**Indian Health Service**

**Remittance Advice Remark Codes**

**August 18, 2005**

+---+--------------------------+----------------------------+----------+
| * | **Short Description**    | **Long Description**       | *        |
| * |                          |                            | *Notes** |
| C |                          |                            |          |
| o |                          |                            |          |
| d |                          |                            |          |
| e |                          |                            |          |
| * |                          |                            |          |
| * |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | X-ray not taken within   | X-ray not taken within the |          |
| 1 | the past 12 months or    | past 12 months or near     |          |
|   | near enough to start of  | enough to the start of     |          |
|   | treatment                | treatment.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Not paid separately when | Not paid separately when   |          |
| 2 | the patient is an        | the patient is an          |          |
|   | inpatient.               | inpatient.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Equipment is the same or | Equipment is the same or   |          |
| 3 | similar to equipment     | similar to equipment       |          |
|   | already being used.      | already being used.        |          |
+---+--------------------------+----------------------------+----------+
| M | This is the last monthly | This is the last monthly   |          |
| 4 | installment payment for  | installment payment for    |          |
|   | this durable medical     | this durable medical       |          |
|   | equipment.               | equipment.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Mo rental pymt con\'t    | Month rental payments can  |          |
| 5 | til earlier: 15th of 1st | continue until the earlier |          |
|   | mo or mo equipmnt not    | of the 15th month from the |          |
|   | needed                   | first rental month, or the |          |
|   |                          | month when the equipment   |          |
|   |                          | is no longer needed.       |          |
+---+--------------------------+----------------------------+----------+
| M | You furnish & srvc item  | You must furnish and       |          |
| 6 | til pt doesnt need it,   | service this item for as   |          |
|   | we pay mntnce/srvc evry  | long as the patient        |          |
|   | 6 mo per.                | continues to need it. We   |          |
|   |                          | can pay for maintenance    |          |
|   |                          | and/or servicing fore very |          |
|   |                          | 6 month period after the   |          |
|   |                          | end of the 15th paid       |          |
|   |                          | rental month or the end of |          |
|   |                          | the warranty period.       |          |
+---+--------------------------+----------------------------+----------+
| M | No rental pymt after     | No rental payments after   |          |
| 7 | item purchased or after  | the item is purchased, or  |          |
|   | total rental pymt =      | after the total of issued  |          |
|   | purchase price           | rental payments equals the |          |
|   |                          | purchase price.            |          |
+---+--------------------------+----------------------------+----------+
| M | We don\'t take bloodgas  | We do not accept blood gas |          |
| 8 | tst res when tst         | tests results when the     |          |
|   | condcted by medsuplr or  | test was conducted by a    |          |
|   | while pat on Oxy         | medical supplier or taken  |          |
|   |                          | while the patient is on    |          |
|   |                          | oxygen.                    |          |
+---+--------------------------+----------------------------+----------+
| M | 10th rental must, offer  | This is the tenth rental   |          |
| 9 | patient choice to        | month. You must offer the  |          |
|   | purchase                 | patient the choice of      |          |
|   |                          | changing the rental to a   |          |
|   |                          | purchase agreement.        |          |
+---+--------------------------+----------------------------+----------+
| M | Equipment purchases      | Equipment purchases are    |          |
| 1 | limited to 1st or 10th   | limited to the first or    |          |
| 0 | month of medical         | the tenth month of medical |          |
|   | necessity                | necessity.                 |          |
+---+--------------------------+----------------------------+----------+
| M | DME, orthotics &         | DME, orthotics and         |          |
| 1 | prosthetics must be      | prosthetics must be billed |          |
| 1 | billed to DME who srvc   | to the DME carrier who     |          |
|   | pat\'s zip code          | services the patient\'s    |          |
|   |                          | zip code.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Diagnostic tests by phys | Diagnostic tests performed |          |
| 1 | must indicate if         | by a physician must        |          |
| 2 | purchased srvc included  | indicate whether purchased |          |
|   | on claim                 | services are included on   |          |
|   |                          | the claim.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Only one initial visit   | Only one initial visit is  | Modified |
| 1 | is covered per specialty | covered per specialty per  | 6/30/03  |
| 3 | per medical group.       | medical group.             |          |
+---+--------------------------+----------------------------+----------+
| M | No separat pymt for      | No separate payment for an |          |
| 1 | injctn admind drng off   | injection administered     |          |
| 4 | vst, nopymt for off vst  | during an office visit,    |          |
|   | ifonly injctn            | and no payment for a full  |          |
|   |                          | office visit if the        |          |
|   |                          | patient only received an   |          |
|   |                          | injection.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Separately billd         | Separately billed          |          |
| 1 | srvc/tst bundled         | services/tests have been   |          |
| 5 | components same prcdr.   | bundled as they are        |          |
|   | Separate pymt not allwd  | considered components of   |          |
|   |                          | the same procedure.        |          |
|   |                          | Separate payment is not    |          |
|   |                          | allowed.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Please see the letter or | Please see the letter or   | Rea      |
| 1 | bulletin of (date) for   | bulletin of (date) for     | ctivated |
| 6 | further information.     | further information.       | 4/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Payment approved as you  | Payment approved as you    |          |
| 1 | didn\'t/couldn\'t know   | did not know, and could    |          |
| 7 | not normally covered for | not reasonably have been   |          |
|   | patient                  | expected to know, that     |          |
|   |                          | this would not normally    |          |
|   |                          | have been covered for this |          |
|   |                          | patient. In the future,    |          |
|   |                          | you will be liable for     |          |
|   |                          | charges for the same       |          |
|   |                          | service(s) under the same  |          |
|   |                          | or similar conditions.     |          |
+---+--------------------------+----------------------------+----------+
| M | Certain srvcs approved   | Certain services may be    | Modified |
| 1 | home use, Hosp and SNF   | approved for home use.     | 6/30/03  |
| 8 | are not considered       | Neither a hospital nor a   |          |
|   | patient\'s home          | Skilled Nursing Facility   |          |
|   |                          | (SNF) is considered to be  |          |
|   |                          | a patient\'s home.         |          |
+---+--------------------------+----------------------------+----------+
| M | Missing oxygen           | Missing oxygen             | Modified |
| 1 | certifi                  | certi                      | 8/1/04,  |
| 9 | cation/re-certification. | fication/re-certification. | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | HCPCS.                     | 2/28/03  |
| 0 | HCPCS.                   |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | place of residence for     | 2/28/03  |
| 1 | place of residence for   | this service/item provided |          |
|   | srvc/item provided in a  | in a home.                 |          |
|   | home                     |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | number of miles traveled.  | 2/28/03  |
| 2 | number of miles          |                            |          |
|   | traveled.                |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Missing                 | [Missing Invoice.]{.mark}  | [        |
| M | Invoice.]{.mark}         |                            | Modified |
| 2 |                          |                            | 8/1/05   |
| 3 |                          |                            | ]{.mark} |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | number of doses per vial.  | 2/28/03  |
| 4 | number of doses per      |                            |          |
|   | vial.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Payment adjusted, info  | [Payment has been adjusted | [        |
| M | furnished does not       | because the information    | Modified |
| 2 | substantiate this level  | furnished does not         | 10/1/02, |
| 5 | of service]{.mark}       | substantiate the need for  | 6/30/03, |
| ] |                          | this level of service. If  | 8/1/05   |
| { |                          | you believe the service    | ]{.mark} |
| . |                          | should have been fully     |          |
| m |                          | covered as billed, or if   |          |
| a |                          | you did not know and could |          |
| r |                          | not reasonably have been   |          |
| k |                          | expected to know that we   |          |
| } |                          | would not pay for this     |          |
|   |                          | level of service, or if    |          |
|   |                          | you notified the patient   |          |
|   |                          | in writing in advance that |          |
|   |                          | we would not pay for this  |          |
|   |                          | level of service and       |          |
|   |                          | he/she agreed in writing   |          |
|   |                          | to pay, ask us to review   |          |
|   |                          | your claim within120 days  |          |
|   |                          | of the date of this        |          |
|   |                          | notice. If you do not      |          |
|   |                          | request an appeal, we      |          |
|   |                          | will, upon application     |          |
|   |                          | from the patient,          |          |
|   |                          | reimburse him/her for the  |          |
|   |                          | amount you have collected  |          |
|   |                          | from him/her in excess of  |          |
|   |                          | any deductible and         |          |
|   |                          | coinsurance amounts. We    |          |
|   |                          | will recover the           |          |
|   |                          | reimbursement from you as  |          |
|   |                          | an overpayment.]{.mark}    |          |
+---+--------------------------+----------------------------+----------+
| [ | [Pymt adjusted, info not | [Payment has been adjusted | [        |
| M | substantiate level of    | because the information    | Modified |
| 2 | srvc, refund pat w/in 30 | furnished does not         | 10/1/02, |
| 6 | days]{.mark}             | substantiate the need for  | 6/30/03, |
| ] |                          | this level of service. If  | 8/1/05   |
| { |                          | you have collected any     | ]{.mark} |
| . |                          | amount from the patient    |          |
| m |                          | for this level of service  |          |
| a |                          | /any amount that exceeds   |          |
| r |                          | the limiting charge for    |          |
| k |                          | the less extensive         |          |
| } |                          | service, the law requires  |          |
|   |                          | you to refund that amount  |          |
|   |                          | to the patient within 30   |          |
|   |                          | days of receiving this     |          |
|   |                          | notice. The requirements   |          |
|   |                          | for refund are in 1842(l)  |          |
|   |                          | of the Social Security Act |          |
|   |                          | and 42CFR411.408. The      |          |
|   |                          | section specifies that     |          |
|   |                          | physicians who knowingly   |          |
|   |                          | and willfully fail to make |          |
|   |                          | appropriate refunds may be |          |
|   |                          | subject to civil monetary  |          |
|   |                          | penalties and/or exclusion |          |
|   |                          | from the program. If you   |          |
|   |                          | have any questions about   |          |
|   |                          | this notice, please        |          |
|   |                          | contact this               |          |
|   |                          | office.]{.mark}            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Pat relieved of         | [The patient has been      | [        |
| M | liability of pymt.       | relieved of liability of   | Modified |
| 2 | Provider liable for      | payment of these items and | 10/1/02] |
| 7 | charges including        | services under the         | {.mark}, |
| ] | coins.]{.mark}           | limitation of liability    | [8/1/05  |
| { |                          | provision of the law. You, | ]{.mark} |
| . |                          | the provider, are          |          |
| m |                          | ultimately liable for the  |          |
| a |                          | patient\'s waived charges, |          |
| r |                          | including any charges for  |          |
| k |                          | coinsurance, since the     |          |
| } |                          | items or services were not |          |
|   |                          | reasonable and necessary   |          |
|   |                          | or constituted custodial   |          |
|   |                          | care, and you knew or      |          |
|   |                          | could reasonably have been |          |
|   |                          | expected to know, that     |          |
|   |                          | they were not covered. You |          |
|   |                          | may appeal this            |          |
|   |                          | determination. You may ask |          |
|   |                          | for an appeal regarding    |          |
|   |                          | both the coverage          |          |
|   |                          | determination and the      |          |
|   |                          | issue of whether you       |          |
|   |                          | exercised due care. The    |          |
|   |                          | appeal request must be     |          |
|   |                          | filed within 120 days of   |          |
|   |                          | the date you receive this  |          |
|   |                          | notice. You must make the  |          |
|   |                          | request through this       |          |
|   |                          | office.]{.mark}            |          |
+---+--------------------------+----------------------------+----------+
| M | Not qualify for pymt     | This does not qualify for  |          |
| 2 | under Part B when Part A | payment under Part B when  |          |
| 8 | coverage exhausted/not   | Part A coverage is         |          |
|   | available                | exhausted or not otherwise |          |
|   |                          | available.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Missing operative        | Missing operative report.  | Modified |
| 2 | report.                  |                            | 8/1/04,  |
| 9 |                          |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| M | Missing pathology        | Missing pathology report.  | Modified |
| 3 | report.                  |                            | 8/1/04,  |
| 0 |                          |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| M | Missing radiology        | Missing radiology report.  | Modified |
| 3 | report.                  |                            | 8/1/04,  |
| 1 |                          |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| M | Conditional payment      | This is a conditional      |          |
| 3 | pending decision on this | payment made pending a     |          |
| 2 | service by patient\'s    | decision on this service   |          |
|   | primary payer            | by the patient\'s primary  |          |
|   |                          | payer. This payment may be |          |
|   |                          | subject to refund upon     |          |
|   |                          | your receipt of any        |          |
|   |                          | additional payment for     |          |
|   |                          | this service from another  |          |
|   |                          | payer. You must contact    |          |
|   |                          | this office immediately    |          |
|   |                          | upon receipt of an         |          |
|   |                          | additional payment for     |          |
|   |                          | this service.              |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 3 | ssing/incomplete/invalid | UPIN for the               | 2/28/03  |
| 3 | UPIN for the             | ord                        |          |
|   | order                    | ering/referring/performing | Dea      |
|   | ing/referring/performing | provider.                  | ctivated |
|   | provider.                |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Claim lacks the CLIA     | Claim lacks the CLIA       | Dea      |
| 3 | certification number.    | certification number.      | ctivated |
| 4 |                          |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 3 | ssing/incomplete/invalid | pre-operative photos or    | 2/28/03  |
| 5 | pre-operative photos or  | visual field results.      | Dea      |
|   | visual field results.    |                            | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 2/5/05   |
+---+--------------------------+----------------------------+----------+
| M | 11th rental mo, we       | This is the 11th rental    |          |
| 3 | can\'t pay until you     | month. We cannot pay for   |          |
| 6 | indicate patient offered | this until you indicate    |          |
|   | purchase option          | that the patient has been  |          |
|   |                          | given the option of        |          |
|   |                          | changing the rental to a   |          |
|   |                          | purchase.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Service not covered when | Service not covered when   |          |
| 3 | the patient is under age | the patient is under age   |          |
| 7 | 35.                      | 35.                        |          |
+---+--------------------------+----------------------------+----------+
| M | Pt liable chrgs,informd  | The patient is liable for  |          |
| 3 | in writing prior srvc    | the charges for this       |          |
| 8 | provided we wouldn\'t    | service as you informed    |          |
|   | pay, pt agrd             | the patient in writing     |          |
|   |                          | before the service was     |          |
|   |                          | furnished that we would    |          |
|   |                          | not pay for it, and the    |          |
|   |                          | patient agreed to pay.     |          |
+---+--------------------------+----------------------------+----------+
| M | Pat not liable           | The patient is not liable  | Modified |
| 3 | pymt,noncoverage notice  | for payment for this       | 2/1/04   |
| 9 | provided pat not comply  | service as the advance     |          |
|   | program requirmnt        | notice of non-coverage you |          |
|   |                          | provided the patient did   |          |
|   |                          | not comply with program    |          |
|   |                          | requirements.              |          |
+---+--------------------------+----------------------------+----------+
| M | Claim must be assigned   | Claim must be assigned and |          |
| 4 | and must be filed by the | must be filed by the       |          |
| 0 | practitioner\'s          | practitioner\'s employer.  |          |
|   | employer.                |                            |          |
+---+--------------------------+----------------------------+----------+
| M | We do not pay for this   | We do not pay for this as  |          |
| 4 | as the patient has no    | the patient has no legal   |          |
| 1 | legal obligation to pay  | obligation to pay for      |          |
|   | for this.                | this.                      |          |
+---+--------------------------+----------------------------+----------+
| M | The medical necessity    | The medical necessity form |          |
| 4 | form must be personally  | must be personally signed  |          |
| 2 | signed by the attending  | by the attending           |          |
|   | physician.               | physician.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Pymt for srvc previously | Payment for this service   | Dea      |
| 4 | made to you/another      | previously issued to you   | ctivated |
| 3 | prvdr by diff            | or another provider by     | eff.     |
|   | carrier/intermediary     | another                    | 1/31/04  |
|   |                          | carrier/intermediary.      |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | condition code.            | 2/28/03  |
| 4 | condition code.          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | occurrence code(s).        | 2/28/03, |
| 5 | occurrence codes(s).     |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | occurrence span code(s).   | 2/28/03, |
| 6 | occurrence span code(s). |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | internal or document       | 2/28/03  |
| 7 | internal or document     | control number.            |          |
|   | control number.          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pymt for srvcs rendered  | Payment for services       | Dea      |
| 4 | to hosp inpat made to    | furnished to hospital      | ctivated |
| 8 | hosp, req pymt from      | inpatients (other than     | eff.     |
|   | hosp, not pat            | professional services of   | 1/31/04  |
|   |                          | physicians) can only be    |          |
|   |                          | made to the hospital. You  |          |
|   |                          | must request payment from  |          |
|   |                          | the hospital rather than   |          |
|   |                          | the patient for this       |          |
|   |                          | service.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | value code(s) or           | 2/28/03  |
| 9 | value code(s) or         | amount(s).                 |          |
|   | amount(s).               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | revenue code(s).           | 2/28/03  |
| 0 | revenue code(s).         |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | procedure codes(s).        | 2/28/03, |
| 1 | procedure codes(s).      |                            | 2/1/04,  |
|   |                          |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | \"from\" date(s) of        | 2/28/03  |
| 2 | \"from\" date(s) of      | service.                   |          |
|   | service.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | days or units of service.  | 2/28/03  |
| 3 | days or units of         |                            |          |
|   | service.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | total charges.             | 2/28/03  |
| 4 | total charges.           |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Not pay self-admin       | We do not pay for          |          |
| 5 | anti-emetic drugs not    | self-administered          |          |
| 5 | admin w/covered oral     | anti-emetic drugs that are |          |
|   | anti-cancer drug         | not administered with a    |          |
|   |                          | covered oral anti-cancer   |          |
|   |                          | drug.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | payer identifier.          | 2/28/03  |
| 6 | payer identifier.        |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | provider identifier.       | 2/28/03, |
| 7 | provider identifier.     |                            | Dea      |
|   |                          |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | claim information.         | 2/28/03, |
| 8 | claim information.       | Resubmit claim after       | Dea      |
|   | Resubmit claim after     | corrections.               | ctivated |
|   | corrections.             |                            | eff.     |
|   |                          |                            | 2/5/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | \"to\" date(s) of service. | 2/28/03  |
| 9 | \"to\" date(s) of        |                            |          |
|   | service.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing Certificate of   | Missing Certificate of     | Modified |
| 6 | Medical Necessity.       | Medical Necessity.         | 8/1/04,  |
| 0 |                          |                            | 6/30/03  |
+---+--------------------------+----------------------------+----------+
| M | We can\'t pay for this,  | We cannot pay for this as  |          |
| 6 | approval period for FDA  | the approval period for    |          |
| 1 | clinical trial has       | the FDA clinical trial has |          |
|   | expired                  | expired.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 6 | ssing/incomplete/invalid | treatment authorization    | 2/28/03  |
| 2 | treatment authorization  | code.                      |          |
|   | code.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| M | We do not pay for more   | We do not pay for more     | Dea      |
| 6 | than one of these on the | than one of these on the   | ctivated |
| 3 | same day.                | same day.                  | eff.     |
|   |                          |                            | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 6 | ssing/incomplete/invalid | other diagnosis.           | 2/28/03  |
| 4 | other diagnosis.         |                            |          |
+---+--------------------------+----------------------------+----------+
| M | 1 interpreting phys chrg | One interpreting physician |          |
| 6 | per claim allowed when   | charge can be submitted    |          |
| 5 | purch diagnostic test    | per claim when a purchased |          |
|   | indicated                | diagnostic test is         |          |
|   |                          | indicated. Please submit a |          |
|   |                          | separate claim for each    |          |
|   |                          | interpreting physician.    |          |
+---+--------------------------+----------------------------+----------+
| M | recrds show diagnostic   | Our records indicate that  |          |
| 6 | tst subjct price limits  | you billed diagnostic      |          |
| 6 | billed&proc submt incld  | tests subject to price     |          |
|   | prof comp                | limitations and the        |          |
|   |                          | procedure code submitted   |          |
|   |                          | includes a professional    |          |
|   |                          | component. Only the        |          |
|   |                          | technical component is     |          |
|   |                          | subject to price           |          |
|   |                          | limitations. Please submit |          |
|   |                          | the technical and          |          |
|   |                          | professional components of |          |
|   |                          | this service as separate   |          |
|   |                          | line items.                |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 6 | ssing/incomplete/invalid | other procedure code(s).   | 2/28/03, |
| 7 | other procedure code(s). |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 6 | ssing/incomplete/invalid | attending, attending,      | 2/28/03, |
| 8 | attnd/o                  | ordering, rendering,       | 2/1/04,  |
|   | rder/render/supvsr/refer | supervising or referring   | Dea      |
|   | phys id.                 | physician identification.  | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Paid at reg rate, you    | Paid at the regular rate   | Modified |
| 6 | didn\'t submit           | as you did not submit      | 2/1/04   |
| 9 | justifying documentation | documentation to justify   |          |
|   | for mod proc code        | the modified procedure     |          |
|   |                          | code.                      |          |
+---+--------------------------+----------------------------+----------+
| M | NDC code submitted was   | NDC code submitted for     |          |
| 7 | translated to HCPCS for  | this service was           |          |
| 0 | processing, cont         | translated to a HCPCS code |          |
|   | sumbitting NDC           | for processing, but please |          |
|   |                          | continue to submit the NDC |          |
|   |                          | on future claims for this  |          |
|   |                          | item.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Total payment reduced    | Total payment reduced due  |          |
| 7 | due to overlap of tests  | to overlap of tests        |          |
| 1 | billed.                  | billed.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Did not enter full       | Did not enter full 8-digit | Dea      |
| 7 | 8-digit date             | date (MM/DD/CCYY).         | ctivated |
| 2 | (MM/DD/CCYY).            |                            | eff.     |
|   |                          |                            | 10/16/03 |
+---+--------------------------+----------------------------+----------+
| M | HPSA bonus only paid on  | The HPSA/Physician         | Modified |
| 7 | prof comp of srvc.       | Scarcity bonus can only be | 8/1/04   |
| 3 | Rebill as separate prof  | paid on the professional   |          |
|   | and tech comp            | component of this service. |          |
|   |                          | Rebill as separate         |          |
|   |                          | professional and technical |          |
|   |                          | components.                |          |
+---+--------------------------+----------------------------+----------+
| M | This service does not    | This service does not      | Modified |
| 7 | qualify for a            | qualify for a              | 12/2/04  |
| 4 | HPSA/Physician Scarcity  | HPSA/physician Scarcity    |          |
|   | bonus payment.           | bonus payment.             |          |
+---+--------------------------+----------------------------+----------+
| M | Allwd amt adj. Mult      | Allowed amount adjusted.   |          |
| 7 | automated multichannel   | Multiple automated         |          |
| 5 | tst perfrmd sameday      | multichannel tests         |          |
|   | combined for pymt        | performed on the same day  |          |
|   |                          | combined for payment.      |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | diagnosis or condition.    | 2/28/03  |
| 6 | diagnosis or condition.  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | place of service.          | 2/28/03  |
| 7 | place of service.        |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | HCPCS modifier.            | 2/28/03  |
| 8 | HCPCS modifier.          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | charge.                    | 2/28/03  |
| 9 | charge.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Not covr\'d when         | Not covered when performed | Modified |
| 8 | performed during same    | during the same            | 10/31/02 |
| 0 | sess\'n/date as prev     | session/date as a          |          |
|   | processed srvc for pat   | previously processed       |          |
|   |                          | service for the patient.   |          |
+---+--------------------------+----------------------------+----------+
| M | You are required to code | You are required to code   | Modified |
| 8 | to the highest level of  | to the highest level of    | 2/1/04   |
| 1 | specificity              | specificity.               |          |
+---+--------------------------+----------------------------+----------+
| M | Service is not covered   | Service is not covered     |          |
| 8 | when patient is under    | when patient is under age  |          |
| 2 | age 50.                  | 50.                        |          |
+---+--------------------------+----------------------------+----------+
| M | Service is not covered   | Service is not covered     |          |
| 8 | unless the patient is    | unless the patient is      |          |
| 3 | classified as at high    | classified as at high      |          |
|   | risk.                    | risk.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Medical code sets used   | Medical code sets used     | Modified |
| 8 | must be the codes in     | must be the codes in       | 2/1/04   |
| 4 | effect at the time of    | effect at the time of      |          |
|   | service                  | service.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Subjected to review of   | Subjected to review of     |          |
| 8 | physician evaluation and | physician evaluation and   |          |
| 5 | management services.     | management services.       |          |
+---+--------------------------+----------------------------+----------+
| M | Service denied, payment  | Service denied because     | Modified |
| 8 | already for same/similar | payment already made for   | 6/30/03  |
| 6 | procedure w/in set time  | same/similar procedure     |          |
|   | frame                    | within set time frame.     |          |
+---+--------------------------+----------------------------+----------+
| M | Claim/service(s)         | Claim/service(s) subjected |          |
| 8 | subjected to CFO-CAP     | to CFO-CAP prepayment      |          |
| 7 | prepayment review.       | review.                    |          |
+---+--------------------------+----------------------------+----------+
| M | We cannot pay for lab    | We cannot pay for          | Dea      |
| 8 | tests unless billed by   | laboratory tests unless    | ctivated |
| 8 | the lab that did the     | billed by the laboratory   | eff.     |
|   | work.                    | that did the work.         | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Not covered more than    | Not covered more than once |          |
| 8 | once under age 40.       | under age 40.              |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Not covered more than    | Not covered more than once |          |
| 9 | once in a 12 month       | in a 12 month period.      |          |
| 0 | period.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Lab procedures           | Lab procedures with        |          |
| 9 | w/different CLIA cert    | different CLIA             |          |
| 1 | numbers must be billed   | certification numbers must |          |
|   | on separate claims.      | be billed on separate      |          |
|   |                          | claims.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Services subjected to    | Services subjected to      | Dea      |
| 9 | review under the Home    | review under the Home      | ctivated |
| 2 | Health Medical Review    | Health Medical Review      | eff.     |
|   | Initiative.              | Initiative.                | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Info suppld supprts      | Information supplied       |          |
| 9 | break in therapy. New    | supports a break in        |          |
| 3 | capped rentl per         | therapy. A new capped      |          |
|   | w/delivery of equip      | rental period began with   |          |
|   |                          | delivery of this           |          |
|   |                          | equipment.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Info suppld doesn\'t     | Information supplied does  |          |
| 9 | supprt break in therapy. | not support a break in     |          |
| 4 | New capped rentl period  | therapy. A new capped      |          |
|   | won\'t begin             | rental period will not     |          |
|   |                          | begin.                     |          |
+---+--------------------------+----------------------------+----------+
| M | Services subjected to    | Services subjected to Home |          |
| 9 | Home Health Initiative   | Health Initiative medical  |          |
| 5 | medical review/cost      | review/cost report audit.  |          |
|   | report audit.            |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Tech comp of service     | The technical component of |          |
| 9 | furnished to inpatient   | a service furnished to an  |          |
| 6 | may only be billed by    | inpatient may only be      |          |
|   | that inpat fac           | billed by that inpatient   |          |
|   |                          | facility. You must contact |          |
|   |                          | the inpatient facility for |          |
|   |                          | technical component        |          |
|   |                          | reimbursement. If not      |          |
|   |                          | already billed, you should |          |
|   |                          | bill us for the            |          |
|   |                          | professional component     |          |
|   |                          | only.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Not pd to practitioner   | Not paid to practitioner   |          |
| 9 | when provided to pat in  | when provided to patient   |          |
| 7 | POS.Pymt incl in         | in this place of service.  |          |
|   | reimburse to fac         | Payment included in the    |          |
|   |                          | reimbursement issued the   |          |
|   |                          | facility.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Begin using Universal    | Begin to report the        | Dea      |
| 9 | Product Number, soon     | Universal Product Number   | ctivated |
| 8 | payment denied if        | on claims for items of     | eff.     |
|   | no/wrong UPN             | this type. We will soon    | 1/31/04  |
|   |                          | begin to deny payment for  |          |
|   |                          | items of this type if      |          |
|   |                          | billed without the correct |          |
|   |                          | UPN.                       |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 9 | ssing/incomplete/invalid | Universal Product          | 2/28/03  |
| 9 | Universal Product        | Number/Serial Number.      |          |
|   | Number/Serial Number.    |                            |          |
+---+--------------------------+----------------------------+----------+
| M | We don\'t pay oral       | We do not pay for an oral  |          |
| 1 | anti-emetic not admin    | anti-emetic drug that is   |          |
| 0 | immed w/in 48 hrs of     | not administered for use   |          |
| 0 | admin covrd chemo        | immediately before, at, or |          |
|   |                          | within 48 hours of         |          |
|   |                          | administration of a        |          |
|   |                          | covered chemotherapy drug. |          |
+---+--------------------------+----------------------------+----------+
| M | Begin using G1-G5 mod    | Begin to report a G1-G5    | Dea      |
| 1 | w/this HCPCS. Soon deny  | modifier with this HCPCS.  | ctivated |
| 0 | payment if billed w/out  | We will soon begin to deny | eff.     |
| 1 | G1-G5 mod                | payment for this service   | 1/31/04  |
|   |                          | if billed without a G1-G5  |          |
|   |                          | modifier.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Service not performed on | Service not performed on   |          |
| 1 | equipment approved by    | equipment approved by the  |          |
| 0 | the FDA for this         | FDA for this purpose.      |          |
| 2 | purpose.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Info supprt brk in       | Information supplied       |          |
| 1 | ther/info on rec not     | supports a break in        |          |
| 0 | supprt need/pmt          | therapy. However, the      |          |
| 3 | reduc/new capd rent per  | medical information we     |          |
|   |                          | have for this patient does |          |
|   |                          | not support the need for   |          |
|   |                          | this item as billed. We    |          |
|   |                          | have approved payment for  |          |
|   |                          | this item at a reduced     |          |
|   |                          | level, and a new capped    |          |
|   |                          | rental period will begin   |          |
|   |                          | with the delivery of this  |          |
|   |                          | equipment.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Info suppld supports     | Information supplied       |          |
| 1 | break in therapy. New    | supports a break in        |          |
| 0 | capped rentl period      | therapy. A new capped      |          |
| 4 | w/deliv of equip         | rental period will begin   |          |
|   |                          | with delivery of the       |          |
|   |                          | equipment. This is the     |          |
|   |                          | maximum approved under the |          |
|   |                          | fee schedule for this item |          |
|   |                          | or service.                |          |
+---+--------------------------+----------------------------+----------+
| M | Info not suprt brk in    | Information supplied does  |          |
| 1 | ther/infoonrec not suprt | not support a break in     |          |
| 0 | need/pmt rdc/nonew capd  | therapy. The medical       |          |
| 5 | rent per                 | information we have for    |          |
|   |                          | this patient does not      |          |
|   |                          | support the need for this  |          |
|   |                          | item as billed. We have    |          |
|   |                          | approved payment for this  |          |
|   |                          | item at a reduced level,   |          |
|   |                          | and a new capped rental    |          |
|   |                          | period will not begin.     |          |
+---+--------------------------+----------------------------+----------+
| M | Info suppld not support  | Information supplied does  | Dea      |
| 1 | break in therapy/New     | not support a break in     | ctivated |
| 0 | capped rental period     | therapy. A new capped      | eff.     |
| 6 | will not begin           | rental period will not     | 1/31/04  |
|   |                          | begin. This is the maximum |          |
|   |                          | approved under the fee     |          |
|   |                          | schedule for this item or  |          |
|   |                          | service.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Pymt reduced as 90-day   | Payment reduced as 90-day  |          |
| 1 | rolling average          | rolling average hematocrit |          |
| 0 | hematocrit for ESRD      | for ESRD patient exceeded  |          |
| 7 | patient exceeds 36.5%    | 36.5%.                     |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | provider identifier for    | 2/28/03, |
| 0 | prov ident for prov who  | the provider who           | Dea      |
| 8 | interpreted diagnostic   | interpreted the diagnostic | ctivated |
|   | test                     | test.                      | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | We provide bundled pymt  | We have provided you with  |          |
| 1 | for teleconsultation.    | a bundled payment for a    |          |
| 0 | Send 25% pymt to refer   | teleconsultation.You must  |          |
| 9 | practitionr              | send 25 percent of the     |          |
|   |                          | teleconsultation payment   |          |
|   |                          | to the referring           |          |
|   |                          | practitioner.              |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | provider identifier for    | 2/28/03, |
| 1 | prov ident for prov      | the provider from whom you | Dea      |
| 0 | interpret srvcs          | purchased interpretation   | ctivated |
|   | purchased from           | services.                  | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | We don\'t pay            | We do not pay for          |          |
| 1 | chiropractic             | chiropractic manipulative  |          |
| 1 | manipulative treatmnt    | treatment when the patient |          |
| 1 | when patient refuses     | refuses to have an x-ray   |          |
|   | x-ray taken              | taken.                     |          |
+---+--------------------------+----------------------------+----------+
| M | Apprvd amt based on max  | The approved amount is     |          |
| 1 | allowance for item under | based on the maximum       |          |
| 1 | DMEPOS Competitive       | allowance for this item    |          |
| 2 | Bidding Demo             | under the DMEPOS           |          |
|   |                          | Competitive Bidding        |          |
|   |                          | Demonstration.             |          |
+---+--------------------------+----------------------------+----------+
| M | Pat use srvc prior curnt | Our records indicate that  |          |
| 1 | rnd DMEPOS Competitve    | this patient began using   |          |
| 1 | Bid Demo/aprvd amt allw  | this service(s)prior to    |          |
| 3 | prior rnd                | the current round of the   |          |
|   |                          | DMEPOS Competitive Bidding |          |
|   |                          | Demonstration. Therefore,  |          |
|   |                          | the approved amount is     |          |
|   |                          | based on the allowance in  |          |
|   |                          | effect prior to this round |          |
|   |                          | of bidding for this item.  |          |
+---+--------------------------+----------------------------+----------+
| M | Srvc processed           | This service was processed |          |
| 1 | accordance rules &       | in accordance with rules   |          |
| 1 | guidelines under         | and guidelines under the   |          |
| 4 | Competitive Bid Demo     | Competitive Bidding        |          |
|   | Project                  | Demonstration Project. If  |          |
|   |                          | you would like more        |          |
|   |                          | information regarding this |          |
|   |                          | project, you may phone     |          |
|   |                          | 1-888-289-0710.            |          |
+---+--------------------------+----------------------------+----------+
| M | This item denied when    | This item is denied when   |          |
| 1 | provided to this patient | provided to this patient   |          |
| 1 | by a non-demonstration   | by anon-demonstration      |          |
| 5 | supplier                 | supplier.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Paid under Competitive   | Paid under the Competitive | Modified |
| 1 | Bid Demo. Proj ending,   | Bidding Demonstration      | 2/1/04   |
| 1 | future srvcs may not be  | project. Project is        |          |
| 6 | paid                     | ending, and future         |          |
|   |                          | services may not be paid   |          |
|   |                          | under this project.        |          |
+---+--------------------------+----------------------------+----------+
| M | Not covered unless       | Not covered unless         | Modified |
| 1 | submitted via electronic | submitted via electronic   | 6/30/03  |
| 1 | claim.                   | claim.                     |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Letter to follow         | Letter to follow           |          |
| 1 | containing further       | containing further         |          |
| 1 | information.             | information.               |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | National Drug Code (NDC).  | 2/28/03, |
| 1 | National Drug Code       |                            | 4/1/04   |
| 9 | (NDC).                   |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Miss/incmplt/invld       | Missing/incomplete/invalid | Modified |
| 1 | provid subst phys srvc   | provider identifier for    | 2/28/03, |
| 2 | reciprocal billing/locum | the substituting physician | Dea      |
| 0 | tenens arngmt            | who furnished the          | ctivated |
|   |                          | service(s) under a         | 6/2/05   |
|   |                          | reciprocal billing or      |          |
|   |                          | locum tenens arrangement.  |          |
+---+--------------------------+----------------------------+----------+
| M | We pay for this service  | We pay for this service    |          |
| 1 | only when performed with | only when performed with a |          |
| 2 | a covered cryosurgical   | covered cryosurgical       |          |
| 1 | ablation                 | ablation.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | level of subluxation.      | 2/28/03  |
| 2 | level of subluxation.    |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | name, strength, or dosage  | 2/28/03  |
| 2 | name, strength, or       | of the drug furnished.     |          |
| 3 | dosage of the drug       |                            |          |
|   | furnished.               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing indication of    | Missing indication of      | Modified |
| 1 | whether patient owns     | whether the patient owns   | 8/1/04,  |
| 2 | equip req part/supply    | the equipment that         | 2/28/03  |
| 4 |                          | requires the part or       |          |
|   |                          | supply.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | information on the period  | 2/28/03  |
| 2 | info on period time      | of time for which the      |          |
| 5 | service/supply/equipment | service/supply/equipment   |          |
|   | needed                   | will be needed.            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | individual lab codes       | 2/28/03  |
| 2 | individual lab codes     | included in the test.      |          |
| 6 | included in the test.    |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing patient medical  | Missing patient medical    | Modified |
| 1 | record for this service. | record for this service.   | 8/1/04,  |
| 2 |                          |                            | 2/28/03  |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | date of the patient\'s     | 2/28/03, |
| 2 | date of the patient\'s   | last physician visit.      | Dea      |
| 8 | last physician visit.    |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | indicator of x-ray         | 2/28/03, |
| 2 | indicator of x-ray       | availability for review.   | 6/30/03  |
| 9 | availability for review. |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing invoice/stmnt    | Missing invoice or         | Modified |
| 1 | cert cost lens, less     | statement certifying the   | 8/1/04,  |
| 3 | disc/type lens use       | actual cost of the lens,   | 2/28/03  |
| 0 |                          | less discounts, and/or the |          |
|   |                          | type of intraocular lens   |          |
|   |                          | used.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Missing physician        | Missing physician          | Modified |
| 1 | financial relationship   | financial relationship     | 8/1/04,  |
| 3 | form.                    | form.                      | 2/28/03  |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing pacemaker        | Missing pacemaker          | Modified |
| 1 | registration form.       | registration form.         | 8/1/04,  |
| 3 |                          |                            | 2/28/03  |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Claim not identify who   | Claim did not identify who |          |
| 1 | performed purchased      | performed the purchased    |          |
| 3 | diagnostic test or       | diagnostic test or the     |          |
| 3 | amount charged           | amount you were charged    |          |
|   |                          | for the test.              |          |
+---+--------------------------+----------------------------+----------+
| M | Performed by a           | Performed by a             | Modified |
| 1 | facility/supplier in     | facility/supplier in which | 6/30/03  |
| 3 | which the provider has a | the provider has a         |          |
| 4 | financial interest.      | financial interest.        |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | plan of treatment.         | 2/28/03  |
| 3 | plan of treatment.       |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| 1 | ssing/incomplete/invalid | indication that the        | 2/28/03  |
| 3 | indication service       | service was supervised or  |          |
| 6 | supervised/valuated by   | evaluated by a physician.  |          |
|   | physician                |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Part B coinsurance under | Part B coinsurance under a |          |
| 1 | a demonstration project. | demonstration project.     |          |
| 3 |                          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pat id demo partcpnt/not | Patient identified as a    |          |
| 1 | enrld demo time srvcs    | demonstration participant  |          |
| 3 | render. Cvrg limit demo  | but the patient was not    |          |
| 8 | partcpnts                | enrolled in the            |          |
|   |                          | demonstration at the time  |          |
|   |                          | services were rendered.    |          |
|   |                          | Coverage is limited to     |          |
|   |                          | demonstration              |          |
|   |                          | participants.              |          |
+---+--------------------------+----------------------------+----------+
| M | Denied services exceed   | Denied services exceed the |          |
| 1 | the coverage limit for   | coverage limit for the     |          |
| 3 | the demonstration.       | demonstration.             |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Srvc not cvrd til after  | Service not covered until  | Dea      |
| 1 | pat 50 birthday, ie, no  | after the patient's 50th   | ctivated |
| 4 | cvrg prior day after 50  | birthday, i.e., no         | eff.     |
| 0 | birthday                 | coverage prior to the day  | 1/30/04  |
|   |                          | after the 50th birthday    |          |
+---+--------------------------+----------------------------+----------+
| M | Missing physician        | Missing physician          | Modified |
| 1 | certified plan of care.  | certified plan of care.    | 8/1/04,  |
| 4 |                          |                            | 2/28/03  |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing American         | Missing American Diabetes  | Modified |
| 1 | Diabetes Association     | Association Certificate of | 8/1/04,  |
| 4 | Certificate of           | Recognition.               | 2/28/03  |
| 2 | Recognition              |                            |          |
+---+--------------------------+----------------------------+----------+
| M | We have no record you    | We have no record that you |          |
| 1 | are licensed to          | are licensed to dispensed  |          |
| 4 | dispensed drugs in the   | drugs in the State where   |          |
| 3 | State where located      | located.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Pre-/post-operative care | Pre-/post-operative care   |          |
| 1 | payment included in      | payment is included in the |          |
| 4 | allowance for the        | allowance for the          |          |
| 4 | surgery/procedure        | surgery/procedure.         |          |
+---+--------------------------+----------------------------+----------+
| [ | [If not agree aprvd      | [If you do not agree with  | [        |
| M | srvc, appeal. One who    | what we approved for these | Modified |
| A | not do 1st clm rev.      | services, you may appeal   | 1        |
| 0 | Write w/in 120           | our decision. To make sure | 0/31/02, |
| 1 | day]{.mark}              | that we are fair to you,   | 6/30/03, |
| ] |                          | we require another         | 8/1/05   |
| { |                          | individual that did not    | ]{.mark} |
| . |                          | process your initial claim |          |
| m |                          | to conduct the appeal.     |          |
| a |                          | However, in order to be    |          |
| r |                          | eligible for an appeal,    |          |
| k |                          | you must write to us       |          |
| } |                          | within 120 days of the     |          |
|   |                          | date you received this     |          |
|   |                          | notice, unless you have a  |          |
|   |                          | good reason for being      |          |
|   |                          | late.]{.mark}              |          |
+---+--------------------------+----------------------------+----------+
| [ | [If not agree            | [If you do not agree with  | [        |
| M | detrmnation,right to     | this determination, you    | Modified |
| A | appeal.Write w/in 120    | have the right to appeal.  | 1        |
| 0 | dy.Dec by QIO w/in 60    | You must file a written    | 0/31/02, |
| 2 | dy]{.mark}               | request for an appeal      | 6/30/03, |
| ] |                          | within 120 days of the     | 8/1/05   |
| { |                          | date you receive this      | ]{.mark} |
| . |                          | notice. Decisions made by  |          |
| m |                          | a Quality Improvement      |          |
| a |                          | Organization (QIO) must be |          |
| r |                          | appealed to that QIO       |          |
| k |                          | within 60 days.]{.mark}    |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [If not agree w/approved | [If you do not agree with  | [        |
| M | amt & \$100 or more in   | the approved amounts and   | Modified |
| A | dispute, ask hearing     | \$100 or more is in        | 1        |
| 0 | w/in 6 months]{.mark}    | dispute (less deductible   | 0/31/02, |
| 3 |                          | and coinsurance), you may  | 6/30/03, |
| ] |                          | ask for a hearing within   | 8/1/05   |
| { |                          | six months of the date of  | ]{.mark} |
| . |                          | this notice. To meet the   |          |
| m |                          | \$100, you may combine     |          |
| a |                          | amounts on other claims    |          |
| r |                          | that have been denied,     |          |
| k |                          | including reopened appeals |          |
| } |                          | if you received a revised  |          |
|   |                          | decision. You must appeal  |          |
|   |                          | each claim on time. At the |          |
|   |                          | reconsideration, you must  |          |
|   |                          | present any new evidence   |          |
|   |                          | which could affect out     |          |
|   |                          | decision.]{.mark}          |          |
+---+--------------------------+----------------------------+----------+
| M | 2ndry pymt not consdrd   | Secondary payment cannot   |          |
| A | w/out id/pymt info from  | be considered without the  |          |
| 0 | primry. Info not         | identity of or payment     |          |
| 4 | report/illegible         | information from the       |          |
|   |                          | primary payer. The         |          |
|   |                          | information was either not |          |
|   |                          | reported or was illegible. |          |
+---+--------------------------+----------------------------+----------+
| M | Incorrect admission date | Incorrect admission date   | Dea      |
| A | patient status or type   | patient status or type of  | ctivated |
| 0 | of bill entry on claim.  | bill entry on claim.       | eff.     |
| 5 |                          |                            | 10/16/03 |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | beginning and/or ending    | 2/28/03, |
| 0 | beginning and/or ending  | date(s).                   | Dea      |
| 6 | date(s).                 |                            | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | The claim information    | The claim information has  |          |
| A | has also been forwarded  | also been forwarded to     |          |
| 0 | to Medicaid for review.  | Medicaid for review.       |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Also sbmt clm pat oth    | You should also submit     |          |
| A | ins poss pmt supl ben.We | this claim to the          |          |
| 0 | not fwd/supl cvrg not    | patient\'s other insurer   |          |
| 8 | Medigap/MCR              | for potential payment of   |          |
|   |                          | supplemental benefits. We  |          |
|   |                          | did not forward the claim  |          |
|   |                          | information as the         |          |
|   |                          | supplemental coverage is   |          |
|   |                          | not with a Medigap plan,   |          |
|   |                          | or you do not participate  |          |
|   |                          | in Medicare.               |          |
+---+--------------------------+----------------------------+----------+
| M | Claim submitted unassgn  | Claim submitted as         |          |
| A | but processed assgn. You | unassigned but processed   |          |
| 0 | agrd accept assignmt all | as assigned. You agreed to |          |
| 9 | claims                   | accept assignment for all  |          |
|   |                          | claims.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Patient\'s payment in    | The patient\'s payment was |          |
| A | excess amount owed. You  | in excess of the amount    |          |
| 1 | must refund overpayment  | owed. You must refund the  |          |
| 0 | to patient               | overpayment to the         |          |
|   |                          | patient.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Pmt conditional.If       | Payment is being issued on | Dea      |
| A | no-fault/l               | a conditional basis. If    | ctivated |
| 1 | iability/WorkComp/VA/grp | no-fault insurance,        | eff.     |
| 1 | plan cvrg, rfnd may due  | liability insurance,       | 1/31/04  |
|   | us                       | Workers\' Compensation,    |          |
|   |                          | Department of Veterans     |          |
|   |                          | Affairs, or a group health |          |
|   |                          | plan for employees and     |          |
|   |                          | dependents also covers     |          |
|   |                          | this claim, a refund may   |          |
|   |                          | be due us. Please contact  |          |
|   |                          | us if the patient is       |          |
|   |                          | covered by any of these    |          |
|   |                          | sources.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Not estblsh right under  | You have not established   |          |
| A | the law to bill srvc     | that you have the right    |          |
| 1 | furnish by person        | under the law to bill for  |          |
| 2 | furnish this srvc        | services furnished by the  |          |
|   |                          | person(s) that furnished   |          |
|   |                          | this (these) service(s).   |          |
+---+--------------------------+----------------------------+----------+
| M | May be subject penalties | You may be subject to      |          |
| A | if bill patient amounts  | penalties if you bill the  |          |
| 1 | not reported w/PR group  | patient for amounts not    |          |
| 3 | code.                    | reported with the PR       |          |
|   |                          | (patient responsibility)   |          |
|   |                          | group code.                |          |
+---+--------------------------+----------------------------+----------+
| M | Pat mbr emplyr-sponsrd   | Patient is a member of an  |          |
| A | hlthpln.Srvc outside pln | employer-sponsored prepaid |          |
| 1 | not cvrd.Pmt this clm    | health plan. Services from |          |
| 4 | not notifd               | outside that health plan   |          |
|   |                          | are not covered. However,  |          |
|   |                          | as you were not previously |          |
|   |                          | notified of this, we are   |          |
|   |                          | paying this time. In the   |          |
|   |                          | future, we will not pay    |          |
|   |                          | you for non-plan services. |          |
+---+--------------------------+----------------------------+----------+
| M | Claim separated expedite | Your claim has been        |          |
| A | handling. Receive        | separated to expedite      |          |
| 1 | separate notice for oth  | handling. You will receive |          |
| 5 | srvcs report             | a separate notice for the  |          |
|   |                          | other services reported.   |          |
+---+--------------------------+----------------------------+----------+
| M | The patient is covered   | The patient is covered by  |          |
| A | by the Black Lung        | the Black Lung Program.    |          |
| 1 | Program. Send this claim | Send this claim to the     |          |
| 6 | to them                  | Department of Labor,       |          |
|   |                          | Federal Black Lung         |          |
|   |                          | Program, P.O. Box          |          |
|   |                          | 828,Lanham-Seabrook MD     |          |
|   |                          | 20703.                     |          |
+---+--------------------------+----------------------------+----------+
| M | Prim pyr&pd prim         | We are the primary payer   |          |
| A | rate.Contct pat oth ins  | and have paid at the       |          |
| 1 | to rfd excess pd due     | primary rate. You must     |          |
| 7 | erroneous prim pmt       | contact the patient\'s     |          |
|   |                          | other insurer to refund    |          |
|   |                          | any excess it may have     |          |
|   |                          | paid due to its erroneous  |          |
|   |                          | primary payment.           |          |
+---+--------------------------+----------------------------+----------+
| M | Claim info fwd pat suppl | The claim information is   |          |
| A | ins. Send any ques       | also being forwarded to    |          |
| 1 | regarding supplemental   | the patient\'s             |          |
| 8 | ben to them              | supplemental insurer. Send |          |
|   |                          | any questions regarding    |          |
|   |                          | supplemental benefits to   |          |
|   |                          | them.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Inf notsent              | Information was not sent   |          |
| A | Medigap.Incrrct/invld    | to the Medigap insurer due |          |
| 1 | info sbmt on ins.Vfy inf | to incorrect/invalid       |          |
| 9 | sbmt 2ndry clm direct    | information you submitted  |          |
|   |                          | concerning that insurer.   |          |
|   |                          | Please verify your         |          |
|   |                          | information and submit     |          |
|   |                          | your secondary claim       |          |
|   |                          | directly to that insurer.  |          |
+---+--------------------------+----------------------------+----------+
| M | SNF not cvrd care        | Skilled Nursing Facility   | Modified |
| A | primary urethral         | (SNF) stay not covered     | 6/30/03  |
| 2 | catheter for             | when care is primarily     |          |
| 0 | convenience/control      | related to the use of an   |          |
|   | incontinence             | urethral catheter for      |          |
|   |                          | convenience or the control |          |
|   |                          | of incontinence.           |          |
+---+--------------------------+----------------------------+----------+
| M | SSA records indicate     | SSA records indicate       |          |
| A | mismatch with name and   | mismatch with name and     |          |
| 2 | sex.                     | sex.                       |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Payment of less than     | Payment of less than       |          |
| A | \$1.00 suppressed.       | \$1.00 suppressed.         |          |
| 2 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Demand bill approved as  | Demand bill approved as    |          |
| A | result of medical        | result of medical review.  |          |
| 2 | review.                  |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | C                        | Christian Science          | Modified |
| A | hristianScienceSanitariu | Sanitarium/ Skilled        | 6/30/03  |
| 2 | m/SkilledNursingFacility | Nursing Facility (SNF)     |          |
| 4 | (SNF) bill same benefit  | bill in the same benefit   |          |
|   | period                   | period.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Patient may not elect    | A patient may not elect to |          |
| A | change hospice provider  | change a hospice provider  |          |
| 2 | more than once in a      | more than once in a        |          |
| 5 | benefit period           | benefit period.            |          |
+---+--------------------------+----------------------------+----------+
| M | Our records indicate     | Our records indicate that  |          |
| A | that you were previously | you were previously        |          |
| 2 | informed of this rule.   | informed of this rule.     |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | entitlement number or name | 2/28/03  |
| 2 | entitlement number or    | shown on the claim.        |          |
| 7 | name shown on the claim. |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Rcpt notice by           | Receipt of this notice by  |          |
| A | phys/suplr not accpt     | a physician or supplier    |          |
| 2 | assgn is info only &     | who did not accept         |          |
| 8 | they not party determin  | assignment is for          |          |
|   |                          | information only and does  |          |
|   |                          | not make the physician or  |          |
|   |                          | supplier a party to the    |          |
|   |                          | determination. No          |          |
|   |                          | additional rights to       |          |
|   |                          | appeal this decision,      |          |
|   |                          | above those rights already |          |
|   |                          | provided for by            |          |
|   |                          | regulation/instruction,    |          |
|   |                          | are conferred by receipt   |          |
|   |                          | of this notice.            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | provider name, city,       | 2/28/03, |
| 2 | provider name, city,     | state, or zip code.        | Dea      |
| 9 | state, or zip code.      |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | type of bill.              | 2/28/03  |
| 3 | type of bill.            |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | beginning and ending dates | 2/28/03  |
| 3 | beginning and ending     | of the period billed.      |          |
| 1 | dates of the period      |                            |          |
|   | billed.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | number of covered days     | 2/28/03  |
| 3 | number of covered days   | during the billing period. |          |
| 2 | during the billing       |                            |          |
|   | period.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | noncovered days during the | 2/28/03  |
| 3 | noncovered days during   | billing period.            |          |
| 3 | the billing period.      |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | number of coinsurance days | 2/28/03  |
| 3 | number of coinsurance    | during the billing period. |          |
| 4 | days during the billing  |                            |          |
|   | period.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | number of lifetime reserve | 2/28/03  |
| 3 | number of lifetime       | days.                      |          |
| 5 | reserve days.            |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient name.              | 2/28/03  |
| 3 | patient name.            |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient\'s address.        | 2/28/03  |
| 3 | patient\'s address.      |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | birth date.                | 2/28/03, |
| 3 | birth date.              |                            | Dea      |
| 8 |                          |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | gender.                    | 2/28/03  |
| 3 | gender.                  |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | admission date.            | 2/28/03  |
| 4 | admission date.          |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | admission type.            | 2/28/03  |
| 4 | admission type.          |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | admission source.          | 2/28/03  |
| 4 | admission source.        |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient status.            | 2/28/03  |
| 4 | patient status.          |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | No appeal rights.        | No appeal rights.          |          |
| A | Adjudicative decision    | Adjudicative decision      |          |
| 4 | based on law.            | based on law.              |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | As previously advised,   | As previously advised, a   |          |
| A | portion/all of payment   | portion or all of your     |          |
| 4 | is being held in a       | payment is being held in a |          |
| 5 | special account          | special account.           |          |
+---+--------------------------+----------------------------+----------+
| M | New info                 | The new information was    |          |
| A | considered/addtnl pmt    | considered, however,       |          |
| 4 | can\'t issd. Please      | additional payment cannot  |          |
| 6 | review info listed for   | be issued. Please review   |          |
|   | expln                    | the information listed for |          |
|   |                          | the explanation.           |          |
+---+--------------------------+----------------------------+----------+
| M | Records show opted out   | Our records show you have  |          |
| A | MCR, agree w/patient not | opted out of Medicare,     |          |
| 4 | bill MCR. We can\'t pay. | agreeing with the patient  |          |
| 7 | Pat resp                 | not to bill Medicare for   |          |
|   |                          | services/tests/supplies    |          |
|   |                          | furnished. As result, we   |          |
|   |                          | cannot pay this claim. The |          |
|   |                          | patient is responsible for |          |
|   |                          | payment.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | name or address of         | 2/28/03  |
| 4 | name or address of       | responsible party or       |          |
| 8 | responsible party or     | primary payer.             |          |
|   | primary payer            |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Miss/incmplt/invld prov  | Missing/incomplete/invalid | Modified |
| A | id home hlth agcy/hosp   | six-digit provider         | 2/28/03, |
| 4 | phys perf care pln       | identifier for home health | Dea      |
| 9 | ovrsight srvcs           | agency or hospice for      | ctivated |
|   |                          | physician(s) performing    | eff.     |
|   |                          | care plan oversight        | 8/1/04   |
|   |                          | services.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Miss/incmplt/invld       | Missing/incomplete/invalid | Modified |
| A | Investigational Device   | Investigational Device     | 2/28/03  |
| 5 | Exemption \# FDA-apprvd  | Exemption number for       |          |
| 0 | clin trial srvc          | FDA-approved clinical      |          |
|   |                          | trial services.            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | CLIA certification number  | 2/28/03, |
| 5 | CLIA cert \# for lab     | for laboratory services    | 12/      |
| 1 | service billed by phys   | billed by physician office | 2/04,Dea |
|   | office lab               | laboratory.                | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 2/5/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | date.                      | 2/28/03, |
| 5 | date.                    |                            | Dea      |
| 2 |                          |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | Competitive Bidding        | 2/1/04   |
| 5 | Competitive Bidding      | Demonstration Project      |          |
| 3 | Demonstration Project Id | identification.            |          |
+---+--------------------------+----------------------------+----------+
| M | Physician certification  | Physician certification or |          |
| A | or election consent for  | election consent for       |          |
| 5 | hospice care not         | hospice care not received  |          |
| 4 | received timely          | timely.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Not cvrd pat recd med    | Not covered as patient     |          |
| A | hlth care svc,auto       | received medical health    |          |
| 5 | revoke recv relig        | care services,             |          |
| 5 | non-med hlth care svc    | automatically revoking     |          |
|   |                          | his/her election to        |          |
|   |                          | receive religious          |          |
|   |                          | non-medical health care    |          |
|   |                          | services.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Opted out MCR, agree     | Our records show you have  |          |
| A | w/pat not bill MCR.      | opted out of Medicare,     |          |
| 5 | Can\'t pay. Pat resp     | agreeing with the patient  |          |
| 6 | limiting chrg amt        | not to bill Medicare for   |          |
|   |                          | services/tests/supplies    |          |
|   |                          | furnished. As result, we   |          |
|   |                          | cannot pay this claim. The |          |
|   |                          | patient is responsible for |          |
|   |                          | payment, but under Federal |          |
|   |                          | law, you cannot charge the |          |
|   |                          | patient more than the      |          |
|   |                          | limiting charge amount.    |          |
+---+--------------------------+----------------------------+----------+
| M | Pat submitd written      | Patient submitted written  |          |
| A | request revoke election  | request to revoke his/her  |          |
| 5 | religious non-med health | election for religious     |          |
| 7 | care srvcs               | non-medical health care    |          |
|   |                          | services.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | release of information     | 2/28/03  |
| 5 | release of information   | indicator.                 |          |
| 8 | indicator.               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pat ovrpd. Rfnd pat w/in | The patient overpaid you   |          |
| A | 30 days the diff between | for these services. You    |          |
| 5 | pymnt and pat            | must issue the patient a   |          |
| 9 | responsibility           | refund within 30 days for  |          |
|   |                          | the difference between     |          |
|   |                          | his/he rpayment and the    |          |
|   |                          | total amount shown as      |          |
|   |                          | patient responsibility on  |          |
|   |                          | this notice.               |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient relationship to    | 2/28/03  |
| 6 | patient relationship to  | insured.                   |          |
| 0 | insured.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | social security number or  | 2/28/03  |
| 6 | social security \# or    | health insurance claim     |          |
| 1 | health insurance claim   | number.                    |          |
|   | number                   |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Telephone review         | Telephone review decision. |          |
| A | decision.                |                            |          |
| 6 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | principal diagnosis.       | 2/28/03  |
| 6 | principal diagnosis.     |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | We should be 3rd payer.  | Our records indicate that  |          |
| A | Can\'t process til recvd | we should be the third     |          |
| 6 | pymt info from 1st & 2nd | payer for this claim. We   |          |
| 4 | payers                   | cannot process this claim  |          |
|   |                          | until we have received     |          |
|   |                          | payment information from   |          |
|   |                          | the primary and secondary  |          |
|   |                          | payers.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | admitting diagnosis.       | 2/28/03  |
| 6 | admitting diagnosis.     |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | principal procedure code.  | 2/28/03, |
| 6 | principal procedure      |                            | 12/2/04  |
| 6 | code.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Correction to a prior    | Correction to a prior      |          |
| A | claim.                   | claim.                     |          |
| 6 |                          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Not x-over claim, 2nd    | We did not crossover this  |          |
| A | ins info incomplete.     | claim because the          |          |
| 6 | Supply complt info/use   | secondary insurance        |          |
| 8 | PLANID of ins            | information on the claim   |          |
|   |                          | was incomplete. Please     |          |
|   |                          | supply complete            |          |
|   |                          | information or use the     |          |
|   |                          | PLANID of the insurer to   |          |
|   |                          | assure correct and timely  |          |
|   |                          | routing of the claim.      |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | remarks.                   | 2/28/03  |
| 6 | remarks.                 |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | provider representative    | 2/28/03  |
| 7 | provider representative  | signature.                 |          |
| 0 | signature.               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | provider representative    | 2/28/03  |
| 7 | provider representative  | signature date.            |          |
| 1 | signature date.          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pat ovrpd assigned       | The patient overpaid you   |          |
| A | srvcs. Rfnd pat w/in 30  | for these assigned         |          |
| 7 | days the diff between    | services. You must issue   |          |
| 2 | pymt & pat resp          | the patient a refund       |          |
|   |                          | within 30 days for the     |          |
|   |                          | difference between his/her |          |
|   |                          | payment to you and the     |          |
|   |                          | total of the amount shown  |          |
|   |                          | as patient responsibility  |          |
|   |                          | and as paid to the patient |          |
|   |                          | on this notice.            |          |
+---+--------------------------+----------------------------+----------+
| M | Info remit assoc w/MCR   | Informational remittance   |          |
| A | demo. No pmt issd        | associated with a Medicare |          |
| 7 | fee-for-srvc MCR pat     | demonstration. No payment  |          |
| 3 | elect managed care       | issued under               |          |
|   |                          | fee-for-service Medicare   |          |
|   |                          | as patient has elected     |          |
|   |                          | managed care.              |          |
+---+--------------------------+----------------------------+----------+
| M | Payment replaces earlier | This payment replaces an   |          |
| A | payment that was either  | earlier payment for this   |          |
| 7 | lost, damaged or         | claim that was either      |          |
| 4 | returned                 | lost, damaged or returned. |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient or authorized      | 2/28/03  |
| 7 | patient or authorized    | representative signature.  |          |
| 5 | representative           |                            |          |
|   | signature.               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing/incmplete/invld  | Missing/incomplete/invalid | Modified |
| A | prov id HHA/hospice phys | provider identifier for    | 2/28/03, |
| 7 | perform care pln         | home health agency or      | 2/1/04   |
| 6 | ovrsight srvcs           | hospice when physician is  |          |
|   |                          | performing care plan       |          |
|   |                          | oversight services.        |          |
+---+--------------------------+----------------------------+----------+
| M | Pat ovrpd. Rfnd pat w/in | The patient overpaid you.  |          |
| A | 30 days diff betwn pat   | You must issue the patient |          |
| 7 | pmt less prev pyr pmt &  | a refund within30 days for |          |
| 7 | pat resp                 | the difference between the |          |
|   |                          | patient\'s payment less    |          |
|   |                          | the total of our and other |          |
|   |                          | payer payments and the     |          |
|   |                          | amount shown as patient    |          |
|   |                          | responsibility on this     |          |
|   |                          | notice.                    |          |
+---+--------------------------+----------------------------+----------+
| M | Patient overpaid. Refund | The patient overpaid you.  | Dea      |
| A | patient w/in 30 days     | You must issue the patient | ctivated |
| 7 | diff between allowed amt | a refund within30 days for | eff.     |
| 8 | & pat pmt                | the difference between our | 1/31/04  |
|   |                          | allowed amount total and   |          |
|   |                          | the amount paid by the     |          |
|   |                          | patient.                   |          |
+---+--------------------------+----------------------------+----------+
| M | Billed in excess of      | Billed in excess of        |          |
| A | interim rate.            | interim rate.              |          |
| 7 |                          |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Info notice. Pmt issd    | Informational notice. No   |          |
| A | hosp by intermediary for | payment issued for this    |          |
| 8 | srvc this encnter under  | claim with this notice.    |          |
| 0 | demo proj                | Payment issued to the      |          |
|   |                          | hospital by its            |          |
|   |                          | intermediary for all       |          |
|   |                          | services for this          |          |
|   |                          | encounter under a          |          |
|   |                          | demonstration project.     |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | provider/supplier          | 2/28/03  |
| 8 | provider/supplier        | signature.                 |          |
| 1 | signature.               |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Miss/incmplt/invald      | Missing/incomplete/invalid | Modified |
| A | prov/suplr billing #/id  | provider/supplier billing  | 2/28/03, |
| 8 | or billing               | number/identifier or       | Dea      |
| 2 | nam,addr,city,st,zip,ph  | billing name, address,     | ctivated |
|   | \#                       | city, state, zip code, or  | 6/2/05   |
|   |                          | phone number.              |          |
+---+--------------------------+----------------------------+----------+
| [ | [Did not indicate        | [Did not indicate whether  | [        |
| M | whether we are the       | we are the primary or      | Modified |
| A | primary or secondary     | secondary payer.]{.mark}   | 8/1/05   |
| 8 | payer.]{.mark}           |                            | ]{.mark} |
| 3 |                          |                            |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pat id participant       | Patient identified as      |          |
| A | Nat\'l Emphysema         | participating in the       |          |
| 8 | Treatment Trial but pat  | National Emphysema         |          |
| 4 | not participnt/apprvd    | Treatment Trial but our    |          |
|   |                          | records indicate that this |          |
|   |                          | patient is either not a    |          |
|   |                          | participant, or has not    |          |
|   |                          | yet been approved for this |          |
|   |                          | phase of the study.        |          |
|   |                          | Contact Johns Hopkins      |          |
|   |                          | University, the study      |          |
|   |                          | coordinator, to resolve if |          |
|   |                          | there was a discrepancy.   |          |
+---+--------------------------+----------------------------+----------+
| M | Oth primry pyr; you not  | Our records indicate that  | Dea      |
| A | complete/enter accurate  | a primary payer exists     | ctivated |
| 8 | ins plan/grp/progrm name | (other than ourselves);    | eff.     |
| 5 | or id \#                 | however, you did not       | 8/1/04   |
|   |                          | complete or enter          |          |
|   |                          | accurately the insurance   |          |
|   |                          | plan/group/program name or |          |
|   |                          | identification number.     |          |
|   |                          | Enter the PlanID when      |          |
|   |                          | effective.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | group or policy number of  | 2/28/03, |
| 8 | group or policy \# of    | the insured for the        | Dea      |
| 6 | insured for the primary  | primary coverage.          | ctivated |
|   | coverage                 |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | insured\'s name for the    | 2/28/03, |
| 8 | insured\'s name for the  | primary payer.             | Dea      |
| 7 | primary payer.           |                            | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | insured\'s address and/or  | 2/28/03  |
| 8 | insured\'s address       | telephone number for the   |          |
| 8 | and/or phone \# for      | primary payer.             |          |
|   | primary payer            |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | patient\'s relationship to | 2/28/03  |
| 8 | patient\'s relationship  | the insured for the        |          |
| 9 | to insured for primary   | primary payer.             |          |
|   | payer                    |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | employment status code for | 2/28/03  |
| 9 | employment status code   | the primary insured.       |          |
| 0 | for the primary insured. |                            |          |
+---+--------------------------+----------------------------+----------+
| M | This determination is    | This determination is the  |          |
| A | the result of the appeal | result of the appeal you   |          |
| 9 | you filed.               | filed.                     |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Missing plan information | Missing plan information   | Modified |
| A | for other insurance.     | for other insurance.       | 8/1/04,  |
| 9 |                          |                            | 2/28/03, |
| 2 |                          |                            | 2/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Non-PIP (Periodic        | Non-PIP (Periodic Interim  | Modified |
| A | Interim Payment) claim.  | Payment) claim.            | 6/30/03  |
| 9 |                          |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [\"Attending phys not    | [Did not enter the         | [Rea     |
| M | hospice employee\" not   | statement \"Attending      | ctivated |
| A | on clm cert render phys  | physician not hospice      | 4/1/04,  |
| 9 | not emply hosp]{.mark}   | employee\" on the claim to | Modified |
| 4 |                          | certify that the rendering | 8/1/05   |
| ] |                          | physician is not an        | ]{.mark} |
| { |                          | employee of the            |          |
| . |                          | hospice.]{.mark}           |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | De-activate and refer to | De-activate and refer to   | Modified |
| A | M51.                     | M51.                       | 2/28/03  |
| 9 |                          |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Claim rejected. Coded    | Claim rejected. Coded as a |          |
| A | MCR Managed Care Demo    | Medicare Managed Care      |          |
| 9 | but pat not enrld MCR    | Demonstration but patient  |          |
| 6 | mangd care pln           | is not enrolled in a       |          |
|   |                          | Medicare managed care      |          |
|   |                          | plan.                      |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | Medicare Managed Care      | 2/28/03  |
| 9 | Medicare Managed Care    | Demonstration contract     |          |
| 7 | Demonstration contract   | number.                    |          |
|   | number.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Claim Rejectd. Not       | Claim Rejected. Does not   | Dea      |
| A | correct MCR Managed Care | contain the correct        | ctivated |
| 9 | Demo contract \# for     | Medicare Managed Care      | eff.     |
| 8 | this beneficiary         | Demonstration contract     | 10/16/03 |
|   |                          | number for this            |          |
|   |                          | beneficiary.               |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | Medigap information.       | 2/28/03  |
| 9 | Medigap information.     |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | date of current illness or | 2/28/03, |
| 1 | date of current illness  | symptoms                   | 3/29/05  |
| 0 | or symptoms              |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | A SNF responsible        | A Skilled Nursing Facility | Modified |
| A | payment of outside prov  | (SNF) is responsible for   | 6/30/03  |
| 1 | who furnish srvcs/supls  | payment of outside         |          |
| 0 | to residents             | providers who furnish      |          |
| 1 |                          | these services/supplies to |          |
|   |                          | residents.                 |          |
+---+--------------------------+----------------------------+----------+
| M | Missng/incmplt/invld     | Missing/incomplete/invalid | Modified |
| A | name/prov id             | name or provider           | 2/28/03, |
| 1 | rendering/referr         | identifier for the         | Dea      |
| 0 | ing/ordering/supervising | rendering/refe             | ctivated |
| 2 | prov                     | rring/ordering/supervising | eff.     |
|   |                          | provider.                  | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| M | Hemophilia Add On.       | Hemophilia Add On.         |          |
| A |                          |                            |          |
| 1 |                          |                            |          |
| 0 |                          |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Dea      |
| A | ssing/incomplete/invalid | date the patient was last  | ctivated |
| 1 | date pat last seen or    | seen or the provider       | eff.     |
| 0 | provider id of attending | identifier of the          | 1/31/04  |
| 4 | phys                     | attending physician.       |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | provider number for this   | 2/28/03, |
| 1 | provider number for this | place of service.          | Dea      |
| 0 | place of service.        |                            | ctivated |
| 5 |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| M | PIP (Periodic Interim    | PIP (Periodic Interim      | Modified |
| A | Payment) claim.          | Payment) claim.            | 6/30/03  |
| 1 |                          |                            |          |
| 0 |                          |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Paper claim contains     | Paper claim contains more  |          |
| A | more than three separate | than three separate data   |          |
| 1 | data items in field 19.  | items in field 19.         |          |
| 0 |                          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Paper claim contains     | Paper claim contains more  |          |
| A | more than one data item  | than one data item in      |          |
| 1 | in field 23.             | field 23.                  |          |
| 0 |                          |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Claim processed in       | Claim processed in         |          |
| A | accordance with          | accordance with ambulatory |          |
| 1 | ambulatory surgical      | surgical guidelines.       |          |
| 0 | guidelines.              |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Miss/incmplt/invld info  | Missing/incomplete/invalid | Modified |
| A | if diagnostic performd   | information on whether the | 2/28/03  |
| 1 | outside entity/no        | diagnostic test(s) were    |          |
| 1 | purchasd tests           | performed by an outside    |          |
| 0 |                          | entity or if no purchased  |          |
|   |                          | tests are included on the  |          |
|   |                          | claim.                     |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | purchase price of the      | 2/28/03  |
| 1 | purchase price of        | test(s) and/or the         |          |
| 1 | test/performing lab\'s   | performing laboratory\'s   |          |
| 1 | name & addr              | name and address.          |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | group practice             | 2/28/03  |
| 1 | group practice           | information.               |          |
| 1 | information.             |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Incmplt/invld TIN submtd | Incomplete/invalid         |          |
| A | per IRS.Not process.May  | taxpayer identification    |          |
| 1 | not bill pat pnding      | number (TIN) submitted by  |          |
| 1 | corrct TIN               | you per the Internal       |          |
| 3 |                          | Revenue Service. Your      |          |
|   |                          | claims cannot be processed |          |
|   |                          | without your correct TIN,  |          |
|   |                          | and you may not bill the   |          |
|   |                          | patient pending correction |          |
|   |                          | of your TIN. There are no  |          |
|   |                          | appeal rights for          |          |
|   |                          | unprocessable claims, but  |          |
|   |                          | you may resubmit this      |          |
|   |                          | claim after you have       |          |
|   |                          | notified this office of    |          |
|   |                          | your correct TIN.          |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | information on where the   | 2/28/03  |
| 1 | information on where the | services were furnished.   |          |
| 1 | services were furnished. |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | physical location (name    | 2/28/03  |
| 1 | physical location where  | and address, or PIN) where |          |
| 1 | services rendered in a   | the service(s) were        |          |
| 5 | HPSA                     | rendered in a Health       |          |
|   |                          | Professional Shortage Area |          |
|   |                          | (HPSA).                    |          |
+---+--------------------------+----------------------------+----------+
| M | Stmt \"Homebound\" not   | Did not complete the       | Rea      |
| A | on claim validate lab    | statement \"Homebound\" on | ctivated |
| 1 | srvcs performed at       | the claim to validate      | 4/1/04   |
| 1 | home/in institutn        | whether laboratory         |          |
| 6 |                          | services were performed at |          |
|   |                          | home or in an institution. |          |
+---+--------------------------+----------------------------+----------+
| M | This claim has been      | This claim has been        |          |
| A | assessed a \$1.00 user   | assessed a \$1.00 user     |          |
| 1 | fee.                     | fee.                       |          |
| 1 |                          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Coins/deduct amts apply  | Coinsurance and/or         |          |
| A | for srvcs/suppls furn    | deductible amounts apply   |          |
| 1 | MCR-elig vet thru VA. No | to a claim for services or |          |
| 1 | MCR pmt                  | supplies furnished to a    |          |
| 8 |                          | Medicare-eligible veteran  |          |
|   |                          | through a facility of the  |          |
|   |                          | Department of Veterans     |          |
|   |                          | Affairs. No Medicare       |          |
|   |                          | payment issued.            |          |
+---+--------------------------+----------------------------+----------+
| M | Provider level           | Provider level adjustment  |          |
| A | adjustment for late      | for late claim filing      |          |
| 1 | claim filing applies to  | applies to this claim.     |          |
| 1 | this claim.              |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | CLIA certification number. | 2/28/03  |
| 1 | CLIA certification       |                            |          |
| 2 | number.                  |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | x-ray date.                | 2/28/03, |
| 1 | x-ray date.              |                            | 6/30/03, |
| 2 |                          |                            | 2/1/04,  |
| 1 |                          |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | initial treatment date.    | 2/28/03, |
| 1 | initial treatment date.  |                            | 12/2/04  |
| 2 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Center not selected      | Your center was not        |          |
| A | participate in study,    | selected to participate in |          |
| 1 | therefore, we cannot pay | this study, therefore, we  |          |
| 2 | for services             | cannot pay for these       |          |
| 3 |                          | services.                  |          |
+---+--------------------------+----------------------------+----------+
| M | Processed for IME only.  | Processed for IME only.    | Dea      |
| A |                          |                            | ctivated |
| 1 |                          |                            | eff.     |
| 2 |                          |                            | 1/31/04  |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Per legislation          | Per legislation governing  |          |
| A | governing this program,  | this program, payment      |          |
| 1 | payment constitutes      | constitutes payment in     |          |
| 2 | payment in full.         | full.                      |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Pancreas transplant not  | Pancreas transplant not    | New code |
| A | covered unless kidney    | covered unless kidney      | 10/21/01 |
| 1 | transplant performed.    | transplant performed.      |          |
| 2 |                          |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Reserved for future use. | Reserved for future use.   | Dea      |
| A |                          |                            | ctivated |
| 1 |                          |                            | 6/2/05   |
| 2 |                          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid | Modified |
| A | ssing/incomplete/invalid | FDA approval number.       | 2/28/03, |
| 1 | FDA approval number.     |                            | 3/29/05  |
| 2 |                          |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | This provider was not    | This provider was not      | Dea      |
| A | certified for this       | certified for this         | ctivated |
| 1 | procedure on this date   | procedure on this date of  | eff.     |
| 2 | of service.              | service.                   | 1/31/04  |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Incmplt/invld info,no    | Your claim contains        |          |
| A | appeal rights            | incomplete and/or invalid  |          |
| 1 | afforded.Submt new clm   | information, and no appeal |          |
| 3 | w/ complt/corct info     | rights are afforded        |          |
| 0 |                          | because the claim is       |          |
|   |                          | unprocessable. Please      |          |
|   |                          | submit a new claim with    |          |
|   |                          | the complete/correct       |          |
|   |                          | information.               |          |
+---+--------------------------+----------------------------+----------+
| M | Phys already paid in     | Physician already paid for |          |
| A | conjunction w/demo clm.  | services in conjunction    |          |
| 1 | Have phys withdraw clm & | with this demonstration    |          |
| 3 | rfnd pmt                 | claim. You must have the   |          |
| 1 |                          | physician withdraw that    |          |
|   |                          | claim and refund the       |          |
|   |                          | payment before we can      |          |
|   |                          | process your claim.        |          |
+---+--------------------------+----------------------------+----------+
| M | Adjustment to the        | Adjustment to the          |          |
| A | pre-demonstration rate.  | pre-demonstration rate.    |          |
| 1 |                          |                            |          |
| 3 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Claim overlaps inpatient | Claim overlaps inpatient   |          |
| A | stay. Rebill only        | stay. Rebill only those    |          |
| 1 | services rendered        | services rendered outside  |          |
| 3 | outside inpat stay       | the inpatient stay.        |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| M | Mi                       | Missing/incomplete/invalid |          |
| A | ssing/incomplete/invalid | provider number of the     |          |
| 1 | provider number of       | facility where the patient |          |
| 3 | facility where patient   | resides.                   |          |
| 4 | resides                  |                            |          |
+---+--------------------------+----------------------------+----------+
| N | May appeal this decision | You may appeal this        | Modified |
| 1 | in writing. Instruction  | decision in writing within | 2/28/03  |
|   | incld contract/plan      | the required time limits   |          |
|   | benefit doc              | following receipt of this  |          |
|   |                          | notice by following the    |          |
|   |                          | instructions included in   |          |
|   |                          | your contract or plan      |          |
|   |                          | benefit documents.         |          |
+---+--------------------------+----------------------------+----------+
| N | allowance made           | This allowance has been    |          |
| 2 | accordance most          | made in accordance with    |          |
|   | appropriate course of    | the most appropriate       |          |
|   | treatment provision of   | course of treatment        |          |
|   | plan                     | provision of the plan.     |          |
+---+--------------------------+----------------------------+----------+
| N | Missing consent form.    | Missing consent form.      | Modified |
| 3 |                          |                            | 8/1/04,  |
|   |                          |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 4 | ssing/incomplete/invalid | prior insurance carrier    | 2/28/03  |
|   | prior insurance carrier  | EOB.                       |          |
|   | EOB.                     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | EOB received from        | EOB received from previous |          |
| 5 | previous payer. Claim    | payer. Claim not on file.  |          |
|   | not on file.             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | FEHB law(U.S.C.          | Under FEHB law (U.S.C.     | Modified |
| 6 | 8904(b)),can\'t pay more | 8904(b)), we cannot pay    | 2/28/03  |
|   | for cvrd care than MCR   | more for covered care than |          |
|   | allwd if A/B cvrg        | the amount Medicare would  |          |
|   |                          | have allowed if the        |          |
|   |                          | patient were enrolled in   |          |
|   |                          | Medicare Part A and/or     |          |
|   |                          | Medicare Part B.           |          |
+---+--------------------------+----------------------------+----------+
| N | Processing claim/service | Processing of this         |          |
| 7 | included consideration   | claim/service has included |          |
|   | under Major Medical      | consideration under Major  |          |
|   | provisions               | Medical provisions.        |          |
+---+--------------------------+----------------------------+----------+
| N | X-over clm deny by prev  | Crossover claim denied by  |          |
| 8 | pyr&complt dat not       | previous payer and         |          |
|   | fwd.Resubmt to pyr to    | complete claim data not    |          |
|   | provd adjud dat          | forwarded. Resubmit this   |          |
|   |                          | claim to this payer to     |          |
|   |                          | provide adequate data for  |          |
|   |                          | adjudication.              |          |
+---+--------------------------+----------------------------+----------+
| N | Adjustment represents    | Adjustment represents the  |          |
| 9 | the estimated amount the | estimated amount the       |          |
|   | primary payer may have   | primary payer may have     |          |
|   | paid.                    | paid.                      |          |
+---+--------------------------+----------------------------+----------+
| N | Clm/svc adj on findings  | Claim/service adjusted     | Modified |
| 1 | rev org/prof             | based on the findings of a | 10/31/02 |
| 0 | conslt/manual            | review                     |          |
|   | adjudicatn/med or dentl  | organization/professional  |          |
|   | advsr                    | consult/manual             |          |
|   |                          | adjudication/medical or    |          |
|   |                          | dental advisor.            |          |
+---+--------------------------+----------------------------+----------+
| N | Denial reversed because  | Denial reversed because of |          |
| 1 | of medical review.       | medical review.            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Pol prov cvrg suppl MCR. | Policy provides coverage   |          |
| 1 | Mbr not MCR B,mbr resp   | supplemental to Medicare.  |          |
| 2 | pmt of chrg would be     | As member does not appear  |          |
|   | cvrd by MCR              | to be enrolled in Medicare |          |
|   |                          | Part B, the member is      |          |
|   |                          | responsible for payment of |          |
|   |                          | the portion of the charge  |          |
|   |                          | that would have been       |          |
|   |                          | covered by Medicare.       |          |
+---+--------------------------+----------------------------+----------+
| N | Payment based on         | Payment based on           |          |
| 1 | professional/technical   | professional/technical     |          |
| 3 | component modifier(s).   | component modifier(s).     |          |
+---+--------------------------+----------------------------+----------+
| N | Payment based on         | Payment based on a         |          |
| 1 | contractual amt or       | contractual amount or      |          |
| 4 | agreemet, fee schedule,  | agreement, fee schedule,   |          |
|   | or max allowable amt     | or maximum allowable       |          |
|   |                          | amount.                    |          |
+---+--------------------------+----------------------------+----------+
| N | Services for a newborn   | Services for a newborn     |          |
| 1 | must be billed           | must be billed separately. |          |
| 5 | separately.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Family/member            | Family/member              |          |
| 1 | Out-of-Pocket maximum    | Out-of-Pocket maximum has  |          |
| 6 | met. Payment based on a  | been met. Payment based on |          |
|   | higher percentage.       | a higher percentage.       |          |
+---+--------------------------+----------------------------+----------+
| N | Per admission            | Per admission deductible.  | Dea      |
| 1 | deductible.              |                            | ctivated |
| 7 |                          |                            | eff.     |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Payment based on the     | Payment based on the       | Dea      |
| 1 | Medicare allowed amount. | Medicare allowed amount.   | ctivated |
| 8 |                          |                            | eff.     |
|   |                          |                            | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Procedure code           | Procedure code incidental  |          |
| 1 | incidental to primary    | to primary procedure.      |          |
| 9 | procedure.               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Service not payable with | Service not payable with   |          |
| 2 | other service rendered   | other service rendered on  |          |
| 0 | on the same date.        | the same date.             |          |
+---+--------------------------+----------------------------+----------+
| [ | [Your line item has been | [Your line item has been   | [        |
| N | separated into multiple  | separated into multiple    | Modified |
| 2 | lines to expedite        | lines to expedite          | 8/1/05   |
| 1 | handling.]{.mark}        | handling.]{.mark}          | ]{.mark} |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Procedure code           | This procedure code was    | Modified |
| 2 | added/changed as it more | added/changed because it   | 1        |
| 2 | accurately describes     | more accurately describes  | 0/31/02, |
|   | services rendered        | the services rendered.     | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| N | Pat liabilty maybe       | Patient liability may be   | 8/13/01  |
| 2 | affectd due coord of ben | affected due to            |          |
| 3 | w/oth carriers/max       | coordination of benefits   |          |
|   | benefit provision        | with other carriers and/or |          |
|   |                          | maximum benefit            |          |
|   |                          | provisions.                |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | Electronic Funds Transfer  | 2/28/03  |
| 4 | Electronic Funds         | (EFT) banking information. |          |
|   | Transfer (EFT) banking   |                            |          |
|   | information.             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Co contractd by ben plan | This company has been      |          |
| 2 | prov admin clm pmt svc   | contracted by your benefit |          |
| 5 | only,not assume finan    | plan to provide            |          |
|   | risk/oblig               | administrative claims      |          |
|   |                          | payment services only.     |          |
|   |                          | This company does not      |          |
|   |                          | assume financial risk or   |          |
|   |                          | obligation with respect to |          |
|   |                          | claims processed on behalf |          |
|   |                          | of your benefit plan.      |          |
+---+--------------------------+----------------------------+----------+
| N | Missing itemized bill.   | Missing itemized bill.     | Modified |
| 2 |                          |                            | 8/1/04,  |
| 6 |                          |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 2 | ssing/incomplete/invalid | treatment number.          | 2/28/03  |
| 7 | treatment number.        |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Consent form             | Consent form requirements  |          |
| 2 | requirements not         | not fulfilled.             |          |
| 8 | fulfilled.               |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Missing                 | [Missing                   | [        |
| N | document                 | docu                       | Modified |
| 2 | ation/orders/notes/summa | mentation/orders/notes/sum | 8/1/04,  |
| 9 | ry/report/chart.]{.mark} | mary/report/chart.]{.mark} | 2/28/03, |
| ] |                          |                            | 8/1/05   |
| { |                          |                            | ]{.mark} |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Patient ineligible for   | Patient ineligible for     | Modified |
| 3 | this service.            | this service.              | 6/30/03  |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 3 | ssing/incomplete/invalid | prescribing provider       | 2/28/03, |
| 1 | prescribing provider     | identifier.                | 12/2/04  |
|   | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim must be submitted  | Claim must be submitted by | Modified |
| 3 | by the provider who      | the provider who rendered  | 6/30/03  |
| 2 | rendered the service.    | the service.               |          |
+---+--------------------------+----------------------------+----------+
| N | No record of health      | No record of health check  |          |
| 3 | check prior to           | prior to initiation of     |          |
| 3 | initiation of treatment. | treatment.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Incorrect claim form for | Incorrect claim form for   |          |
| 3 | this service.            | this service.              |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Program                  | Program                    |          |
| 3 | integrity/utilization    | integrity/utilization      |          |
| 5 | review decision.         | review decision.           |          |
+---+--------------------------+----------------------------+----------+
| N | Claim must meet primary  | Claim must meet primary    |          |
| 3 | payer processing         | payer\'s processing        |          |
| 6 | requirements before we   | requirements before we can |          |
|   | considr payment          | consider payment.          |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 3 | ssing/incomplete/invalid | tooth number/letter.       | 2/28/03  |
| 7 | tooth number/letter.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 3 | ssing/incomplete/invalid | place of service.          | 2/28/03, |
| 8 | place of service.        |                            | Dea      |
|   |                          |                            | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 2/5/05   |
+---+--------------------------+----------------------------+----------+
| N | Procedure code is not    | Procedure code is not      |          |
| 3 | compatible with tooth    | compatible with tooth      |          |
| 9 | number/letter.           | number/letter.             |          |
+---+--------------------------+----------------------------+----------+
| N | Missing x-ray.           | Missing x-ray.             | Modified |
| 4 |                          |                            | 2/28/03, |
| 0 |                          |                            | 6/30/03, |
|   |                          |                            | 2/1/04,  |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Authorization request    | Authorization request      | Dea      |
| 4 | denied.                  | denied.                    | ctivated |
| 1 |                          |                            | eff.     |
|   |                          |                            | 10/16/03 |
+---+--------------------------+----------------------------+----------+
| N | No record of mental      | No record of mental health |          |
| 4 | health assessment.       | assessment.                |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Bed hold or leave days   | Bed hold or leave days     |          |
| 4 | exceeded                 | exceeded.                  |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Pyr share reg            | Payer\'s share of          | Dea      |
| 4 | surchr                   | regulatory surcharges,     | ctivated |
| 4 | g/assessmts/allwncs/hlth | assessments, allowances or | eff.     |
|   | care-relatd tx pd        | health care-related taxes  | 10/16/03 |
|   | directly reg auth        | paid directly to the       |          |
|   |                          | regulatory authority.      |          |
+---+--------------------------+----------------------------+----------+
| N | Payment based on         | Payment based on           |          |
| 4 | authorized amount.       | authorized amount.         |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid |          |
| 4 | ssing/incomplete/invalid | admission hour.            |          |
| 6 | admission hour.          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim conflicts with     | Claim conflicts with       |          |
| 4 | another inpatient stay.  | another inpatient stay.    |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim information not    | Claim information does not |          |
| 4 | agree with information   | agree with information     |          |
| 8 | received from oth        | received from other        |          |
|   | insurance carrier        | insurance carrier.         |          |
+---+--------------------------+----------------------------+----------+
| N | Court ordered coverage   | Court ordered coverage     |          |
| 4 | information needs        | information needs          |          |
| 9 | validation.              | validation.                |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | discharge information.     | 2/28/03  |
| 0 | discharge information.   |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Electronic interchange   | Electronic interchange     |          |
| 5 | agreement not on file    | agreement not on file for  |          |
| 1 | for provider/submitter.  | provider/submitter.        |          |
+---+--------------------------+----------------------------+----------+
| N | Patient not enrolled in  | Patient not enrolled in    |          |
| 5 | billing provider\'s      | the billing provider\'s    |          |
| 2 | managed care plan on     | managed care plan on the   |          |
|   | date of service          | date of service.           |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | point of pick-up address.  | 2/28/03  |
| 3 | point of pick-up         |                            |          |
|   | address.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim information is     | Claim information is       |          |
| 5 | inconsistent with        | inconsistent with          |          |
| 4 | pre-certified/authorized | pre-certified/authorized   |          |
|   | services.                | services.                  |          |
+---+--------------------------+----------------------------+----------+
| N | Procedures for billing   | Procedures for billing     |          |
| 5 | gr                       | with                       |          |
| 5 | oup/referring/performing | group/referring/performing |          |
|   | providers were not       | providers were not         |          |
|   | followed                 | followed.                  |          |
+---+--------------------------+----------------------------+----------+
| N | Procedure code billd not | Procedure code billed is   | Modified |
| 5 | correct/valid for        | not correct/valid for the  | 2/28/03  |
| 6 | services billd/date of   | services billed or the     |          |
|   | service billd            | date of service billed.    |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | prescribing date.          | 2/28/03, |
| 7 | prescribing date.        |                            | 12/2/04  |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 5 | ssing/incomplete/invalid | patient liability amount.  | 2/28/03  |
| 8 | patient liability        |                            |          |
|   | amount.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Please refer to provider | Please refer to your       |          |
| 5 | manual for additional    | provider manual for        |          |
| 9 | program and provider     | additional program and     |          |
|   | information              | provider information.      |          |
+---+--------------------------+----------------------------+----------+
| N | A valid NDC is required  | A valid NDC is required    | Dea      |
| 6 | for payment of drug      | for payment of drug claims | ctivated |
| 0 | claims effective October | effective October 02.      | eff.     |
|   | 02.                      |                            | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Rebill services on       | Rebill services on         |          |
| 6 | separate claims.         | separate claims.           |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Inpatient admission      | Inpatient admission spans  |          |
| 6 | spans multiple rate      | multiple rate periods.     |          |
| 2 | periods. Resubmit        | Resubmit separate claims.  |          |
|   | separate claims.         |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Rebill services on       | Rebill services on         |          |
| 6 | separate claim lines.    | separate claim lines.      |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | The \"from\" and \"to\"  | The \"from\" and \"to\"    |          |
| 6 | dates must be different. | dates must be different.   |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Procedure code/rate      | Procedure code or          | Modified |
| 6 | count not determined/on  | procedure rate count       | 2/28/03  |
| 5 | file, for date of        | cannot be determined, or   |          |
|   | service/provider         | was not on file, for the   |          |
|   |                          | date of service/provider.  |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 6 | ssing/incomplete/invalid | documentation.             | 2/28/03, |
| 6 | documentation.           |                            | 12/2/04, |
|   |                          |                            | Dea      |
|   |                          |                            | ctivated |
|   |                          |                            | eff.     |
|   |                          |                            | 2/5/05   |
+---+--------------------------+----------------------------+----------+
| N | Prof provider srvcs not  | Professional provider      |          |
| 6 | paid separately.         | services not paid          |          |
| 7 | Included in fac pmt      | separately. Included in    |          |
|   | under demo project       | facility payment under a   |          |
|   |                          | demonstration project.     |          |
|   |                          | Apply to that facility for |          |
|   |                          | payment, or resubmit your  |          |
|   |                          | claim if: the facility     |          |
|   |                          | notifies you the patient   |          |
|   |                          | was excluded from this     |          |
|   |                          | demonstration; or if you   |          |
|   |                          | furnished these services   |          |
|   |                          | in another location on the |          |
|   |                          | date of the patient\'s     |          |
|   |                          | admission or discharge     |          |
|   |                          | from a demonstration       |          |
|   |                          | hospital. If services were |          |
|   |                          | furnished in a facility    |          |
|   |                          | not involved in the        |          |
|   |                          | demonstration on the same  |          |
|   |                          | date the patient was       |          |
|   |                          | discharged from or         |          |
|   |                          | admitted to a              |          |
|   |                          | demonstration facility,    |          |
|   |                          | you must report the        |          |
|   |                          | provider ID number for the |          |
|   |                          | non-demonstration facility |          |
|   |                          | on the new claim.          |          |
+---+--------------------------+----------------------------+----------+
| N | Prior payment cancelled, | Prior payment being        |          |
| 6 | subsequently notified    | cancelled as we were       |          |
| 8 | patient covered by a     | subsequently notified this |          |
|   | demo project             | patient was covered by a   |          |
|   |                          | demonstration project in   |          |
|   |                          | this site of service.      |          |
|   |                          | Professional services were |          |
|   |                          | included in the payment    |          |
|   |                          | made to the facility. You  |          |
|   |                          | must contact the facility  |          |
|   |                          | for your payment. Prior    |          |
|   |                          | payment made to you by the |          |
|   |                          | patient or another insurer |          |
|   |                          | for this claim must be     |          |
|   |                          | refunded to the payer      |          |
|   |                          | within 30 days.            |          |
+---+--------------------------+----------------------------+----------+
| N | PPS code changed by      | PPS (Prospective Payment   | Modified |
| 6 | claims processing        | System) code changed by    | 6/30/03  |
| 9 | system. Insufficient     | claims processing system.  |          |
|   | visits or therapies.     | Insufficient visits or     |          |
|   |                          | therapies.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Home health consolidated | Home health consolidated   | Modified |
| 7 | billing and payment      | billing and payment        | 2/28/03  |
| 0 | applies.                 | applies.                   |          |
+---+--------------------------+----------------------------+----------+
| N | unassigned claim         | Your unassigned claim for  | Modified |
| 7 | drug/bio/clin diagnostic | a drug or biological,      | 2/12/02, |
| 1 | lab/ambulance srvc       | clinical diagnostic        | 6/30/03  |
|   | processed assigned       | laboratory services or     |          |
|   |                          | ambulance service was      |          |
|   |                          | processed as an assigned   |          |
|   |                          | claim. You are required by |          |
|   |                          | law to accept assignment   |          |
|   |                          | for these types of claims. |          |
+---+--------------------------+----------------------------+----------+
| N | PPS code changed by      | PPS (Prospective Payment   | Modified |
| 7 | medical reviewers. Not   | System) code changed by    | 6/30/03  |
| 2 | supported by clinical    | medical reviewers. Not     |          |
|   | records                  | supported by clinical      |          |
|   |                          | records.                   |          |
+---+--------------------------+----------------------------+----------+
| N | A SNF resp pmt outside   | A Skilled Nursing Facility | Modified |
| 7 | prov who furnish         | is responsible for payment | 7/24/01, |
| 3 | srvcs/supls under        | of outside providers who   | 2/28/03, |
|   | arrangemnt to resident   | furnish these              | Dea      |
|   |                          | services/supplies under    | ctivated |
|   |                          | arrangement to its         | eff.     |
|   |                          | residents.                 | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Resubmt w/multiple       | Resubmit with multiple     |          |
| 7 | claims, each claim cvrg  | claims, each claim         |          |
| 4 | srvcs provided only 1    | covering services provided |          |
|   | calendar month           | in only one calendar       |          |
|   |                          | month.                     |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | tooth surface information. | 2/28/03  |
| 5 | tooth surface            |                            |          |
|   | information.             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | number of riders.          | 2/28/03  |
| 6 | number of riders.        |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 7 | ssing/incomplete/invalid | designated provider        | 2/28/03  |
| 7 | designated provider      | number.                    |          |
|   | number.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Necessary components of  | The necessary components   |          |
| 7 | child and teen checkup   | of the child and teen      |          |
| 8 | (EPSDT) were not         | checkup (EPSDT) were not   |          |
|   | completed.               | completed.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Service billed is not    | Service billed is not      |          |
| 7 | compatible with patient  | compatible with patient    |          |
| 9 | location information.    | location information.      |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | Modified |
| 8 | ssing/incomplete/invalid | prenatal screening         | 2/28/03  |
| 0 | prenatal screening       | information.               |          |
|   | information.             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Procedure billed is not  | Procedure billed is not    |          |
| 8 | compatible with tooth    | compatible with tooth      |          |
| 1 | surface code.            | surface code.              |          |
+---+--------------------------+----------------------------+----------+
| N | Prov must accpt ins pmt  | Provider must accept       |          |
| 8 | as pmt in full 3rd party | insurance payment as       |          |
| 2 | pyr contrct says full    | payment in full when a     |          |
|   | reimburse                | third party payer contract |          |
|   |                          | specifies full             |          |
|   |                          | reimbursement.             |          |
+---+--------------------------+----------------------------+----------+
| N | No appeal right.         | No appeal rights.          |          |
| 8 | Adjudicative decision    | Adjudicative decision      |          |
| 3 | based provisions of      | based on the provisions of |          |
|   | demonstration project    | a demonstration project.   |          |
+---+--------------------------+----------------------------+----------+
| N | Further installment      | Further installment        |          |
| 8 | payments forthcoming.    | payments forthcoming.      |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Final installment        | Final installment payment. |          |
| 8 | payment.                 |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Fail trial pelvic muscle | A failed trial of pelvic   |          |
| 8 | exer traing req biofdbck | muscle exercise training   |          |
| 6 | traing trt urinary incnt | is required in order for   |          |
|   | cvrd                     | biofeedback training for   |          |
|   |                          | the treatment of urinary   |          |
|   |                          | incontinence to be         |          |
|   |                          | covered.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Home use of biofeedback  | Home use of biofeedback    |          |
| 8 | therapy is not covered.  | therapy is not covered.    |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Payment conditional. An  | This payment is being made |          |
| 8 | HHA episode care notice  | conditionally. An HHA      |          |
| 8 | has been filed for this  | episode of care notice has |          |
|   | patient                  | been filed for this        |          |
|   |                          | patient. When a patient is |          |
|   |                          | treated under a HHA        |          |
|   |                          | episode of care,           |          |
|   |                          | consolidated billing       |          |
|   |                          | requires that certain      |          |
|   |                          | therapy services and       |          |
|   |                          | supplies, such as this, be |          |
|   |                          | included in the HHA\'s     |          |
|   |                          | payment. This payment will |          |
|   |                          | need to be recouped from   |          |
|   |                          | you if we establish that   |          |
|   |                          | the patient is             |          |
|   |                          | concurrently receiving     |          |
|   |                          | treatment under a HHA      |          |
|   |                          | episode of care.           |          |
+---+--------------------------+----------------------------+----------+
| N | Payment info forwarded   | Payment information for    |          |
| 8 | more one other payer,    | this claim has been        |          |
| 9 | but only one identified  | forwarded to more than one |          |
|   | on remit                 | other payer, but format    |          |
|   |                          | limitations permit only    |          |
|   |                          | one of the secondary       |          |
|   |                          | payers to be identified in |          |
|   |                          | this remittance advice.    |          |
+---+--------------------------+----------------------------+----------+
| N | Covered only when        | Covered only when          |          |
| 9 | performed by the         | performed by the attending |          |
| 0 | attending physician.     | physician.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Services not included in | Services not included in   |          |
| 9 | the appeal review.       | the appeal review.         |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | This facility is not     | This facility is not       |          |
| 9 | certified for digital    | certified for digital      |          |
| 2 | mammography.             | mammography.               |          |
+---+--------------------------+----------------------------+----------+
| N | Sep claim required each  | A separate claim must be   |          |
| 9 | place of service. Srvcs  | submitted for each place   |          |
| 3 | multiple site not billd  | of service. Services       |          |
|   | same clm                 | furnished at multiple      |          |
|   |                          | sites may not be billed in |          |
|   |                          | the same claim.            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim/Service denied     | Claim/Service denied       |          |
| 9 | more specific taxonomy   | because a more specific    |          |
| 4 | code required for        | taxonomy code is required  |          |
|   | adjudication             | for adjudication.          |          |
+---+--------------------------+----------------------------+----------+
| N | This provider            | This provider              | New code |
| 9 | type/provider specialty  | type/provider specialty    | 7/31/01, |
| 5 | may not bill this        | may not bill this service. | Modified |
|   | service.                 |                            | 2/28/03  |
+---+--------------------------+----------------------------+----------+
| N | Pat refractory conven\'l | Patient must be refractory | New Code |
| 9 | ther & approp surg       | to conventional therapy    | 8/24/01  |
| 6 | candidate implantation   | (documented behavioral,    |          |
|   | w/anesth occur           | pharmacologic and/or       |          |
|   |                          | surgical corrective        |          |
|   |                          | therapy) and bean          |          |
|   |                          | appropriate surgical       |          |
|   |                          | candidate such that        |          |
|   |                          | implantation with          |          |
|   |                          | anesthesia can occur.      |          |
+---+--------------------------+----------------------------+----------+
| N | Strss incnt/urnry        | Patients with stress       | New code |
| 9 | obstr/spec neuro dis     | incontinence, urinary      | 8/24/01  |
| 7 | assoc w/2ndry manif      | obstruction, and specific  |          |
|   | above 3 indicatn excl    | neurologic diseases (e.g., |          |
|   |                          | diabetes with peripheral   |          |
|   |                          | nerve involvement)which    |          |
|   |                          | are associated with        |          |
|   |                          | secondary manifestations   |          |
|   |                          | of the above three         |          |
|   |                          | indications are excluded.  |          |
+---+--------------------------+----------------------------+----------+
| N | Patient must have        | Patient must have had a    | New code |
| 9 | successful test          | successful test            | 8/24/01  |
| 8 | stimulation to support   | stimulation in order to    |          |
|   | subsequent implantation  | support subsequent         |          |
|   |                          | implantation. Before a     |          |
|   |                          | patient is eligible for    |          |
|   |                          | permanent implantation,    |          |
|   |                          | he/she must demonstrate a  |          |
|   |                          | 50 percent or greater      |          |
|   |                          | improvement through test   |          |
|   |                          | stimulation. Improvement   |          |
|   |                          | is measured through        |          |
|   |                          | voiding diaries.           |          |
+---+--------------------------+----------------------------+----------+
| N | Pat must demo adeq       | Patient must be able to    | New code |
| 9 | abilty void diary data   | demonstrate adequate       | 8/24/01  |
| 9 | clin reslt implant proc  | ability to record voiding  |          |
|   | properly eval            | diary data such that       |          |
|   |                          | clinical results of the    |          |
|   |                          | implant procedure can be   |          |
|   |                          | properly evaluated.        |          |
+---+--------------------------+----------------------------+----------+
| N | PPS (Prospect Payment    | PPS (Prospect Payment      | New code |
| 1 | System) code corrected   | System) code corrected     | 9/14/01, |
| 0 | during adjudication.     | during adjudication.       | Modified |
| 0 |                          |                            | 6/30/03  |
+---+--------------------------+----------------------------+----------+
| N | Add\'l info need to      | Additional information is  | Dea      |
| 1 | process claim. Please    | needed in order to process | ctivated |
| 0 | resubmit w/id \#         | this claim. Please         | eff.     |
| 1 | provider where service   | resubmit the claim with    | 1/31/04  |
|   |                          | the identification number  |          |
|   |                          | of the provider where this |          |
|   |                          | service took place. The    |          |
|   |                          | Medicare number of the     |          |
|   |                          | site of service provider   |          |
|   |                          | should be preceded with    |          |
|   |                          | the letters \"HSP\" and    |          |
|   |                          | entered into item #32 on   |          |
|   |                          | the claim form. You may    |          |
|   |                          | bill only one site of      |          |
|   |                          | service provider number    |          |
|   |                          | per claim.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Denied w/out reviewing   | This claim has been denied | New code |
| 1 | med rec, requested rec   | without reviewing the      | 10/31/01 |
| 0 | not received or received | medical record because the |          |
| 2 | timely                   | requested records were not |          |
|   |                          | received or were not       |          |
|   |                          | received timely.           |          |
+---+--------------------------+----------------------------+----------+
| N | Social Security rec say  | Social Security records    | New code |
| 1 | pat prisoner at time of  | indicate that this patient | 1        |
| 0 | srvc. Pat liable hlth    | was a prisoner when the    | 2/05/01, |
| 3 | care cost                | service was rendered. This | Modified |
|   |                          | payer does not cover items | 4/8/02,  |
|   |                          | and services furnished to  | 2/28/03, |
|   |                          | an individual while they   | 6/30/03  |
|   |                          | are in State or local      |          |
|   |                          | custody under a penal      |          |
|   |                          | authority, unless under    |          |
|   |                          | State or local law, the    |          |
|   |                          | individual is personally   |          |
|   |                          | liable for the cost of his |          |
|   |                          | or her health care while   |          |
|   |                          | incarcerated and the State |          |
|   |                          | or local government        |          |
|   |                          | pursues such debt in the   |          |
|   |                          | same way and with the same |          |
|   |                          | vigor as any other debt.   |          |
+---+--------------------------+----------------------------+----------+
| N | Not payable under claims | This claim/service is not  | New code |
| 1 | jurisdiction area. Id    | payable under our claims   | 1/29/02, |
| 0 | correct MCR contractor   | jurisdiction area. You can | Modified |
| 4 | thru CMS                 | identify the correct       | 10/31/02 |
|   |                          | Medicare contractor to     |          |
|   |                          | process this claim/service |          |
|   |                          | through the CMS website at |          |
|   |                          | www.cms.hhs.gov.           |          |
+---+--------------------------+----------------------------+----------+
| N | This is a misdirected    | This is a misdirected      | New code |
| 1 | claim/service for an RRB | claim/service for an RRB   | 1/29/02  |
| 0 | beneficiary.             | beneficiary. Submit paper  |          |
| 5 |                          | claims to the RRB carrier: |          |
|   |                          | Palmetto GBA, P.O. Box     |          |
|   |                          | 10066,Augusta, GA 30999.   |          |
|   |                          | Call 866-749-4301 for RRB  |          |
|   |                          | EDI information for        |          |
|   |                          | electronic claims          |          |
|   |                          | processing.                |          |
+---+--------------------------+----------------------------+----------+
| N | Payment for services to  | Payment for services       | New code |
| 1 | SNF inpatients can only  | furnished to Skilled       | 1/31/02  |
| 0 | be made to the SNF.      | Nursing Facility           |          |
| 6 |                          | (SNF)inpatients (except    |          |
|   |                          | for excluded services) can |          |
|   |                          | only be made to the SNF.   |          |
|   |                          | You must request payment   |          |
|   |                          | from the SNF rather than   |          |
|   |                          | the patient for this       |          |
|   |                          | service.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Services to SNF          | Services furnished to      | New code |
| 1 | inpatient must be inpat  | Skilled Nursing Facility   | 1/31/02  |
| 0 | claim. Can\'t bill       | (SNF) inpatients must be   |          |
| 7 | separately as outpat     | billed on the inpatient    |          |
|   |                          | claim. They cannot be      |          |
|   |                          | billed separately as       |          |
|   |                          | outpatient services.       |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       |                            | Modified |
| 1 | ssing/incomplete/invalid |                            | 2/28/03  |
| 0 | upgrade information.     |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | This claim chosen for    | This claim was chosen for  | New code |
| 1 | complex review & denied  | complex review and was     | 2/26/02  |
| 0 | after reviewing medical  | denied after reviewing the |          |
| 9 | records.                 | medical records.           |          |
+---+--------------------------+----------------------------+----------+
| N | This facility is not     | This facility is not       | New code |
| 1 | certified for film       | certified for film         | 2/28/02  |
| 1 | mammography.             | mammography.               |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | No appeal right except   | No appeal right except     | New code |
| 1 | duplicate claim/service  | duplicate claim/service    | 2/28/02  |
| 1 | issue.                   | issue. This service was    |          |
| 1 |                          | included in a claim that   |          |
|   |                          | has been previously billed |          |
|   |                          | and adjudicated.           |          |
+---+--------------------------+----------------------------+----------+
| N | This claim is excluded   | This claim is excluded     | New code |
| 1 | from your electronic     | from your electronic       | 2/28/02  |
| 1 | remittance advice.       | remittance advice.         |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Only one initial visit   | Only one initial visit is  | New code |
| 1 | is covered per           | covered per physician,     | 4/16/02, |
| 1 | physician, group         | group practice or          | Modified |
| 3 | practice or provider.    | provider.                  | 6/30/03  |
+---+--------------------------+----------------------------+----------+
| N | Dur transition Ambulance | During the transition to   | New code |
| 1 | Fee Schedule, pmt basd   | the Ambulance Fee          | 5/30/02  |
| 1 | lessr of blended         | Schedule, payment is based |          |
| 4 | amt/submt chrg           | on the lesser of a blended |          |
|   |                          | amount calculated using a  |          |
|   |                          | percentage of the          |          |
|   |                          | reasonable charge/cost and |          |
|   |                          | fee schedule amounts, or   |          |
|   |                          | the submitted charge for   |          |
|   |                          | the service. You will be   |          |
|   |                          | notified yearly what the   |          |
|   |                          | percentages for the        |          |
|   |                          | blended payment            |          |
|   |                          | calculation will be.       |          |
+---+--------------------------+----------------------------+----------+
| N | This decision was based  | This decision was based on | New code |
| 1 | on a local medical       | a local medical review     | 6/26/02, |
| 1 | review policy (LMRP).    | policy (LMRP). An LMRP     | Modified |
| 5 |                          | provides a guide to assist | 9/16/02, |
|   |                          | in determining whether a   | 6/30/03, |
|   |                          | particular item or service | 4/1/04   |
|   |                          | is covered. A copy of this |          |
|   |                          | policy is available        |          |
|   |                          | ath                        |          |
|   |                          | ttp://www.cms.hhs.gov/mcd, |          |
|   |                          | or if you do not have web  |          |
|   |                          | access, you may contact    |          |
|   |                          | the contractor to request  |          |
|   |                          | a copy of the LMRP.        |          |
+---+--------------------------+----------------------------+----------+
| N | Pmt conditional, srvc    | This payment is being made | New code |
| 1 | provided in home,        | conditionally because the  | 6/30/02  |
| 1 | possible pat undr home   | service was provided in    |          |
| 6 | hlth episode care        | the home, and it is        |          |
|   |                          | possible that the patient  |          |
|   |                          | is under a home health     |          |
|   |                          | episode of care. When a    |          |
|   |                          | patient is treated under a |          |
|   |                          | home health episode of     |          |
|   |                          | care, consolidated billing |          |
|   |                          | requires that certain      |          |
|   |                          | therapy services and       |          |
|   |                          | supplies, such as this, be |          |
|   |                          | included in the home       |          |
|   |                          | health agency\'s (HHA\'s)  |          |
|   |                          | payment. This payment will |          |
|   |                          | need to be recouped from   |          |
|   |                          | you if we establish that   |          |
|   |                          | the patient is             |          |
|   |                          | concurrently receiving     |          |
|   |                          | treatment under an HHA     |          |
|   |                          | episode of care.           |          |
+---+--------------------------+----------------------------+----------+
| N | This service is paid     | This service is paid only  | New code |
| 1 | only once in a           | once in a patient\'s       | 7/30/02, |
| 1 | patient\'s lifetime.     | lifetime.                  | Modified |
| 7 |                          |                            | 6/30/03  |
+---+--------------------------+----------------------------+----------+
| N | This service is not paid | This service is not paid   | New code |
| 1 | if billed more than once | if billed more than once   | 7/30/02  |
| 1 | every 28 days.           | every 28 days.             |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Svc not pd if billd once | This service is not paid   | New code |
| 1 | evry 28 days, & pat      | if billed once every 28    | 7/30/02, |
| 1 | 5/more consec days in    | days, and the patient has  | Modified |
| 9 | any inpat/SNF            | spent 5 or more            | 6/30/03  |
|   |                          | consecutive days in any    |          |
|   |                          | inpatient or               |          |
|   |                          | Skilled/nursing Facility   |          |
|   |                          | (SNF) within those 28      |          |
|   |                          | days.                      |          |
+---+--------------------------+----------------------------+----------+
| N | Payment subject home     | Payment is subject to home | New code |
| 1 | health prospective pymt  | health prospective payment | 8/9/02,  |
| 2 | sys partial episode pymt | system partial episode     | Modified |
| 0 | adjustment               | payment adjustment.        | 6/30/03  |
|   |                          | Patient was                |          |
|   |                          | transfe                    |          |
|   |                          | rred/discharged/readmitted |          |
|   |                          | during payment episode.    |          |
+---+--------------------------+----------------------------+----------+
| N | Med B no pay itm/svc     | Medicare Part B does not   | New code |
| 1 | provided by typ prac for | pay for items or services  | 9/9/02,  |
| 2 | beneficiary in a Med A   | provided by this type of   | Modified |
| 1 | (SNF) stay               | practitioner for           | 8/1/04,  |
|   |                          | beneficiaries in a         | 6/30/03  |
|   |                          | Medicare Part A covered    |          |
|   |                          | Skilled Nursing Facility   |          |
|   |                          | (SNF) stay.                |          |
+---+--------------------------+----------------------------+----------+
| [ | [Add-on code cannot be   | [Add-on code cannot be     | [New     |
| N | billed by                | billed by itself.]{.mark}  | code     |
| 1 | itself.]{.mark}          |                            | 9/12/02, |
| 2 |                          |                            | Modified |
| 2 |                          |                            | 8/1/05   |
| ] |                          |                            | ]{.mark} |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | This split service &     | This is a split service    | New code |
| 1 | represents portion of    | and represents a portion   | 9/24/02  |
| 2 | units from originally    | of the units from the      |          |
| 3 | submitted srvc           | originally submitted       |          |
|   |                          | service.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Pmt denied. Info not     | Payment has been denied    | New code |
| 1 | substantiate need for    | for the/made only for a    | 9/26/02  |
| 2 | this more extensive      | less extensive servie/item |          |
| 4 | service/item             | because the information    |          |
|   |                          | furnished does not         |          |
|   |                          | substantiate the need for  |          |
|   |                          | the (more extensive)       |          |
|   |                          | service/item. The patient  |          |
|   |                          | is liable for the charges  |          |
|   |                          | for this service/item as   |          |
|   |                          | you informed the patient   |          |
|   |                          | in writing before the      |          |
|   |                          | service/item was furnished |          |
|   |                          | that we would not pay for  |          |
|   |                          | it, and the patient agreed |          |
|   |                          | to pay.                    |          |
+---+--------------------------+----------------------------+----------+
| [ | [Payment denied,         | [Payment has been (denied  | [New     |
| N | information not          | for the/made only for a    | code     |
| 1 | substantiate need for    | less extensive)            | 9/26/02, |
| 2 | more extensive           | service/item because the   | Modified |
| 5 | service/itm]{.mark}      | information furnished does | 8/1/05   |
| ] |                          | not substantiate the need  | ]{.mark} |
| { |                          | for the (more extensive)   |          |
| . |                          | service/item. If you have  |          |
| m |                          | collected any amount from  |          |
| a |                          | the patient, you must      |          |
| r |                          | refund that amount to the  |          |
| k |                          | patient within 30 days of  |          |
| } |                          | receiving this             |          |
|   |                          | notice.]{.mark}            |          |
|   |                          |                            |          |
|   |                          | [The requirements for a    |          |
|   |                          | refund are in §1834(a)(18) |          |
|   |                          | of the Social Security Act |          |
|   |                          | (and in §§1834(j)(4) and   |          |
|   |                          | 1879(h) by cros-reference  |          |
|   |                          | to §1834(a)(18)). Section  |          |
|   |                          | 1834(a)(18)(B) specifies   |          |
|   |                          | that suppliers which       |          |
|   |                          | knowingly and willfully    |          |
|   |                          | fail to make appropriate   |          |
|   |                          | refunds may be subject to  |          |
|   |                          | civil money penalties      |          |
|   |                          | and/or exclusion from the  |          |
|   |                          | Medicare program. If you   |          |
|   |                          | have any questions about   |          |
|   |                          | this notice, please        |          |
|   |                          | contact this               |          |
|   |                          | office.]{.mark}            |          |
+---+--------------------------+----------------------------+----------+
| N | Social Security Records  | Social Security Records    | New code |
| 1 | indicate that this       | indicate that this         | 10/17/02 |
| 2 | individual has been      | individual has been        |          |
| 6 | deported.                | deported. This payer does  |          |
|   |                          | not cover items and        |          |
|   |                          | services furnished to      |          |
|   |                          | individuals who have been  |          |
|   |                          | deported.                  |          |
+---+--------------------------+----------------------------+----------+
| N | This is misdirected      | This is a misdirected      | New code |
| 1 | claim/service for United | claim/service for a United | 1        |
| 2 | Mine Workers of America  | Mine Workers of America    | 0/31/02, |
| 7 | beneficiary              | beneficiary. Please submit | Modified |
|   |                          | claims to them.            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | This amount represents   | This amount represents the | New code |
| 1 | the prior to coverage    | prior to coverage portion  | 10/31/02 |
| 2 | portion of the           | of the allowance.          |          |
| 8 | allowance.               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | This amount represents   | This amount represents the | New code |
| 1 | the dollar amount not    | dollar amount not eligible | 10/31/02 |
| 2 | eligible due to the      | due to the patient\'s age. |          |
| 9 | patient\'s age.          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Consult plan benefit     | Consult plan benefit       | New code |
| 1 | documents for            | documents for information  | 10/31/02 |
| 3 | information about        | about restrictions for     |          |
| 0 | restrictions this        | this service.              |          |
|   | service.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Total payments under     | Total payments under       | New code |
| 1 | multiple contracts       | multiple contracts cannot  | 10/31/02 |
| 3 | cannot exceed allowance  | exceed the allowance for   |          |
| 1 | for this service         | this service.              |          |
+---+--------------------------+----------------------------+----------+
| N | Pmt will cease for srvcs | Payments will cease for    | New code |
| 1 | this US Gov\'t           | services rendered by this  | 10/31/02 |
| 3 | debarrd/excld prov after | US Government debarred or  |          |
| 2 | 30 day grace per         | excluded provider after    |          |
|   |                          | the 30 day grace period as |          |
|   |                          | previously notified.       |          |
+---+--------------------------+----------------------------+----------+
| N | Services for             | Services for               | New code |
| 1 | predetermination &       | predetermination and       | 10/31/02 |
| 3 | services requesting      | services requesting        |          |
| 3 | payment processed        | payment are being          |          |
|   | separately               | processed separately.      |          |
+---+--------------------------+----------------------------+----------+
| N | Represents scheduled     | This represents your       | New code |
| 1 | pymt for service. If     | scheduled payment for this | 10/31/02 |
| 3 | treatment discont\'d,    | service. If treatment has  |          |
| 4 | contact Cust Srvc        | been discontinued, please  |          |
|   |                          | contact Customer Service.  |          |
+---+--------------------------+----------------------------+----------+
| N | Record fees are          | Record fees are the        | New code |
| 1 | patient\'s               | patient\'s responsibility  | 10/31/02 |
| 3 | responsibility and       | and limited to the         |          |
| 5 | limited to the specified | specified co-payment.      |          |
|   | co-payment               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | To obtain info on        | To obtain information on   | New code |
| 1 | process to file appeal   | the process to file an     | 10/31/02 |
| 3 | in AZ, call Depart\'s    | appeal in Arizona, call    |          |
| 6 | Consumr Assist Off       | the Department\'s Consumer |          |
|   |                          | Assistance Office at (602) |          |
|   |                          | 912-8444 or(800) 325-2548. |          |
+---+--------------------------+----------------------------+----------+
| N | You may file appeal      | The provider acting on the | New code |
| 1 | w/Payer/file complaint   | Member\'s behalf, may file | 1        |
| 3 | w/State Insurance        | an appeal with the Payer.  | 0/31/02, |
| 7 | Regulatory Auth          | The provider, acting on    | Modified |
|   |                          | the Member\'s behalf, may  | 8/1/04,  |
|   |                          | file a complaint with the  | 2/28/03  |
|   |                          | State Insurance Regulatory |          |
|   |                          | Authority without first    |          |
|   |                          | filing an appeal, if the   |          |
|   |                          | coverage decision involves |          |
|   |                          | an urgent condition for    |          |
|   |                          | which care has not been    |          |
|   |                          | rendered. The address may  |          |
|   |                          | be obtained from the State |          |
|   |                          | Insurance Regulatory       |          |
|   |                          | Authority.                 |          |
+---+--------------------------+----------------------------+----------+
| N | If disagree Dentl        | In the event you disagree  | New code |
| 1 | Advisor opinion&add\'l   | with the Dental Advisor\'s | 10/31/02 |
| 3 | info relative, submt     | opinion and have           |          |
| 8 | radiographs 2nd rev      | additional information     |          |
|   |                          | relative to the case, you  |          |
|   |                          | may submit radiographs to  |          |
|   |                          | the Dental Advisor Unit at |          |
|   |                          | the subscriber\'s dental   |          |
|   |                          | insurance carrier for a    |          |
|   |                          | second Independent Dental  |          |
|   |                          | Advisor Review.            |          |
+---+--------------------------+----------------------------+----------+
| N | Code of Fed Reg, Ch 32,  | Under the Code of Federal  | New code |
| 1 | Sect 199.13              | Regulations, Chapter 32,   | 10/31/02 |
| 3 | non-particpat prov not   | Section 199.13             |          |
| 9 | approp appealing prty    | anon-participating         |          |
|   |                          | provider is not an         |          |
|   |                          | appropriate appealing      |          |
|   |                          | party. Therefore, if you   |          |
|   |                          | disagree with the Dental   |          |
|   |                          | Advisor\'s opinion, you    |          |
|   |                          | may appeal the             |          |
|   |                          | determination if appointed |          |
|   |                          | in writing, by the         |          |
|   |                          | beneficiary, to act as     |          |
|   |                          | his/her representative.    |          |
|   |                          | Should you be appointed as |          |
|   |                          | a representative, submit a |          |
|   |                          | copy of this letter, a     |          |
|   |                          | signed statement           |          |
|   |                          | explaining the matter in   |          |
|   |                          | which you disagree, and    |          |
|   |                          | any radiographs and        |          |
|   |                          | relevant information to    |          |
|   |                          | the subscriber\'s Dental   |          |
|   |                          | insurance carrier within   |          |
|   |                          | 90 days from the date of   |          |
|   |                          | this letter.               |          |
+---+--------------------------+----------------------------+----------+
| N | Not authorized OCONUS    | You have not been          | New code |
| 1 | provider, not considered | designated as an           | 10/31/02 |
| 4 | an appropriate appealing | authorized OCONUS provider |          |
| 0 | party.                   | therefore are not          |          |
|   |                          | considered an appropriate  |          |
|   |                          | appealing party. If the    |          |
|   |                          | beneficiary has appointed  |          |
|   |                          | you, in writing, to act as |          |
|   |                          | his/her representative and |          |
|   |                          | you disagree with the      |          |
|   |                          | Dental Advisor\'s opinion, |          |
|   |                          | you may appeal by          |          |
|   |                          | submitting a copy of this  |          |
|   |                          | letter, a signed statement |          |
|   |                          | explaining the matter in   |          |
|   |                          | which you disagree, and    |          |
|   |                          | any relevant information   |          |
|   |                          | to the subscriber\'s       |          |
|   |                          | Dental insurance carrier   |          |
|   |                          | within 90days from the     |          |
|   |                          | date of this letter.       |          |
+---+--------------------------+----------------------------+----------+
| N | Patient not reside       | The patient was not        | New code |
| 1 | long-term care facility  | residing in a long-term    | 10/31/02 |
| 4 | during all/part service  | care facility during all   |          |
| 1 | dates billed             | or part of the service     |          |
|   |                          | dates billed.              |          |
+---+--------------------------+----------------------------+----------+
| N | The original claim was   | The original claim was     | New code |
| 1 | denied. Resubmit a new   | denied. Resubmit a new     | 10/31/02 |
| 4 | claim, not a replacement | claim, not a replacement   |          |
| 2 | claim.                   | claim.                     |          |
+---+--------------------------+----------------------------+----------+
| N | The patient not in       | The patient was not in a   | New code |
| 1 | hospice program during   | hospice program during all | 10/31/02 |
| 4 | all or part of service   | or part of the service     |          |
| 3 | dates billed             | dates billed.              |          |
+---+--------------------------+----------------------------+----------+
| N | The rate changed during  | The rate changed during    | New code |
| 1 | the dates of service     | the dates of service       | 10/31/02 |
| 4 | billed.                  | billed.                    |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 1 | ssing/incomplete/invalid | provider identifier for    | 1        |
| 4 | provider identifier for  | this place of service.     | 0/31/02, |
| 5 | this place of service.   |                            | Dea      |
|   |                          |                            | ctivated |
|   |                          |                            | 6/2/05   |
+---+--------------------------+----------------------------+----------+
| N | Missing screening        | Missing screening          | New code |
| 1 | document.                | document.                  | 1        |
| 4 |                          |                            | 0/31/02, |
| 6 |                          |                            | Modified |
|   |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Long term care case      | Long term care case mix or | New code |
| 1 | mix/per diem rate not    | per diem rate cannot be    | 10/31/02 |
| 4 | determined,pat ID \#     | determined because the     |          |
| 7 | miss/incmplt/invld       | patient ID number is       |          |
|   |                          | missing, incomplete, or    |          |
|   |                          | invalid on the assignment  |          |
|   |                          | request.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 1 | ssing/incomplete/invalid | date of last menstrual     | 10/31/02 |
| 4 | date of last menstrual   | period.                    |          |
| 8 | period.                  |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Rebill all applicable    | Rebill all applicable      | New code |
| 1 | services on a single     | services on a single       | 10/31/02 |
| 4 | claim.                   | claim.                     |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 1 | ssing/incomplete/invalid | model number.              | 10/31/02 |
| 5 | model number.            |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | phone contact services   | Telephone contact services | New code |
| 1 | not paid til             | will not be paid until the | 10/31/02 |
| 5 | face-to-face contact     | face-to-face contact       |          |
| 1 | requirement met          | requirement has been met.  |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 1 | ssing/incomplete/invalid | replacement claim          | 10/31/02 |
| 5 | replacement claim        | information.               |          |
| 2 | information.             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 1 | ssing/incomplete/invalid | room and board rate.       | 10/31/02 |
| 5 | room and board rate.     |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | This payment was delayed | This payment was delayed   | New code |
| 1 | for correction of        | for correction of          | 10/31/02 |
| 5 | provider\'s mailing      | provider\'s mailing        |          |
| 4 | address.                 | address.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Our records not indicate | Our records do not         | New code |
| 1 | oth ins on file. submit  | indicate that other        | 10/31/02 |
| 5 | oth ins info for our     | insurance is on file.      |          |
| 5 | records                  | Please submit other        |          |
|   |                          | insurance information for  |          |
|   |                          | our records.               |          |
+---+--------------------------+----------------------------+----------+
| N | Patient responsible      | The patient is responsible | New code |
| 1 | difference between       | for the difference between | 10/31/02 |
| 5 | approved treatment &     | the approved treatment and |          |
| 6 | elective treatment       | the elective treatment.    |          |
+---+--------------------------+----------------------------+----------+
| N | Transportation to/from   | Transportation to/from     | New code |
| 1 | this destination is not  | this destination is not    | 2/28/03, |
| 5 | covered.                 | covered.                   | Modified |
| 7 |                          |                            | 2/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Transportation in a      | Transportation in a        | New code |
| 1 | vehicle other than an    | vehicle other than an      | 2/28/03  |
| 5 | ambulance is not         | ambulance is not covered.  |          |
| 8 | covered.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Payment denied/reduced,  | Payment denied/reduced     | New code |
| 1 | mileage not covered when | because mileage is not     | 2/28/03  |
| 5 | patient not in the       | covered when the patient   |          |
| 9 | ambulance                | is not in the ambulance.   |          |
+---+--------------------------+----------------------------+----------+
| N | Patient choose option    | The patient must choose an | New code |
| 1 | before pymt made for     | option before a payment    | 2/28/03, |
| 6 | procedure/               | can be made for this       | Modified |
| 0 | equipment/supply/service | procedure                  | 2/1/04   |
|   |                          | /equipment/supply/service. |          |
+---+--------------------------+----------------------------+----------+
| N | This drug/service/supply | This drug/service/supply   | New code |
| 1 | is covered only when the | is covered only when the   | 2/28/03  |
| 6 | associated service is    | associated service is      |          |
| 1 | covered                  | covered.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Alert. Claim paid, but   | This is an alert. Although | New code |
| 1 | billed test/specialty    | your claim was paid, you   | 2/28/03  |
| 6 | not included Lab         | have billed for a          |          |
| 2 | Certification            | test/specialty not         |          |
|   |                          | included in your           |          |
|   |                          | Laboratory Certification.  |          |
|   |                          | Your failure to correct    |          |
|   |                          | the laboratory             |          |
|   |                          | certification information  |          |
|   |                          | wil result in a denial of  |          |
|   |                          | payment in the near        |          |
|   |                          | future.                    |          |
+---+--------------------------+----------------------------+----------+
| N | Medical record does not  | Medical record does not    | New code |
| 1 | support code billed per  | support code billed per    | 2/28/03  |
| 6 | the code definition.     | the code definition.       |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Transportation to/from   | Transportation to/from     | Dea      |
| 1 | this destination is not  | this destination is not    | ctivated |
| 6 | covered.                 | covered.                   | eff.     |
| 4 |                          |                            | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Transportation in a      | Transportation in a        | Dea      |
| 1 | vehicle other than an    | vehicle other than an      | ctivated |
| 6 | ambulance is not         | ambulance is not covered.  | eff.     |
| 5 | covered.                 |                            | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Payment denied/reduced,  | Payment denied/reduced     | Dea      |
| 1 | mileage not covered when | because mileage is not     | ctivated |
| 6 | patient not in the       | covered when the patient   | eff.     |
| 6 | ambulance                | is not in the ambulance.   | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | Charges exceed the       | Charges exceed the         | New code |
| 1 | post-transplant coverage | post-transplant coverage   | 2/28/03  |
| 6 | limit.                   | limit.                     |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Patient choose option    | The patient must choose an | Dea      |
| 1 | before payment for       | option before a payment    | ctivated |
| 6 | procedure/e              | can be made for this       | eff.     |
| 8 | quipment/supply/service. | procedure                  | 1/31/04  |
|   |                          | /equipment/supply/service. |          |
+---+--------------------------+----------------------------+----------+
| N | This drug/service/supply | This drug/service/supply   | Dea      |
| 1 | is covered only when the | is covered only when the   | ctivated |
| 6 | associated service is    | associated service is      | eff.     |
| 9 | covered.                 | covered.                   | 1/31/04  |
+---+--------------------------+----------------------------+----------+
| N | A new/revised/renewed    | A new/revised/renewed      | New code |
| 1 | certificate of medical   | certificate of medical     | 2/28/03  |
| 7 | necessity is needed.     | necessity is needed.       |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Payment for              | Payment for repair or      | New code |
| 1 | repair/replacement is    | replacement is not covered | 2/28/03  |
| 7 | not covered or has       | or has exceeded the        |          |
| 1 | exceeded the purchase    | purchase price.            |          |
|   | price                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Patient not liable       | The patient is not liable  | New code |
| 1 | denied/adjusted charge   | for the denied/adjusted    | 2/28/03  |
| 7 | for receiving any        | charge(s) for receiving    |          |
| 2 | updated service/item     | any updated service/item.  |          |
+---+--------------------------+----------------------------+----------+
| N | No qualifying hospital   | No qualifying hospital     | New code |
| 1 | stay dates were provided | stay dates were provided   | 2/28/03  |
| 7 | for this episode of      | for this episode of care.  |          |
| 3 | care.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Not cvrd                 | This is not a covered      | New code |
| 1 | srvc/proc/equip/bed, pat | service/procedure/         | 2/28/03  |
| 7 | liability limited amts   | equipment/bed, however     |          |
| 4 | in adj under group       | patient liability is       |          |
|   | \"PR\"                   | limited to amounts shown   |          |
|   |                          | in the adjustments under   |          |
|   |                          | group \"PR\".              |          |
+---+--------------------------+----------------------------+----------+
| N | Missing Review           | Missing Review             | New code |
| 1 | Organization Approval.   | Organization Approval.     | 2/28/03, |
| 7 |                          |                            | Modified |
| 5 |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Srvcs provided aboard    | Services provided aboard a | New code |
| 1 | ship cvrd only when      | ship are covered only when | 2/28/03  |
| 7 | United States registry & | the ship is of United      |          |
| 6 | in US waters             | States registry and is in  |          |
|   |                          | United States waters. In   |          |
|   |                          | addition, a doctor         |          |
|   |                          | licensed to practice in    |          |
|   |                          | the United States must     |          |
|   |                          | provide the service.       |          |
+---+--------------------------+----------------------------+----------+
| N | Not sent to patient\'s   | We did not send this claim | New code |
| 1 | other insurer. They      | to patient\'s other        | 2/28/03, |
| 7 | indicated no add\'l      | insurer. They have         | Modified |
| 7 | payment can be made      | indicated no additional    | 6/30/03  |
|   |                          | payment can be made.       |          |
+---+--------------------------+----------------------------+----------+
| N | Missing pre-operative    | Missing pre-operative      | New code |
| 1 | photos or visual field   | photos or visual field     | 2/28/03, |
| 7 | results.                 | results.                   | Modified |
| 8 |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | Add\'l information       | Additional information has | New code |
| 1 | requested from member.   | been requested from the    | 2/28/03  |
| 7 | Charges be reconsidered  | member. The charges will   |          |
| 9 | upon receipt             | be reconsidered upon       |          |
|   |                          | receipt of that            |          |
|   |                          | information.               |          |
+---+--------------------------+----------------------------+----------+
| N | This item/service not    | This item or service does  | New code |
| 1 | meet criteria for the    | not meet the criteria for  | 2/28/03  |
| 8 | category under which it  | the category under which   |          |
| 0 | was billed               | it was billed.             |          |
+---+--------------------------+----------------------------+----------+
| N | Add\'l info req another  | Additional information has | New code |
| 1 | prov involved in care.   | been requested from        | 2/28/03  |
| 8 | Chrgs be reconsidered    | another provider involved  |          |
| 1 | upon receipt             | in the care of this        |          |
|   |                          | member. The charges will   |          |
|   |                          | be reconsidered upon       |          |
|   |                          | receipt of that            |          |
|   |                          | information.               |          |
+---+--------------------------+----------------------------+----------+
| N | This claim/service must  | This claim/service must be | New code |
| 1 | be billed according to   | billed according to the    | 2/28/03  |
| 8 | the schedule for this    | schedule for this plan.    |          |
| 2 | plan.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Predetermination         | This is a predetermination | New code |
| 1 | advisory msg, when       | advisory message, when     | 2/28/03  |
| 8 | service submitted,       | this service is submitted  |          |
| 3 | add\'l documents         | for payment additional     |          |
|   | required                 | documentation as specified |          |
|   |                          | in plan documents will be  |          |
|   |                          | required to process        |          |
|   |                          | benefits.                  |          |
+---+--------------------------+----------------------------+----------+
| N | Rebill technical and     | Rebill technical and       | New code |
| 1 | professional components  | professional components    | 2/28/03  |
| 8 | separately.              | separately.                |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Do not resubmit this     | Do not resubmit this       | New code |
| 1 | claim/service.           | claim/service.             | 2/28/03  |
| 8 |                          |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | NAS required for this    | Non-Availability Statement | New code |
| 1 | service. Contact the     | (NAS) required for this    | 2/28/03  |
| 8 | nearest MTF for          | service. Contact the       |          |
| 6 | assistance.              | nearest Military Treatment |          |
|   |                          | Facility (MTF) for         |          |
|   |                          | assistance.                |          |
+---+--------------------------+----------------------------+----------+
| N | May request review       | You may request a review   | New code |
| 1 | follow receipt notice,   | in writing within the      | 2/28/03  |
| 8 | follow instr             | required time limits       |          |
| 7 | contract/plan benefit    | following receipt of this  |          |
|   | doc                      | notice by following the    |          |
|   |                          | instructions included in   |          |
|   |                          | your contract or plan      |          |
|   |                          | benefit documents.         |          |
+---+--------------------------+----------------------------+----------+
| N | The approved level of    | The approved level of care | New code |
| 1 | care does not match the  | does not match the         | 2/28/03  |
| 8 | procedure code           | procedure code submitted.  |          |
| 8 | submitted.               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Service has been paid as | This service has been paid | New code |
| 1 | a one-time exception to  | as a one-time exception to | 2/28/03  |
| 8 | the plan\'s benefit      | the plan\'s benefit        |          |
| 9 | restrictions             | restrictions.              |          |
+---+--------------------------+----------------------------+----------+
| N | Missing contract         | Missing contract           | New code |
| 1 | indicator.               | indicator.                 | 2/28/03, |
| 9 |                          |                            | Modified |
| 0 |                          |                            | 8/1/04   |
+---+--------------------------+----------------------------+----------+
| N | The provider must update | The provider must update   | New code |
| 1 | insurance information    | insurance information      | 2/28/03  |
| 9 | directly with payer.     | directly with payer.       |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Patient is a             | Patient is a               | New code |
| 1 | Medicaid/Qualified       | Medicaid/Qualified         | 2/28/03  |
| 9 | Medicare Beneficiary.    | Medicare Beneficiary.      |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Specific                 | Specific                   | New code |
| 1 | federal/state/local      | federal/state/local        | 2/28/03  |
| 9 | program may cover        | program may cover this     |          |
| 3 | service through another  | service through another    |          |
|   | payer                    | payer.                     |          |
+---+--------------------------+----------------------------+----------+
| N | Technical component not  | Technical component not    | New code |
| 1 | paid if provider does    | paid if provider does not  | 2/28/03  |
| 9 | not own the equipment    | own the equipment used.    |          |
| 4 | used.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | The technical component  | The technical component    | New code |
| 1 | must be billed           | must be billed separately. | 2/28/03  |
| 9 | separately.              |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Patient eligible to      | Patient eligible to apply  | New code |
| 1 | apply for other coverage | for other coverage which   | 2/28/03  |
| 9 | which may be primary.    | may be primary.            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | The subscriber must      | The subscriber must update | New code |
| 1 | update insurance         | insurance information      | 2/28/03  |
| 9 | information directly     | directly with payer.       |          |
| 7 | with payer.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Rendering provider must  | Rendering provider must be | New code |
| 1 | be affiliated with the   | affiliated with the pay-to | 2/28/03  |
| 9 | pay-to provider.         | provider.                  |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Additional payment       | Additional payment         | New code |
| 1 | approved based on        | approved based on          | 2/28/03  |
| 9 | payer-initiated          | payer-initiated            |          |
| 9 | review/audit.            | review/audit.              |          |
+---+--------------------------+----------------------------+----------+
| N | The professional         | The professional component | New code |
| 2 | component must be billed | must be billed separately. | 2/28/03  |
| 0 | separately.              |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mental hlth fac resp pmt | A mental health facility   | New code |
| 2 | of outside providers of  | is responsible for payment | 2/28/03  |
| 0 | services/supplies to     | of outside providers who   |          |
| 1 | residents                | furnish these              |          |
|   |                          | services/supplies to       |          |
|   |                          | residents.                 |          |
+---+--------------------------+----------------------------+----------+
| N | Additional               | Additional                 | New code |
| 2 | information/explanation  | information/explanation    | 6/30/03  |
| 0 | will be sent separately  | will be sent separately    |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 2 | ssing/incomplete/invalid | anesthesia time/units      | 6/30/03  |
| 0 | anesthesia time/units    |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Srvcs under review       | Services under review for  | New code |
| 2 | possible pre-existing    | possible pre-existing      | 6/30/03  |
| 0 | condition. Send med rec  | condition. Send medical    |          |
| 4 | for prior 12 mo          | records for prior 12       |          |
|   |                          | months                     |          |
+---+--------------------------+----------------------------+----------+
| N | Information provided was | Information provided was   | New code |
| 2 | illegible                | illegible                  | 6/30/03  |
| 0 |                          |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | The supporting           | The supporting             | New code |
| 2 | documentation does not   | documentation does not     | 6/30/03  |
| 0 | match the claim          | match the claim            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 2 | ssing/incomplete/invalid | birth weight               | 6/30/03  |
| 0 | birth weight             |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 2 | ssing/incomplete/invalid | DRG code                   | 6/30/03  |
| 0 | DRG code                 |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/invalid/incomplete | New code |
| 2 | ssing/invalid/incomplete | taxpayer identification    | 6/30/03  |
| 0 | taxpayer identification  | number (TIN)               |          |
| 9 | number (TIN)             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | You may appeal this      | You may appeal this        | New code |
| 2 | decision                 | decision                   | 6/30/03  |
| 1 |                          |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | You may not appeal this  | You may not appeal this    | New code |
| 2 | decision                 | decision                   | 6/30/03  |
| 1 |                          |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Charges processed under  | Charges processed under a  | New code |
| 2 | a Point of Service       | Point of Service benefit   | 6/30/03  |
| 1 | benefit                  |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 2 | ssing/incomplete/invalid | facility/discrete unit     | 4/1/04   |
| 1 | facility/discrete unit   | DRG/DRG exempt status      |          |
| 3 | DRG/DRG exempt status    | information                |          |
|   | info                     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New code |
| 2 | ssing/incomplete/invalid | history of the related     | 4/1/04   |
| 1 | history of the related   | initial surgical           |          |
| 4 | initial surgical         | procedure(s)               |          |
|   | procedure(s)             |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Payer prov supp/sec cov  | A payer providing          | New code |
| 2 | can not req determ from  | supplemental or secondary  | 4/1/04   |
| 1 | prim payer as cond of    | coverage shall not require |          |
| 5 | determ                   | a claims determination for |          |
|   |                          | this service from a        |          |
|   |                          | primary payer as a         |          |
|   |                          | condition of making its    |          |
|   |                          | own claims determination   |          |
+---+--------------------------+----------------------------+----------+
| N | We pay only one site of  | We pay only one site of    | New code |
| 2 | service per provider per | service per provider per   | 8/1/04   |
| 1 | claim                    | claim                      |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | You furnish/svc item as  | You must furnish and       | New code |
| 2 | pat needs. We pay        | service this item for as   | 8/1/04   |
| 1 | mntce/svc for period     | long as the patient        |          |
| 8 | spec in cont/man         | continues to need it. We   |          |
|   |                          | can pay for maintenance    |          |
|   |                          | and/or servicing for the   |          |
|   |                          | time period specified in   |          |
|   |                          | the contract or coverage   |          |
|   |                          | manual.                    |          |
+---+--------------------------+----------------------------+----------+
| N | Payment based on         | Payment based on previous  | New code |
| 2 | previous payer's allowed | payer's allowed amount     | 8/1/04   |
| 1 | amount                   |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | See payer web site/Cust  | See the payer's web site   | New code |
| 2 | Svc dept to obtain       | or contact the payer's     | 8/1/04   |
| 2 | forms/instruction for    | Customer Service           |          |
| 0 | filing dispute           | department to obtain forms |          |
|   |                          | and instructions for       |          |
|   |                          | filing a provider dispute. |          |
+---+--------------------------+----------------------------+----------+
| N | Missing Admitting        | Missing Admitting History  | New code |
| 2 | History and Physical     | and Physical Report        | 8/1/04   |
| 2 | Report                   |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | Admitting History and    | Admitting History and      | 8/1/04   |
| 2 | Physical Report          | Physical Report            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Missing documentation of | Missing documentation of   | New code |
| 2 | benefit to the patient   | benefit to the patient     | 8/1/04   |
| 2 | during initial treatment | during initial treatment   |          |
| 3 | period                   | period.                    |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid doc   | Incomplete/invalid         | New code |
| 2 | of benefit to the        | documentation of benefit   | 8/1/04   |
| 2 | patient during initial   | to the patient during      |          |
| 4 | treatment period         | initial treatment period.  |          |
+---+--------------------------+----------------------------+----------+
| [ | [Incomplete/invalid      | [Incomplete/invalid        | [New     |
| N | document                 | docu                       | code     |
| 2 | ation/orders/notes/summa | mentation/orders/notes/sum | 8/1/04,  |
| 2 | ry/report/chart.]{.mark} | mary/report/chart.]{.mark} | Modified |
| 5 |                          |                            | 8/1/05   |
| ] |                          |                            | ]{.mark} |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | American Diabetes        | American Diabetes          | 8/1/04   |
| 2 | Association Certificate  | Association Certificate of |          |
| 6 | of Recognition.          | Recognition.               |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | Certificate of Medical   | Certificate of Medical     | 8/1/04   |
| 2 | Necessity.               | Necessity.                 |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid consent | New code |
| 2 | consent form.            | form.                      | 8/1/04   |
| 2 |                          |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | contract indicator       | contract indicator.        | 8/1/04   |
| 2 |                          |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid ind   | Incomplete/invalid         | New code |
| 2 | whether patient owns     | indication of whether the  | 8/1/04   |
| 3 | equip that requires the  | patient owns the equipment |          |
| 0 | part/supply              | that requires the part or  |          |
|   |                          | supply.                    |          |
+---+--------------------------+----------------------------+----------+
| N | Incomp/inv invoice/state | Incomplete/invalid invoice | New code |
| 2 | cert cost of lens less   | or statement certifying    | 8/1/04   |
| 3 | disc and/or type intra   | the actual cost of the     |          |
| 1 | lens used                | lens, less discounts,      |          |
|   |                          | and/or the type of         |          |
|   |                          | intraocular lens used.     |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | itemized bill            | itemized bill.             | 8/1/04   |
| 3 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | operative report         | operative report.          | 8/1/04   |
| 3 |                          |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid oxygen  | New code |
| 2 | oxygen                   | cert                       | 8/1/04   |
| 3 | certi                    | ification/recertification. |          |
| 4 | fication/recertification |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | pacemaker registration   | pacemaker registration     | 8/1/04   |
| 3 | form                     | form.                      |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | pathology report.        | pathology report.          | 8/1/04   |
| 3 |                          |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid patient | New code |
| 2 | patient medical record   | medical record for this    | 8/1/04   |
| 3 | for this service         | service.                   |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | physician certified plan | physician certified plan   | 8/1/04   |
| 3 | of care                  | of care.                   |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | physician financial      | physician financial        | 8/1/04   |
| 3 | relationship form        | relationship form.         |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | radiology report         | radiology report.          | 8/1/04   |
| 4 |                          |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid Review  | New code |
| 2 | Review Organization      | Organization Approval.     | 8/1/04   |
| 4 | Approval                 |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid x-ray | Incomplete/invalid x-ray.  | New code |
| 2 |                          |                            | 8/1/04   |
| 4 |                          |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid/not   | Incomplete/invalid/not     | New code |
| 2 | approved screening       | approved screening         | 8/1/04   |
| 4 | document                 | document.                  |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid       | Incomplete/invalid         | New code |
| 2 | pre-operative            | pre-operative              | 8/1/04   |
| 4 | photos/visual field      | photos/visual field        |          |
| 4 | results                  | results.                   |          |
+---+--------------------------+----------------------------+----------+
| N | Incomplete/invalid plan  | Incomplete/invalid plan    | New code |
| 2 | information for other    | information for other      | 8/1/04   |
| 4 | insurance                | insurance                  |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | State regulated patient  | State regulated patient    | New Code |
| 2 | payment limitations      | payment limitations apply  | 12/2/04  |
| 4 | apply to this service.   | to this service.           |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | assistant surgeon          | 12/2/04  |
| 4 | assistant surgeon        | taxonomy.                  |          |
| 7 | taxonomy.                |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | assistant surgeon name.    | 12/2/04  |
| 4 | assistant surgeon name.  |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | assistant surgeon primary  | 12/2/04  |
| 4 | assistant surgeon        | identifier.                |          |
| 9 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | assistant surgeon          | 12/2/04  |
| 5 | assistant surgeon        | secondary identifier.      |          |
| 0 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | attending provider         | 12/2/04  |
| 5 | attending provider       | taxonomy.                  |          |
| 1 | taxonomy.                |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | attending provider name.   | 12/2/04  |
| 5 | attending provider name. |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | attending provider primary | 12/2/04  |
| 5 | attending provider       | identifier.                |          |
| 3 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | attending provider         | 12/2/04  |
| 5 | attending provider       | secondary identifier.      |          |
| 4 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider taxonomy. | 12/2/04  |
| 5 | billing provider         |                            |          |
| 5 | taxonomy.                |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider/supplier  | 12/2/04  |
| 5 | billing                  | name.                      |          |
| 6 | provider/supplier name.  |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider/supplier  | 12/2/04  |
| 5 | billing                  | primary identifier.        |          |
| 7 | provider/supplier        |                            |          |
|   | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider/supplier  | 12/2/04  |
| 5 | billing                  | address.                   |          |
| 8 | provider/supplier        |                            |          |
|   | address.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider/supplier  | 12/2/04  |
| 5 | billing                  | secondary identifier.      |          |
| 9 | provider/supplier        |                            |          |
|   | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | billing provider/supplier  | 12/2/04  |
| 6 | billing                  | contact information.       |          |
| 0 | provider/supplier        |                            |          |
|   | contact information.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | operating provider name.   | 12/2/04  |
| 6 | operating provider name. |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | operating provider primary | 12/2/04  |
| 6 | operating provider       | identifier.                |          |
| 2 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | operating provider         | 12/2/04  |
| 6 | operating provider       | secondary identifier.      |          |
| 3 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | ordering provider name.    | 12/2/04  |
| 6 | ordering provider name.  |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | ordering provider primary  | 12/2/04  |
| 6 | ordering provider        | identifier.                |          |
| 5 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | ordering provider address. | 12/2/04  |
| 6 | ordering provider        |                            |          |
| 6 | address.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | ordering provider          | 12/2/04  |
| 6 | ordering provider        | secondary identifier.      |          |
| 7 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | ordering provider contact  | 12/2/04  |
| 6 | ordering provider        | information.               |          |
| 8 | contact information.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other provider name.       | 12/2/04  |
| 6 | other provider name.     |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other provider primary     | 12/2/04  |
| 7 | other provider primary   | identifier.                |          |
| 0 | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other provider secondary   | 12/2/04  |
| 7 | other provider secondary | identifier.                |          |
| 1 | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer attending      | 12/2/04  |
| 7 | other payer attending    | provider identifier.       |          |
| 2 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer operating      | 12/2/04  |
| 7 | other payer operating    | provider identifier.       |          |
| 3 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer other provider | 12/2/04  |
| 7 | other payer other        | identifier.                |          |
| 4 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer purchased      | 12/2/04  |
| 7 | other payer purchased    | service provider           |          |
| 5 | service provider         | identifier.                |          |
|   | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer referring      | 12/2/04  |
| 7 | other payer referring    | provider identifier.       |          |
| 6 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer rendering      | 12/2/04  |
| 7 | other payer rendering    | provider identifier.       |          |
| 7 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | other payer service        | 12/2/04  |
| 7 | other payer service      | facility provider          |          |
| 8 | facility provider        | identifier.                |          |
|   | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | pay-to provider name.      | 12/2/04  |
| 7 | pay-to provider name.    |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | pay-to provider primary    | 12/2/04  |
| 8 | pay-to provider primary  | identifier.                |          |
| 0 | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | pay-to provider address.   | 12/2/04  |
| 8 | pay-to provider address. |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | pay-to provider secondary  | 12/2/04  |
| 8 | pay-to provider          | identifier.                |          |
| 2 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | purchased service provider | 12/2/04  |
| 8 | purchased service        | identifier.                |          |
| 3 | provider identifier.     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | referring provider         | 12/2/04  |
| 8 | referring provider       | taxonomy.                  |          |
| 4 | taxonomy.                |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | referring provider name.   | 12/2/04  |
| 8 | referring provider name. |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | referring provider primary | 12/2/04  |
| 8 | referring provider       | identifier.                |          |
| 6 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | referring provider         | 12/2/04  |
| 8 | referring provider       | secondary identifier.      |          |
| 7 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | rendering provider         | 12/2/04  |
| 8 | rendering provider       | taxonomy.                  |          |
| 8 | taxonomy.                |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | rendering provider name.   | 12/2/04  |
| 8 | rendering provider name. |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | rendering provider primary | 12/2/04  |
| 9 | rendering provider       | identifier.                |          |
| 0 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | rendering provider         | 12/2/04  |
| 9 | rendering provider       | secondary identifier.      |          |
| 1 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | service facility name.     | 12/2/04  |
| 9 | service facility name.   |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | service facility primary   | 12/2/04  |
| 9 | service facility primary | identifier.                |          |
| 3 | identifier.              |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | service facility primary   | 12/2/04  |
| 9 | service facility primary | address.                   |          |
| 4 | address.                 |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | service facility secondary | 12/2/04  |
| 9 | service facility         | identifier.                |          |
| 5 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | supervising provider name. | 12/2/04  |
| 9 | supervising provider     |                            |          |
| 6 | name.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | supervising provider       | 12/2/04  |
| 9 | supervising provider     | primary identifier.        |          |
| 7 | primary identifier.      |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | supervising provider       | 12/2/04  |
| 9 | supervising provider     | secondary identifier.      |          |
| 8 | secondary identifier.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 2 | ssing/incomplete/invalid | occurrence date(s).        | 12/2/04  |
| 9 | occurrence date(s).      |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | occurrence span date(s).   | 12/2/04  |
| 0 | occurrence span date     |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | procedure date(s).         | 12/2/04  |
| 0 | procedure date(s).       |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | other procedure date(s).   | 12/2/04  |
| 0 | other procedure date(s). |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | principal procedure date.  | 12/2/04  |
| 0 | principal procedure      |                            |          |
| 3 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | dispensed date.            | 12/2/04  |
| 0 | dispensed date.          |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | accident date.             | 12/2/04  |
| 0 | accident date.           |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | acute manifestation date.  | 12/2/04  |
| 0 | acute manifestation      |                            |          |
| 6 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | adjudication or payment    | 12/2/04  |
| 0 | adjudication or payment  | date.                      |          |
| 7 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | appliance placement date.  | 12/2/04  |
| 0 | appliance placement      |                            |          |
| 8 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | assessment date.           | 12/2/04  |
| 0 | assessment date.         |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | assumed or relinquished    | 12/2/04  |
| 1 | assumed or relinquished  | care date.                 |          |
| 0 | care date.               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | authorized to return to    | 12/2/04  |
| 1 | authorized to return to  | work date.                 |          |
| 1 | work date.               |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | begin therapy date.        | 12/2/04  |
| 1 | begin therapy date.      |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | certification revision     | 12/2/04  |
| 1 | certification revision   | date.                      |          |
| 3 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | diagnosis date.            | 12/2/04  |
| 1 | diagnosis date.          |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | disability from date.      | 12/2/04  |
| 1 | disability from date.    |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | disability to date.        | 12/2/04  |
| 1 | disability to date.      |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | discharge hour.            | 12/2/04  |
| 1 | discharge hour.          |                            |          |
| 7 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | discharge or end of care   | 12/2/04  |
| 1 | discharge or end of care | date.                      |          |
| 8 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | hearing or vision          | 12/2/04  |
| 1 | hearing or vision        | prescription date.         |          |
| 9 | prescription date.       |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | Home Health Certification  | 12/2/04  |
| 2 | Home Health              | Period.                    |          |
| 0 | Certification Period.    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last admission period.     | 12/2/04  |
| 2 | last admission period.   |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last certification date.   | 12/2/04  |
| 2 | last certification date. |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last contact date.         | 12/2/04  |
| 2 | last contact date.       |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last seen/visit date.      | 12/2/04  |
| 2 | last seen/visit date.    |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last worked date.          | 12/2/04  |
| 2 | last worked date.        |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | last x-ray date.           | 12/2/04  |
| 2 | last x-ray date.         |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | other insured birth date.  | 12/2/04  |
| 2 | other insured birth      |                            |          |
| 7 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | Oxygen Saturation Test     | 12/2/04  |
| 2 | Oxygen Saturation Test   | date.                      |          |
| 8 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | patient birth date.        | 12/2/04  |
| 2 | patient birth date.      |                            |          |
| 9 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | patient death date.        | 12/2/04  |
| 3 | patient death date.      |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | physician order date.      | 12/2/04  |
| 3 | physician order date.    |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | prior hospital discharge   | 12/2/04  |
| 3 | prior hospital discharge | date.                      |          |
| 2 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | prior placement date.      | 12/2/04  |
| 3 | prior placement date.    |                            |          |
| 3 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | re-evaluation date.        | 12/2/04  |
| 3 | re-evaluation date.      |                            |          |
| 4 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | referral date.             | 12/2/04  |
| 3 | referral date.           |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | replacement date.          | 12/2/04  |
| 3 | replacement date.        |                            |          |
| 6 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | secondary diagnosis date.  | 12/2/04  |
| 3 | secondary diagnosis      |                            |          |
| 7 | date.                    |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | shipped date.              | 12/2/04  |
| 3 | shipped date.            |                            |          |
| 8 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | similar illness or symptom | 12/2/04  |
| 3 | similar illness or       | date.                      |          |
| 9 | symptom date.            |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | subscriber birth date.     | 12/2/04  |
| 4 | subscriber birth date.   |                            |          |
| 0 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | surgery date.              | 12/2/04  |
| 4 | surgery date.            |                            |          |
| 1 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | test performed date.       | 12/2/04  |
| 4 | test performed date.     |                            |          |
| 2 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Miss/incomp/invalid      | Missing/incomplete/invalid | New Code |
| 3 | Transcutaneous Electric  | Transcutaneous Electrical  | 12/2/04  |
| 4 | Nerve Stim (TENS) trial  | Nerve Stimulator (TENS)    |          |
| 3 | start date.              | trial start date.          |          |
+---+--------------------------+----------------------------+----------+
| N | Miss/incomp/invalid      | Missing/incomplete/invalid | New Code |
| 3 | Transcutaneous Electric  | Transcutaneous Electrical  | 12/2/04  |
| 4 | Nerve Stim (TENS) trial  | Nerve Stimulator (TENS)    |          |
| 4 | end date.                | trial end date.            |          |
+---+--------------------------+----------------------------+----------+
| N | Date range not valid     | Date range not valid with  | New Code |
| 3 | with units submitted.    | units submitted.           | 3/30/05  |
| 4 |                          |                            |          |
| 5 |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Mi                       | Missing/incomplete/invalid | New Code |
| 3 | ssing/incomplete/invalid | oral cavity designation    | 3/30/05  |
| 4 | oral cavity designation  | code                       |          |
| 6 | code                     |                            |          |
+---+--------------------------+----------------------------+----------+
| N | Claim for                | Your claim for a referred  | New Code |
| 3 | referred/purchased srv   | or purchased service       | 3/30/05  |
| 4 | cannot be paid payment   | cannot be paid because     |          |
| 7 | already made for same    | payment has already been   |          |
|   | service to another       | made for this same service |          |
|   | provider by pay          | to another provider by a   |          |
|   | contractor               | payment contractor         |          |
|   |                          | representing the payer     |          |
+---+--------------------------+----------------------------+----------+
| [ | [You chose that this     | [You chose that this       | [New     |
| N | serv/sup/drug be         | service/supply/drug would  | Code     |
| 3 | rend/supp & billed       | be rendered/supplied and   | 8/1/05   |
| 4 | different                | billed by a different      | ]{.mark} |
| 8 | prac/supplier]{.mark}    | prac                       |          |
| ] |                          | titioner/supplier.]{.mark} |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [The administration      | [The administration method | [New     |
| N | method and drug must be  | and drug must be reported  | Code     |
| 3 | reported to adjudicate   | to adjudicate this         | 8/1/05   |
| 4 | this service.]{.mark}    | service.]{.mark}           | ]{.mark} |
| 9 |                          |                            |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Missing/incomp/invalid  | [                          | [New     |
| N | description of service   | Missing/incomplete/invalid | Code     |
| 3 | for a (NOC) code or      | description of service for | 8/1/05   |
| 5 | Unlisted proc]{.mark}    | a Not Otherwise Classified | ]{.mark} |
| 0 |                          | (NOC) code or an Unlisted  |          |
| ] |                          | procedure.]{.mark}         |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Service date outside of | [Service date outside of   | [New     |
| N | the approved treatment   | the approved treatment     | Code     |
| 3 | plan service             | plan service               | 8/1/05   |
| 5 | dates.]{.mark}           | dates.]{.mark}             | ]{.mark} |
| 1 |                          |                            |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [No scheduled payments   | [There are no scheduled    | [New     |
| N | for this service. Submit | payments for this service. | Code     |
| 3 | a claim for each patient | Submit a claim for each    | 8/1/05   |
| 5 | visit]{.mark}            | patient visit.]{.mark}     | ]{.mark} |
| 2 |                          |                            |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Ben estimated when      | [Benefits have been        | [New     |
| N | services have been       | estimated, when the actual | Code     |
| 3 | rendered add pay         | services have been         | 8/1/05   |
| 5 | considered based on      | rendered, additional       | ]{.mark} |
| 3 | claim]{.mark}            | payment will be considered |          |
| ] |                          | based on the submitted     |          |
| { |                          | claim.]{.mark}             |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Incomplete/invalid      | [Incomplete/invalid        | [New     |
| N | invoice.]{.mark}         | invoice.]{.mark}           | Code     |
| 3 |                          |                            | 8/1/05   |
| 5 |                          |                            | ]{.mark} |
| 4 |                          |                            |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+
| [ | [Request appeal in 30    | [The law permits           | [New     |
| N | days delay refund until  | exceptions to the refund   | Code     |
| 3 | review]{.mark}           | requirements in two        | 8/1/05   |
| 5 |                          | cases: - If you did not    | ]{.mark} |
| 5 |                          | know, and could not have   |          |
| ] |                          | reasonably been expected   |          |
| { |                          | to know, that you would    |          |
| . |                          | not pay for this service;  |          |
| m |                          | or -- If you notified the  |          |
| a |                          | patient in writing before  |          |
| r |                          | providing the service that |          |
| k |                          | you believed that we were  |          |
| } |                          | likely to deny the         |          |
|   |                          | service, and the patient   |          |
|   |                          | signed a statement         |          |
|   |                          | agreeing to pay for the    |          |
|   |                          | service.]{.mark}           |          |
|   |                          |                            |          |
|   |                          | [If you come within either |          |
|   |                          | exception, or if you       |          |
|   |                          | believe the carrier was    |          |
|   |                          | wrong in its determination |          |
|   |                          | that we do not pay for     |          |
|   |                          | this service, you should   |          |
|   |                          | request review of this     |          |
|   |                          | determination within 30    |          |
|   |                          | days of the date of this   |          |
|   |                          | notice. Your request for   |          |
|   |                          | review should include any  |          |
|   |                          | additional information     |          |
|   |                          | necessary to support your  |          |
|   |                          | position.]{.mark}          |          |
|   |                          |                            |          |
|   |                          | [If you request an appeal  |          |
|   |                          | within 30 days of          |          |
|   |                          | receiving this notice, you |          |
|   |                          | may delay refunding the    |          |
|   |                          | amount to the patient      |          |
|   |                          | until you receive the      |          |
|   |                          | results of the review. If  |          |
|   |                          | the review decision is     |          |
|   |                          | favorable to you, you do   |          |
|   |                          | not need to make any       |          |
|   |                          | refund. If, however, the   |          |
|   |                          | review is unfavorable, the |          |
|   |                          | law specified that you     |          |
|   |                          | must make the refund       |          |
|   |                          | within 15 days of          |          |
|   |                          | receiving the unfavorable  |          |
|   |                          | review decision.]{.mark}   |          |
|   |                          |                            |          |
|   |                          | [The law also permits you  |          |
|   |                          | to request an appeal at    |          |
|   |                          | any time within 120 days   |          |
|   |                          | of the date you receive    |          |
|   |                          | this notice. However, an   |          |
|   |                          | appeal request that is     |          |
|   |                          | received more than 30 days |          |
|   |                          | after the date of this     |          |
|   |                          | notice, does not permit    |          |
|   |                          | you to delay making the    |          |
|   |                          | refund. Regardless of when |          |
|   |                          | a review is requested, the |          |
|   |                          | patient will be notified   |          |
|   |                          | that you have requested    |          |
|   |                          | one, and will receive a    |          |
|   |                          | copy of the                |          |
|   |                          | determination.]{.mark}     |          |
|   |                          |                            |          |
|   |                          | [The patient has received  |          |
|   |                          | a separate notice of the   |          |
|   |                          | denial decision. The       |          |
|   |                          | notice advises that he/she |          |
|   |                          | may be entitled to a       |          |
|   |                          | refund of any amounts      |          |
|   |                          | paid, if you should have   |          |
|   |                          | known the we would not pay |          |
|   |                          | and did not tell him/her.  |          |
|   |                          | It also instructs the      |          |
|   |                          | patient to contact our     |          |
|   |                          | office if she/she does not |          |
|   |                          | hear anything about a      |          |
|   |                          | refund within 30           |          |
|   |                          | days.]{.mark}              |          |
|   |                          |                            |          |
|   |                          | []{.mark}                  |          |
|   |                          |                            |          |
|   |                          | []{.mark}                  |          |
+---+--------------------------+----------------------------+----------+
| [ | [Service not covered     | [This service is not       | [New     |
| N | when performed with or   | covered when performed     | Code     |
| 3 | subsequent to a          | with, or subsequent to, a  | 8/1/05   |
| 5 | non-covered              | non-covered                | ]{.mark} |
| 6 | service]{.mark}          | service.]{.mark}           |          |
| ] |                          |                            |          |
| { |                          |                            |          |
| . |                          |                            |          |
| m |                          |                            |          |
| a |                          |                            |          |
| r |                          |                            |          |
| k |                          |                            |          |
| } |                          |                            |          |
+---+--------------------------+----------------------------+----------+