N1 to N100 denial code appreviations

Medicaid Claim Denial Codes 

N1 - N50 


N1 You may appeal this decision in writing within the required time limits following receipt
of this notice by following the instructions included in your contract or plan benefit
documents.
Note: (Modified 2/28/03)
N2 This allowance has been made in accordance with the most appropriate course of
treatment provision of the plan.
N3 Missing consent form.
Note: (Modified 2/28/03) Related to N228
N4 Missing/incomplete/invalid prior insurance carrier EOB.
Note: (Modified 2/28/03)
N5 EOB received from previous payer. Claim not on file.
N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the
amount Medicare would have allowed if the patient were enrolled in Medicare Part A
and/or Medicare Part B.
Note: (Modified 2/28/03)
N7 Processing of this claim/service has included consideration under Major Medical provisions.
N8 Crossover claim denied by previous payer and complete claim data not forwarded.
Resubmit this claim to this payer to provide adequate data for adjudication.
N9 Adjustment represents the estimated amount the primary payer may have paid.
N10 Claim/service adjusted based on the findings of a review organization/professional
consult/manual adjudication/medical or dental advisor.
Note: (Modified 10/31/02)
N11 Denial reversed because of medical review.
N12 Policy provides coverage supplemental to Medicare. As member does not appear 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.
N13 Payment based on professional/technical component modifier(s).
N14 Payment based on a contractual amount or agreement, fee schedule, or maximum
allowable amount.
N15 Services for a newborn must be billed separately.
N16 Family/member Out-of-Pocket maximum has been met. Payment based on a higher
percentage.
N17 Per admission deductible.
Note: (Deactivated eff. 8/1/04) Consider using Reason Code 1
N18 Payment based on the Medicare allowed amount.
Note: (Deactivated eff. 1/31/2004) Consider using N14
N19 Procedure code incidental to primary procedure.
N20 Service not payable with other service rendered on the same date.
N21 Your line item has been separated into multiple lines to expedite handling.
Note: (Modified 8/1/05)
N22 This procedure code was added/changed because it more accurately describes the
services rendered.
Note: (Modified 10/31/02, 2/28/03)
N23 Patient liability may be affected due to coordination of benefits with other carriers
and/or maximum benefit provisions.
Note: (Modified 8/13/01)
N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
Note: (Modified 2/28/03)
N25 This company has been contracted by your benefit plan to provide 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.
N26 Missing itemized bill.
Note: (Modified 2/28/03) Related to N232
N27 Missing/incomplete/invalid treatment number.
Note: (Modified 2/28/03)
N28 Consent form requirements not fulfilled.
N29 Missing documentation/orders/notes/summary/report/chart.
Note: (Modified 2/28/03, 8/1/05) Related to N225
N30 Patient ineligible for this service.
Note: (Modified 6/30/03)
N31 Missing/incomplete/invalid prescribing provider identifier.
Note: (Modified 12/2/04)
N32 Claim must be submitted by the provider who rendered the service.
Note: (Modified 6/30/03)
N33 No record of health check prior to initiation of treatment.
N34 Incorrect claim form for this service.
N35 Program integrity/utilization review decision.
N36 Claim must meet primary payer’s processing requirements before we can consider
payment.
N37 Missing/incomplete/invalid tooth number/letter.
Note: (Modified 2/28/03)
N38 Missing/incomplete/invalid place of service.
Note: (Deactivated eff. 2/5/05) Consider using M77
N39 Procedure code is not compatible with tooth number/letter.
N40 Missing x-ray.
Note: (Modified 2/1/04) Related to N242
N41 Authorization request denied.
Note: (Deactivated eff. 10/16/03) Consider using Reason Code 39
N42 No record of mental health assessment.
N43 Bed hold or leave days exceeded.
N44 Payer’s share of regulatory surcharges, assessments, allowances or health care-related
taxes paid directly to the regulatory authority.
Note: (Deactivated eff. 10/16/03) Consider using Reason Code 137
N45 Payment based on authorized amount.
N46 Missing/incomplete/invalid admission hour.
N47 Claim conflicts with another inpatient stay.
N48 Claim information does not agree with information received from other insurance
carrier.
N49 Court ordered coverage information needs validation.
N50 Missing/incomplete/invalid discharge information.
Note: (Modified 2/28/03)
N51 Electronic interchange agreement not on file for provider/submitter.
N52 Patient not enrolled in the billing provider's managed care plan on the date of service.
N53 Missing/incomplete/invalid point of pick-up address.
Note: (Modified 2/28/03)
N54 Claim information is inconsistent with pre-certified/authorized services.
N55 Procedures for billing with group/referring/performing providers were not followed.
N56 Procedure code billed is not correct/valid for the services billed or the date of service
billed.
Note: (Modified 2/28/03)
N57 Missing/incomplete/invalid prescribing date.
Note: (Modified 12/2/04) Related to N304
N58 Missing/incomplete/invalid patient liability amount.
Note: (Modified 2/28/03)
N59 Please refer to your provider manual for additional program and provider information.
N60 A valid NDC is required for payment of drug claims effective October 02.
Note: (Deactivated eff. 1/31/2004) Consider using M119
N61 Rebill services on separate claims.
N62 Inpatient admission spans multiple rate periods. Resubmit separate claims.
N63 Rebill services on separate claim lines.
N64 The “from” and “to” dates must be different.
N65 Procedure code or procedure rate count cannot be determined, or was not on file, for
the date of service/provider.
Note: (Modified 2/28/03)
N66 Missing/incomplete/invalid documentation.
Note: (Deactivated eff. 2/5/05) Consider using N29 or N225.
N67 Professional provider services not paid separately. Included in 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.
N68 Prior payment being cancelled as we were subsequently notified this 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.

N69 PPS (Prospective Payment System) code changed by claims processing system.
Insufficient visits or therapies.
Note: (Modified 6/30/03)
N70 Home health consolidated billing and payment applies.
Note: (Modified 2/28/02)
N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or
ambulance service was processed as an assigned claim. You are required by law to
accept assignment for these types of claims.
Note: (Modified 2/21/02, 6/30/03)
N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported
by clinical records.
Note: (Modified 6/30/03)
N73 A Skilled Nursing Facility is responsible for payment of outside providers who furnish
these services/supplies under arrangement to its residents.
Note: (Deactivated eff. 1/31/04) Consider using MA101 or N200
N74 Resubmit with multiple claims, each claim covering services provided in only one
calendar month.
N75 Missing/incomplete/invalid tooth surface information.
Note: (Modified 2/28/03)
N76 Missing/incomplete/invalid number of riders.
Note: (Modified 2/28/03)
N77 Missing/incomplete/invalid designated provider number.
Note: (Modified 2/28/03)
N78 The necessary components of the child and teen checkup (EPSDT) were not
completed.
N79 Service billed is not compatible with patient location information.
N80 Missing/incomplete/invalid prenatal screening information.
Note: (Modified 2/28/03)
N81 Procedure billed is not compatible with tooth surface code.
N82 Provider must accept insurance payment as payment in full when a third party payer
contract specifies full reimbursement.
N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration
project.
N84 Further installment payments forthcoming.
N85 Final installment payment.
N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback
training for the treatment of urinary incontinence to be covered.
N87 Home use of biofeedback therapy is not covered.
N88 This payment is being made conditionally. An HHA episode of care notice has 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.
N89 Payment information for this claim has been forwarded to more than one other payer,
but format limitations permit only one of the secondary payers to be identified in this
remittance advice.
N90 Covered only when performed by the attending physician.
N91 Services not included in the appeal review.
N92 This facility is not certified for digital mammography.
N93 A separate claim must be submitted for each place of service. Services furnished at
multiple sites may not be billed in the same claim.
N94 Claim/Service denied because a more specific taxonomy code is required for
adjudication.
N95 This provider type/provider specialty may not bill this service.
Note: (New code 7/31/01, Modified 2/28/03)
N96 Patient must be refractory to conventional therapy (documented behavioral,
pharmacologic and/or surgical corrective therapy) and be an appropriate surgical
candidate such that implantation with anesthesia can occur.
Note: (New code 8/24/01)
N97 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases
(e.g., diabetes with peripheral nerve involvement) which are associated with
secondary manifestations of the above three indications are excluded.
Note: (New code 8/24/01)
N98 Patient must have had a successful test stimulation in order to 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.
Note: (New code 8/24/01)
N99 Patient must be able to demonstrate adequate ability to record voiding diary data such
that clinical results of the implant procedure can be properly evaluated.
Note: (New code 8/24/01)
N100 PPS (Prospect Payment System) code corrected during adjudication.
Note: (New code 9/14/01. Modified 6/30/03)

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claim denial code list M 12 - M134

Medicaid Claim Denial Codes
MA 12 - 63

MA12 You have not established that you have the right under the law to bill for services
furnished by the person(s) that furnished this (these) service(s).
MA13 You may be subject to penalties if you bill the patient for amounts not reported with
the PR (patient responsibility) group code.
MA14 Patient is a member of an employer-sponsored prepaid health plan. Services from
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.
MA15 Your claim has been separated to expedite handling. You will receive a separate notice
for the other services reported.
MA16 The patient is covered by the Black Lung Program. Send this claim to the Department
of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.
MA17 We are the primary payer and have paid at the primary rate. You must contact the
patient's other insurer to refund any excess it may have paid due to its erroneous
primary payment.
MA18 The claim information is also being forwarded to the patient's supplemental insurer.
Send any questions regarding supplemental benefits to them.
MA19 Information was not sent to the Medigap insurer due to incorrect/invalid information
you submitted concerning that insurer. Please verify your information and submit your
secondary claim directly to that insurer.
MA20 Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the
use of an urethral catheter for convenience or the control of incontinence.
Note: (Modified 6/30/03)
MA21 SSA records indicate mismatch with name and sex.
MA22 Payment of less than $1.00 suppressed.
MA23 Demand bill approved as result of medical review.
MA24 Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit
period.
Note: (Modified 6/30/03)
MA25 A patient may not elect to change a hospice provider more than once in a benefit
period.
MA26 Our records indicate that you were previously informed of this rule.
MA27 Missing/incomplete/invalid entitlement number or name shown on the claim.
Note: (Modified 2/28/03)
MA28 Receipt of this notice by a physician or supplier who did not accept 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.
MA29 Missing/incomplete/invalid provider name, city, state, or zip code.
Note: (Deactivated eff. 6/2/05)
MA30 Missing/incomplete/invalid type of bill.
Note: (Modified 2/28/03)
MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.
Note: (Modified 2/28/03)
MA32 Missing/incomplete/invalid number of covered days during the billing period.
Note: (Modified 2/28/03)
MA33 Missing/incomplete/invalid noncovered days during the billing period.
Note: (Modified 2/28/03)
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
Note: (Modified 2/28/03)
MA35 Missing/incomplete/invalid number of lifetime reserve days.
Note: (Modified 2/28/03)
MA36 Missing/incomplete/invalid patient name.
MA37 Missing/incomplete/invalid patient's address.
Note: (Modified 2/28/03)
MA38 Missing/incomplete/invalid birth date.
Note: (Deactivated eff. 6/2/05)
MA39 Missing/incomplete/invalid gender.
Note: (Modified 2/28/03)
MA40 Missing/incomplete/invalid admission date.
Note: (Modified 2/28/03)
MA41 Missing/incomplete/invalid admission type.
Note: (Modified 2/28/03)
MA42 Missing/incomplete/invalid admission source.
Note: (Modified 2/28/03)
MA43 Missing/incomplete/invalid patient status.
Note: (Modified 2/28/03)
MA44 No appeal rights. Adjudicative decision based on law.
MA45 As previously advised, a portion or all of your payment is being held in a special
account.
MA46 The new information was considered, however, additional payment cannot be issued.
Please review the information listed for the explanation.
MA47 Our records show you have opted out of Medicare, agreeing with the patient not to bill
Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The
patient is responsible for payment.
MA48 Missing/incomplete/invalid name or address of responsible party or primary payer.
Note: (Modified 2/28/03)
MA49 Missing/incomplete/invalid six-digit provider identifier for home health agency or
hospice for physician(s) performing care plan oversight services.
Note: (Deactivated eff.8/1/04) Consider using MA76
MA50 Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved
clinical trial services.
Note: (Modified 2/28/03)
MA51 Missing/incomplete/invalid CLIA certification number for laboratory services billed by
physician office laboratory.
Note: (Deactivated eff. 2/5/05) Consider using MA120
MA52 Missing/incomplete/invalid date.
Note: (Deactivated eff. 6/2/05)
MA53 Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
Note: (Modified 2/1/04)
MA54 Physician certification or election consent for hospice care not received timely.
MA55 Not covered as patient received medical health care services, automatically revoking
his/her election to receive religious non-medical health care services.
MA56 Our records show you have opted out of Medicare, agreeing with the patient 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.
MA57 Patient submitted written request to revoke his/her election for religious non-medical
health care services.
MA58 Missing/incomplete/invalid release of information indicator.
Note: (Modified 2/28/03)
MA59 The patient overpaid you for these services. You must issue the patient a refund within
30 days for the difference between his/her payment and the total amount shown as
patient responsibility on this notice.
MA60 Missing/incomplete/invalid patient relationship to insured.
Note: (Modified 2/28/03)
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
Note: (Modified 2/28/03)
MA62 Telephone review decision.
MA63 Missing/incomplete/invalid principal diagnosis.
Note: (Modified 2/28/03)

MA 64- MA 113

MA64 Our records indicate that we should be the third payer for this claim. We cannot
process this claim until we have received payment information from the primary and
secondary payers.
MA65 Missing/incomplete/invalid admitting diagnosis.
Note: (Modified 2/28/03)
MA66 Missing/incomplete/invalid principal procedure code.
Note: (Modified 12/2/04) Related to N303
MA67 Correction to a prior claim.
MA68 We did not crossover this claim because the secondary insurance 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.
MA69 Missing/incomplete/invalid remarks.
Note: (Modified 2/28/03)
MA70 Missing/incomplete/invalid provider representative signature.
Note: (Modified 2/28/03)
MA71 Missing/incomplete/invalid provider representative signature date.
Note: (Modified 2/28/03)
MA72 The patient overpaid you for these assigned services. You must issue 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.
MA73 Informational remittance associated with a Medicare demonstration. No payment
issued under fee-for-service Medicare as patient has elected managed care.
MA74 This payment replaces an earlier payment for this claim that was either lost, damaged
or returned.
MA75 Missing/incomplete/invalid patient or authorized representative signature.
Note: (Modified 2/28/03)
MA76 Missing/incomplete/invalid provider identifier for home health agency or hospice when
physician is performing care plan oversight services.
Note: (Modified 2/28/03, 2/1/04)
MA77 The patient overpaid you. You must issue the patient a refund within 30 days for 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.
MA78 The patient overpaid you. You must issue the patient a refund within 30 days for the
difference between our allowed amount total and the amount paid by the patient.
Note: (Deactivated eff. 1/31/2004) Consider using MA59
MA79 Billed in excess of interim rate.
MA80 Informational notice. No payment issued for this claim with this notice. Payment
issued to the hospital by its intermediary for all services for this encounter under a
demonstration project.
MA81 Missing/incomplete/invalid provider/supplier signature.
Note: (Modified 2/28/03)
MA82 Missing/incomplete/invalid provider/supplier billing number/identifier or billing name,
address, city, state, zip code, or phone number.
Note: (Deactivated eff. 6/2/05)
MA83 Did not indicate whether we are the primary or secondary payer.
Note: (Modified 8/1/05)
MA84 Patient identified as participating in the National Emphysema 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.
MA85 Our records indicate that a primary payer exists (other than ourselves); however, you
did not complete or enter accurately the insurance plan/group/program name or
identification number. Enter the PlanID when effective.
Note: (Deactivated eff. 8/1/04) Consider using MA92
MA86 Missing/incomplete/invalid group or policy number of the insured for the primary
coverage.
Note: (Deactivated eff. 8/1/04) Consider using MA92
MA87 Missing/incomplete/invalid insured's name for the primary payer.
Note: (Deactivated eff. 8/1/04) Consider using MA92
MA88 Missing/incomplete/invalid insured's address and/or telephone number for the primary
payer.
Note: (Modified 2/28/03)
MA89 Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
Note: (Modified 2/28/03)
MA90 Missing/incomplete/invalid employment status code for the primary insured.
Note: (Modified 2/28/03).
MA91 This determination is the result of the appeal you filed.
MA92 Missing plan information for other insurance.
Note: (Modified 2/1/04) Related to N245
MA93 Non-PIP (Periodic Interim Payment) claim.
Note: (Modified 6/30/03)
MA94 Did not enter the statement “Attending physician not hospice employee” on the claim
form to certify that the rendering physician is not an employee of the hospice.
Note: (Reactivated 4/1/04, Modified 8/1/05)
MA95 De-activate and refer to M51.
Note: (Modified 2/28/03)
MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not
enrolled in a Medicare managed care plan.
MA97 Missing/incomplete/invalid Medicare Managed Care Demonstration contract number.
Note: (Modified 2/28/03)
MA98 Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration
contract number for this beneficiary.
Note: (Deactivated eff. 10/16/03) Consider using MA97
MA99 Missing/incomplete/invalid Medigap information.
Note: (Modified 2/28/03)
MA100 Missing/incomplete/invalid date of current illness or symptoms
Note: (Modified 2/28/03, 3/30/05)
MA101 A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who
furnish these services/supplies to residents.
Note: (Modified 6/30/03)
MA102 Missing/incomplete/invalid name or provider identifier for the rendering/referring/
ordering/ supervising provider.
Note: (Deactivated eff. 8/1/04) Consider using M68
MA103 Hemophilia Add On.
MA104 Missing/incomplete/invalid date the patient was last seen or the provider identifier of
the attending physician.
Note: (Deactivated eff. 1/31/2004) Consider using M128 or M57
MA105 Missing/incomplete/invalid provider number for this place of service.
Note: (Deactivated eff. 6/2/05)
MA106 PIP (Periodic Interim Payment) claim.
Note: (Modified 6/30/03)
MA107 Paper claim contains more than three separate data items in field 19.
MA108 Paper claim contains more than one data item in field 23.
MA109 Claim processed in accordance with ambulatory surgical guidelines.
MA110 Missing/incomplete/invalid information on whether the diagnostic test(s) were
performed by an outside entity or if no purchased tests are included on the claim.
Note: (Modified 2/28/03)
MA111 Missing/incomplete/invalid purchase price of the test(s) and/or the performing
laboratory's name and address.
Note: (Modified 2/28/03)
MA112 Missing/incomplete/invalid group practice information.
Note: (Modified 2/28/03)
MA113 Incomplete/invalid taxpayer identification number (TIN) submitted by you per the
Internal 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.
MA114 Missing/incomplete/invalid information on where the services were furnished.
Note: (Modified 2/28/03)
MA115 Missing/incomplete/invalid physical location (name and address, or PIN) where the
service(s) were rendered in a Health Professional Shortage Area (HPSA).
Note: (Modified 2/28/03)
MA116 Did not complete the statement "Homebound" on the claim to validate whether
laboratory services were performed at home or in an institution.
Note: (Reactivated 4/1/04)
MA117 This claim has been assessed a $1.00 user fee.
MA118 Coinsurance and/or deductible amounts apply to a claim for services or supplies
furnished to a Medicare-eligible veteran through a facility of the Department of
Veterans Affairs. No Medicare payment issued.
MA119 Provider level adjustment for late claim filing applies to this claim.
MA120 Missing/incomplete/invalid CLIA certification number.
Note: (Modified 2/28/03)
MA121 Missing/incomplete/invalid x-ray date.
Note: (Modified 12/2/04)
MA122 Missing/incomplete/invalid initial treatment date.
Note: (Modified 12/2/04)
MA123 Your center was not selected to participate in this study, therefore, we cannot pay for
these services.
MA124 Processed for IME only.
Note: (Deactivated eff. 1/31/2004) Consider using Reason Code 74
MA125 Per legislation governing this program, payment constitutes payment in full.
MA126 Pancreas transplant not covered unless kidney transplant performed.
Note: (New Code 10/12/01)
MA127 Reserved for future use.
Note: (Deactivated eff. 6/2/05)
MA128 Missing/incomplete/invalid FDA approval number.
Note: (Modified 2/28/03, 3/30/05)
MA129 This provider was not certified for this procedure on this date of service.
Note: (Deactivated eff. 1/31/2004) Consider using MA120 and Reason Code B7
MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are
afforded because the claim is unprocessable. Please submit a new claim with the
complete/correct information.
MA131 Physician already paid for services in conjunction with this demonstration claim. You
must have the physician withdraw that claim and refund the payment before we can
process your claim.
MA132 Adjustment to the pre-demonstration rate.
MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient
stay.
MA134 Missing/incomplete/invalid provider number of the facility where the patient resides

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OA : Other adjustments - denial code list

MCR - 835 Denial Code List 


OA : Other adjustments

OA 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

OA 5 The procedure code/bill type is inconsistent with the place of service.

OA 6 The procedure/revenue code is inconsistent with the patient's age.

OA 7 The procedure/revenue code is inconsistent with the patient's gender.

OA 8 The procedure code is inconsistent with the provider type/specialty (taxonomy).

OA 9 The diagnosis is inconsistent with the patient's age.

OA 10 The diagnosis is inconsistent with the patient's gender.

OA 11 The diagnosis is inconsistent with the procedure.

OA 12 The diagnosis is inconsistent with the provider type.

OA 13 The date of death precedes the date of service.

OA 14 The date of birth follows the date of service.

OA 16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

OA 18 Duplicate claim/service.

OA 19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

OA 20 Claim denied because this injury/illness is covered by the liability carrier.

OA 21 Claim denied because this injury/illness is the liability of the no-fault carrier.

OA 40 Charges do not meet qualifications for emergent/urgent care.

OA 44 Prompt-pay discount.

OA 53 Services by an immediate relative or a member of the same household are not covered.

OA 59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)

OA 61 Charges adjusted as penalty for failure to obtain second surgical opinion.

OA 74 Indirect Medical Education Adjustment.

OA 75 Direct Medical Education Adjustment.

OA 87 Transfer amount.

OA 90 Ingredient cost adjustment.

OA 95 Benefits adjusted. Plan procedures not followed.

OA 100 Payment made to patient/insured/responsible party.

OA 104 Managed care withholding.

OA 105 Tax withholding.

OA 106 Patient payment option/election not in effect.

OA 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

OA 116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.

OA 118 Charges reduced for ESRD network support.

OA 121 Indemnification adjustment.

OA 122 Psychiatric reduction.

OA 130 Claim submission fee.

OA 131 Claim specific negotiated discount.

OA 132 Prearranged demonstration project adjustment.

OA 133 The disposition of this claim/service is pending further review.

OA 134 Technical fees removed from charges.

OA 136 Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA).

OA 137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

OA 141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.

OA 143 Portion of payment deferred.

OA 147 Provider contracted/negotiated rate expired or not on file.

OA 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.

OA 155 This claim is denied because the patient refused the service/procedure.

OA 156 Flexible spending account payments

OA 161 Provider performance bonus

OA 186 Payment adjusted since the level of care changed

OA 187 Health Savings account payments

OA 189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

OA 192 Non standard adjustment code from paper remittance advice.

OA 199 Revenue code and Procedure code do not match.

OA 206 NPI denial - missing

OA 208 NPI denial - not matched

OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)

OA A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

OA A6 Prior hospitalization or 30 day transfer requirement not met.

OA A8 Claim denied; ungroupable DRG

OA B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

OA B12 Services not documented in patients' medical records.

OA B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

OA B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

OA B18 Payment adjusted because this procedure code and modifier were invalid on the date of service

OA B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.

OA B22 This payment is adjusted based on the diagnosis.

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CO : Contractual Obligations denial code list

MCR - 835 Denial Code List  

CO : Contractual Obligations

CO 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits.

CO 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.

CO 29 The time limit for filing has expired.

CO 38 Services not provided or authorized by designated (network/primary care) providers.

CO 39 Services denied at the time authorization/pre-certification was requested.

CO 45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).

CO 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.

CO 50 These are non-covered services because this is not deemed a `medical necessity' by the payer.

CO 51 These are non-covered services because this is a pre-existing condition

CO 54 Multiple physicians/assistants are not covered in this case .

CO 55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.

CO 56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.

CO 58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

CO 60 Charges for outpatient services with this proximity to inpatient services are not covered.

CO 66 Blood Deductible.

CO 69 Day outlier amount.

CO 70 Cost outlier - Adjustment to compensate for additional costs.

CO 76 Disproportionate Share Adjustment.

CO 78 Non-Covered days/Room charge adjustment.

CO 89 Professional fees removed from charges.

CO 91 Dispensing fee adjustment.

CO 94 Processed in Excess of charges.

CO 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

CO 101 Predetermination: anticipated payment upon completion of services or claim adjudication.

CO 102 Major Medical Adjustment.

CO 103 Provider promotional discount (e.g., Senior citizen discount).

CO 107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.

CO 110 Billing date predates service date.

CO 111 Not covered unless the provider accepts assignment.

CO 114 Procedure/product not approved by the Food and Drug Administration.

CO 117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.

CO 119 Benefit maximum for this time period or occurrence has been reached.

CO 125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

CO 128 Newborn's services are covered in the mother's Allowance.

CO 135 Claim denied. Interim bills cannot be processed.

CO 138 Claim/service denied. Appeal procedures not followed or time limits not met.

CO 139 Contracted funding agreement - Subscriber is employed by the provider of services.

CO 146 Payment denied because the diagnosis was invalid for the date(s) of service reported.

CO 157 Payment denied/reduced because service/procedure was provided as a result of an act of war.

CO 158 Payment denied/reduced because the service/procedure was provided outside of the United States.

CO 159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.

CO 160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.

CO 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.

CO 165 Payment denied /reduced for absence of, or exceeded referral

CO 167 This (these) diagnosis(es) is (are) not covered.

CO 170 Payment is denied when performed/billed by this type of provider.

CO 171 Payment is denied when performed/billed by this type of provider in this type of facility.

CO 172 Payment is adjusted when performed/billed by a provider of this specialty

CO 174 Payment denied because this service was not prescribed prior to delivery

CO 175 Payment denied because the prescription is incomplete

CO 176 Payment denied because the prescription is not current

CO 183 The referring provider is not eligible to refer the service billed.

CO 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.

CO 185 The rendering provider is not eligible to perform the service billed.

CO 188 This product/procedure is only covered when used according to FDA recommendations.

CO 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

CO 191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier.

CO 193 Original payment decision is being maintained. This claim was processed properly the first time.

CO 205 Pharmacy discount card processing fee

CO 211 National Drug Codes (NDC) not eligible for rebate, are not covered.

CO A4 Medicare Claim PPS Capital Day Outlier Amount.

CO A5 Medicare Claim PPS Capital Cost Outlier Amount.

CO A7 Presumptive Payment Adjustment

CO B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.

CO B14 Payment denied because only one visit or consultation per physician per day is covered.

CO B16 Payment adjusted because `New Patient' qualifications were not met.

CO B23 Payment denied because this provider has failed an aspect of a proficiency testing program.

CO B4 Late filing penalty.

CO B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.

CO B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.

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PR - Patient Responsebility denial code list

MCR - 835 Denial Code List  
PR - Patient Responsebility

Here you can see all the denial codes .

PR 1 Deductible Amount

PR 2 Coinsurance Amount

PR 3 Co-payment Amount

PR 25 Payment denied. Your Stop loss deductible has not been met.

PR 26 Expenses incurred prior to coverage.

PR 27 Expenses incurred after coverage terminated.

PR 31 Claim denied as patient cannot be identified as our insured.

PR 32 Our records indicate that this dependent is not an eligible dependent as defined.

PR 33 Claim denied. Insured has no dependent coverage.

PR 34 Claim denied. Insured has no coverage for newborns.

PR 35 Lifetime benefit maximum has been reached.

PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)

PR 126 Deductible -- Major Medical

PR 127 Coinsurance -- Major Medical

PR 140 Patient/Insured health identification number and name do not match.

PR 149 Lifetime benefit maximum has been reached for this service/benefit category.

PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.

PR 168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan

PR 177 Payment denied because the patient has not met the required eligibility requirements

PR 200 Expenses incurred during lapse in coverage

PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).

PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan

PR B1 Non-covered visits.

PR B9 Services not covered because the patient is enrolled in a Hospice.

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Medicare and Medicare Denial code List Remark Code List - N series

N151 Telephone contact services will not be paid until the face-to-face contact requirement

has been met.
Note: (New Code 10/31/02)
N152 Missing/incomplete/invalid replacement claim information.
Note: (New Code 10/31/02)
N153 Missing/incomplete/invalid room and board rate.
Note: (New Code 10/31/02)
N154 This payment was delayed for correction of provider's mailing address.
Note: (New Code 10/31/02)
N155 Our records do not indicate that other insurance is on file. Please submit other
insurance information for our records.
Note: (New Code 10/31/02)
N156 The patient is responsible for the difference between the approved treatment and the
elective treatment.
Note: (New Code 10/31/02)
N157 Transportation to/from this destination is not covered.
Note: (New Code 2/28/03, Modified 2/1/04)
N158 Transportation in a vehicle other than an ambulance is not covered.
Note: (New Code 2/28/03)
N159 Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Note: (New Code 2/28/03)
N160 The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Note: (New Code 2/28/03, Modified 2/1/04)
N161 This drug/service/supply is covered only when the associated service is covered.
Note: (New Code 2/28/03)
N162 This is an alert. Although your claim was paid, you have billed for a test/specialty not
included in your Laboratory Certification. Your failure to correct the laboratory
certification information will result in a denial of payment in the near future.
Note: (New Code 2/28/03)
N163 Medical record does not support code billed per the code definition.
Note: (New Code 2/28/03)
N164 Transportation to/from this destination is not covered.
Note: (Deactivated eff. 1/31/04) Consider using N157
N165 Transportation in a vehicle other than an ambulance is not covered.
Note: (Deactivated eff. 1/31/04) Consider using N158)
N166 Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Note: (Deactivated eff. 1/31/04) Consider using N159
N167 Charges exceed the post-transplant coverage limit.
Note: (New Code 2/28/03)
N168 The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Note: (Deactivated eff. 1/31/04) Consider using N160
N169 This drug/service/supply is covered only when the associated service is covered.
Note: (Deactivated eff. 1/31/04) Consider using N161
N170 A new/revised/renewed certificate of medical necessity is needed.
Note: (New Code 2/28/03)
N171 Payment for repair or replacement is not covered or has exceeded the purchase price.
Note: (New Code 2/28/03)
N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated
service/item.
Note: (New Code 2/28/03)
N173 No qualifying hospital stay dates were provided for this episode of care.
Note: (New Code 2/28/03)
N174 This is not a covered service/procedure/ equipment/bed, however patient liability is
limited to amounts shown in the adjustments under group "PR".
Note: (New Code 2/28/03)
N175 Missing Review Organization Approval.
Note: (Modified 8/1/04) Related to N241
N176 Services provided aboard a ship are covered only when the ship is of United States
registry and is in United States waters. In addition, a doctor licensed to practice in the
United States must provide the service.
Note: (New Code 2/28/03)
N177 We did not send this claim to patient’s other insurer. They have indicated no additional
payment can be made.
Note: (New Code 2/28/03. Modified 6/30/03)
N178 Missing pre-operative photos or visual field results.
Note: (Modified 8/1/04) Related to N244
N179 Additional information has been requested from the member. The charges will be
reconsidered upon receipt of that information.
Note: (New Code 2/28/03)
N180 This item or service does not meet the criteria for the category under which it was
billed.
Note: (New Code 2/28/03)
N181 Additional information has been requested from another provider involved in the care
of this member. The charges will be reconsidered upon receipt of that information.
Note: (New Code 2/28/03)
N182 This claim/service must be billed according to the schedule for this plan.
Note: (New Code 2/28/03)
N183 This is a predetermination advisory message, when this service is submitted for
payment additional documentation as specified in plan documents will be required to
process benefits.
Note: (New Code 2/28/03)
N184 Rebill technical and professional components separately.
Note: (New Code 2/28/03)
N185 Do not resubmit this claim/service.
Note: (New Code 2/28/03)
N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military
Treatment Facility (MTF) for assistance.
Note: (New Code 2/28/03)
N187 You may request a review in writing within the required time limits following receipt of
this notice by following the instructions included in your contract or plan benefit
documents.
Note: (New Code 2/28/03)
N188 The approved level of care does not match the procedure code submitted.
Note: (New Code 2/28/03)
N189 This service has been paid as a one-time exception to the plan's benefit restrictions.
Note: (New Code 2/28/03)
N190 Missing contract indicator.
Note: (Modified 8/1/04) Related to N229
N191 The provider must update insurance information directly with payer.
Note: (New Code 2/28/03)
N192 Patient is a Medicaid/Qualified Medicare Beneficiary.
Note: (New Code 2/28/03)
N193 Specific federal/state/local program may cover this service through another payer.
Note: (New Code 2/28/03)
N194 Technical component not paid if provider does not own the equipment used.
Note: (New Code 2/28/03)
N195 The technical component must be billed separately.
Note: (New Code 2/28/03)
N196 Patient eligible to apply for other coverage which may be primary.
Note: (New Code 2/28/03)
N197 The subscriber must update insurance information directly with payer.
Note: (New Code 2/28/03)
N198 Rendering provider must be affiliated with the pay-to provider.
Note: (New Code 2/28/03)
N199 Additional payment approved based on payer-initiated review/audit.
Note: (New Code 2/28/03)
N200 The professional component must be billed separately.
Note: (New Code 2/28/03)

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CO 97 - CO 97 Payment adjusted because this procedure/service is not paid separately.

CO 97 Payment adjusted because this procedure/service is not paid separately.

Explanation:

• The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Solution :

Denial indicates services billed may have already been submitted as part of another service billed for the same date of service (services were bundled). Please make note of quarterly updates to the National Correct Coding Initiative (CCI) edits .

• The purpose of NCCI edits is to ensure the most comprehensive codes are billed, rather than component parts.

Some services may always be bundled into other services provided or not separately payable. For instance:

• E/M services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.

• Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.

• Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day.

• Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.

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Reject reason code C7010 / T5052 reason and actions need to take.

Q: We are receiving reject reason code C7010. What steps can we take to avoid this reason code?

Reason Code: C7010
Description : THE EDITED INPATIENT OR OUTPATIENT CLAIM HAS FROM/THRU DATES THAT OVERLAP A HOSPICE ELECTION PERIOD AND IS NOT INDICATED AS TREATMENT OF A NON-TERMINAL CONDITION (CONDITION CODE '07'). OR A MCCD/DMD NOTICE OF ELECTION (89A) FROM DATE OVERLAPS A HOSPICE ELE CTION PERIOD.

A: You are receiving this reason code when the beneficiary was/is enrolled in a hospice election period for the date of service(s).
• Confirm the beneficiary’s eligibility via direct data entry (DDE), interactive voice response (IVR) system, or Secure Provider Online Tool (the SPOT)
• If the information is invalid 
Contact the hospice provider and ask them to submit their last claim for the beneficiary with occurrence code 42 and the date of disenrollment. Once the records are deleted or updated, refile the claim to Medicare
• If the information is valid and the services provided to the beneficiary are related to their terminal condition for hospice services
Refile the claim with the hospice provider listed on the beneficiary’s records
• If the information is valid and the services provided to the beneficiary are not related to their terminal condition for hospice services
Refile the claim with a condition code 07 (treatment of non-terminal condition for hospice patient)

Reject reason code T5052
Q: We are receiving reject reason code T5052. What steps can we take to avoid this reason code?

Reason Code : T5052
Description : THE CENTER FOR MEDICARE AND MEDICAID SERVICES RECORDS INDICATE THE THE BENEFICIARY IS NOT IN FILE. PLEASE VERIFY THE BENEFICIARY'S IDENTIFICATION AND SUBMIT A NEW CLAIM.

A: You are receiving this reason code when the Centers for Medicare and Medicaid Services (CMS) records indicate the beneficiary is not on file. Verify the beneficiary’s Medicare health identification number and resubmit the claim if the patient is eligible for Medicare Part A coverage. 
There are several ways to obtain beneficiary eligibility:
• Users can access eligibility information via direct data entry (DDE) .
• Contact the interactive voice response (IVR) system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
• 270/271 eligibility transactions -- you can obtain eligibility information in a batch format for a number of beneficiaries.
• Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
Always remember to check with the beneficiary and/or representative for eligibility prior to submitting claims to Medicare. 
There are also a few things you can do when a beneficiary comes to your facility:
• Always obtain a copy of the red, white, and blue Medicare card prior to providing services.
• Ensure the eligibility dates on the card indicate their coverage is currently valid and not expired or a future date.
• Make sure the name on the claim matches the name as it appears on the Medicare red, white, and blue card. Do not use nicknames.
• If everything matches on the Medicare card, the beneficiary should verify eligibility with the Social Security Administration (SSA)

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