CODE DETAIL_DESCRIPTION EDI_CROSSWALK

Transcription

1 CODE DETAIL_DESCRIPTION EDI_CROSSWALK 030 Missing service provider zip code (box 32) 835:CO* Missing pickup zip code on the claim 835:CO* Billed charges should be zero for home health claim 835:CO* Hospital based ASC claim can't be submitted on UB form 835:CO* Service dates are not in the same calendar year 835:CO* Invalid place of service 835:CO* Invalid type of bill 835:CO* Subscriber not actively enrolled on service date 835:CO* Member not actively enrolled on service date 835:CO* No coverage during service period 835:CO* Coverage change during service period Benefit not covered for spouse 835:CO* Benefit not covered for dependent 835:CO* COB Claim 835:CO* This is COB claim for a member who does not have double_coverage Out of network provider: submit the claim to Cofinity for pricing. P.O. Box 2720 Farmington Hills, MI Allowed amount is Zero Multiple primary coverage Submitted Allowed amount present on a Complete Process (CP) claim Type of Bill - Deny Action Service date after receive date Date of service before date of birth 835:CO* Interim billing 835:CO* Missing Diagnosis pointer OR Invalid ICD Diagnosis code 835:CO* Additional digit is required for the ICD Diagnosis code 835:CO* Unknown CPT code - Please resubmit with a HIPAA valid CPT code 835:CO* Inactive CPT code - Please resubmit with a HIPAA valid CPT code 835:CO* Unknown Modifier - Please resubmit with a HIPAA valid Modifier 835:CO*4 207 Unknown ICD Procedure code - Please resubmit with a valid code 835:CO*47

2 215 Missing Admission source for the Revenue code submitted, for NONPPO provider Invalid Value Codes for the Revenue codes submitted, for NONPPO provider HOST claim cannot be submitted with zero total charges Referring provider NPI is missing in Ancillary claim Current claim falls within the history claim date range Current claim falls outside the history claim date range Unknown Secondary ICD Diagnosis Code Invalid Diagnosis Code Invalid Secondary Diagnosis Code Invalid Procedure code Authorization is required for this service No proper auth has been obtain by provider or member, copayment amount in case o 835:CO* Applied benefit per authorized network Applied benefits per authorized network. Missing auth network on line(s) Not enough money in the COB Savings to pay member obligation Claim submitted with ICD9 Diagnosis codes. Please re-submit claim with ICD10 Diagnosis codes Claim submitted with ICD10 Diagnosis codes. Please re-submit claim with ICD9 Diagnosis codes Unlisted code - Please resubmit using a more specific code and/or a description of code 835:CO* Payment Reduced by Deductible Amount 835:PR*1 302 A copayment has been applied to this service 835:PR*3 303 A coinsurance has been applied to this service 835:PR*2 304 Member in Hospice Reduced paid by percent_allowed after out_of_pocket is met 835:PR*2 306 Payment adjusted based on modifier submitted 835:CO* Additional digit is required for the Secondary ICD Diagnosis code -

3 310 Family Deductible limit is met Reduced paid by provider withhold 835:CO* Reduced allowed by Subro amount Number of visit per year exceed max, reduced visits Number of visits exceeded max, reduced visits Applied copay balance Unable to take balance copay There is no paid amount after applied copay balance Recalculated allowed amount Reduced Amount BY MAX Allowed 835:CO* Individual out of pocket limit for benefit year is met Copay has already been taken for this visit. 835:CO*B5 333 Family lifetime max limit is met 835:CO* Family out of pocket limit for benefit year is met 835:CO* Individual lifetime out of pocket limit is met 835:CO* Family lifetime out of pocket limit is met Number of copayment met Reduced number of copays Alternate HHRG Code and anticipate payment is available. Check Report for details Individual Deductible limit is met Exceeded max allowed amount for claim 835:CO* Member annual allowed amount exceeded max 835:CO* Annual allowed amount for ben_cat exceeds max. 835:CO*B5 346 Member lifetime allowed amount exceeded max 835:CO* Family annual allowed amount exceeded max 835:CO* Individual life max for benefit category exceeded max 835:CO* Family life max for benefit category exceeded 835:CO* Family annual allowed amount for benefit category exceeded max 835:CO*B5 357 Member age excludes benefit coverage 835:CO*B5 361 Student age limitation in this plan 835:CO*B5 362 Missing COBRA information -

4 364 Performed service is not part of contract which will be paid under global_fee_co This service is still within days_after from range in this global_fee_contract, Global_fee_accumulator has been updated with a new event_date Remaining portion will not be paid, since this is max amount which can be covered 835:CO*B5 368 Subscriber enrolled in Cobra, will keep his or her ID Billed charges paid by Member Paid amount on the replacement claim is less than the backed-out claim Submitted DRG not same as the Calculated DRG Void Claim Standard Medicaid Fee Schedule Fee schedule is not active Possible COB Possible COB - Multiple Coverage HCFA / Outpatient per case contract with provider 835:CO* UB per line item contract with provider 835:CO* Payment is fee schedule based 835:CO* Percent billed contract with provider 835:CO* Capitation contract with provider 835:CO* Global_fee contract with provider 835:CO* Payment Based on Per Diem Rate 835:CO* Inpatient Per_admit contract with provider 835:CO* Grouper contract with provider 835:CO* DRG contract with provider requires DRG code be present on UB92 form 835:CO* HCFA payment by service code per day/claim Add NDC AWP payment 835:CO* Code not in Fee Schedule. 835:CO* Not paid because of capitation contract 835:CO* Lower allowed amount by Rebundler percentage Allowed amount reduced because of multiple ASC surgery grouping 835:CO*45

5 416 Additional charges have been applied Paid by additional charges Schedule amount exceed Billed amount; Pay billed amount Additional charges charges will not be paid since the total allowable amount is greater than bill amount Zip code requires carrier and locality Applied Combined Par Network benefits Preexisting conditions 835:CO* Authorization not found Authorization given to different member Authorization has been denied 835:CO* Denied by Rebundler 835:CO* New Line Item Duplicate Line Item 835:CO* Assistant Surgeon limit exceeded for this procedure 835:CO* reduced paid according to rebundler rule 835:CO* Rider Option selected Rider Option - Number of visits exceeds allowable 835:CO*B1 512 Reduced paid by discount amount 835:CO* Age is out of range for the given Primary Diagnosis 835:CO*6 529 Gender is invalid for the given Primary Diagnosis. 835:CO*7 530 Age is out of range for the given code 835:CO*6 531 Gender code is invalid for the given CPT 835:CO*7 533 MODIFIER NOT CONSIDERED ELIGIBLE BY SIGNATURE CARE - PROV W/O 835:CO*B Stop Loss amount reached 835:CO* Claim being denied over filing limit 835:CO* Total charges not equal to total charges of line items Manual overwrite Manual Payment 835:CO* Manual Denied 835:OA* Injectable/infusion/Pathology/Lab code requires prior approval by the UR Department 835:CO*197

6 605 Inappropriate Coding or Claim Form 835:CO* Primary Carrier EOB Required or proof of termination of Primary carrier 835:CO* Not A Covered Benefit 835:CO* Denied - No Medical Coverage 835:CO* Denied - No Dental Coverage 835:CO* Denied - No Vision Coverage 835:CO* Duplicate Claim 835:CO* Eligibility Documentation Required (i.e., Birth Certificate, Marriage License, Divorce Decree) 835:CO* Exceeds filing limit - Can Not Bill Patient 835:CO* Investigating Other Insurance For COB or MVA. 835:CO* Denied Incidental Procedure 835:CO*B1 617 Invalid/Deleted Diagnosis Code 835:CO* Invalid/Deleted Procedure Code 835:CO* Medical Records Must Be Submitted. 835:CO* Other Insurance Information Required 835:CO* Part of global code or Procedure is within the global period or procedure performed by the same provider 835:CO* Prior/After UR Authorized Dates 835:CO* Denied - Over Plan Filing Limit 835:CO* Unlisted Procedure - Submit specific CPT/HCPCS or detailed description of service required in comment field and Documentation of Medical Necessity 835:CO* Not A Billable Service By This Provider 835:CO* An established patient E/M code should have been used. 835:CO* Denied-Service Exceeds Plan Limit 835:CO* Charges Incurred After Term Date 835:CO* Duplicate Line Item 835:CO* Claim Exceeds Authorized Visits 835:CO* Denied -No UR Authorization/Authorization not approved 835:CO* Diagnosis Does Not Match Authorized Diagnosis 835:CO* Penalty - No Out Of Network Authorization 835:CO*197

7 635 Inappropriate Place Of Service Billed 835:CO* Itemized Statement Required 835:CO* Denied Related To Workmans Comp 835:CO* Provider Not Properly Credentialed 835:CO* Paid or Processed as Secondary 835:OA* Charges Incurred Prior To Effective Date 835:CO* Requested Information Received 835:CO* Require Copy Of Operative Report 835:CO* Pending For Medicare Effective Date 835:CO* Age Is Out Of Range For Given CPT 835:CO*6 645 Incorrect Patient Demographics 835:CO* Require Attending Physicians Name-field 31 and/or NPI in field 24J 835:CO* Denied Requested Information Not Received 835:CO* Required Description of Primary's Remark Codes 835:CO* Denied-Exceeds allowed quantity or frequency 835:CO* Denied-Submit to Community Mental Health. Inpatient behavioral services are a carve out for Medicaid beneficiaries. 835:CO* Allowable Applied to the Deductible 835:PR*1 652 This Is A Predetermination Dual eligible enrollee-eligible for, not enrolled in Medicare 835:CO*A5 654 Denied - Subsequent PT/OT/ST visits must be authorized by Navant 734/ :CO* Submit Original Primary EOB 835:CO* Maximum Pay Amount. Patient Owes Balance 835:CO* Resubmit With Anesthesia Code/Modifier 835:CO*4 658 Denied-Present on Admission Indicator Required, information may be missing or invalid. 835:CO* Exceeds Yearly Dental Maximum 835:CO* Primary diagnosis code not recognized by this DRG Grouper. Please map diagnosis to the prev. versio 835:CO*A Denied-Missing Multiple Surgical Modifier 835:CO*4 662 Services not provided by a designated or contracted PCP. 835:CO*164

8 663 No Secondary Consideration Until Primary's Request Satisfied 835:CO* Require Primary Carrier's EOB 835:CO* Additional Payment 835:CO* Split Claim Needed for Non Covered Charges 835:CO* Denied-Require facility name and address where services were rendered, box :OA* EOB and Claim Do Not Match 835:CO* Denied - The immunization must be billed with the immunization administration code. 835:CO* Forward claim to Psychcare :CO* Denied-Submit claim to Beacon Health Options - PO Box 1854 Hicksville, NY :CO* Not Included In Case Rate 835:CO* Resubmit- illegible EOB 835:CO* Split Payment Due To Benefits 835:CO* Denied - Replacement/void claim received 835:CO* Require Copy of Birth Certificate 835:CO* Require eligibility verification form 835:CO* Send medical records to: PO Box 27476, Salt Lake City, UT , fax 866/ :OA* Submit Claim to Occupational Eyewear Network at 3824 Thirteen Mile Rd, Warren, MI ATTN:Total 835:CO* Claim not submitted with contracted TIN/ NPI/ payee information 835:CO* Paid per settlement 835:CO* Service line pending fee schedule/pricer update. Payment to be adjusted when fee available. 835:CO* Non-Network/InActive Provider/Non-contracted Physician 835:OA* Denied by Medical Director after Review 835:CO* Covered In Contracted Case Rate 835:CO* Per primary carrier EOB, This is a provider write-off 835:CO* Denied-Exceeds annual maximum benefit limit 835:CO*119

9 688 Resubmission of a claim under review or previously denied by TC3/CHANGE HEALTH CARE 835:OA* Submit Claim to Cofinity for Pricing 835:CO* Dx code not listed in the Emergency Transport Diagnosis Code Database 835:CO* Not a THC Enrollee/Incorrect Member/Claimant 835:CO* Resubmit with a THC referral 835:CO* Resubmit with Prenatal Dates 835:CO* INVALID PLACE OF SERVICE 835:CO*A1 695 Not covered by Medicaid/ Medicare 835:OA* Service included 835:CO* Previously paid 835:CO*B Charges are covered under a capitation agreement 835:CO* Service is not authorized on the referral or authorization 835:CO* Payment applied to plan deductible 835:CO* Number of visit exceeds annual allowable 835:CO* Adjust Allowed amount to amount per visit max. 835:CO* Claim exceeds days since accident (EOB) 835:CO*B5 704 Claim exceed EOB max pay amount 835:CO* Payment is according EOB formula Benefit reduced by plan deductible 835:CO* Missing accident date for accident related claim 835:PR*2 711 Claim had been paid at header level This visit has been paid. 835:CO* Minimum % OF billed applied Exceed maximum allowed time for pended claim - Denied Applied Header level Add-on Amount Applied ices edits Denied based on ices edits 835:CO* Applied percent reduction as per ICES Denied based on pricing reduction Benefit Payment Copay Order (Deductible/Copay) Benefit Payment Copay Order (Copay/Deductible) -

10 911 Change description later - PCP logic Pay according to Professional general contract Pay according to PCP contract - 00L No errors found - 00V No errors found For hss Professional - 00Z Pricer - No errors - 01G GROUPER - CODE IS INVALID, OR NOT VALID FOR SERVICE DATE - 01Z Pricer - No available APC/fee schedule rate 835:CO*204 02I No HIPPS code on claim - 02J No HIPPS code on the claim - 02Z Pricer - Invalid HCPCS code - 03Z Pricer - Invalid payment status - 04Z Not Covered Under OPPS - 07Q No DRG weights/rates (for Illinois Medicaid, Nebraska Medicaid, New York Legacy, and Ohio Medicaid also see Chapter 5 of EASYGroup DRG Pricer User Guide) - 08Z Pricer - Invalid modifier for pricing - 09Z Pricer - Packaged service 835:CO*97 10Z Pricer - Line item denial or rejection from ACE/ write off - 13Z Pricer - ZIP code missing or invalid, for ambulance fee schedule service only - 16H Conflicting birthweight as derived from diagnosis codes or birthweight in grams conflicts with birthweight diagnosis codes - 21Q Present on Admission Indicator Required/Invalid - 22P Denial claim - 23P Invalid service date, from-thru dates,or admission date - 24Q Non-covered claim (Kentucky Medicaid, Virginia Medicaid, and Medicare Inpatient) - 27G Invalid or no Treatment Authorization code - 28Z No available extended fee schedule rate - 35Z This is a quality measurement code used for reporting purposes only. -

11 36P Incorrect billing of Automated Multi-Channel Chemistry (AMCC) ESRDrelated tests. - 38P Invalid or Missing Required Claims Data 835:CO*16 41P Invalid billing of therapy services - 46Q Newborn claims that do not contain an UB-04 Value Code of 54 with the birth weight in the UB-04 Value Amount field will be issued this Pricer Return Code. - 62P Closed or inactive rate record - AA0 Authorization Class does not match - AA1 Authorization - LOS does not match 835:CO*197 AA4 Authorization - unit exceeded - AA9 Copayment paid per service day - AC1 Visit falls before the event period. - E01 Misrepresentation of Diagnosis 835:OA*146 E02 Failure by referring provider to comply with investigative requests 835:OA*228 E03 Failure by rendering provider to comply with investigative requests 835:OA*228 E04 Denied - Unbundled Service/Exclusive or Incidental Relationship. 835:OA*234 E05 Deliberate performance of unwarranted services 835:OA*125 E06 Billing for services/supplies not provided 835:OA*125 E07 Misrepresentation of services/supplies provided 835:CO*B12 E08 Treatment is not in accordance with standard of care 835:OA*56 E09 No documentation in medical record of services billed, medical record does not support billed service. 835:OA*B12 E10 Auto insurance primary 835:CO*20 E11 Primary payment exceeds allowable 835:CO*45 E12 HCPCS Code Required 835:OA*189 E13 THC primary carrier 835:OA*22 E14 Denied- NDC Code Required in HCFA box 24 or in UB service line area per MSA Bulletin :OA*206 E15 Denied-Invalid/ missing or incorrect Modifier 835:OA*4 E16 Denied- NDC is invalid for the billed service code 835:OA*206

12 E17 Denied- Electronic Referral Required, refer to 835:OA*165 E18 Injection is covered under Medicare Part D. Contact Catamaran at for direction on filin 835:OA*133 E19 Injection pending Part D filing submission 835:OA*133 E20 Denied-No history of inpatient services or observation provided for Transitional Care Management Services 835:OA*96 E21 Denied - DOS is outside of the required timeframe 835:OA*96 E22 Denied- Date of visits and EDC required in field 19 or appropriate EDI loop 835:CO*16 E23 Denied - Prenatal global billing must be rebilled as separate services and include DOS and EDC 835:CO*16 E24 Denied by Medicare/Primary Insurer 835:CO*22 E25 Multiple procedure reduction of 50% applied per CMS guidelines 835:CO*59 E26 Denied- Services not supported by patient history or documentation. 835:CO*107 E27 Denied- No additional payment, no cost sharing applied by Medicare/ primary insurer 835:CO*16 E28 Denied-Awaiting eligibility determination from health insurance marketplace due to non-payment of premium. 835:OA*257 E29 Resubmission of a claim under review by TC3/CHANGE HEALTH CARE 835:OA*133 E30 Send medical records to:5720 Smetana Drive, Suite 400, Minnetonka, MN FAX: :OA*133 E31 Denied- Medicare is primary, EOB is required. 835:CO*22 E32 Denied- Left against medical advice- not a covered benefit 835:CO*204 E33 Denied-The requisition form was not signed by the ordering physician. 835:CO*16 E34 Denied- Inappropriate use of Modifier -59. According to CCI data, there are not any CCI conflicts for this code. 835:OA*4 E35 Denied - Does not meet inpatient hospital claim requirements for newborns 835:OA*252 E40 Payment requires submission of completed HRA- fax to :CO*16

13 E41 Denied - Diagnosis describes an external cause, or requires the ICD code for the first underlying disease, and should never be listed as the primary diagnosis for a procedure. 835:CO*146 E42 service or supply may be considered investigational and experimental 835:CO*55 E44 Denied- Drug code requires name of drug, dosage, and NDC of the drug furnished in comment field. 835:CO*226 E45 Processed as Secondary Contractual Obligation or No Primary Member Obligation. 835:OA*192 E46 Processed as secondary - capitated service - no additional payment 835:OA*192 E47 Denied- Psychotropic injectable carve-out drugs reimbursable by MDCH 835:CO*16 E48 Denied-Send Itemized Statement to: Equian, 300 Union Blvd., Ste 200, Lakewood, CO Fax :CO*16 E49 Charges denied by Equian due to identification of clean claim issues 835:OA*216 E50 Charges Pended by Equian due to identification of clean claim issues 835:OA*216 E51 Informational- Paid in accordance to Equian recommendation 835:OA*216 E52 Claim forwarded to Equian for forensic review 835:OA*216 E53 Denied - Service included in Mendelson Bundle Project 835:OA*216 E54 Informational - Paid in accordance to Mendelson Bundle Project 835:OA*216 E55 Informational- Coordination of Benefits THC Primary 835:CO*22 E56 Informational-Reduction of 25% applied per CMS guidelines 835:CO*59 E57 Informational-Multiple Endoscopy payment reduction 835:CO*59 E58 Denied-Per the ICD-10-CM Excludes note guideline, diagnosis codes identify two conditions that cannot be reported together 835:CO*181 E59 Denied- Diagnosis and Modifier combination are inappropriate 835:CO*4 E60 Denied- Principal procedure code is invalid 835:CO*181 E61 Denied-Federal Health Care Programs are prohibited from paying for services by HHS-OIG excluded provider or physicians 835:CO*181 E62 Denied-ICD procedure code is non-covered 835:CO*181 E63 Informational - Processed as secondary, service not covered by primary carrier. 835:OA*192 E64 D-Submitted to First Health for repricing 835:CO*109

14 E65 E66 E67 Informational- The presence of modifier 54, 55, or 56 indicates that only the preop, intraoperative, or post-op portion of the global fee should be reimbursed. Denied - Discrepancy detected between the number of units on this claim line and the difference between the Beginning DOS and the Ending DOS. Documentation does not support billed units. Denied-visit is the same day as a procedure with a status indicator of T or S without modifier :CO*59 835:CO*16 835:OA*4 E68 Denied - The primary procedure code that is associated with this add-on procedure code has received a denied status. Please review billing procedures. 835:CO*16 E69 Denied - Check Refund Adjustment Claim 835:CO*B13 E70 Informational- Paid in accordance to VARIS recommendation 835:OA*216 Updated 11/28/2017