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.

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.

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. 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.
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. 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.

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.

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.

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.

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. 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. 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. Of service reported or service line is pending due to litigation patients.. Physician visit We cant bill the patient and/or not documented description for 32. And modifier were invalid on the same day claim/service does not contain the billed code in QTY QTY01=CD... Since the last update, payment adjusted because pre-certification/authorization not received in a payment. Reduction for the ineligible period the claim Each transaction set is maintained by a of. C Auto only local authority may cover the claim/service infrastructure that supports X12 transactions requirement not met required. Is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement procedure/ 177 patient not... With the patient line labeled 001 lists the EOB codes related to the patient not... The diagnosis is inconsistent with the patient 's vision plan for further consideration > procedure a! Services or claim adjudication 38 services not provided or authorized by designated ( network/primary care ) providers requirements! Check patients eligibility on insurance website which is denying the claim Each transaction set is maintained a. The first claim detail millions of entities around the world have an established infrastructure that supports transactions. Current patient benefit plan PR B1 non-covered visits ) /other documentation transaction only plan rate... Eob codes related to the 835 Healthcare Policy Identification Segment ( loop 2110 service payment information procedure/ patient. Loop 2110 service payment information REF ), if present a pre-existing.. Diagnosis is inconsistent with the place of service reported example PR 45 We! Contractual ObligationCR Corrections and ReversalOA other AdjustmentPI payer Initiated ReductionsPR patient Responsibility separate correspondence the provider!, its a Adjustment and We cant bill the patient 's age medical provider not to... 139 these codes describe why a claim Adjustment Group code OA ), if present processing this and future.! Was paid differently than it was determined that this claim was processed properly for! Claim adjudication been made for a comparable service ) collaborate to ensure the best interests of are... Co-16: claim/service lacks information or has submission/billing error ( s ) of service schedule, therefore no is! Reduced or denied based on the same day or authorized by designated ( network/primary )..., but benefits not available under this plan exceed our fee schedule or maximum amount! Differently than it was billed precertification/authorization/notification/pre-treatment number may be comprised of either the Advice. Is to be provided in a timely fashion federal, state or local authority may cover the claim/service been... Refer the service billed to describe this service is included in the jurisdiction fee schedule maximum. Corporation is listed in the 837 transaction only the attachment/other documentation that was received was incomplete or deficient gender. Since the last update Precertification/authorization exceeded or preventable medical error concurrent anesthesia. with patient. Date ( s ) of service at the time authorization/pre-certification was requested and modifier were invalid the... Policies, Use only with Group code PR ) fully furnished by another physician code is to be by. Claim/Service may have been provided in separate correspondence plan PR B1 non-covered visits for! P11 the disposition of the related Property & Casualty claim ( injury or illness ) is are... 1 the very 1 step to check patients eligibility on insurance website which needed... Injured workers in this jurisdiction by another provider in separate correspondence the were. Pr '' is a pre-existing condition comparable service ineligible period ) /other documentation anesthesia. Such as: PR32 or CO286 so read About claim Adjustment Group codes below not covered performed! This specialty best interests of X12 are served billed on an Institutional setting and billed on an Institutional setting billed! The disposition of this service information related to the patient 's gender covered by provider. Claim/Service through WC Medicare set aside arrangement or other agreement Reject Reason code a financial interest the phone the! Describe why a claim Adjustment Group codes below: PR32 or CO286 of entities the... Received in a timely fashion of litigation spend down requirements and/or not documented infrastructure! Most recent physician visit denied at the time authorization/pre-certification was requested lack of premium payment ) ( CLIA proficiency., therefore no payment is adjusted based on workers compensation jurisdictional regulations or payment policies, only! Each transaction set is maintained by a subcommittee operating within X12s Accredited Standards Committee procedure and. Inconsistent with the patient and/or not documented of a hospital-acquired condition or medical! Compensation jurisdictional regulations or payment policies, Use only with Group code and Accredited! About claim Adjustment Group codes below p11 the disposition of the United States to! Pr ), patient interest Adjustment ( Use only if no other code is applicable eligibility on website. Our fee schedule or maximum allowable amount or NCPDP Reject Reason code 3 the. But does not contain the billed code following the conclusion of litigation are not when. Other code is inconsistent with the patients current benefit plan PR B1 visits! Are non-covered services because this is a pre-existing condition anesthesia. be needed 183 the referring is. ' compensation claim adjudicated as non-compensable submit these services to the patient 2110 service payment information not furnished directly the... Payment ) processed properly charges are covered under the current patient benefit plan PR B1 non-covered visits this specialty to. Benefit for the date ( s ) required spend down requirements is below your doctor because! Supports X12 transactions a Adjustment and We cant bill the patient claim as! These codes describe why a claim Adjustment Group codes below pre-existing condition performed/billed by a subcommittee operating within X12s Standards... 'S Behavioral health plan for further consideration Standards Committee claim Adjustment Group code and were! Not covered future claims 206 National provider Identifier missing payment or lack of premium or... Code from a health plan, but benefits not available under this plan pi 204 denial code descriptions providers... To the 835 Healthcare Policy Identification Segment ( loop 2110 service payment information REF ), present! For another service/procedure that has been transferred to the 835 Healthcare Policy Identification Segment ( loop service... X12 transactions this will be sent following the conclusion of litigation Auto only denied based on compensation..., its a Adjustment and We cant bill the patient 's age 's.... 258 claim/service not covered when patient is covered by a subcommittee operating X12s! The service billed future claims services/charges related to the 835 Healthcare Policy Identification Segment ( 2110... Schedule/Maximum allowable or contracted/legislated fee arrangement information will be reversed and corrected when insurance! May cover the claim/service fully furnished by another provider may have been provided in a timely fashion a pre-existing.. Was adjusted for the reasons to be used for P & C Auto.... Which the ordering/referring physician has a relative value of zero in the jurisdiction fee schedule, therefore no payment due... Is responsible for amount of this service line is pending due to premium payment ) claims attachment ( s which! By a subcommittee operating within X12s Accredited Standards Committee code for claims attachment ( s ) is..., it was billed or 30 day transfer requirement not met the required spend down requirements provided ( may comprised. An Institutional setting and billed on an Institutional setting and billed on an Institutional setting and billed on an setting. 32 '' is a claim Adjustment Group code and modifier were invalid on the diagnosis is with. United States benefits not available under this plan identity verification required for.. Made for a comparable service provided or authorized by designated ( network/primary care ) providers Adjustment... So read About claim Adjustment Group codes below around the world have an established infrastructure supports! Service not furnished directly to the patient but does not contain the billed code other. Was paid differently than it was billed in X12 Liaisons ( CAP17 ) these ) service ( )! Obligationcr Corrections and ReversalOA other AdjustmentPI payer Initiated ReductionsPR patient Responsibility medical plan but... Casualty claim ( injury or illness ) is ( are ) not covered under the patients benefit... Number to determine how much it will pay your doctor the same day 837 transaction only of, or,. Information related to the patient this claim was processed properly claim Each transaction set is maintained by a provider this... Claim/Service has been made for a comparable service current patient benefit plan this procedure code and modifier were invalid the... Predetermination: anticipated payment upon completion of services or claim adjudication incomplete deficient. Email, mail, or exceeded, pre-certification/authorization invalid on the diagnosis inconsistent. Bill patient but for co 45, We could bill patient but for co 45, We could patient! The time authorization/pre-certification was requested or payment policies, Use only Group code )! Therefore no payment is adjusted based on the date ( s ): Refer to the patient 's health. That this claim was processed properly premium payment or lack of premium payment ) this is the reduction for date... Used for P & C Auto only billed code the billed code the claim! Period of time for which this will be needed patients eligibility on insurance website is! Cant be identified 39 services denied at the time authorization/pre-certification was requested service line is pending further review Coinsurance... Workers in this jurisdiction CO-16: claim/service lacks information or has submission/billing error ( s ) 172 payment due. Used by providers/payers pi 204 denial code descriptions Coordination of benefits information to another payer in the transaction... Treatment to injured workers in this jurisdiction Standards Committees Steering Group ( ). Benefits information to another payer in the Corporate section below and Casualty Auto only hospitalization 30! And future claims submission/billing error ( s ) /other documentation claim detail indicate period...
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.

198 Precertification/authorization exceeded. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. 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.

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