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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Addendum G
Data Requirements - Adjustment/Denial Reason Codes
Revision:  C-36, April 15, 2020
Figure 2.G-1  Denial Codes
Adjust/Denial Reason Code
Description
HIPAA Adjustment Reason Codes Release 11/05/2007.
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
The 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.
17
Requested information was not provided or was insufficient/incomplete.
18
Duplicate claim/service.
19
This is a work-related injury/illness and thus the liability of the Workers’ Compensation Carrier.
20
This injury/illness is covered by the liability carrier.
21
This injury/illness is the liability of the no-fault carrier.
22
This care may be covered by another payer per coordination of benefits.
24
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.
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.
31
Patient cannot be identified as our insured.
32
Our records indicate that this dependent is not an eligible dependent as defined.
33
Insured has no dependent coverage.
34
Insured has no coverage for newborns.
35
Lifetime benefit maximum has been reached.
38
Services not provided or authorized by designated (network) providers.
39
Services denied at the time authorization/pre-certification was requested.
40
Charges do not meet qualifications for emergent/urgent care.
46
This (these) service(s) is (are) not covered.
47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
48
This (these) procedure(s) is (are) not covered.
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.
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
Procedure/treatment is deemed experimental/investigational by the payer.
56
Procedure/treatment has not been deemed ‘proven to be effective’ by the payer.
58
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
60
Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
89
Professional fees removed from charges.
96
Non-covered charge(s).
97
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
98
The hospital must file the Medicare claim form for this inpatient non-physician service.
106
Patient payment option/election not in effect.
107
The related or qualifying claim/service was not identified on this claim.
110
Billing date predates service date.
111
Not covered unless the provider accepts assignment.
112
Service not furnished directly to the patient and/or not documented.
113
Payment denied because service/procedure was provided outside the United States or as a result of war.
114
Procedure/product not approved by the Food and Drug Administration.
115
Procedure postponed, canceled, or delayed.
116
The advance indemnification notice signed by the patient did not comply with requirements.
119
Benefit maximum for this time period has been reached.
128
Newborn’s services are covered in the mother’s Allowance.
129
Prior processing information appears incorrect.
134
Technical fees removed from charges.
135
Interim bills cannot be processed.
136
Failure to follow prior payer’s coverage rules.
138
Appeal procedures not followed or time limits not met.
140
Patient/Insured health identification number and name do not match.
141
Claim spans eligible and ineligible periods of coverage.
146
Diagnosis was invalid for the date(s) of service reported.
147
Provider contracted/negotiated rate expired or not on file.
148
Information from another provider was not provided or was insufficient/incomplete.
149
Benefit maximum for this time period or occurrence has been reached.
155
Patient refused the service/procedure.
166
These services were submitted after this payer’s responsibility for processing claims under this plan ended.
167
This (these) diagnosis(es) is (are) not covered.
168
Service(s) have been considered under the patient’s medical plan. Benefits are not available under this dental plan.
170
Payment is denied when performed/billed by this type of provider.
171
Payment is denied when performed/billed by this type of provider in this type of facility.
174
Service was not prescribed prior to delivery.
175
Prescription is incomplete.
176
Prescription is not current.
177
Patient has not met the required eligibility requirements.
181
Procedure code was invalid on the date of service.
182
Procedure modifier was invalid on the date of service.
183
The referring provider is not eligible to refer the service billed.
184
The prescribing/ordering provider is not eligible to prescribe/order the service billed.
185
The rendering provider is not eligible to perform the service billed.
188
This product/procedure is only covered when used according to FDA recommendations.
191
Not a work related injury/illness and thus not the liability of the Workers’ Compensation carrier.
196
Claim/service denied based on prior payer’s coverage determination.
199
Revenue code and procedure code do not match.
200
Expenses incurred during lapse in coverage.
201
Workers’ Compensation (WC) case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement.
202
Non-covered personal comfort or convenience services.
204
Payment adjusted for discontinued or reduced service.
206
National Provider Identifier - missing.
207
National Provider Identifier - Invalid format.
208
National Provider Identifier - Not matched.
213
Non-compliance with the physician self-referral prohibition legislation or payer policy.
214
Workers’ Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment.
220
The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required.
226
Information requested from the billing/rendering provider was not provided or was insufficient/income.
227
Information requested form the patient/insured/responsible party was not provided or was insufficient.
228
Denied for failure of this provider, another provider or the subscriber to supply requested information.
231
Mutually exclusive procedures cannot be done in the same day/setting.
236
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 (NCCI).
239
Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
244
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.
250
The attachment content received is inconsistent with the expected content.
251
The attachment content received did not contain the content required to process this claim or service.
254
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient’s medical plan for further consideration.
256
Service not payable per managed care contract.
258
Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state orlocal authority may cover the claim/service.
267
Claim/service spans multiple months. Rebill as separate claim/service.
268
The claim spans two calendar years. Please resubmit one claim per calendar year.
269
Anesthesia not covered for this service/procedure. Note: Refer to the 835 Healthcare PolicyIdentification Segment (loop 2110 Service Payment Information REF), if present.
270
Claim received by the medical plan, but benefits not available under this plan. Submit theseservices to the patient’s dental plan for further consideration.
272
Coverage/program guidelines were not met.
273
Coverage/program guidelines were exceeded.
274
Fee/service not payable per patient Care Coordination arrangement.
275
Prior payer’s (or payers’) patient responsibility (deductible, coinsurance, copayment) notcovered. (Use only with Group Code PR).
276
Services denied by the prior payer(s) are not covered by this payer.
283
Attending provider is not eligible to provide direction of care.
284
Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.
285
Appeal procedures not followed.
286
Appeal time limits not met.
287
Referral exceeded.
288
Referral absent.
289
Services considered under the dental and medical plans, benefits not available.
299
The billing provider is not eligible to receive payment for the service billed.
A1
Claim/service denied.
A6
Prior hospitalization or 30 day transfer requirement not met.
A8
Ungroupable DRG.
B1
Non-covered visits.
B5
Coverage/program guidelines were not met or were exceeded.
B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B9
Patient is enrolled in a Hospice.
B12
Services not documented in patients’ medical records.
B13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14
Only one visit or consultation per physician per day is covered.
B15
This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
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.
B20
Procedure/service was partially or fully furnished by another provider.
B23
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
D1
Claim/service denied. Level of subluxation is missing or inadequate.
D2
Claim lacks the name, strength, or dosage of the drug furnished.
D3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
D4
Claim/service does not indicate the period of time for which this will be needed.
D5
Claim/service denied. Claim lacks individual lab codes included in the test.
D6
Claim/service denied. Claim did not include patient’s medical record for the service.
D7
Claim.service denied. Claim lacks date of patient’s most recent physician visit.
D8
Claim/service denied. Claim lacks indicator that ‘x-ray is available for review.’
D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
D10
Claim/service denied. Completed physician financial relationship form not on file.
D11
Claim lacks completed pacemaker registration form.
D12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test of the amount you were charged for the test.
D13
Claim/service denied. Performed by the facility/supplier in which the ordering/referring physician has a financial interest.
D14
Claim lacks indication that plan of treatment is on file.
D15
Claim lacks indication that service was supervised or evaluated by a physician.
D16
Claim lacks prior payer payment information.
D17
Claim/Service has invalid non-covered days.
D18
Claim/Service has missing diagnosis information.
D19
Claim/Service lacks Physician/Operative or other supporting documentation.
D20
Claim/Service missing service/product information.
D21
This (these) diagnosis(es) is (are) missing or are invalid.
P2
Not a work related injury/illness and thus not the liability of the Workers’ Compensation carrier.
P3
Workers’ Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement.
P4
Workers’ Compensation claim adjudicated as non-compensable. This payer not liable for claim or service/treatment.
P7
The applicable fee schedule/fee database does not contain the billed code.
P10
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation.
P14
The benefit for this service is included in the payment/allowance for another service/procedure that has been performed on the same day.
P16
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.
P17
Referral not authorized by attending physician per regulatory requirement.
P19
Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
P20
Service not paid under jurisdiction allowed outpatient facility fee schedule.
P21
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP).
W3
The benefit for this service is included in the payment/allowances for another service/procedure that has been performed on the same day.
W5
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction (Use with Group Code CO or OA).
W6
Referral not authorized by attending physician per regulatory requirement.
W9
Service not paid under jurisdiction allowed outpatient facility fee schedule.
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.
Figure 2.G-2  Denial/Adjustment Codes
Adjust/Denial Reason Code
Description
HIPAA Adjustment Reason Codes Release 11/05/2007.
23
The impact of prior payer(s) adjudication including payments and/or adjustments.
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.
59
Processed based on multiple or concurrent procedure rules.
62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
63
Correction to prior claim.
65
Procedure code was incorrect. This payment reflects the correct code.
78
Non-Covered days/Room charge adjustment.
93
No Claim Level Adjustments.
95
Plan procedures not followed.
108
Rent/purchase guidelines were not met.
117
Transportation is only covered to the closest facility that can provide the necessary care.
120
Patient is covered by a managed care plan.
125
Submission/billing error(s).
137
Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
150
Payer deems the information submitted does not support this level of services.
151
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
152
Payer deems the information submitted does not support this length of service.
153
Payer deems the information submitted does not support this dosage.
154
Payer deems the information submitted does not support this day’s supply.
157
Service/procedure was provided as a result of an act of war.
158
Service/procedure was provided outside of the United States.
159
Service/procedure was provided as a result of terrorism.
160
Injury/illness was the result of an activity that is a benefit exclusion.
163
Attachment referenced on the claim was not received.
164
Attachment referenced on the claim was not received in a timely fashion.
165
Referral absent or exceeded.
169
Alternate benefit has been provided.
172
Payment is adjusted when performed/billed by a provider of this specialty.
173
Service was not prescribed by a physician.
178
Patient has not met the required spend down requirements.
179
Patient has not met the required waiting requirements.
180
Patient has not met the required residency requirements.
186
Level of care change adjustment.
189
Not otherwise classified or ‘unlisted’ procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.
190
Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
193
Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
194
Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
195
Refund issued to an erroneous priority payer for this claim/service.
197
Precertification/authorization/notification absent.
198
Precertification/authorization exceeded.
203
Discontinued or reduced service.
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.
210
Payment adjusted because precertification/authorization not received in a timely fashion.
211
National Drug Codes (NDCs) not eligible for rebate, are not covered.
212
Administrative surcharges are not covered.
215
Based on subrogation of a third party settlement.
216
Based on the findings of a review organization.
217
Based on the payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement.
218
Based on the entitlement to benefits.
219
Based on extent of injury.
221
Worker’s Compensation claim is under investigation.
222
Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.
224
Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
233
Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
234
This procedure is not paid separately. At least one Remark Code must be provided.
237
Legislated/regulatory penalty.
238
Claim spans eligible and ineligible periods of coverage, this is a reduction for ineligible period. (Use Group Code PR).
240
The diagnosis is inconsistent with the patient’s birth weight.
241
Low Income Subsidy (LIS) co-payment amount.
242
Services not provided by network/primary care providers.
243
Services not authorized by network/primary care providers.
245
Provider performance program withhold.
246
This non-payable code is for required reporting only.
247
Deductible for professional service rendered in an Institutional setting and billed on an Institutional claim.
248
Coinsurance for professional service rendered in an Institutional setting and billed on an Institutional claim.
252
An attachment is required to adjudicate this claim/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).
253
Sequestration - reduction in federal spending.
257
The disposition of the claim/service is undetermined during the premium payment graceperiod per Health Insurance Exchange requirements. This claim/service will be reversed andcorrected when the grace period ends (due to the premium payment or lack of premiumpayment). (Use only with Group Code OA).
261
The procedure or service is inconsistent with the patient’s history.
278
Performance program proficiency requirements not met. (Use only with Group Code CO or PI.)Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service PaymentInformation REF), if present.
279
Services not provided by Preferred network providers.
280
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.
282
The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
290
Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.
291
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.
292
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.
296
Pre-certification/authorization/notification/pre-treatment number valid but does not apply to provider.
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.
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.
A3
Medicare Secondary Payer liability met.
B4
Late filing penalty.
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.
B8
Alternative services were available, and should have been utilized.
B16
‘New Patient’ qualifications were not met.
B19
Claim/Service adjusted because of the finding of a Review Organization.
B21
The charges were reduced because the service/care was partially furnished by another physician.
B22
This payment is adjusted based on the diagnosis.
D22
Reimbursement was adjusted for the reasons to be provided in separate correspondence.
D23
This dual eligible patient is covered by Medicare Part D per Medicare retro-eligibility.
P5
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement.
P6
Based on entitlement to benefits.
P8
Claim is under investigation.
P9
No available or correlating CPT/HCPCS code to describe this service.
P11
The disposition of the related Property and Casualty claim (injury or illness) is pending due to litigation.
P13
Payment reduced or denied based on Workers’ Compensation jurisdictional regulations or payment policies, use only if no other code is applicable.
P18
Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
P22
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies.
P23
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment.
P27
Payment denied based on the Liability Coverage benefits jurisdictional regulations and/or payment policies. 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') 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 Property and Casualty Auto only.
W2
Payment reduced or denied based on Workers’ Compensation jurisdictional regulations or payment policies, use only if no other code is applicable.
W4
Workers’ Compensation Medical Treatment Guideline Adjustment.
W8
Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
Y2
Payment adjustment 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.
Y3
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdiction fee schedule adjustment.
Figure 2.G-3  Adjustment/Remark Codes
Adjust/Denial Reason Code
Description
HIPAA Adjustment Reason Codes Release 11/05/2007.
1
Deductible amount
2
Coinsurance amount
3
Copayment amount
36
Balance does not exceed copayment amount.
37
Balance does not exceed deductible.
41
Discount agreed to in Preferred Provider contract.
42
Charges exceed our fee schedule or maximum allowable amount.
43
Gramm-Rudman reduction.
44
Prompt-pay discount.
45
Charges exceed fee schedule/maximum allowable or contracted/ legislated fee arrangement.
61
Penalty for failure to obtain second surgical opinion.
64
Denial reversed per Medical Review.
66
Blood Deductible.
67
Lifetime reserve days. (Handled in QTY, QTY01=LA)
68
DRG weight. (Handled in CLP12)
69
Day outlier amount.
70
Cost outlier amount - Adjustment to compensate for additional costs.
71
Primary Payer amount.
72
Coinsurance day. (Handled in QTY, QTY01=CD)
73
Administrative days.
74
Indirect Medical Education (IDME) Adjustment.
75
Direct Medical Education Adjustment.
76
Disproportionate Share Adjustment.
77
Covered days. (Handled in QTY, QTY01=CA)
79
Cost Report days. (Handled in MIA15)
80
Outlier days. (Handled in QTY, QTY01=OU)
81
Discharges.
82
PIP days.
83
Total Visits.
84
Capital Adjustment. (Handled in MIA)
85
Patient Interest Adjustment.
86
Statutory Adjustment.
87
Transfer amount.
88
Adjustment amount represents collection against receivable created in prior overpayment.
90
Ingredient cost adjustment.
91
Dispensing fee adjustment.
92
Claim Paid in full.
94
Processed in Excess of charges.
99
Medicare Secondary Payer Adjustment Amount.
100
Payment made to patient/insured/responsible party/employer.
101
Predetermination: anticipated payment upon completion of services or claim adjudication.
102
Major Medical Adjustment.
103
Provider promotional discount (e.g., Senior citizen discount).
104
Managed care withholding.
105
Tax withholding.
109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
118
ESRD network support adjustment.
121
Indemnification adjustment - compensation for outstanding member responsibility.
122
Psychiatric reduction.
123
Payer refund due to overpayment.
124
Payer refund amount - not our patient.
126
Deductible -- Major Medical
127
Coinsurance -- Major Medical
130
Claim submission fee.
131
Claim specific negotiated discount.
132
Prearranged demonstration project adjustment.
133
The disposition of this claim/service is pending further review.
139
Contracted funding agreement - Subscriber is employed by the provider of services.
142
Monthly Medicaid patient liability amount.
143
Portion of payment deferred.
144
Incentive adjustment, e.g., preferred product/service.
145
Premium payment withholding.
156
Flexible spending account payment.
161
Provider performance bonus.
162
State-mandated requirement for property and casualty.
187
Health Savings account payments.
192
Non-standard adjustment code from paper remittance.
205
Pharmacy discount card processing fee.
223
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.
225
Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837).
229
Partial charge amount not considered by Medicare due to the initial claim Type of Bill (TOB) being 12X.
230
No available or correlating CPT/HCPCS code to describe this service.
232
Institutional transfer amount.
235
Sales tax.
249
This claim has been identified as a readmission. (Use only with Group Code CO).
255
The disposition of the related Property and Casualty claim (illness or injury) is pending due to litigation. (Use only with Group Code OA.)
256
Service not payable per managed care contract.
259
Additional payment for Dental/Vision service utilization.
260
Processed under Medicaid ACA Enhanced Fee Schedule
262
Adjustment for delivery cost. Note: To be used for pharmaceuticals only.
263
Adjustment for shipping cost. Note: To be used for pharmaceuticals only.
264
Adjustment for postage cost. Note: To be used for pharmaceuticals only.
265
Adjustment for administrative cost. Note: To be used for pharmaceuticals only.
266
Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only.
271
Prior contractual reductions related to a current periodic payment as part of a contractualpayment schedule when deferred amounts have been previously reported. (Use only withgroup code OA.)
277
The disposition of the claim/service is undetermined during the premium payment graceperiod, per Health Insurance SHOP Exchange requirements. This claim/service will be reversedand corrected when the grace period ends (due to premium payment or lack of premiumpayment). (Use only with Group Code OA.)
281
Deductible waived per contractual agreement. Use only with Group Code CO.
282
The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
293
Payment made to employer.
294
Payment made to attorney.
295
Pharmacy Direct/Indirect Renumeration.
A0
Patient refund amount.
A2
Contractual adjustment.
A4
Medicare Claim PPS Capital Day Outlier Amount.
A5
Medicare Claim PPS Capital Cost Outlier Amount.
A7
Presumptive Payment Adjustment
B2
Covered visits.
B3
Covered charges.
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.
B11
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
P1
State-mandated requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
P12
Workers’ Compensation jurisdictional fee schedule adjustment.
P15
Workers’ Compensation Medical Treatment Guideline Adjustment.
P24
Payment adjusted based on Preferred Provider Organization (PPO).
P25
Payment adjusted based on Medical Provider Network (MPN).
P26
Payment adjusted based on Voluntary Provider Network (VPN).
P28
Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies.
P29
Liability Benefits jurisdictional fee schedule adjustment.
W1
Workers’ Compensation State Fee Schedule Adjustment
W7
Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
- END -

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