedure code is within the global period of the Procedure code on line | 96 | M86 |
T57 | The date of Service is past timely filing guidelines. | 29 | |
T58 | The units of Service billed for the Procedure code exceed the allowed number of units. | 50 | N362 |
T59 | Per NCCI Edits, the a history Procedure has an unbundle relationship with the Procedure code | 97 | M80 |
T60 | Per NCCI Edits, the Procedure code has an unbundle relationship with a code in history | 97 | M80 |
T61 | And ICD-9 Diagnosis code in history was compared to an ICD-10 Diagnosis code on the current Claim. | ||
T62 | The Diagnosis code and modifier combination are inappropriate | ||
T63 | The Procedure code has an unbundle relationship with a history Procedure code. | 97 | M80 |
T64 | A history Procedure code has an unbundle relationship with the code on the current line | 97 | M80 |
T65 | The frequency of the Procedure code has exceeded the allowable maximum frequency for code | 119 | N435 |
T66 | Procedure is identified as an ambulance code and requires an ambulance modifier | 4 | |
T67 | The presence of modifier GZ indicates is not eligible for payment. | 96 | N30 |
T68 | Procedure indicate multiple imaging Services were performed. Per CMS, a 25% reduction of the professional component applies. | 59 | |
T69 | Procedure indicate that multiple imaging Services were performed. Per CMS, a 25% reduction of the professional component applies to history. | 59 | |
T70 | A multiple Procedure reduction should be applied to Claim line | 59 | |
T71 | Based on Claim line, a multiple Procedure reduction should be applied to history | 59 | |
U99 | Claim requires configuration review. | 133 | |
W01 | Invalid Diagnosis code unnecessary 4th/5th digit for patient’s admission on/disCharge date. | 146 | M76 |
W02 | Invalid Diagnosis code missing 4th/5th digit for patient’s admission/ disCharge date. | 146 | M76 |
W03 | Invalid Procedure code. Not found on table of valid ICD-CM codes. | 16 | M51 |
W04 | Invalid Procedure code. Unnecessary 4th digit. | 16 | M51 |
W05 | Invalid Procedure code. Missing 4th digit. | 16 | M51 |
W06 | Invalid Procedure code. Found on ICD-CM table but not valid for patient’s admission/disCharge date. | 16 | M51 |
W07 | Invalid Procedure code. Unnecessary 4th digit for patient’s admission/ disCharge date. | 16 | M51 |
W08 | Invalid Procedure code. Missing 4th digit for patient’s admission/ disCharge date. | 16 | M51 |
W09 | Claim lacks required HCPCS Level II code for radiopharmaceutical drug. | 16 | M20 |
W10 | Revenue codes 381 and 382 can only be used when billing for packed red blood cells and whole blood. | ||
W11 | Non-approved partial hospitalization mental health Services cannot be submitted with a bill type of 13X and condition code 41. | ||
W12 | Approved partial hospitalization mental health Services submitted with TOB 12X, 13X or 14X must have condition code 41 on the Claim. | ||
W13 | The Charged amount for HCPCS code C9898 cannot exceed $1.01. | ||
W14 | Service was provided after the end date of the approved coverage in the national coverage determination. | ||
W15 | Only whole blood revenue codes can be used when billing for whole blood. | 16 | M50 |
W16 | HCPCS code is not approved for a partial hospitalization Claim. | 16 | M51 |
W17 | HCPCS code can only be billed on a partial hospitalization Claim. | 16 | M51 |
W18 | The Charge on line exceeds the token Charge $1.01. | 16 | M54 |
W19 | Service was provided after the end date of coverage for the National Coverage Determination Policy. | 96 | N386 |
W20 | Service is denied per Medically Unlikely Edits, the units billed exceed the allowable units for code. | 96 | N362 |
W21 | Per LCD or NCD, the patient’s age does not meet policy requirements for the Procedure code and/or Diagnosis code. | 6 | N115 |
W22 | Per LCD or NCD guidelines, at CTP/HCPCS code is needed to meet policy requirements. | 96 | N115 |
W23 | Per LCD or NCD guidelines, Procedure code has a denied relationship. | 96 | N115 |
W24 | Per LCD or NCD, the frequency does not meet policy requirements for the Procedure code. | 96 | N115 |
W25 | Per LCD or NCD, the patient’s gender does not meet policy requirements for the Procedure code and/or a Diagnosis code. | 7 | N115 |
W26 | Per LCD or NCD guidelines, a Diagnosis code(s), which meets medical necessity for the Procedure code is missing or invalid. | 96 | N115 |
W27 | Per LCD or NCD guidelines, a modifier, which meets medical necessity for the Procedure code is missing or invalid. | 96 | N115 |
W28 | Per LCD or NCD, the condition code is missing or does not meet policy requirements for the Procedure code. | 96 | N115 |
W29 | Per LCD or NCD guidelines, a primary Diagnosis code, which meets medical necessity for the Procedure code is missing or invalid. | 96 | N115 |
W30 | Per LCD or NCD guidelines, Procedure code has a profiled relationship. Please review the policy. | 96 | N115 |
W31 | Per LCD or NCD guidelines, documentation should be requested or reviewed for the Procedure code | 96 | N115 |
W32 | Per LCD or NCD guidelines, a secondary Diagnosis code, to meet medical necessity for the Procedure code, is missing or invalid. | 96 | N115 |
W33 | Per LCD or NCD guidelines, a tertiary Diagnosis code, to meet medical necessity for the Procedure code is missing or invalid. | 96 | N115 |
W34 | Per LCD or NCD, the revenue code does not meet policy requirements for the Procedure code. | 96 | N115 |
W35 | Per LCD or NCD, the type of bill does not meet policy requirements for the Procedure code. | 96 | N115 |
W36 | Per LDC or NCD, the value code is missing or does not meet policy requirements for the Procedure code. | 96 | N115 |
W37 | Per Medically Unlikely Edits, the units of Service billed for the Procedure code exceed the allowed units | 50 | N362 |
W38 | Per NCCI Edits, a history Procedure has an unbundle relationship with the Procedure code on line | 97 | M80 |
W39 | Per NCCI Edits, the Procedure code has an unbundle relationship with one in history | 97 | M80 |
W40 | The Statement Covers Period Through Date of Service is past the facility timely filing limit. | 29 | |
W41 | An ICD-9 Diagnosis code in history was compared to an ICD-10 Diagnosis code on the current Claim. | 96 | N569 |
W42 | The HCPCS add-on code 33225 is lacking a required primary code on the Claim. | 234 | N122 |
W43 | Procedure code must be submitted with required device or Procedure code on the same date of Service. | 16 | M20 |
W44 | Review the conditional or independent bilateral Procedure code for possible payment adjustment | 59 | N644 |
W45 | Procedure code is retained from the transfer relationship | P14 | |
W46 | History Procedure code is retained from the transfer relationship | P14 | |
W47 | The units have exceeded the allowable maximum frequency per time span | 119 | N640 |
W48 | The units including history have exceeded the allowable maximum frequency per time span. | 119 | N640 |
W49 | The units have exceeded the allowable maximum frequency per time span | 119 | N640 |
W50 | The units have exceeded the allowable maximum frequency per time span | 119 | N640 |
W51 | Multiple Procedures billed for the same Service Date in which a reduction is applicable, per CMS guidelines. | 59 | N644 |
W52 | Procedure Code should be denied due to a rebundle into another code | 97 | M80 |
W53 | History Procedure should be denied due to a rebundle into another code | 97 | M80 |
W54 | The surgical Procedure code contains a termination modifier, and all other Services on Claim should be denied based on CMS guidelines. | 97 | M80 |
W55 | The surgical Procedure code contain a terminated modifier and should be reviewed for a 50% reduction. | 59 | |
W56 | Bundled codes transfer into new Procedure to be added to Claim | 59 | |
W57 | Age and gender conflict; the Admission Diagnosis code is not permissible for the patient’s age and gender | 16 | MA65 |
W58 | Age and gender conflict; the Other Diagnosis code is not permissible for the patient’s age and gender. | 16 | M64 |
W59 | Age and gender conflict; the Principal Diagnosis code is not permissible for the patient’s age and gender. | 16 | MA63 |
W60 | The Admission Diagnosis code is invalid because it has an incomplete number of digits. | 16 | MA65 |
W61 | The Admission Diagnosis code is invalid | 16 | MA65 |
W62 | The Admission Diagnosis code is missing | 16 | MA65 |
W63 | The Other Procedure code is invalid based on the Admission date | 16 | M67 |
W64 | The Other Diagnosis code is invalid because it has an incomplete number of digits. | 16 | M64 |
W65 | The Other Procedure code must contain a fourth or fifth digit in order to be valid. | 16 | M64 |
W66 | The Other Diagnosis code must be valid and is effective based on the through date on the Claim. | 16 | M64 |
W67 | The Other Procedure code must be in the ICD-PSC code Table. | 16 | M67 |
W68 | The Other Procedure code contains an unnecessary digit. | 16 | M67 |
W69 | The Principal Procedure code must be valid and is effective based on the admission date on the Claim. | 16 | MA66 |
W70 | The Principal Diagnosis code does not contain a complete number of digits. | 16 | MA63 |
W71 | The Principal Procedure code must be complete in order to be valid. | 16 | MA66 |
W72 | The Principal Diagnosis code is not valid based on the through date on the Claim. | 16 | MA63 |
W73 | The Principal Procedure code must be in the ICD-PSC code Table. | 16 | MA66 |
W74 | The Principal Diagnosis code is missing on the Claim | 16 | MA63 |
W75 | The Principal Procedure code contains an unnecessary digit. | 16 | MA66 |
W76 | The Other Diagnosis code is a duplicate of the Principal Diagnosis code | 16 | MA64 |
W77 | The Other Diagnosis code is a duplicate of another Other Diagnosis code on the Claim. | 16 | M64 |
W78 | Age conflict; the Admission Diagnosis is not permissible for the patient’s age. | 9 | |
W79 | Age conflict; the Other diagnoses is not permissible for the patient’s age. | 9 | |
W80 | Age conflict; the Principal Diagnosis is not permissible for the patient’s age. | 9 | |
W81 | Gender conflict; the patient’s gender and Admission Diagnosis code, on the Claim are not permissible. | 10 | N657 |
W82 | Gender conflict; the patient’s gender and other Diagnosis code, on the Claim are not permissible. | 10 | N657 |
W83 | Gender conflict; the patient’s gender and Other Procedure code on the Claim are not permissible. | 7 | |
W84 | Gender conflict; the patient’s gender and Principal Diagnosis code, on the Claim are not permissible. | 10 | N657 |
W85 | Gender conflict; the patient’s gender and Principal Procedure code, on the Claim are not permissible. | 7 | |
W86 | Manifestation codes cannot be used as the Admission Diagnosis. | 16 | MA65 |
W87 | Manifestation codes cannot be used as the Principal Diagnosis. | 16 | MA63 |
W88 | Principal Diagnosis code indicates a questionable admission. | 16 | MA63 |
W89 | Diagnosis code is unacceptable as a principal Diagnosis unless a required secondary Diagnosis is included on the Claim. | 16 | MA63 |
W90 | Diagnosis code is unacceptable as a principal Diagnosis. | 16 | MA63 |
W91 | An E-code cannot be used as the Admission Diagnosis code. | 16 | MA65 |
W92 | An E-code cannot be used as the Principal Diagnosis code. | 16 | MA63 |
W93 | A non-covered over age 65 ICD Procedure code is on the Claim and the patient is older than 60 years of age. | 6 | N129 |
W94 | Procedure code is non-covered when a designated Diagnosis code is present. | 11 | |
W95 | Procedure code is non-covered unless the exemption ICD Procedure code or exemption ICD Diagnosis code is present. | 96 | N30 |
W96 | Claim contains Procedure codes that may be bilateral Procedures: The documentation for Procedures, should be reviewed. | 16 | N657 |
W97 | Age invalid. Must be in range 0-124 years. | 16 | N329 |
W98 | The patient gender is missing. | 16 | MA39 |
W99 | The Patient Gender is invalid. Gender must be M, F, or U. | 16 | MA39 |
X01 | Information only – linked OCE Edit 6 | ||
X02 | Information only – linked to OCE Edit 6. | ||
X03 | Information only – linked to OCE Edits 16 and 17. | ||
X04 | Information only – linked to OCE Edits 16 and 17. | ||
X05 | Information only – linked to OCE Edits 16 and 17. | ||
X06 | Information only – linked to OCE Edits 16 and 17. | ||
X07 | Edit indicates that Services essential to a Procedure should not be separately coded. | 234 | M15 |
X08 | Edit indicates that Services essential to a Procedure should not be separately coded. | 234 | M80 |
X09 | Procedure is considered part of a more comprehensive Procedure. The provider should submit the proper code. | 234 | M15 |
X10 | Procedure is considered part of a more comprehensive Procedure. The provider should submit the proper code. | 234 | M80 |
X11 | Procedure is considered part of a more comprehensive Procedure for site. The provider should submit the proper code. | B15 | M51 |
X12 | Procedure is considered part of a more comprehensive Procedure for site. The provider should submit the proper code. | B15 | M80 |
X13 | Edit indicates that with and without codes should not be used together. | 50 | M51 |
X14 | Edit indicates that with and without codes should not be used together. | B15 | M80 |
X15 | Edit indicates that anesthesia should not be reported separately when administered by the operating physician. | 194 | M80 |
X16 | Edit indicates that anesthesia should not be reported separately when administered by the operating physician. | 194 | |
X17 | Edit indicates that individual lab tests should not be reported separately when a lab panel exists. | 97 | M15 |
X18 | Edit indicates that individual lab tests should not be reported separately when a lab panel exists. | 97 | M15 |
X19 | Edit indicates that only the code for the more invasive Service should be reported. | 50 | M51 |
X20 | Edit indicates that only the code for the more invasive Service should be reported. | 50 | M51 |
X21 | Preparation or monitor Services that are integral to performance of the Procedure should not be coded in addition to the Procedure. | 234 | N390 |
X22 | Preparation or monitor Services that are integral to performance of the Procedure should not be coded in addition to the Procedure. | 234 | M15 |
X23 | These codes should not be reported together per Current Procedural Terminology coding guidelines. | 16 | M81 |
X24 | These codes should not be reported together per Current Procedural Terminology coding guidelines. | 16 | M81 |
X25 | These codes should not be reported together per Current Procedural Terminology coding guidelines. | 16 | M81 |
X26 | These codes should not be reported together per Current Procedural Terminology coding guidelines. | 16 | M81 |
X27 | Certain Services are not typically performed together. | 234 | N20 |
X28 | Certain Services are not typically performed together. | 234 | N20 |
X29 | These codes indicate Mutually Exclusive Services considered reasonably impossible or improbable to perform on same patient at same time. | 231 | |
X30 | Codes indicate Mutually Exclusive Services considered reasonably impossible or improbable to perform on same patient at the same time. | 231 | |
X31 | Two codes with opposing sex designations cannot be reported for the same patient visit. | 7 | |
X32 | Two codes with opposing sex designations cannot be reported for the same patient visit. | 108 | N370 |
X33 | Supporting information for OCE/Mutually exclusive Procedure Edits 019MEP. | ||
X34 | Supporting information for OCE/Mutually exclusive Procedure Edits 020CCP. | ||
X35 | Information only – An appropriate modifier on code 1 or code 2 may affect Edit. | ||
X36 | Claim contains a statutory denied Diagnosis and will be denied by Medicare. | 96 | N425 |
X37 | Procedure code is not valid or not valid for the Service date on the Claim line. | 181 | |
X38 | Procedure code is not valid or not valid for the Service date on the Claim line. | 181 | |
X39 | Procedure code not currently covered. | 96 | N425 |
X40 | Procedure code is not covered based on a statutory requirement. | 96 | N425 |
X41 | Service does not have a supporting Diagnosis Code under applicable medical necessity policy requirements. | 50 | M26 |
X42 | Code violates age requirements of an applicable Local or National Coverage Determination Policy. | 96 | N115 |
X43 | Code violates age requirements of an applicable Local or National Coverage Determination Policy. | 6 | N115 |
X44 | Code violates gender requirements of an applicable Local or National Coverage Determination Policy. | 7 | N115 |
X45 | Code violates sex contrains of applicable medical necessity policy LCD or NCD, or the patient sex on Claim is missing or invalid. | ||
X46 | Service lacks the required accompanying Procedure according to a Local or National Coverage Determination Policy. | 96 | N115 |
X47 | Service lacks the required accompanying Procedure according to a Local or National Coverage Determination Policy. | 96 | N115 |
X48 | Age invalid; not in range 0-124 years. | 50 | N129 |
X49 | Edit occurred because the sex is invalid. It is not 1 or 2, M or F. | 16 | MA39 |
X50 | Invalid disCharge disposition/patient status. | 16 | N50 |
X52 | An emergency code cannot be used as a principal Diagnosis. | 146 | MA63 |
X53 | A manifestation code cannot be used as principal Diagnosis. | 146 | MA63 |
X55 | The principal Diagnosis is invalid. The principal Diagnosis indicates questionable admission. | 146 | |
X56 | The principal Diagnosis is invalid. It is an unacceptable principal Diagnosis. | 146 | MA63 |
X57 | The principal Diagnosis is invalid because it is without the required secondary Diagnosis. | 146 | MA63 |
X58 | Principal Diagnosis suggests surgery but there are no O R Procedure codes on Claim. | ||
X59 | Edit occurred because all operating room Procedure codes on Claim are non-specific. | ||
X60 | Two or more different bilateral joint Procedures are present on the Claim. | ||
X61 | Admit DX code not found on table of valid ICD-CM codes or missing/ unnecessary 4th/5th digit. | ||
X62 | The patient age and Diagnosis are inconsistent. | 10 | N657 |
X63 | The patient gender and Diagnosis are inconsistent. | 10 | N657 |
X64 | The patient age and sex are inconsistent with the patient Diagnosis. | 10 | N657 |
X65 | Insurer may be secondary payer to Auto Insurance, Worker’s Comp, etc. | ||
X66 | An emergency Diagnosis code cannot be used as an admitting Diagnosis. | 146 | MA65 |
X67 | A manifestation code cannot be submitted as admitting Diagnosis. | 146 | MA65 |
X68 | Dx not found on the table of valid ICD-CM codes or missing/unnecessary 4th/5th digit. | ||
X69 | Diagnosis code is a duplicate of the principle Diagnosis. | 146 | MA63 |
X70 | The patient age and Diagnosis are inconsistent. | 10 | N657 |
X71 | The patient age and sex are inconsistent with the patient Diagnosis. | 10 | N657 |
X72 | The patient age and sex are inconsistent with the patient Diagnosis. | 10 | N657 |
X73 | Diagnosis code suggests that insurer may be secondary payer to Auto Insurance, Workers’ Comp, No Fault, etc. | ||
X74 | Diagnosis code is a duplicate of another secondary Diagnosis code on Claim. | 146 | M64 |
X75 | Proc not found on table of valid ICD-CM codes or missing/unnecessary 4th/5th digit. | ||
X76 | The patient gender and Procedure are inconsistent. | 7 | N115 |
X77 | Procedure is not covered. | 96 | N30 |
X78 | Edit occurred because an open biopsy code was used when a closed biopsy code may be more appropriate. | ||
X79 | Procedure is covered in limited circumstances only. | 59 | |
X80 | Identifies bilateral Procedures. | ||
X81 | DOS to Units Discrepancy for Facility. | ||
X82 | The units are greater than one for a bilateral Procedure with modifier 50. | 16 | M53 |
X83 | Modifier FB submitted for a Service which is not assigned to payment status S or T or V or X. | 4 | N519 |
X84 | Revenue code 068X and Procedure code 99291 not submitted on the same date of Service as G0390. | 199 | N657 |
X85 | The Claim lacks allowed accompanying Procedure code for device. | 16 | M51 |
X86 | Edit occurred because Claim is a possible duplicate of another Claim. | 18 | N522 |
X87 | Occurred because the Principal ICD Procedure Code is invalid, has a missing date, or has an invalid date. | ||
X88 | ICD-CM Diagnosis that is denied based on statutory exclusion. | ||
X89 | Proposed alternate closed biopsy code. | 59 | |
X90 | Edit occurred because the admitting Diagnosis code is invalid. | 16 | MA65 |
X91 | Edit occurred because the admitting Diagnosis code is invalid It contains an unnecessary 4th or 5th digit. | 16 | MA65 |
X92 | Edit occurred because the admitting Diagnosis code is invalid. It has a missing 4th or 5th digit. | 16 | MA65 |
X93 | Invalid patient admission date DX the patient admission date. | 146 | MA65 |
X94 | Invalid DOA DX, 4th/5th digit date of admission. It contains an unnecessary 4th or 5th digit. | 146 | MA65 |
X95 | Invalid DOA DX missing digit 4,5 date of admission. It has a missing 4th or 5th digit. | 146 | MA65 |
X96 | Edit occurred because an invalid Diagnosis code cannot be found on table of valid ICD-10-CM codes. | 16 | M76 |
X97 | Edit occurred because the Diagnosis code is invalid. It has an unnecessary 4th or 5th digit. | 16 | M76 |
X98 | Edit occurred because the Diagnosis code is invalid. It has a missing 4th or 5th digit. | 16 | M76 |
X99 | Edit occurred because an invalid Diagnosis code was found on ICD-CM table but is not valid for patient admit or disCharge date. | 146 | M76 |
Y01 | The account ID field is missing or invalid. | 16 | N382 |
Y02 | The BDSf Edit validates the Service Date at the line level. | ||
Y03 | The FTD Edit validates the Admission and DisCharge Dates at the Claim Level. | 16 | M52 |
Y04 | The CCA Edit verifies that the condition codes on the Claim are valid. | 16 | M44 |
Y05 | The PSC Edit identifies Claims that are missing or contains an invalid Patient DisCharge Status Code. | 16 | MA43 |
Y06 | The REV Edit identifies line items that contain missing or invalid Revenue Codes. | ||
Y07 | The TOB Edit identifies Claims that are missing or contains an invalid Type of Bill. | 16 | MA30 |
Y08 | The VAL Edit confirms that the Value Codes on the Claim are valid. | 16 | M49 |
Y09 | The ICMf Edit validates that the Claim contains the required primary Diagnosis prior to HSS processing. | 16 | MA63 |
Y10 | The Claim has a missing Patient ID. Analysis cannot be performed without a Patient ID. | 16 | N382 |
Y11 | The DOBf Edit identifies a Claim that has a missing or invalid DOB. Certain Edits cannot be performed without the patient DOB. | 16 | N329 |
Y12 | The PSXf Edit identifies a Claim with a missing or invalid patient gender. Certain Edits cannot be performed without the patient gender. | ||
Y13 | Edit identifies a Claim missing a Provider ID. Analysis cannot be performed without a Provider ID. | 207 | N257 |
Y14 | The IPA Edit validates that the ICD Procedure codes on the Claim are valid. | ||
Y15 | The OCC Edit validates that the occurrence codes on the Claim are valid. | ||
Y16 | The OSC Edit validates that the occurrence span codes on the Claim are valid. | ||
Y17 | The SOA Edit identifies Claims that contain an invalid Source of Admission code. | 16 | MA42 |
Y18 | The TOA Edit identifies Claims that contain an invalid Type of Admission code. | 16 | MA41 |
Y19 | Edit identifies line items that are potentially duplicates when two lines entered on one or more Claims are identical. | 18 | N522 |
Y20 | Identifies an entire outpatient Claim that is a potential duplicate of a previously submitted outpatient Claim. | ||
Y21 | Edit identifies an entire inpatient Claim that is a potential duplicate of a previously submitted inpatient Claim. | 18 | N522 |
Y22 | Identifies an entire inpatient Claim that is a potential duplicate of a previously submitted inpatient Claim. | ||
Y23 | Edit occurred because the first listed Diagnosis field is blank or any Diagnosis code is not valid for Service dates on the Claim. | 146 | M76 |
Y24 | Edit occurred because the Diagnosis code includes an age range and the patient age is outside of that range. | 9 | N657 |
Y25 | Edit occurred because the Diagnosis code includes gender designation and the patient gender does not match. | 16 | MA39 |
Y26 | Edit occurred because the Diagnosis code has an MSP alert warning indicator. | ||
Y27 | Edit occurred because the first letter of the first listed Diagnosis code is an E. | 146 | M76 |
Y28 | Edit occurred because the submitted Procedure code is not valid for the Service dates on the Claim. | 181 | M20 |
Y29 | Edit occurred because the Procedure code includes an age range and the patient age is outside of that range. | ||
Y30 | Edit occurred because the Procedure code includes gender designation and the patient gender does not match. | 16 | MA39 |
Y31 | Edit occurred because the Procedure code has a noncovered Service indicator meaning it is not covered. | 96 | N115 |
Y32 | Edit occurred because Condition Code 21 indicates the provider is requesting verification of denial. | 96 | N30 |
Y33 | Edit occurred because the Claim was submitted with Condition Code 20. | 16 | M44 |
Y34 | Edit occurred because the Procedure code has a questionable covered Service indicator. | 16 | N657 |
Y35 | Edit occurred because a Procedure code indicates a Service N/C by Medicare based on the type of bill and condition codes on Claim. | ||
Y36 | Edit occurred because the Procedure code does not have an OPPS indicator, but may be payable in other settings. | ||
Y37 | Edit occurred because the sum of units or all lines with the same proc except lab with mod 91, exceeds the max allowed for proc. | ||
Y38 | Edit occurred because multiple exclusive bilateral proc codes are present, 2 or more times on the same svc date, without a mod 50. | ||
Y39 | Edit occurred where multiple exclusive bilateral Procedure codes are present on same Service date with or without modifier 50. | 4 | N519 |
Y40 | Edit occurred because Medicare designated Procedure as pay status C meaning Procedure is not covered when performed as outpatient. | 5 | M77 |
Y41 | Edit occurred because two mutually exclusive Procedures were billed with same Service date. | 234 | M80 |
Y42 | Procedure is one of a pair of mutually exclusive Procedures and both codes exist on a Claim with the same Service date. | 234 | M15 |
Y43 | Edit occurred because the Procedure is identified as a component of another Procedure also on the Claim for the same Service date. | 97 | M15 |
Y44 | Edit occurred because the Procedure is identified as a component of another Procedure also on the Claim for the same Service date. | 97 | M15 |
Y45 | Edit occurred because one or more type T or S Procedures are on same day as an Evaluation Management code without modifier 25. | 182 | N657 |
Y46 | Edit occurred because the modifier is not in the list of valid Outpatient Prospective Payment System modifiers. | 182 | N657 |
Y47 | Only Edits for valid modifiers not specific to outpatient facility Claims. | 182 | N657 |
Y48 | Edit occurred because the From, Thru, or Service date is invalid or Service dt falls outside range of the From and Thru dates. | ||
Y49 | Edit occurred because the age is non-numeric or outside the range of 0-124 years. | 50 | N129 |
Y50 | Service is not covered for member. The provider should submit the proper code or medical documentation. | 16 | MA39 |
Y51 | Edit occurred because only incidental Services were reported. | 97 | N20 |
Y52 | Edit occurred because Procedure code indicator is Not Recognized. | 16 | N657 |
Y53 | Edit occurred because the principal Diagnosis is not related to mental health on a partial hospitalization Claim. | 16 | MA63 |
Y54 | Edit occurred because Ambulatory Payment Class 323 or 324 or 325 is present and three or more qualifying criteria are not present. | 16 | N657 |
Y55 | Edit occurred because electroconvulsive therapy or a significant Procedure occurs on the same day as partial hospitalization. | ||
Y56 | Edit occurred because a partial hospitalization Claim is suspended for medical review and does not span more than three days. | 16 | N657 |
Y57 | Edit occurred because Claims suspended for medical review and spans more than three days and mental health Services not 57 percent. | 16 | N657 |
Y58 | Edit occurred because Claims suspended for medical review and spans more than three days and mental health Services not 57 percent. | 16 | N657 |
Y59 | Edit occurred because a mental health Service assigned to Ambulatory Payment Class 323 or 324 or 325 does not exist. | 16 | N657 |
Y60 | Edit occurred because electroconvulsive therapy or a non-mental health proc is present on same day as extensive mental hlth svcs. | ||
Y61 | Modifier 73 is present with an independent or conditional bilateral Procedure with modifier 50 or a Procedure with more than 1 unit. | 4 | N519 |
Y62 | Edit occurred because the Claim contains an implanted device with no surgical or other Service to implant the device. | 16 | M67 |
Y63 | Edit occurred because one of a pair of mutually exclusive Procedures with same Service date and no qualifying NCCI modifier. | 4 | N519 |
Y64 | Edit occurred because one of a pair of mutually exclusive Procedures with same Service date and no qualifying NCCI modifier. | 4 | N519 |
Y65 | Procedure is a component of another code on the Claim without a qualifying NCCI modifier on the same day. | 4 | N519 |
Y66 | Procedure is a component of another code on the Claim without a qualifying NCCI modifier on the same day in history. | 4 | N519 |
Y67 | The Edit occurred because is not a valid revenue code. | 16 | M50 |
Y68 | Edit occurred because multiple medical visits are present on the same day with the same Revenue Code without Condition Code G0. | 16 | M44 |
Y69 | HCPCS code 36430 requires a HCPCS code for the blood product to billed for the same date of Service. | 16 | M51 |
Y70 | Edit occurred because Observation Revenue code 762 is used with a Procedure code that does not represent an Observation Service. | 199 | N657 |
Y71 | Edit occurred because Services with Service indicator C are present on a separate Procedure list. | 96 | M2 |
Y72 | Edit occurred because Type of Bill 12X or 14X is present with Condition Code 41. | 16 | MA30 |
Y73 | Edit occurred because Claim consists entirely of a combination of lines that are denied or rejected or are considered packaged. | 97 | N390 |
Y74 | Edit occurred because Claim line contains a revenue code that requires a Procedure code. | 16 | M20 |
Y75 | Edit is assigned to all other Claim lines when one or more line contains a Procedure code with a status indicator of C. | 96 | M2 |
Y76 | Edit occurred because a Claim line contains a Procedure code which is noncovered by statute. | 96 | N425 |
Y77 | Edit occurred because multiple observations on Claim are paid separately if the required criteria are met for each one. | ||
Y78 | Edit occurred because Claim shows billable observation but dx is not in list of dx codes that qualify for separate observation py | ||
Y79 | Edit occurred because observation codes G0243 or G0244 are billed on a Claim with Type of Bill not equal to 13X. | 16 | MA30 |
Y80 | Edit occurred because blood components that are not allowed to be coded together are reported on the same Date of Service. | 96 | N56 |
Y81 | Edit occurred because Procedure code starting with letter C is used without Bill Type 12X or 13X or 14X. | 16 | MA30 |
Y82 | Edit occurred because no E/M visit the day of or the day before the observation and the date of observation is not 12/31 or 1/1. | ||
Y83 | Edit occurred because no Evaluation Management visit the day of or day before the observation and date is December 31 or January 1. | 96 | N56 |
Y84 | Edit occurred because code G0379 is present w/o code G0378 for same Claim with bill type 13x | 96 | N56 |
Y85 | Edit occurred because code G0292 or G0293 or G0294 are on the Claim and Diagnosis V707 is not present as admit or second Diagnosis. | 16 | MA65 |
Y86 | Edit occurred because modifier CA is on 1 or more lines with Indicator C and same Service date or modifier CA with multiple units. | 96 | N56 |
Y87 | Edit occurred because proc code reported has a status indicator of Y indicating item can only be billed to DME Regional Carrier. | 16 | M51 |
Y88 | Edit occurred because Procedure is not reportable on an Outpatient Prospective Payment System Claim. | 96 | N56 |
Y89 | Edit occurred because Procedure G0129 Occupational Therapy is furnished as a component of partial hospitalization treatment program. | 96 | N56 |
Y90 | Edit occurred because Procedure G0176 Activity Therapy furnished as a component of partial hospitalization treatment program daily. | 96 | N56 |
Y91 | Edit occurred because the line item contains a revenue code that is not recognized. | 16 | M50 |
Y92 | Edit occurred because C9399 was billed which is a drug that received Federal Drug Administration approval but is an unlisted code. | 16 | N350 |
Y93 | Edit occurred because the Service was performed prior to the date of Federal Drug Administration approval. | 188 | N386 |
Y94 | Edit occurred because the Service was performed prior to the effective date as specified in the National Coverage Determination. | 96 | N386 |
Y95 | Edit occurred because the Service was performed outside an approved clinical trial period. | 96 | M61 |
Y96 | Edit occurred because modifier CA has been reported and 20 is not patient status code in form locator 22. | 182 | N657 |
Y97 | Edit occurred because a Procedure was not reported with 1 or more associated device codes. | 96 | N56 |
Y98 | Edit occurred because a Procedure code has a status indicator of M and it cannot be reported to the fiscal intermediary. | 16 | M51 |
Y99 | Edit occurred because blood products are billed with Revenue code 39X and modifier BL without a line billed with Revenue Code 38X. | 16 | M50 |
Z01 | The Account ID is missing. | 16 | N382 |
Z02 | The Procedure code was crosswalked to an appropriate anesthesia code. | 59 | |
Z03 | Claim line is being disallowed because the anesthesia Procedure code was performed by a non-anesthesia provider. | 96 | N95 |
Z04 | Claim line is not reimbursed because more than one anesthesia Procedure code was billed on the same date of Service. | 59 | N633 |
Z05 | Service is not paid in addition to another anesthesia Service on the same day. | 59 | N633 |
Z06 | Claim line is being disallowed because there is a missing or invalid beginning or ending date of Service (DOS). | 16 | MA31 |
Z07 | line is eligible for a Bilateral Procedure Reduction. | 59 | N644 |
Z08 | The place of Service code is missing or invalid. | 16 | M77 |
Z09 | The surgical Procedure cannot be crosswalked to an anesthesia code without report. | 252 | M29 |
Z10 | Service is not normally performed for members in age range. | 6 | N129 |
Z11 | It is a deleted or invalid code or modifier for date of Service . The provider should submit the proper code. | 181 | M20 |
Z12 | It is a deleted or invalid code or modifier for date of Service . The provider should submit the proper code. | 181 | M20 |
Z13 | Service is not covered for member. The provider should submit the proper code or medical documentation. | 7 | N115 |
Z14 | Documentation is required when a modifier 59 is billed with the Procedure code. | 252 | M127 |
Z15 | It is a duplicate of previous Claim. If corrected billing please resubmit according to billing guidelines. | 18 | N522 |
Z16 | Claim line is being disallowed because the patients date of birth is missing, invalid, or after the date of Service. | 16 | N329 |
Z17 | Claim line is being disallowed because number of units doesn’t match the date span between the beginning and ending dates of Service. | 16 | N345 |
Z18 | It is a duplicate of a previous Claim. If corrected billing please resubmit according to billing guidelines. | 18 | N522 |
Z19 | The System was unable to obtain results for Claim line. | ||
Z20 | Claim line is being disallowed because an E and M code is within the global period with a same Diagnosis category by same provider. | 97 | N525 |
Z21 | The Procedure code on Claim line is retained from a transfer relationship. | 97 | M15 |
Z22 | Claim line is disallowed because a surgical code was submitted w/in the period w/a Dx from same category by the same provider. | 97 | N525 |
Z23 | A history Claim line is disallowed because its Procedure code is unbundled and is considered exclusive. | 97 | M80 |
Z24 | A history Claim line is disallowed because its Procedure code is unbundled and is considered unbundled. | 97 | M80 |
Z25 | A history Claim line is disallowed because its Procedure code is disallowed as part of a rebundle relationship. | 97 | M80 |
Z26 | A Procedure code on a history Claim line was part of a transfer relationship, but the Procedure code was retained. | ||
Z27 | condition is not normal for patient age. | 9 | N657 |
Z28 | Service is not covered when performed for the reported Diagnosis. | 50 | M64 |
Z29 | Service is not covered when performed for the reported Diagnosis. | 50 | M64 |
Z30 | Claim line is being disallowed because there is no primary Diagnosis code. | 16 | MA63 |
Z31 | The Procedure can be crosswalked to two or more anesthesia codes and review is required to determine the appropriate code. | 252 | M29 |
Z32 | Claim line is being disallowed because Diagnosis code requires a fourth and/or fifth digit to provide appropriate specificity. | 16 | M64 |
Z33 | The Claim line contains an inappropriate modifier combination. | 4 | N519 |
Z34 | It is an invalid modifier for date of Service. The provider should submit the proper code. | 4 | N519 |
Z35 | condition is not normal for patient gender. | 16 | N657 |
Z36 | Procedure requires modifier 26 be billed. | 4 | N517 |
Z37 | Reimbursement for surgical assistant is not allowed on Procedure code. | 54 | N646 |
Z38 | Edit occurred because the Bilateral adjustment does not apply to Procedure code. | ||
Z39 | It is a bundled Service. The payment is included in the Service to which item or Service is incident. | 234 | M15 |
Z40 | It is a bundled Service. The payment is included in the Service to which item or Service is incident. | 234 | M15 |
Z41 | The provider who rendered these Services is not eligible to assist during surgery. | 96 | N95 |
Z42 | Edit occurred because the Procedure requires supporting documentation for an assistant surgeon. | 252 | M29 |
Z43 | Edit occurred because the Procedure requires supporting documentation for a co-surgeon. | 252 | M29 |
Z44 | Edit occurred because the Procedure requires supporting documentation for team surgery. | 252 | M29 |
Z45 | Procedure is redundant to the primary Procedure and is limited by member plan. | 234 | M15 |
Z46 | Service is a part of the original surgical Procedure and is limited by member plan. | 234 | M15 |
Z47 | modifier is not compatible with Procedure code. The provider should submit the proper code. | 4 | N519 |
Z48 | is a bundled Service. The payment is included in the Service to which item or Service is incident. | 234 | M15 |
Z49 | code or modifier or provider type is invalid. | 4 | N517 |
Z50 | Edit occurred because a non-covered Service was submitted. The member is not liable for these Charges. | 96 | N30 |
Z51 | It is a deleted or invalid code or modifier for date of Service The provider should submit the proper code. | 4 | N519 |
Z52 | modifier is not compatible with Procedure code. The provider should submit the proper code. | 4 | N517 |
Z53 | line is eligible for a multiple Procedure reduction. | 59 | |
Z54 | Physical therapy is not covered in place of Service. The member is not liable for these Charges. | 96 | N428 |
Z55 | Service is a part of the original surgical Procedure and is limited by member plan. | 97 | M15 |
Z56 | It is a deleted/invalid code or modifier for date of Service. The provider should submit the proper code. | 182 | N657 |
Z57 | A Claim line in history is disallowed because its Procedure code is unbundled to a line on Claim. | 234 | M15 |
Z58 | Procedure is considered part of the primary Procedure and is limited by member plan. | 234 | M15 |
Z60 | Service is not covered when performed for the reported Diagnosis. | 16 | M64 |
Z61 | Procedure should not be billed since the member is an established patient. | B16 | |
Z62 | Claim line is being disallowed because the patient ID is missing or invalid. | 16 | N382 |
Z63 | is a deleted or invalid code or modifier for date of Service . The provider should submit the proper code. | 4 | N519 |
Z64 | The place of Service is not typical for the Procedure code. | 5 | M77 |
Z65 | line is eligible for a Assistant/Co/Team Surgery modifier reduction. | ||
Z66 | Procedure is considered part of the primary Procedure and is limited by member plan. | 97 | M15 |
Z67 | Service is a part of the original surgical Procedure and is limited by Member’s plan. | 97 | M144 |
Z68 | Claim line is being disallowed because the provider ID is missing or invalid. | 207 | N257 |
Z69 | The patient gender is missing or invalid. | 16 | MA39 |
Z70 | Claim line is being disallowed because the Procedure code is disallowed as part of a rebundle relationship. | 97 | M80 |
Z71 | Procedure does not normally require the Services of an assistant surgeon. | 54 | N646 |
Z72 | Claim line is being disallowed because the Procedure code does not typically allow an assistant surgeon modifier. | 54 | N646 |
Z74 | Edit occurred because a Diagnosis code on the line is a possible third party liability. | 20 | |
Z75 | A transfer to an appropriate Procedure occurred. Claim lines Procedure was part of the transfer group. | 97 | M15 |
Z76 | Claim line is being disallowed because the Procedure code is unbundled and is considered exclusive. | 97 | M80 |
Z77 | Claim line is being disallowed because the Procedure code is unbundled and is considered unbundle. | 97 | M80 |
Z78 | Edit occurred because the Procedure code is unlisted. | 16 | M51 |
Z79 | Procedure is considered cosmetic and is not a covered Service under Member’s plan. | 96 | N383 |
Z80 | Procedure is considered investigative and is not a covered Service under Member’s plan. | 55 | N623 |
Z81 | Unbundled Proc – Incidental | ||
Z82 | Unbundled Hx Proc – Incidental. | ||
Z83 | Bilateral Procedure Reduction | 59 | N644 |
Z84 | Multiple Procedure Reduction | 59 | |
Z85 | CA modifier requires patient status code 20. | ||
Z86 | Missing or Invalid Additional Procedure. | ||
Z87 | Missing or Invalid Diagnosis for Code to Code. | ||
Z88 | Service is not covered when performed for the reported Diagnosis. | 16 | M64 |
Z89 | modifier is not compatible with Procedure code. The provider should submit the proper code. | 96 | N115 |
Z90 | Service is not covered when performed for the reported Diagnosis. | 50 | M64 |
Z91 | Edit occurred because a primary Diagnosis code is missing or invalid due to a Local or National Coverage Determination. | 16 | MA63 |
Z92 | Edit occurred because a secondary Diagnosis code is missing or in valid due to a Local or National Coverage Determination. | 16 | M76 |
Z93 | Service is not covered when performed for the reported Diagnosis. | 16 | M64 |
Z95 | The frequency and/or Diagnosis does not meet policy requirements for Procedure due to a Local or National Coverage Determination. | 11 | N386 |
Z96 | LCD Part B Frequency with Diagnosis Override. | ||
Z97 | The place of Service does not meet policy requirements for Procedure code due to a Local or National Coverage Determination. | 16 | M77 |
Z98 | The patient’s gender does not meet policy requirements due to a Local or National Coverage Determination. | 16 | MA39 |
Z99 | The age does not meet policy requirements for Procedure or Diagnosis due to a Local or National Coverage Determination. | 50 | N129 |
The following explanation codes or Blue Cross Blue Shield denial codes for remittance and descriptions are based on those that appear in paper (paper) Commercial remittance advice. The identical codes and descriptions are also applicable to commercial remittance advice online that is available on BlueAccess the secure portion on www.bcbst.com. Although the information/action column of the provider isn’t in the remittance guidance however, we have added the information on this page to aid you.
Electronic remittance guidance that is HIPAA compliant (ANSI-835) does not employ the explanation code. Electronic remittance guidance (ANSI-835) utilizes HIPAA-compliant remark as well as adjustment reasons codes.
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