co 256 denial code descriptions Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim lacks completed pacemaker registration form. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Reason Code 184: Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). 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. 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.). This service/equipment/drug is not covered under the patient's current benefit plan. The referring provider is not eligible to refer the service billed. Submission/billing error(s). PR Patient responsibility denial code full list Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. 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). Claim/service spans multiple months. To be used for Property and Casualty Auto only. 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. Note: Refer to the835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 154: Service/procedure was provided as a result of an act of war. Alternative services were available, and should have been utilized. This injury/illness is covered by the liability carrier. Upon review, it was determined that this claim was processed properly. The authorization number is missing, invalid, or does not apply to the billed services or provider. Reason Code 265: The Claim spans two calendar years. Claim/service not covered when patient is in custody/incarcerated. Note: Use code 187. Workers' Compensation claim is under investigation. Reason Code 169: Payment is adjusted when performed/billed by a provider of this specialty. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. The Claim spans two calendar years. Denial codes are codes assigned by health care insurance companies to faulty insurance claims. Reason Code 263: Adjustment for compound preparation cost. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The diagnosis is inconsistent with the procedure. The procedure/revenue code is inconsistent with the patient's age. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code, This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. Reason Code 247: The attachment/other documentation that was received was the incorrect attachment/document. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. What does that sentence mean? Claim/service lacks information which is needed for adjudication. 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. 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. Our records indicate that this dependent is not an eligible dependent as defined. ), Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO). Note: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). (Note: To be used by Property& Casualty only). For use by Property and Casualty only. Stuck at medical billing? Reason Code 186: 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. 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. WebDescription. The impact of prior payer(s) adjudication including payments and/or adjustments. 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 103: Patient payment option/election not in effect. ), This change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Multi-tier licensing categories are based on how licensees benefit from X12's work,replacing traditional one-size-fits-all approaches. Contact work hardening reviewer at (360)902-4480. No current requests. It also happens to be super easy to correct, resubmit and overturn. Reason Code 189: Non-standard adjustment code from paper remittance. 5 The procedure code/bill type is inconsistent with the place of service. Reason Code 141: Incentive adjustment, e.g. Reason Code 111: Procedure/product not approved by the Food and Drug Administration. co 256 denial code descriptions. Provider promotional discount (e.g., Senior citizen discount). Refund to patient if collected. Note: Use code 187. Reason Code 267: Claim/Service denied. What is Denial Code CO 16? How to Avoid in Future? Usage: 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). The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Reason Code 204: National Provider identifier - Invalid format. Reason Code 256: Additional payment for Dental/Vision service utilization, Reason Code 257: Processed under Medicaid ACA Enhance Fee Schedule. Exceeds the contracted maximum number of hours/days/units by this provider for this period. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Reason Code 46: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Adjustment for postage cost. Patient has not met the required residency requirements. (Use only with Group Codes PR or CO depending upon liability). Reason Code 57: Charges for outpatient services are not covered when performed within a period of time prior to orafter inpatient services. Did you receive a code from a health plan, such as: PR32 or CO286? What is CO 24 Denial Code? Refund to patient if collected. Claim/service denied. The EDI Standard is published onceper year in January. Claim/Service missing service/product information. (Use CARC 45). To be used for Property and Casualty only. These codes describe why a claim or service line was paid differently than it was billed. The provider cannot collect this amount from the patient. Reason Code 110: Payment denied because service/procedure was provided outside the United States or as a result of war. Medicare denial codes - OA : Other adjustments, CARC and RARC list 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. Identity verification required for processing this and future claims. co 256 denial code descriptions The provider cannot collect this amount from the patient. Information related to the X12 corporation is listed in the Corporate section below. Patient identification compromised by identity theft. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 50. The diagnosis is inconsistent with the provider type. Reason Code 64: Lifetime reserve days. Denial code CO16 is a Contractual Obligation claim adjustment reason code (CARC). This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Reason Code 48: These are non-covered services because this is a pre-existing condition. MA27: Missing/incomplete/invalid entitlement number or Sequestration - reduction in federal payment. Reason Code 216: Based on extent of injury. Reason Code 32: Lifetime benefit maximum has been reached. 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. #2. Reason Code 168: Payment is denied when performed/billed by this type of provider in this type of facility. *Explain the business scenario or use case when the requested new code would be used, the reason an existing code is no longer appropriate for the code lists business purpose, or reason the current description needs to be revised. X12 is well-positioned to continue to serve its members and the large install base by continuing to support the existing metadata, standards, and implementation tools while also focusing on several key collaborative initiatives. The diagrams on the following pages depict various exchanges between trading partners. 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). Non-covered personal comfort or convenience services. Based on entitlement to benefits. Appeal procedures not followed or time limits not met. Service was not prescribed by a physician. This Payer not liable for claim or service/treatment. Performance program proficiency requirements not met. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Usage: To be used for pharmaceuticals only. Current and past groups and caucuses include: X12 is pleased to recognize individual members and industry representatives whose contributions and achievements have played a role in the development of cross-industry eCommerce standards. However, this amount may be billed to subsequent payer. The billing provider is not eligible to receive payment for the service billed. Reason Code 104: The related or qualifying claim/service was not identified on this claim. Reason Code 43: This (these) service(s) is (are) not covered. PIL02b1 Publishing and Maintaining Externally Developed Implementation Guides, PIL02b2 Publishing and Maintaining Externally Developed Implementation Guides. CO-96 Denial | Medical Billing and Coding Forum - AAPC Reason Code 195: Precertification/authorization exceeded. Claim did not include patient's medical record for the service. Failure to follow prior payer's coverage rules. Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. M127, 596, 287, 95. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Based on payer reasonable and customary fees. Usage: To be used for pharmaceuticals only. Patient payment option/election not in effect. Reason Code 199: Non-covered personal comfort or convenience services. Explanation. Original payment decision is being maintained. Based on subrogation of a third-party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Reason Code 35: Services not provided or authorized by designated (network/primary care) providers. Reason Code 93: Non-covered charge(s). X12s Annual Release Cycle Keeps Implementation Guides Up to Date, B2X Supports Business to Everything for X12 Stakeholders, Winter 2023 Standing Meeting - Pull up a chair, Saddened by the loss of a long-time X12 contributor, Evolving X12s Licensing Model for the Greater Good, Repeating Segments (and Loops) that Use the Same Qualifier, Electronic Data Exchange | Leveraging EDI for Business Success. Reason Code: 204. Denial message co 16 N257 Claim/service lacks information which is needed for adjudication (16) Missing/incomplete/invalid billing provider primary identifier (257) Reason for denial The claim was filed with an invalid or missing NPI How to resolve and avoid future denials File claims with the valid billing provider NPI Expenses incurred after coverage terminated. Reason Code 218: Workers' Compensation claim is under investigation. Identity verification required for processing this and future claims. To be used for Property and Casualty only. (Use Group Codes PR or CO depending upon liability). This change effective 7/1/2013: Claim is under investigation. Failure to follow prior payer's coverage rules. The authorization number is missing, invalid, or does not apply to the billed services or provider. Legislated/Regulatory Penalty. To be used for Property and Casualty only. This payment is adjusted based on the diagnosis. New born's services are covered in the mother's Allowance. Reason Code 208: National Drug Codes (NDC) not eligible for rebate, are not covered. The applicable fee schedule/fee database does not contain the billed code. 03 Co-payment amount. co 256 denial code descriptions 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. Expenses incurred during lapse in coverage, Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. This is not patient specific. Reason Code 180: The referring provider is not eligible to refer the service billed. No maximum allowable defined by legislated fee arrangement. The diagnosis is inconsistent with the patient's gender. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only. 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. 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.). Additional information will be sent following the conclusion of litigation. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. An allowance has been made for a comparable service. Webco 256 denial code descriptions co 256 denial code descriptions on November 29, 2022 on November 29, 2022 If there is no adjustment to a claim/line, then there is no adjustment reason code. Reason Code 251: Claim received by the dental plan, but benefits not available under this plan. Code 204 Know what are challenges in Credentialing, Charge Entry, Payment Posting, Benefits/Eligibility Verification, Prior Authorization, Filing claims, AR Follow Ups, Old AR, Claim Denials, resubmitting rejections with Medical Billing Company , Simplifying Every Step of Credentialing Process, Most trusted and assured Credentialing services for all you need, like. The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR). This change effective 7/1/2013: Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. Services not authorized by network/primary care providers. Lifetime benefit maximum has been reached. Please resubmit on claim per calendar year. Claim/service lacks information or has submission/billing error(s). Webpaired with HIPAA Remark Code 256 Service not payable per managed care contract. 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. 05 The procedure code/bill type is inconsistent with the place of service. Procedure/treatment is deemed experimental/investigational by the payer. Reason Code 150: Payer deems the information submitted does not support this dosage. Additional payment for Dental/Vision service utilization. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Reason Code 128: Claim specific negotiated discount. Reason Code 179: Procedure modifier was invalid on the date of service. This (these) diagnosis(es) is (are) missing or are invalid, Reimbursement was adjusted for the reasons to be provided in separate correspondence. Medicare Claim PPS Capital Cost Outlier Amount. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 227: No available or correlating CPT/HCPCS code to describe this service. Reason Code 140: Portion of payment deferred. This injury/illness is the liability of the no-fault carrier. Patient cannot be identified as our insured. Reason Code 87: Ingredient cost adjustment. Reason Code 243: This non-payable code is for required reporting only. Administrative surcharges are not covered. Usage: 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. The diagnosis is inconsistent with the patient's age. Reason Code B10: Allowed amount has been reduced because a component of the basic procedure/test was paid. The procedure/revenue code is inconsistent with the patient's gender. National Drug Codes (NDC) not eligible for rebate, are not covered. Reason Code 220: Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Reason Code 210: Non-compliance with the physician self-referral prohibition legislation or payer policy. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 134: Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Multiple physicians/assistants are not covered in this case. 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.). Reason Code 37: Charges do not meet qualifications for emergent/urgent care. Submit these services to the patient's dental plan for further consideration. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. The list below shows the status of change requests which are in process. 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). (Use only with Group Code OA). Pharmacy Direct/Indirect Remuneration (DIR). Monday, April 25, 2016 Denial Action on Medicare code MA61, MA27, N256, MA112 AND M79 Beneficiary name and/or Medicare number MA61: Missing/incomplete/invalid Social Security number or health insurance claim number (HICN). Medicare Claim PPS Capital Cost Outlier Amount. Reason Code 211: Workers' Compensation claim adjudicated as non-compensable. Adjustment for postage cost. Claim/service not covered by this payer/processor. Reason Code 126: Prior processing information appears incorrect. Claim/service denied. Note: Used only by Property and Casualty. CO 24 Charges are covered under a capitation agreement or managed care plan .