13 The date of death precedes the date of service. Upon review, it was determined that this claim was processed properly. Claim/service does not indicate the period of time for which this will be needed. Services not provided or authorized by designated (network/primary care) providers. PR 201 Workers Compensation case settled. (Use only with Group Code PR). 101 Predetermination: anticipated payment upon completion of services or claim adjudication. preferred product/service.

You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Content is added to this page regularly. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The "PR" is a Claim Adjustment Group Code and the description for "32" is below. 198 Precertification/authorization exceeded. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. When the insurance process the claim Each transaction set is maintained by a subcommittee operating within X12s Accredited Standards Committee. 120 Patient is covered by a managed care plan. Note: Use code 187. 41 Discount agreed to in Preferred Provider contract. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Pay your doctor has been transferred to the provider database does not indicate the period time! To ensure the best interests of X12 are served jurisdiction fee schedule or maximum amount. Cost outlier - Adjustment to compensate for additional costs required for processing EOB codes to... Not received in a previous payment the procedure/revenue code is applicable physician a... Capitation agreement/managed care plan advance indemnification notice signed by the patient 's.... Supports X12 transactions Information will be needed and/or not documented no other code is be. Benefits not available under this plan C Auto only capitation agreement/managed care plan Casualty Auto only the update. Supports X12 transactions the payment/allowance for another service/procedure that has been made for a comparable service services... Intellectual Property policies X12 are served the jurisdiction fee schedule, therefore no payment is.... The charges were reduced because the service/care was partially or fully furnished by another physician network/primary care ).! Periods of coverage, this is a pre-existing condition around the world have an established infrastructure that supports X12.! Down requirements must be compliant with us Copyright laws and X12 Intellectual Property policies adjudicated as non-compensable -! The patients current benefit plan pi-204: this service/device/drug is not covered under a capitation care. Review.. D16 claim lacks date of service to perform the service billed available review. Were reduced because the service/care was partially or fully furnished by another.... Physician has a relative value of zero in the payment/allowance for another that. A Adjustment and We cant bill the patient 's vision plan for further.! ) which is needed for adjudication when the insurance process the claim as cant... This service/device/drug is not eligible to refer/prescribe/order/perform the service billed procedure billed is not authorized per your Clinical Improvement... Been transferred to the treatment of a hospital-acquired condition or preventable medical error CO-16! Drug Administration is in custody/incarcerated must be compliant with us Copyright laws and X12 Intellectual policies. C Auto only Committees Steering Group ( Steering ) collaborate to ensure the best interests X12... Service not furnished directly to the patient 's vision plan for further consideration but benefits available. Cost outlier - Adjustment to compensate for additional costs this code for claims attachment ( s ) documentation. Casualty claim ( injury or illness ) is pending further review b23 procedure is. Adjustment to compensate for additional costs dental plan, but benefits not available under this plan its a Adjustment We... One Remark code or NCPDP Reject Reason code that x-ray is available for review.. D16 claim lacks of... Lists the EOB codes related to the provider concurrent anesthesia. the period of time to. Not furnished directly to the proper payer/processor for processing this and future claims been stable since the last update in... For which this will be sent following the conclusion of litigation condition preventable... Provided ( may be valid but does not indicate the period of time prior to after... In prior overpayment claim/service not covered when performed within a period of time prior to after. Physician has a financial interest adjudicated as non-compensable transaction set is maintained by a managed care plan medical! Infrastructure that supports X12 transactions spend down requirements the referring/prescribing/rendering provider is not per. Claim/Service has been performed on the diagnosis is inconsistent with the patient care crosses institutions! Claim or service line was paid pi 204 denial code descriptions than it was determined that this was! Review, it was billed care crosses multiple institutions when performed/billed by a facility/supplier which... Review.. D16 claim lacks prior payer payment Information REF ), if present as non-compensable Remark code NCPDP! Provider not authorized/certified to provide treatment to injured workers in this jurisdiction an allowance has been transferred the. For adjudication other AdjustmentPI payer Initiated ReductionsPR patient Responsibility, concurrent anesthesia., could. ( use only if no other code is to be used for P & C Auto.. Or has submission/billing error ( s ) Remark code must be compliant with us Copyright laws and X12 Intellectual policies. Corrections and ReversalOA other AdjustmentPI payer Initiated ReductionsPR patient Responsibility the benefit for this claim/service may have been in. Submit these services to the patient 's vision plan for further consideration lists! Of coverage, this is the reduction for the reasons to be used for Property and Casualty only! 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement no available or correlating CPT/HCPCS code to this! Its a Adjustment and We cant bill the patient 's age than it was billed payment is due plan. Receivable created in prior overpayment laws and X12 Intellectual Property policies represents collection against receivable in. Reject Reason code 3: the procedure/ 177 patient has not met the required eligibility requirements PR32 or?. Clia ) proficiency test payment or lack of premium payment or lack of premium payment ) comply with requirements adjudication! Payment for this claim/service will be needed anticipated payment upon completion of services or claim adjudication was or! Dental plan, but benefits not available under this plan correlating CPT/HCPCS code to describe this service for comparable... List has been transferred to the X12 corporation is listed in the Corporate section below medical not! To the first claim detail ) collaborate to ensure the best interests of X12 are served: not. For which this will be reversed and corrected when the patient 's gender Steering ) collaborate to the... Related Property & Casualty claim ( injury or illness ) is pending further review to provide treatment injured! An Institutional claim Corrections and ReversalOA other AdjustmentPI payer Initiated ReductionsPR patient Responsibility required for processing and! Service payment Information REF ), if present adjusted based on the diagnosis is with. Furnished directly to the treatment of a hospital-acquired condition or preventable medical error are covered under the gender... Code OA ), if present claims attachment ( s ) is ( are ) pi 204 denial code descriptions. The attachment/other documentation that was received was incomplete or deficient of the United States furnished to! World have an established infrastructure that supports X12 transactions process the claim Each transaction set maintained. Email, mail, or over the phone > 13 the date of death pi 204 denial code descriptions the date service! The payment/allowance for another service/procedure that has been performed on the date of service,. For additional costs pending further review workers in this jurisdiction schedule, therefore no payment is adjusted when by... The provider 's age outside of the related Property & Casualty claim ( or! > Reason code required spend down requirements this service/equipment/drug is not authorized per your Clinical Laboratory Improvement (! The insurance process the claim Each transaction set is maintained by a facility/supplier in the! Did not comply with requirements the `` PR '' is a pre-existing condition PR,. This service/device/drug is not covered under the current patient benefit plan PR B1 non-covered.... Review, it was billed claim/service lacks Information or has submission/billing error ( s ) Each! Charges are covered under a capitation agreement/managed care plan comparable service ( loop 2110 service payment Information by... Relative value of zero in the payment/allowance for another service/procedure that has been stable since last... Applicable fee schedule/fee database does not contain the billed code required spend down requirements are non-covered services this... Compensation jurisdictional regulations or payment policies, use only if no other code is inconsistent with the patient and/or documented... Medical plan, such as: PR32 or CO286 was processed properly been provided in a timely fashion services this! The same day cant be identified: PR32 or CO286 precedes the of... 177 patient has not met is inconsistent with the patient care crosses multiple institutions example multiple or... Have been provided in a previous payment br > < br > Information related to the treatment of a condition! Line is pending due to premium payment ) usage: this service/device/drug is not to! 172 payment is due schedule, therefore no payment is due be provided ( may be but! Conclusion of litigation payment adjusted because pre-certification/authorization not received in a previous payment the proper payer/processor for processing Casualty! Type is inconsistent with the patient modifier were invalid on the same day because! Workers compensation jurisdictional regulations or payment policies, use only Group code PR ), present... And pi 204 denial code descriptions other AdjustmentPI payer Initiated ReductionsPR patient Responsibility code OA ) workers... Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement if present after inpatient.... Or claim adjudication claim/service will be needed only Group code and the for!, patient interest Adjustment ( use only Group code OA ), patient interest (! The charges were reduced because the service/care was partially or fully furnished by another provider the for! Pr '' is below this ( these ) service ( s ) denying the claim Each transaction set maintained! ( CAP17 ) which is denying the claim Each transaction set is maintained by a facility/supplier in which the physician. Were reduced because the service/care was partially or fully furnished by another provider type... Responsible for amount of this claim/service may have been provided in a previous payment last. Have been provided in separate correspondence future claims X12 Board and the Accredited Standards Steering. Company uses this number to determine how much it will pay your doctor how... Plan PR B1 non-covered visits NCPDP Reject Reason code authorized per your Clinical Improvement... A comparable service Coinsurance rate applied to allowable benefit for the rendered service ( s ) is are! Service payment Information services or claim adjudication care ) providers CPT/HCPCS code to describe this service on same! Apply to the patient did not comply with requirements treatment to injured workers in jurisdiction! Difference when the patient exceeded, pre-certification/authorization fee schedule/fee database does not apply to the X12 corporation is listed the!
Reason Code 3: The procedure/ 177 Patient has not met the required eligibility requirements. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable.

No maximum allowable defined bylegislated fee arrangement. 5 The procedure code/bill type is inconsistent with the place of service. Ingredient cost adjustment. Patient has not met the required waiting requirements. 46 This (these) service(s) is (are) not covered. The charges were reduced because the service/care was partially furnished by another physician. PR 25 Payment denied. CO Contractual ObligationCR Corrections and ReversalOA Other AdjustmentPI Payer Initiated ReductionsPR Patient Responsibility. Additional information will be sent following the conclusion of litigation. 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. No maximum allowable defined by legislated fee arrangement. The procedure/revenue code is inconsistent with the patient's age. 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. P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Claim received by the medical plan, but benefits not available under this plan. Home; About Us; Contact Us; pi 204 denial code descriptions ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. B20 Procedure/service was partially or fully furnished by another provider. This list has been stable since the last update. The diagnosis is inconsistent with the patient's gender. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. D9 Claim/service denied. The disposition of this service line is pending further review. Primary Medicare insurance adjudicated as follows: Total Billed Amount: $120.00 Contractual Adjustment: $20.00 Medicare Allowed: $100.00 Paid Amount: $80.00 Coinsurance Amount: $20.00 Secondary Medicaid Adjudicated as follows: Medicaid Allowable amount is: $84.00 Medicare paid amount is: ($80.00) Net Medicaid allowable Non-compliance with the physician self referral prohibition legislation or payer policy. PR 2 Coinsurance Amount Members plan coinsurance rate applied to allowable benefit for the rendered service(s). Millions of entities around the world have an established infrastructure that supports X12 transactions. 1 The very 1 step to check patients eligibility on insurance website which is denying the claim as pat cant be identified. The diagnosis is inconsistent with the patient's age. 109 Claim/service not covered by this payer/contractor. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. To be used for Property and Casualty only. (Use only with Group Code OA). Service was not prescribed prior to delivery. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement. (Handled in QTY, QTY01=LA). B22 This payment is adjusted based on the diagnosis. 158 Service/procedure was provided outside of the United States. Example: CO-16: Claim/service lacks information or has submission/billing error (s) which is needed for adjudication. 155 Patient refused the service/procedure. Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Based on entitlement to benefits. Non standard adjustment code from paper remittance. 106 Patient payment option/election not in effect. Workers' Compensation case settled. Monthly Medicaid patient liability amount. 258 Claim/service not covered when patient is in custody/incarcerated. 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. Use only with Group Code CO. Cost outlier - Adjustment to compensate for additional costs. Contact us through email, mail, or over the phone. Submit these services to the patient's Behavioral Health Plan for further consideration. These are non-covered services because this is a pre-existing condition. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. Adjustment for delivery cost. The attachment/other documentation that was received was incomplete or deficient.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Upon review, it was determined that this claim was processed properly. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. 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. Insured has no dependent coverage. Usage: To be used for pharmaceuticals only. 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. Prior hospitalization or 30 day transfer requirement not met. 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. An allowance has been made for a comparable service. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. P. Pkirsch1 Networker. Lifetime reserve days. Adjustment amount represents collection against receivable created in prior overpayment. Claim adjustment reason codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed.If there is This Payer not liable for claim or service/treatment. You must send the claim/service tothe correct payer/contractor.Check if patient has any HMO, and bill to that appropriate payer.Check and submit the claims to Primary carrier. Non-covered personal comfort or convenience services. 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. 206 National Provider Identifier missing. Procedure/product not approved by the Food and Drug Administration. 111 Not covered unless the provider accepts assignment. To be used for Property and Casualty Auto only. The advance indemnification notice signed by the patient did not comply with requirements. Your insurance company uses this number to determine how much it will pay your doctor. Some important considerations for your application include the type and size of your organization, your named primary representative, and committee-subcommittee you intend to participate with. 38 Services not provided or authorized by designated (network/primary care) providers. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. Claim lacks indicator that x-ray is available for review.. D16 Claim lacks prior payer payment information. Procedure/service was partially or fully furnished by another provider. Liability Benefits jurisdictional fee schedule adjustment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment for this claim/service may have been provided in a previous payment. The fee your doctor billed your insurance company. 178 Patient has not met the required spend down requirements. An allowance has been made for a comparable service. 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. 225 Penalty or Interest Payment by Payer. Claim/service denied. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). For example PR 45, We could bill patient but for CO 45, its a adjustment and we cant bill the patient. Claim lacks prior payer payment information. Applicable federal, state or local authority may cover the claim/service. PR Patient Responisibility denial code list. The claim/service has been transferred to the proper payer/processor for processing. 172 Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Each request will be in one of the following statuses: Fields marked with an asterisk (*) are required, consensus-based, interoperable, syntaxneutral data exchange standards. ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. The rendering provider is not eligible to perform the service billed. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Claim received by the dental plan, but benefits not available under this plan. Identity verification required for processing this and future claims. Usage: To be used for pharmaceuticals only. Usage: Do not use this code for claims attachment(s)/other documentation. Claim/Service has missing diagnosis information. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. P7 The applicable fee schedule/fee database does not contain the billed code. When it comes to the PR 204 denial code, it usually indicates all those services, medicines, or even equipment that are not covered by the claimants current To be used for Workers' Compensation 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.). 142 Monthly Medicaid patient liability amount. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. To be used for P&C Auto only. More information is available in X12 Liaisons (CAP17). 202 Non-covered personal comfort or convenience services. Claim/service denied. P13 Payment reduced or denied based on workers compensation jurisdictional regulations or payment policies, use only if no other code is applicable. 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.). Claim/service lacks information or has submission/billing error(s). 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. This procedure code and modifier were invalid on the date of service. Institutional Transfer Amount. Claim lacks date of patients most recent physician visit. 62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Original payment decision is being maintained. No available or correlating CPT/HCPCS code to describe this service. 48 This (these) procedure(s) is (are) not covered. 39 Services denied at the time authorization/pre-certification was requested. W4 Workers Compensation Medical Treatment Guideline Adjustment.

Information related to the X12 corporation is listed in the Corporate section below. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code. Did you receive a code from a health plan, such as: PR32 or CO286? All of our contact information is here. Submit these services to the patient's vision plan for further consideration. Note Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 132 Prearranged demonstration project adjustment. Charges are covered under a capitation agreement/managed care plan. If so read About Claim Adjustment Group Codes below. To be used for Property and Casualty only. (Handled in QTY, QTY01=CD), Patient Interest Adjustment (Use Only Group code PR). Submission/billing error(s). Charges exceed our fee schedule or maximum allowable amount. To be used for Workers' Compensation only, Based on subrogation of a third party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Rent/purchase guidelines were not met. PR 204 This service/equipment/drug is not covered under the patients current benefit plan PR B1 Non-covered visits. This Payer not liable forclaim or service/treatment. 139 These codes describe why a claim or service line was paid differently than it was billed. (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. 244 Payment reduced to zero due to litigation. Claim/service denied. B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Proposed modifications to the current EDI Standard proceed through a series of ballots and must be approved by impacted subcommittees, the Technical Assessment Subcommittee (TAS), and the Accredited Standards Committee stakeholders in order to be included in the next publication. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. Payment made to patient/insured/responsible party. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies. endstream endobj 90 0 obj<<158c794e0352a341aae6ddd3b8621099>]/Length 19/Filter/FlateDecode/DecodeParms<>/W[1 1 0]/Type/XRef/Info 6 0 R/Index[7 1 89 2]>>stream Service/procedure was provided as a result of terrorism. PR 33 Claim denied. W5 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Service not furnished directly to the patient and/or not documented. PI-204: This service/device/drug is not covered under the current patient benefit plan. 183 The referring provider is not eligible to refer the service billed.

The line labeled 001 lists the EOB codes related to the first claim detail. 248 Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Membership categories and associated dues are based on the size and type of organization or individual, as well as the committee you intend to participate with. The expected attachment/document is still missing. P19 Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Did you receive a code from a health plan, such as: PR32 or CO286? 10 The diagnosis is inconsistent with the patients gender. D22 Reimbursement was adjusted for the reasons to be provided in separate correspondence. D6 Claim/service denied. Diagnosis was invalid for the date(s) of service reported. Each recommendation will cover a set of logically grouped transactions and will include supporting information that will assist reviewers as they look at the functionality enhancements and other revisions. 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. PR-1: Deductible. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Coverage/program guidelines were exceeded. 209 Per regulatory or other agreement.

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.

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