Time is money and calling insurance carriers some consider is a waste of time. I don't mind calling the insurance carriers but I normally do my own research on the claim prior to placing the call.
I find that reading Explanation of Benefits can be tricky for some people and I think in my next blog I will write about EOB's and how to read them but for now let's look at some tricks in reading Medicare's EOB's.
Medicare says that these questions are becoming their top tiered questions -
Call: CO-16 this code usually means the claim denied as unprocessable because information was missing or invalid
Resolution: Review the next Remittance Advice code under the CO-16 for the reason why the claim was denied.
Call: I'm working from a report
Resolution: Medicare would like clients to review the Remittance Advice tied to the Explanation of Benefits or Electronic Remittance Advice prior to calling on any claim (this means they would like you to review documentation supplied prior to calling them and wasting their time)
Call: I only know the claim did not pay and I was asked to call -
Resolution: Medicare recommends trying the IVR (interactive voice Response system) prior to talking with a Customer Support Rep or pulling out the EOB or ERA.
Call: I don't have the last page of the Remittance Advice
Resolution: You are getting the codes but you can't tell what they mean so you can either find the original Remittance Advice form or compare your codes to this list which was effective in December 2007:
Payment Reason Codes
CO1
Deductible Amount
CO10
The diagnosis is inconsistent with the patient's gender. Note: Changed as of 2/00
CO100
Payment made to patient/insured/responsible party.
CO101
Predetermination: anticipated payment upon completion of services or claim adjudication. Note: Changed as of 2/99
CO102
Major Medical Adjustment.
CO103
Provider promotional discount (e.g., Senior citizen discount). Note: Changed as of 6/01
CO104
Managed care withholding.
CO105
Tax withholding.
CO106
Patient payment option/election not in effect.
CO107
Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. Note: Changed as of 6/03
CO108
Payment adjusted because rent/purchase guidelines were not met. Note: Changed as of 6/02
CO109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO11
The diagnosis is inconsistent with the procedure.
CO110
Billing date predates service date.
CO111
Not covered unless the provider accepts assignment.
CO112
Payment adjusted as not furnished directly to the patient and/or not documented. Note: Changed as of 2/01
CO113
Payment denied because service/procedure was provided outside the United States or as a result of war. Note: Changed as of 2/01
CO114
Procedure/product not approved by the Food and Drug Administration.
CO115
Payment adjusted as procedure postponed or canceled. Note: Changed as of 2/01
CO116
Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. Note: Changed as of 2/01
CO117
Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. Note: Changed as of 2/01
CO118
Charges reduced for ESRD network support.
CO119
Benefit maximum for this time period has been reached.
CO12
The diagnosis is inconsistent with the provider type.
CO120
Patient is covered by a managed care plan. Note: Inactive for 004030, since 6/99. Use code 24.
CO121
Indemnification adjustment.
CO122
Psychiatric reduction.
CO123
Payer refund due to overpayment. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
CO124
Payer refund amount - not our patient. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
CO125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Note: Changed as of 2/02
CO126
Deductible -- Major Medical Note: New as of 2/97
CO127
Coinsurance -- Major Medical Note: New as of 2/97
CO128
Newborn's services are covered in the mother's Allowance. Note: New as of 2/97
CO129
Payment denied - Prior processing information appears incorrect. Note: Changed as of 2/01
CO13
The date of death precedes the date of service.
CO130
Claim submission fee. Note: Changed as of 6/01
CO131
Claim specific negotiated discount. Note: New as of 2/97
CO132
Prearranged demonstration project adjustment. Note: New as of 2/97
CO133
The disposition of this claim/service is pending further review. Note: Changed as of 10/99
CO134
Technical fees removed from charges. Note: New as of 10/98
CO135
Claim denied. Interim bills cannot be processed. Note: New as of 10/98
CO136
Claim Adjusted. Plan procedures of a prior payer were not followed. Note: Changed as of 6/00
CO137
Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Note: New as of 2/99
CO138
Claim/service denied. Appeal procedures not followed or time limits not met. Note: New as of 6/99
CO139
Contracted funding agreement - Subscriber is employed by the provider of services. Note: New as of 6/99
CO14
The date of birth follows the date of service.
CO140
Patient/Insured health identification number and name do not match. Note: New as of 6/99
CO141
Claim adjustment because the claim spans eligible and ineligible periods of coverage. Note: Changed as of 6/00
CO142
Claim adjusted by the monthly Medicaid patient liability amount. Note: New as of 6/00
CO143
Portion of payment deferred. Note: New as of 2/01
CO144
Incentive adjustment, e.g. preferred product/service. Note: New as of 6/01
CO145
Premium payment withholding Note: New as of 6/02
CO146
Payment denied because the diagnosis was invalid for the date(s) of service reported. Note: New as of 6/02
CO147
Provider contracted/negotiated rate expired or not on file. Note: New as of 6/02
CO148
Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. Note: New as of 6/02
CO149
Lifetime benefit maximum has been reached for this service/benefit category. Note: New as of 10/02
CO15
Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Note: Changed as of 2/01
CO150
Payment adjusted because the payer deems the information submitted does not support this level of service. Note: New as of 10/02
CO151
Payment adjusted because the payer deems the information submitted does not support this many services. Note: New as of 10/02
CO152
Payment adjusted because the payer deems the information submitted does not support this length of service. Note: New as of 10/02
CO153
Payment adjusted because the payer deems the information submitted does not support this dosage. Note: New as of 10/02
CO154
Payment adjusted because the payer deems the information submitted does not support this day's supply. Note: New as of 10/02
CO155
This claim is denied because the patient refused the service/procedure. Note: New as of 6/03
CO16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate Note: Changed as of 2/02
CO165
Payment denied/reduced for absence of, or exceeded, referral .
CO167
This (these) diagnosis (es) is (are) not covered.
CO169
Payment adjusted because an alternate benefit has been provided.
CO17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. Note: Changed as of 2/02
CO170
Payment denied when performed/billed by this type of provider.
CO171
Payment denied when performed/billed by this type of provider in this type of facility.
CO172
Payment adjusted when performed/billed by a provider of this specialty.
CO177
Payment denied because patient has not met the required eligibility requirements.
CO178
Payment adjusted because the patient has not met the required spend down requirements.
CO18
Duplicate claim/service.
CO181
Payment adjusted because this procedure code was invalid on the date of service.
CO183
The referring provider is not eligible to refer the service billed.
CO185
The rendering provider is not eligible to perform the service billed.
CO19
Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
CO2
Coinsurance Amount
CO20
Claim denied because this injury/illness is covered by the liability carrier.
CO21
Claim denied because this injury/illness is the liability of the no-fault carrier.
CO22
Payment adjusted because this care may be covered by another payer per coordination of benefits. Note: Changed as of 2/01
CO23
Payment adjusted because charges have been paid by another payer. Note: Changed as of 2/01
CO24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Note: Changed as of 6/00
CO25
Payment denied. Your Stop loss deductible has not been met.
CO26
Expenses incurred prior to coverage.
CO27
Expenses incurred after coverage terminated.
CO28
Coverage not in effect at the time the service was provided. Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
CO29
The time limit for filing has expired.
CO3
Co-payment Amount
CO30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Note: Changed as of 2/01
CO31
Claim denied as patient cannot be identified as our insured.
CO32
Our records indicate that this dependent is not an eligible dependent as defined.
CO33
Claim denied. Insured has no dependent coverage.
CO34
Claim denied. Insured has no coverage for newborns.
CO35
Lifetime benefit maximum has been reached. Note: Changed as of 10/02
CO36
Balance does not exceed co-payment amount. Note: Inactive for 003040
CO37
Balance does not exceed deductible. Note: Inactive for 003040
CO38
Services not provided or authorized by designated (network/primary care) providers. Note: Changed as of 6/03
CO39
Services denied at the time authorization/pre-certification was requested.
CO4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
CO40
Charges do not meet qualifications for emergent/urgent care.
CO41
Discount agreed to in Preferred Provider contract. Note: Inactive for 003040
CO42
Charges exceed our fee schedule or maximum allowable amount.
CO43
Gramm-Rudman reduction.
CO44
Prompt-pay discount.
CO45
Charges exceed your contracted/ legislated fee arrangement.
CO46
This (these) service(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96.
CO47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Note: Changed as of 6/00
CO48
This (these) procedure(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96.
CO49
These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO5
The procedure code/bill type is inconsistent with the place of service.
CO50
These are non-covered services because this is not deemed a `medical necessity' by the payer.
CO51
These are non-covered services because this is a pre-existing condition
CO52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Note: Changed as of 10/98
CO53
Services by an immediate relative or a member of the same household are not covered.
CO54
Multiple physicians/assistants are not covered in this case .
CO55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO56
Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
CO57
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. Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
CO58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Changed as of 2/01
CO59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. Note: Changed as of 6/00
CO6
The procedure/revenue code is inconsistent with the patient's age. Note: Changed as of 6/02
CO60
Charges for outpatient services with this proximity to inpatient services are not covered.
CO61
Charges adjusted as penalty for failure to obtain second surgical opinion. Note: Changed as of 6/00
CO62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Note: Changed as of 2/01
CO63
Correction to a prior claim. Note: Inactive for 003040
CO64
Denial reversed per Medical Review. Note: Inactive for 003040
CO65
Procedure code was incorrect. This payment reflects the correct code. Note: Inactive for 003040
CO66
Blood Deductible.
CO67
Lifetime reserve days. (Handled in QTY, QTY01=LA) Note: Inactive for 003040
CO68
DRG weight. (Handled in CLP12) Note: Inactive for 003040
CO69
Day outlier amount.
CO7
The procedure/revenue code is inconsistent with the patient's gender. Note: Changed as of 6/02
CO70
Cost outlier - Adjustment to compensate for additonal costs. Note: Changed as of 6/01
CO71
Primary Payer amount. Note: Deleted as of 6/00. Use code 23.
CO72
Coinsurance day. (Handled in QTY, QTY01=CD) Note: Inactive for 003040
CO73
Administrative days. Note: Inactive for 003050
CO74
Indirect Medical Education Adjustment.
CO75
Direct Medical Education Adjustment.
CO76
Disproportionate Share Adjustment.
CO77
Covered days. (Handled in QTY, QTY01=CA) Note: Inactive for 003040
CO78
Non-Covered days/Room charge adjustment.
CO79
Cost Report days. (Handled in MIA15) Note: Inactive for 003050
CO8
The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Changed as of 6/02
CO80
Outlier days. (Handled in QTY, QTY01=OU) Note: Inactive for 003050
CO81
Discharges. Note: Inactive for 003040
CO82
PIP days. Note: Inactive for 003040
CO83
Total visits. Note: Inactive for 003040
CO84
Capital Adjustment. (Handled in MIA) Note: Inactive for 003050
CO85
Interest amount.
CO86
Statutory Adjustment. Note: Inactive for 004010, since 6/98. Duplicative of code 45.
CO87
Transfer amount.
CO88
Adjustment amount represents collection against receivable created in prior overpayment. Note: Inactive for 004050.
CO89
Professional fees removed from charges.
CO9
The diagnosis is inconsistent with the patient's age.
CO90
Ingredient cost adjustment.
CO91
Dispensing fee adjustment.
CO92
Claim Paid in full. Note: Inactive for 003040
CO93
No Claim level Adjustments. Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
CO94
Processed in Excess of charges.
CO95
Benefits adjusted. Plan procedures not followed. Note: Changed as of 6/00
CO96
Non-covered charge(s).
CO97
Payment is included in the allowance for another service/procedure. Note: Changed as of 2/99
CO98
The hospital must file the Medicare claim for this inpatient non-physician service. Note: Inactive for 003040
CO99
Medicare Secondary Payer Adjustment Amount. Note: Inactive for 003040
COA0
Patient refund amount.
COA1
Claim denied charges.
COA2
Contractual adjustment.
COA3
Medicare Secondary Payer liability met. Note: Inactive for 004010, since 6/98.
COA4
Medicare Claim PPS Capital Day Outlier Amount.
COA5
Medicare Claim PPS Capital Cost Outlier Amount.
COA6
Prior hospitalization or 30 day transfer requirement not met. Note:
COA7
Presumptive Payment Adjustment Note:
COA8
Claim denied; ungroupable DRG
COB1
Non-covered visits. Note:
COB10
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. Note:
COB11
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. Note:
COB12
Services not documented in patients' medical records. Note:
COB13
Previously paid. Payment for this claim/service may have been provided in a previous payment. Note:
COB14
Payment denied because only one visit or consultation per physician per day is covered. Note: Changed as of 2/01
COB15
Payment adjusted because this procedure/service is not paid separately. Note: Changed as of 2/01
COB16
Payment adjusted because `New Patient' qualifications were not met. Note: Changed as of 2/01
COB17
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. Note: Changed as of 2/01
COB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission. Note: Changed as of 2/01
COB19
Claim/service adjusted because of the finding of a Review Organization. Note: Inactive for 003070
COB2
Covered visits. Note: Inactive for 003040
COB20
Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01
COB21
The charges were reduced because the service/care was partially furnished by another physician. Note: Inactive for 003040
COB22
This payment is adjused based on the diagnosis. Note: Changed as of 2/01
COB23
Payment denied because this provider has failed an aspect of a proficiency testing program. Note: Changed as of 2/01
COB3
Covered charges. Note: Inactive for 003040
COB4
Late filing penalty.
COB5
Payment adjusted because coverage/program guidelines were not met or were exceeded. Note: Changed as of 2/01
COB6
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. Note: Changed as of 2/01
COB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Changed as of 10/98
COB8
Claim/service not covered/reduced because alternative services were available, and should have been utilized.
COB9
Services not covered because the patient is enrolled in a Hospice.
COD1
Claim/service denied. Level of subluxation is missing or inadequate. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD10
Claim/service denied. Completed physician financial relationship form not on file. Note: Inactive for 003070, since 8/97. Use code 17.
COD11
Claim lacks completed pacemaker registration form. Note: Inactive for 003070, since 8/97. Use code 17.
COD12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Note: Inactive for 003070, since 8/97. Use code 17.
COD13
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Note: Inactive for 003070, since 8/97. Use code 17.
COD14
Claim lacks indication that plan of treatment is on file. Note: Inactive for 003070, since 8/97. Use code 17.
COD15
Claim lacks indication that service was supervised or evaluated by a physician. Note: Inactive for 003070, since 8/97. Use code 17.
COD18
Inactive for 4010 as of 2/99.
COD19
Claim service lacks physician/operative or other supporting documentation (inactive as of version 5010; use code 16).
COD2
Claim lacks the name, strength, or dosage of the drug furnished. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD21
This (these) diagnosis (es) is (are) missing or is (are) invalid.
COD3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD4
Claim/service does not indicate the period of time for which this will be needed. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD5
Claim/service denied. Claim lacks individual lab codes included in the test. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD6
Claim/service denied. Claim did not include patient's medical record for the service. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD7
Claim/service denied. Claim lacks date of patient's most recent physician visit. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD8
Claim/service denied. Claim lacks indicator that `x-ray is available for review.' Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COD9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
COW1
Workers Compensation State Fee Schedule Adjustment Note: New as of 2/00
CR A2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CR07
The procedure/revenue code is inconsistent with the patients gender.
CR1
Deductible amount.
CR10
The diagnosis is inconsistent with the patients gender.
CR100
Payment made to patient/insured/responsible party.
CR102
Major medical adjustment.
CR104
Managed care withholding.
CR107
Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
CR109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CR11
The diagnosis is inconsistent with the patients gender.
CR112
Payment adjusted as not furnished directly to the patient and/or not documented.
CR119
Benefit maximum for this time period or occurrence has been reached.
CR121
Indemnification adjustment.
CR125
Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
CR127
Coinsurance - major medical.
CR129
Payment denied. Prior processing information appears incorrect.
CR13
The date of death precedes the date of service.
CR131
Claim specific negotiated discount.
CR133
The disposition of the claim/service is pending further review.
CR137
Payment/reduction for surcharges, assessments, allowances, or health related taxes.
CR144
Incentive adjustment, e.g., preferred product/service.
CR145
Premium payment withholding.
CR148
Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
CR149
Lifetime benefit maximum has been reached for this service/benefit category.
CR150
Payment adjusted because the payer deems the information submitted does not support this level of service.
CR151
Payment adjusted because the payer deems the information submitted does not support this many services .
CR16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
CR165
Payment denied/reduced for absence of, or exceeded, referral .
CR17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
CR170
Payment adjusted when performed/billed by a provider of this type of provider.
CR172
Payment adjusted when performed/billed by a provider of this specialty.
CR179
Payment adjusted because the patient has not met the required waiting requirements.
CR18
Duplicate claim/service.
CR180
Payment adjusted because the patient has not met the required residency requirements.
CR183
The referring provider is not eligible to refer the service billed.
CR185
The rendering provider is not eligible to perform the service billed.
CR187
Health savings account payments.
CR19
Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
CR2
Coinsurance amount.
CR20
Claim denied because this injury/illness is covered by the liability carrier.
CR21
Claim denied because this injury/illness is the liability of the no-fault carrier.
CR22
Payment adjusted because this care may be covered by another payer per coordination of benefits.
CR23
Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.
CR24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
CR26
Expenses incurred prior to coverage.
CR27
Expenses incurred after coverage terminated.
CR29
The time limit for filing has expired.
CR3
Copayment amount.
CR30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
CR31
Claim denied as patient cannot be identified as our insured.
CR32
Our records indicate that this dependent is not an eligible dependent as defined.
CR33
Claim denied - insured has no dependent coverage.
CR34
Claim denied - insured has no coverage for newborns.
CR35
Lifetime benefit maximum has been reached.
CR38
Services not provided or authorized by designated (network/primary care) providers .
CR39
Services denied at the time authorization/precertification was requested.
CR4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
CR40
Charges do not meet qualifications for emergent/urgent care.
CR42
Charges exceed our fee schedule or maximum allowable amount.
CR45
Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CR46
This (these) service (s) is (are) not covered.
CR47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
CR48
This (these) procedure (s) is (are) not covered.
CR49
These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CR5
The procedure code/bill type is inconsistent with the place of service.
CR50
These are noncovered services because this is not deemed a "medical necessity" by the payer.
CR51
These are noncovered services because this is a preexisting condition.
CR52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
CR54
Multiple physicians/assistants are not covered in this case.
CR55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CR56
Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
CR57
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.
CR58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
CR59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
CR6
The procedure/revenue code is inconsistent with the patient's age.
CR62
Payment denied/reduced for absence of, or exceeded, precertification/authorization.
CR63
Correction to a prior claim.
CR7
The procedure/revenue code is inconsistent with the patients gender.
CR85
Interest amount.
CR88
Adjustment amount represents collection against receivable created in prior overpayment.
CR9
The diagnosis is inconsistent with the patients age.
CR94
Processed in excess of charges.
CR95
Benefits adjusted. Plan procedures not followed.
CR96
Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
CR97
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
CRA1
Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
CRA2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CRA6
Prior hospitalization or 30-day transfer requirement not met.
CRB1
Noncovered visits.
CRB10
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.
CRB11
Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
CRB12
Services not documented in patient's medical records.
CRB13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
CRB14
Payment denied because only one visit or consultation per physician per day is covered.
CRB15
Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
CRB16
Payment adjusted because "new patient" qualifications were not met.
CRB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
CRB20
Payment adjusted because procedure/service was partially or fully furnished by another provider.
CRB22
This payment is adjusted based on the diagnosis.
CRB3
Covered charges.
CRB5
Payment adjusted because coverage/program guidelines were not met or were exceeded.
CRB6
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.
CRB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CRB9
Services not covered because the patient is enrolled in hospice.
CRD19
Claim/service lacks physician/operative or other supporting documentation .
CRD21
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
PR02
Coinsurance amount.
PR07
The procedure/revenue code is inconsistent with the patients gender.
PR1
Deductible amount.
PR10
The diagnosis is inconsistent with the patients gender.
PR100
Payment made to patient/insured/responsible party.
PR104
Managed care withholding.
PR107
Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PR109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
PR11
The diagnosis is inconsistent with the procedure.
PR111
Not covered unless the provider accepts assignment.
PR112
Payment adjusted as not furnished directly to the patient and/or not documented.
PR117
Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
PR119
Benefit maximum for this time period or occurrence has been reached.
PR125
Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
PR126
Deductible - major medical.
PR127
Coinsurance - major medical.
PR129
Payment denied. Prior processing information appears incorrect.
PR13
The date of death precedes the date of service.
PR131
Claim specific negotiated discount.
PR133
The disposition of the claim/service is pending further review.
PR136
Claim adjusted based on failure to follow prior payer's coverage rules.
PR137
Payment/reduction for regulatory surcharges, assessments, allowances, or health related taxes.
PR138
Claim/service denied. Appeal procedures not followed or time limits not met.
PR140
Patient/insured health identification number and name do not match.
PR141
Claim adjustment because the claim spans eligible and ineligible periods of coverage.
PR145
Premium payment withholding.
PR147
Provider contracted/negotiated rate expired or not on file.
PR149
Lifetime benefit maximum has been reached for this service/benefit category.
PR15
Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
PR150
Payment adjusted because the payer deems the information submitted does not support this level of service.
PR151
Payment adjusted because the payer deems the information submitted does not support this many services .
PR156
Flexible spending account payments.
PR16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
PR167
This (these) diagnosis (es) is (are) not covered.
PR17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
PR170
Payment denied when performed/billed by this type of provider.
PR171
Payment denied when performed/billed by this type of provider in this type of facility.
PR172
Payment adjusted when performed/billed by a provider of this specialty.
PR177
Payment denied because the patient has not met the required eligibility requirements.
PR179
Payment adjusted because the patient has not met the required waiting requirements.
PR18
Duplicate claim/service.
PR180
Payment adjusted because the patient has not met the required residency requirements.
PR183
The referring provider is not eligible to refer the service billed.
PR184
The prescribing/ordering provider is not eligible to prescribe/order the service billed.
PR185
The rendering provider is not eligible to perform the service billed.
PR19
Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
PR2
Coinsurance amount.
PR20
Claim denied because this injury/illness is covered by the liability carrier.
PR21
Claim denied because this injury/illness is the liability of the no-fault carrier.
PR22
Payment adjusted because this care may be covered by another payer per coordination of benefits.
PR23
Payment adjusted due to the impact of prior payer's) adjudication including payments and/or adjustments.
PR24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR26
Expenses incurred prior to coverage.
PR27
Expenses incurred after coverage terminated.
PR28
Coverage not in effect at the time the service was provided.
PR29
The time limit for filing has expired.
PR3
Copayment amount.
PR30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
PR31
Claim denied as patient cannot be identified as our insured.
PR32
Our records indicate that this dependent is not an eligible dependent as defined.
PR33
Claim denied - insured has no dependent coverage.
PR34
Claim denied - insured has no coverage for newborns.
PR35
Lifetime benefit maximum has been reached.
PR38
Services not provided or authorized by designated (network/primary care) providers .
PR39
Services denied at the time authorization/precertification was requested.
PR4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
PR40
Charges do not meet qualifications for emergent/urgent care.
PR42
Charges exceed our fee schedule or maximum allowable amount.
PR45
Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
PR46
This (these) service (s) is (are) not covered.
PR47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
PR48
This (these) procedure (s) is (are) not covered.
PR49
These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
PR5
Procedure code/bill type is inconsistent with the place of service.
PR50
These are noncovered services because this is not deemed a "medical necessity" by the payer.
PR51
These are noncovered services because this is a preexisting condition.
PR52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
PR54
Multiple physicians/assistants are not covered in this case.
PR55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
PR56
Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
PR57
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.
PR58
Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
PR59
Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
PR6
The procedure/revenue code is inconsistent with the patient's age.
PR62
Payment denied/reduced for absence of, or exceeded, precertification/authorization.
PR63
Correction to a prior claim.
PR7
The procedure/revenue code is inconsistent with the patients gender.
PR8
The procedure code is inconsistent with the provider type/specialty (taxonomy) .
PR87
Transfer amount.
PR9
The diagnosis is inconsistent with the patients age.
PR92
Claim paid in full.
PR94
Processed in excess of charges.
PR95
Benefits adjusted. Plan procedures not followed.
PR96
Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
PR97
Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
PRA1
Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
PRA2
Contractual adjustment (inactive for 004060; use code 45 with group code CO).
PRA6
Prior hospitalization or 30-day transfer requirement not met.
PRB1
Noncovered visits.
PRB11
Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
PRB12
Services not documented in patient's medical records.
PRB13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
PRB14
Payment denied because only one visit or consultation per physician per day is covered.
PRB15
Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
PRB16
Payment adjusted because "new patient" qualifications were not met.
PRB18
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
PRB20
Payment adjusted because procedure/service was partially or fully furnished by another provider.
PRB22
This payment is adjusted based on the diagnosis.
PRB5
Payment adjusted because coverage/program guidelines were not met or were exceeded.
PRB6
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.
PRB7
This provider was not certified/eligible to be paid for this procedure/service on this date of service.
PRB8
Claim/service not covered/reduced because alternative services were available and should have been utilized.
PRB9
Services not covered because the patient is enrolled in hospice.
PRD19
Claim/service lacks physician/operative or other supporting documentation .
PRD21
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Medicare is asking that everyone learn the new Electronic Remittance Advice coding system and identify your own answers prior to calling their Customer Service department. Sounds like a easy task but we all know a live human being can usually give us more information then what we find on the Explanation of Benefits.
However if we all cut back on our in-coming phone calls maybe Medicare can save some money and be around for when I retire...
Additional Medical Billing and Codingquestions are answered here: Online Medical Coding and Billing Courses
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