Medicaid denial reason code list

Medicaid Claim Denial Codes

1  Deductible Amount
2  Coinsurance Amount
3  Co-payment Amount
4  The procedure code is inconsistent with the modifier used or a required modifier is missing.
5  The procedure code/bill type is inconsistent with the place of service.
6  The procedure/revenue code is inconsistent with the patient's age.
7  The procedure/revenue code is inconsistent with the patient's gender.
8  The procedure code is inconsistent with the provider type/specialty (taxonomy).
9  The diagnosis is inconsistent with the patient's age.
10  The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, or
does not apply to the billed services or provider.
 16 Claim/service lacks information which is needed for adjudication. Additional
information is supplied using remittance advice remarks codes whenever appropriate
Note: Changed as of 2/02
17 Payment adjusted because requested information was not provided or was
insufficient/incomplete. Additional information is supplied using the remittance advice
remarks codes whenever appropriate.
Note: Changed as of 2/02
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the
Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per
coordination of benefits.

23 Payment adjusted due to the impact of prior payer(s) adjudication including payments
and/or adjustments
24 Payment for charges adjusted. Charges are covered under a capitation
agreement/managed care plan.
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility, spend
down, waiting, or residency requirements.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
Note: Changed as of 10/02
36 Balance does not exceed co-payment amount.
Note: Inactive for 003040
37 Balance does not exceed deductible.
Note: Inactive for 003040
38 Services not provided or authorized by designated (network/primary care) providers.
Note: Changed as of 6/03
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.
48 This (these) procedure(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
49 These are non-covered services because this is a routine exam or screening procedure
done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a `medical necessity' by
the payer.
51 These are non-covered services because this is a pre-existing condition
52 The referring/prescribing/rendering provider is not eligible to
refer/prescribe/order/perform the service billed.
Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.
53 Services by an immediate relative or a member of the same household are not
covered.
54 Multiple physicians/assistants are not covered in this case .
55 Claim/service denied because procedure/treatment is deemed
experimental/investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer.
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.
Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
58 Payment adjusted because treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service.
Note: Changed as of 2/01
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Note: Changed as of 6/00
60 Charges for outpatient services with this proximity to inpatient services are not
covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
Note: Changed as of 6/00
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Note: Changed as of 2/01
63 Correction to a prior claim.
Note: Inactive for 003040
64 Denial reversed per Medical Review.
Note: Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood Deductible.
67 Lifetime reserve days. (Handled in QTY, QTY01=LA)
Note: Inactive for 003040
68 DRG weight. (Handled in CLP12)
Note: Inactive for 003040
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs.
Note: Changed as of 6/01
71 Primary Payer amount.
Note: Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD)
Note: Inactive for 003040
73 Administrative days.
Note: Inactive for 003050
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days. (Handled in QTY, QTY01=CA)
Note: Inactive for 003040
78 Non-Covered days/Room charge adjustment.
79 Cost Report days. (Handled in MIA15)
Note: Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU)
Note: Inactive for 003050
81 Discharges.
Note: Inactive for 003040
82 PIP days.
Note: Inactive for 003040
83 Total visits.
Note: Inactive for 003040
84 Capital Adjustment. (Handled in MIA)
Note: Inactive for 003050
85 Interest amount.
86 Statutory Adjustment.
Note: Inactive for 004010, since 6/98. Duplicative of code 45.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior
overpayment.
Note: Inactive for 004050.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim Paid in full.
Note: Inactive for 003040
93 No Claim level Adjustments.
Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
Note: Changed as of 6/00
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.
Note: Changed as of 2/99
98 The hospital must file the Medicare claim for this inpatient non-physician service.
Note: Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount.
Note: Inactive for 003040
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim
adjudication.
Note: Changed as of 2/99
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
Note: Changed as of 6/01
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not
previously paid or identified on this claim.
Note: Changed as of 6/03
108 Payment adjusted because rent/purchase guidelines were not met.
Note: Changed as of 6/02
109 Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
Note: Changed as of 2/01
113 Payment denied because service/procedure was provided outside the United States or
as a result of war.
Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.
Note: Changed as of 2/01
116 Payment denied. The advance indemnification notice signed by the patient did not
comply with requirements.
Note: Changed as of 2/01
117 Payment adjusted because transportation is only covered to the closest facility that
can provide the necessary care.
Note: Changed as of 2/01
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
Note: Changed as of 2/04
120 Patient is covered by a managed care plan.
Note: Inactive for 004030, since 6/99. Use code 24.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
124 Payer refund amount - not our patient.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
125 Payment adjusted due to a submission/billing error(s). Additional information is
supplied using the remittance advice remarks codes whenever appropriate.
Note: Changed as of 2/02
126 Deductible -- Major Medical
Note: New as of 2/97
127 Coinsurance -- Major Medical
Note: New as of 2/97
128 Newborn's services are covered in the mother's Allowance.
Note: New as of 2/97

Posted in: Medicaid denial