Denials management is the most important work in medical billing because if any claim is not paid and denied from insurance companies due to any reason, it is medical billing company’s responsibility to handle the received medical billing denial codes appropriately and try their best to re-process the claim and receive respective payment.
Claims that do not get paid, come back as denials from insurance carriers with a code mention by insurance companies which is known as denial reason codes. This can be due to posting errors, incorrect procedures, diagnosis codes, lack of information, medical records while filing a claim or missing/incomplete patient details.
Table of Contents
- What are the Main Denial Reasons for the Delay in Processing Claims?
- Top 10 Denial Reason Codes in Medical Billing:
- List of Denial Codes in Medical Billing
- Related Articles:
What are the Main Denial Reasons for the Delay in Processing Claims?
The following reasons for the delay in the process of claims in medical billing. Denials management is a way to collect more revenue from insurance companies.
- The claim may not have reached the insurance company’s systems. This is possible due to a bombed transmission or due to an error in the clearinghouse or within the insurance company.
- There could be delay due to backlog in insurance company’s claims processing department. They take longer than usual to process the claims.
Top 10 Denial Reason Codes in Medical Billing:
- [Denial Code CO 27] – The claims will be denied if the patient coverage not effective at the time of Date of service(DOS).
- [CO 22 Denial Code ] – The insurance company may deny the claim stating that their coverage is secondary to the patient.
- [Denial Code CO-31] – The insurance may not be identified as patient records. This could be due to incorrect policy number, incorrect DOB, patient name, etc.
- [CO 29 Denial Code ] – All insurance company has filing limit from DOS. If the claim sent past the limit, it will denied for late filing.
- [CO 96 Denial Code] – Some insurance companies not provided coverage on some specific medical services.
- [Denial Code CO 16] – Sometimes insurance companies required some additional information or records of the patient.
- [Denial Code CO 11] – An insurance company may deny a claim stating that the procedure performed does not match the diagnosis.
- [Denial Code CO 97] – An insurance company may deny a claim stating that services inclusive in another service.
- [Denial Code CO-18] – Some time claim billed twice or thrice to the insurance company so insurance company may deny the claim due to duplicity.
- [Denial Code CO 50] – Denied due to Non-covered services because this is not deemed a ‘medical necessity’ by the payer.
List of Denial Codes in Medical Billing
These codes are also known as ANSI( American National Standard Institutes) CodesANSI Codes Reason CO-1 Deductible Amount CO-2 Co-insurance Amount CO-3 Co-pay Amount CO-4 denial Code The CPT or procedure is inconsistent with Modifier 5 The CPT or procedure is inconsistent with the Place of Service. 6 The CPT or procedure is inconsistent with patients’ age 7 The CPT or procedure is inconsistent with patients’ gender. CO 8 denial code The CPT or procedure is inconsistent with the providers’ specialty. CO 9 denial code The Diagnosis(Dx) code inconsistent patients’ age 10 The Diagnosis(Dx) code inconsistent patients’ gender CO 11 Denial Code The Diagnosis(Dx) code inconsistent with CPT or procedure 12 The Diagnosis(Dx) code inconsistent with provider type. 13 The date of death precedes the date of service(DOS) 14 The of birth follows the DOS 15 The authorization number is missing or invalid CO-16 Denial Code Claim or service lack information. Required for adjudication. 17 Request information not provided or insufficient. CO 18 Duplicate claim 19 This work-related injury so its worker’s compensation insurance liability. 20 This injury or illness covered by the liability carrier. 21 This injury or illness is the liability of the No-fault carrier. CO 22 denial Code Covered by another payer as per COB info. CO 23 Denial Code The impact of prior payer adjudication including payments. CO 24 denial Code Charges covered under a Capitation agreement/managed care plan. 25 Payment denied due to stop-loss deductible not met. 26 The expense incurred prior to coverage. 27 The expense incurred coverage terminated. 28 Coverage was not effective at the time service provided. CO 29 Denial Code The timely filing limit has been expired. 30 Payment adjusted, patient not met required eligibility like spend down, waiting or residency requirements. 31 The patient cant be identified as our insured. 32 The dependent is not eligible as per records. 33 Subscriber or Insured has no dependent coverage. 34 Subscriber or Insured has no coverage for newborn baby. 35 Lifetime benefit has been reached the maximum. 36 Balance not exceeds the co-payment amount. 37 Balance not exceeds the deductible amount 38 Service not provided by network/primary care provider. 39 Service denied at the time authorization or pre-certification requested. 40 Charges do not qualify for emergency or urgent care. 41 Discount agreed in the preferred provider contract. 42 Charges exceed fee schedule/maximum allowable amount. 43 Gramm Rudman reduction. 44 Prompt pay discount. CO 45 denial Code Charges exceed fee schedule/maximum allowable or contracted fee arrangement. 46 The service is not covered. 47 The diagnosis(Dx) is not covered, missing or invalid. 48 The procedure (CPT) is not covered. 49 Routine exam not covered or service is done in conjunction with a routine exam. CO 50 Denial Code Service not covered due to not deemed a “Medical Necessity“. 51 A pre-existing condition is not covered. 52 The rendering or referring provider is not eligible for service billed. 53 Services by an immediate relative of the same household are not covered. 54 Multiple physicians or assistants not covered in this case. 55 Procedure or treatment deemed as experimental or investigational by the payer. 56 Procedure or treatment has not been deemed “proven to be effective” by the payer. 57 Payment denied or reduced because payer submitted information does not support. 58 Treatment rendered in an inappropriate or invalid place of service. 59 Claim processed based on multiple/concurrent procedure rules. 60 Outpatient services not covered when performed within a period of time prior to or after inpatient services. 61 Penalty for failure to obtain a second surgical opinion. 62 Payment denied due to the absence of authorization or pre-certification. 63 Correction of the prior claim. 64 Denial revered a per medical review. 65 The procedure code or CPT was incorrect. Payment reflects correct code 66 Blood deductible 67-68 Not Allocated 69 Day outlier amount 70 Adjustment to compensate for an additional cost- Cost outlier 71 Primary payer amount 72 Co-insurance Day 73 Administrative days 74 Indirect medical education adjustment 75 Direct medical education adjustment. 76 Disproportionate share adjustment. 77 Covered days. 78 Non covered days or room charges adjustment. 79 Cost report days 80 Outlier days 81 Discharges 82 PIP days 83 Total Visits 84 Capital Adjustment 85 Patient Interest Adjustment (Use only group code PR) 86 Statutory Adjustment 87 Transfer Amount 88 Adjustment amount/collection against receivable created in prior overpayment. 89 Removed Professional fee from charges 90 Ingredient cost adjustment 91 Dispensing fee adjustment 92 Claim paid in full 93 No claim level adjustment 94 Processed in excess of charges 95 Plan procedure not followed CO 96 Denial Code Non-covered charges. CO 97 Denial Code Bundeled Services. The payment of this service inclusive in another service. 98 The hospital must file the medicare claim for this inpatient non physician service. 99 Medicare secondary payer adjustment amount. 100 Payment made to patient. 101 Predetermination- anticipated payment upon completeion of service. 102 Major medical adjustment 103 Provider promotional discount 104 Managed care withholding 105 Tax withholding 106 Patient Payment option 107 The related claim or service was not identified on claim. 108 Rent or purchase guidelines were not met. CO 109 Denial Code Covered by another payer. Claim must be send to corrected payer. 110 Billing date predates DOS date. 111 Not covered unless provider accept assignment. 112 Service not furnished directly to patient or or not documented. 113 Payment denied as service provided outside USA or as a result of war. 114 Product or procedure not approved by food and drug administration. 115 Procedure postponed cancelled or delayed. 116 The advance notice of indemnification signed by patient not comply with requirement. 117 Transportation is covered only to closest facility that can provide the necessary care. 118 ESRD network support adjustment. CO 119 Denial Code Maximum benefit has been reached for this time period or occurance. 120 Patient covered under managed care plan. 121 Indemnification adjustment 122 Psychiatric reduction 123 Overpayment refund by Payer. 124 Payer refund -not our patient 125 submission or billing error 126 Deductible- Major Medical 127 Co-insurance – Major Medical 128 Newborns’ service covered under mothers allowance CO 129 denial Code Prior processing information is incorrect. 130 Claim submission fee. 131 Specific negotiated discount on claim 132 Pre arranged demonstration project discount 133 The claim or service is pending for review. 134 Technical fee removed 135 Interim can not be processed 136 Failure to follow prior payers coverage rules. 137 Regulatory surcharge, health related taxes 138 Time limits not met or appeal procedures not followed 139 Subscriber is employed by the provider of services-Contracted funding agreement 140 Patient health identification number and name do not match. 141 Claim spans eligible and ineligible periods of coverage. 142 Monthly Medicaid patient liability amount. 143 Portion of payment deferred 144 Incentive adjustment 145 Premium payment withholding 146 Diagnosis was invalid for DOS reported. 147 Provider contracted rate expired or not on file. 148 Info from another provider was not sufficient or incomplete. Co 149 Denial Code Lifetime benefit reached at maximum for this benefit category. CO 150 Denial Code Payer submitted info not supported for this service. CO 151 Denial Code Payment adjusted as submitted info by payer not supported frequency of service. 152 The information submitted by payer not support this length of service. 153 The information submitted by payer not support this dosage. 154 The information submitted by payer not support this days’ supply. 155 Patient refused the service or procedure. 156 Flexible spending account payment. 157 Service was provided as a result of an act of war. 158 Service was provided outside of USA. 159 Service was provided as a result of terrorism. 160 The injury was the result of an activity which is benefit exclusion. 161 provider performance bonus. 162 State mandate requirement for property & casualty 163 The attachment referenced on the claim was not received. 164 The attachment referenced on the claim was not received within time. 165 Referral absent/exceeded. 166 These services were submitted after the payers responsibility for this plan ended. 167 This diagnosis is not covered. 168 Benefits are not available under this dental plan. Service considered under patient medical plan. 169 Alternative benefit has been provided. 170 Payment denied due to performed by this type of provider. 171 Payment denied due to performed this type of provider. in this type of facility. 172 Payment is adjusted when performed by a provider of this specialty. 173 Service was not prescribed by physician. 174 Service not prescribed prior delivery. 175 Prescription is incomplete. 176 Prescription is not current. 177 Patient not met required eligibility. 178 Patient not met required spend down requirements. 179 Patient not met required waiting requirements. 180 Patient not met required residency requirements. CO 181 Denial Code CPT invalid on DOS or not active for Medicare on the DOS. 182 Procedure modifier invalid on DOS 183 The referring provider is not eligible to refer billed service. 184 The prescribing provider is not eligible to prescribe the service billed. 185 The rendering provider is not eligible to perform the service billed. 186 Level of care change adjustment. 187 Health savings account payments. 188 Service or procedure only coverd when used according to FDA recommendations. 189 Not otherwise classified or unlisted procedure code was billed when there is a specific cpt code for service. 190 Payment is included in allowance for skilled nursing facility. 191 Not a work related injury so not liability of workers comp insurance. 192 Non standard adjustment code for paper remittance. 193 Original payment decision is being maintained upon review. 194 Anesthesia performed by assistant or attending surgeon, operating physician. 195 Refund issued to erroneous priority payer for this claim 196 This code is removed. CO 197 Denial Code Authorization, pre-certification, notification absent. 198 Authorization, pre-certification, notification exceeded. 199 Procedure code and revenue code do not match. 200 Expense incurred during lapse in coverage. 201 Workers compensation case settled. Patient is responsible through WC medicare set aside arrangement or other agreement. 202 Non covered personal convenience services. 203 Discontinued/reduced services. CO 204 denial Code Service, equipment, drug not covered under patient current benefit plan. 205 Pharmacy discount carrd processing fee 206 NPI missing. 207 NPI invalid format. 208 NPI not matched. 209 As per agrerement provider can not collect this amount from patient. 210 Pre-certification, authorization not received timely so payment adjusted. 211 National drug code (NDC) not covered or not eligible. 212 Administrative surcharges not covered. 213 Physician self refferral prohibition legislation non compliance or payer policy. 214 WC claim adjudicated as non compensable. 215 Based on subrogation of a 3rd party settlement. 216 Based on finding of review on organization. 217 Based on payer reasonable and customary fees, no maximum allowable defind by legislated fee arrangement. 218 Based on entitlement to benefit. 219 Based on extent of injury. 220 The applicable fee schedule not contain billed code. 221 Workers Compensation (WC) claim is under review. 222 Exceeds contracted maximum number of days, units, hours by this provider for this period. 223 Adjustment code for mandated federal, state, or local law regulation that is not already covered by another code and is mandated before new code generate or created. 224 Patient identification compromised by identity theft. 225 Penalty or interest payment by payer. 226 Information requested from billing or rendering provider was not provided or insufficient. 227 Information requested from patient or insured provider was not provided or insufficient. 228 Denied to failure of this provider, another provider, or the subscriber to supply requested information to to a previous payer. 229 Partial charge amount not considered by medicare due to initial claim type of bill being 12X. 230 Correlating CPT/HCPCS code is not available to describe this service. 231 Institutional transfer amount- applies to institutional claims only and explains the DRG amount difference when patient care cross multiple institutions. 232 Not available 233 Services related to the treatment of a hospital-acquired condition or preventable medical error. CO-234 Denial Code This procedure is not paid separately. 235 Sales tax. 236 The procedure and modifier combination are not compatible with each other. 237 Legislated or regulatory penalty. CO 252 denial code A CO-252 denial code means that a claim needs additional documentation or information to support claim. CO 253 denial code CO-253 denial code means that the insurance provider has determined that the service or procedure performed is not covered under the patient’s policy, that is why denial of payment.
It is the medical billing and coding company responsibility to manage all denials very effectively and get collect payment from the insurance company. Company’s’ denial management strategy reduces the claim denial ratio and increases the revenue. Denial reason codes list updated by American Medical Association(AMA) from time to time.
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Claim Adjustment Reason Codes | CARC Codes
The author and contributor of this blog "NSingh" is working in Medical Billing and Coding since 2010. He is MBA in marketing and Having vaste experience in different scopes of Medical Billing and Coding as AR-Follow-up, Payment Posting, Charge posting, Coding, etc.