Source: https://nex12.org/index.php/claim-adjustment-reason-codes
Timestamp: 2020-07-02 18:34:32
Document Index: 279309161

Matched Legal Cases: ['art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 02', 'art: 06', 'art: 06', 'art: 06', 'art: 09', 'art: 02', 'art: 10', 'art: 06', 'art: 10', 'art: 06', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 09', 'art: 06', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 01', 'art: 11', 'art: 02', 'art: 10', 'art: 09']

X12 External Code Source 139
These codes describe why a claim or service line was paid differently than it was billed.
About Claim Adjustment Group Codes
Did you receive a code from a health plan, such as: PR32? The "PR" is a Claim Adjustment Group Code and the description for "32" is below. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and explanations are below:
CO Contractual Obligation
CR Corrections and Reversal
Note: This value is not to be used with 005010 and up.
PI Payer Initiated Reductions
4 The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2020
15 The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 11/01/2017 | Stop: 05/01/2018
17 Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/2009
Start: 01/01/1995 | Stop: 04/01/2008
Notes: Redundant to codes 26&27.
30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
Start: 01/01/1995 | Last Modified: 06/02/2013 | Stop: 01/01/2013
Notes: CARC codes 242 and 243 are replacements for this deactivated code
42 Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007
Start: 01/01/1995 | Stop: 07/01/2006
Notes: Use code 96.
52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
Notes: Split into codes 150, 151, 152, 153 and 154.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.
Notes: Duplicative of code 45.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012
88 Adjustment amount represents collection against receivable created in prior overpayment.
Notes: As of 004010, CAS at the claim level is optional.
113 Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.
Notes: Use code 24.
Notes: Refer to implementation guide for proper handling of reversals.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
125 Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.
Notes: Use Group Code PR and code 2.
138 Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 11/01/2017 | Stop: 05/01/2018
141 Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
156 Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
Start: 02/29/2004 | Stop: 07/01/2014
Notes: Use code P1
165 Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 11/01/2017 | Stop: 05/01/2018
168 Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 11/01/2017 | Stop: 05/01/2018
191 Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)
Start: 10/31/2005 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P2
196 Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.
214 Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P4
217 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P5
218 Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Notes: Use code P6
220 The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)
Notes: Use code P7
221 Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)
Start: 01/27/2008 | Last Modified: 07/01/2013 | Stop: 07/01/2014
Notes: Use code P8
230 No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009 | Stop: 07/01/2014
Notes: Use code P9
244 Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P10
255 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P11
297 Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.
298 Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.
299 The billing provider is not eligible to receive payment for the service billed.
300 Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.
301 Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Start: 01/01/1995 | Stop: 07/01/2015
B5 Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 11/01/2015 | Stop: 05/01/2016
Notes: This code has been replaced by 272 and 273.
B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
B18 This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009
B21 The charges were reduced because the service/care was partially furnished by another physician.
Notes: Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
Notes: Use code 17.
Notes: Use code 16 with appropriate claim payment remark code [N4].
D22 Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
Start: 01/27/2008 | Stop: 01/01/2009
D23 This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2009 | Stop: 01/01/2012
W1 Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.
Start: 02/29/2000 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P12
W2 Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 10/17/2010 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P13
W3 The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
Notes: Use code P14
W4 Workers' Compensation Medical Treatment Guideline Adjustment.
Notes: Use code P15
W5 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)
Notes: Use code P16
W6 Referral not authorized by attending physician per regulatory requirement.
Notes: Use code P17
W7 Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
Notes: Use code P18
W8 Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
Notes: Use code P19
W9 Service not paid under jurisdiction allowed outpatient facility fee schedule.
Notes: Use code P20
Y1 Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P21
Y2 Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Notes: Use code P22
Y3 Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Notes: Use code P23