Adjudication Reason Codes

Transcription

1 Adjudication Reason s This report displays actively used Claim Adjudication Reason s Reason Missing/incomplete/invalid provider identifier Service is not authorized M76 Missing/incomplete/invalid diagnosis or condition M77 Missing/incomplete/invalid place of service M46 Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed Adjustment represents the estimated amount the primary payer may have paid Adjusted - Above contract rate Patient not enrolled on the date of service N643 Non-Covered Ancillary Services Duplicate Claim Invalid Diagnosis/Age Combination M53 Invalid Units Invalid age group & procedure code combination Service not in provider profile Claim received after billing period Daily frequency exceeded Weekly frequency exceeded Monthly frequency exceeded Adjusted Against Co-Insurance Max Basic Units Exhausted No rates available Approved Invalid Service or Service Discontinued Authorized units Exceeded N381 Revert - Provider Billing Error N381 Revert - Keying Error Revert - Other Primary Insurance 24-Hour Crisis Care & Service Enrollment Business & Administrative Calls TrilliumHealthResources.org

2 Revert - Authorization/Treatment Revisions Page 2 of N381 Revert - Billing Terms Revised Revert - Additional Units Billed N381 Revert - Third Party Coverage Changes N381 Revert - Other N381 Readju - Provider Billing Error N381 Readju - Keying Error Readju - Other Primary Insurance Readju - Authorization/Treatment Revisions N381 Readju - Billing Terms Revised Readju - Provider Agreement Revised Readju - Third Party Coverage Changes Readju - Not Included In Service Profile N381 Readju - Other MA67 Overid - Provider Billing Error MA67 Overid - Keying Error N109 Overid - Audit Payback Overid - Other Primary Insurance Overid - Authorization/Treatment Revisions Overid - Patient Liability MA67 Overid - Additional Units Billed MA67 Overid - Third Party Coverage Changes Overid - Primary Payment Greater Than MCO Responsibility MA67 Overid - Other Client has other covered insurance (COB) M49 Invalid Amount M76 Invalid Inpatient/ED DX M50 Invalid Revenue No contract exists or rate is not set up yet Revert - Duplicate Claims Revert - EOB Required Readju - Duplicate Claims Readju - EOB Required Trillium EOB Denial s

3 Overid - Duplicate Claims Overid - EOB Required Readju - Rate Change N419 Overid - Rate Change N381 Overid - Contract Terminated Readju - Contract Terminated N377 Readju - Corrected Claim N381 Readju - Audit Recoup MA67 Overid - Corrected Claim MA67 Overid - Audit Payback MA67 Overid - Audit Recoup N377 Revert - Corrected Claim Page 3 of Excess amount over allowed medicare copayment Invalid provider NPI # Invalid rendering/attending provider NPI number Readju - Client Manually Matched Readju - Provider Incorrect Service not in State Contract Claim submitted before service date M62 Overid - Missing/incomplete/invalid treatment authorization code 1108 B7 Non billable service Readju - NPI implementation date revised Readju - Medicaid coverage changes for state denial Overid - Service frequency not exceeded Readju - Service frequency not exceeded N52 Client Medicaid Out of Catchment Area N52 Client Medicaid Out of Catchment Area 1119 A1 MA67 Billing Days Extended Readju- Funding Source change from State to Medicaid Readju- Funding Source change from Medicaid to State 1122 A1 MA67 Overid- Funding Source change from State to Medicaid Overid- Funding Source change from Medicaid to State Readju - Patient not enrolled in the billing provider's managed care plan on the date of service. Trillium EOB Denial s

4 Readju - patient outside PBH five county catchments area. Page 4 of M47 Invalid DCN (Document Ctrl #) or resubmission ref # N377 Revert - Reverted because reversal/replacement claim has been submitted N318 Inpatient stay less than 24 hours N52 Not Medicaid Elig/Out of Catchment Readju - Retroactive Medicaid N381 FFS claim pended for 14 days wait Client not covered by contract N152 Resubmitted claim DOS is after original claim submission date N152 Resubmitted claim does not match with the referenced claim Monthly case rate already paid N Overide - Medicaid Deductible Referenced claims has already been resubmitted. Multiple resubmissions not allowed Readju - Allocation Amount Met Overid - Allocation Amount Met DX code is invalid for service and insurance Charges are covered under a capitation agreement/managed care plan N381 CABHA Service, but submitted NPI is a non CABHA npi N381 SERVICE FACILITY LOCATION IS NOT A VAL, OR COULD NOT BE MAPPED TO ONE SFL Another concurrent service has been approved or waiting to be processed Bill Type Hospital, Outpatient, Non-Payment/Zero Claim M53 Outpatient date range for specified code range is > 2 days M20 Revenue code billed without a corresponding HCPCS code for specified code range N377 Revert - Reprocessed ED Claim Override-Service invalid for recipient's age 1162 B N381 Readju-Auto RetroMedicaid Add on code billed without primary CPT code or code billed on different date than primary CPT code Rendering provider for add on code billed is different than rendering provider on primary CPT code Processed in Excess of charges N255 The taxonomy code for the billing provider is missing N288 Missing/Incomplete/Invalid attending/rendering taxonomy code Trillium EOB Denial s

5 N251 Missing/Incomplete/Invalid attending taxonomy code. Page 5 of Pended due to service not in contract N435 FFS claim billed under sub-capitated NPI M76 Invalid ICD-9 diagnosis code M76 Invalid ICD-10 diagnosis code M76 ICD-9 diagnosis code is invalid for the date(s) of service M76 ICD-10 diagnosis code is invalid for the date(s) of service 1176 A1 N180 Missing/invalid State Benefit Plan for consumer 1177 A1 N180 Procedure or diagnosis code is not valid for consumer s State Benefit Plan Client not covered by contract 1179 M127 Override - Medical Records Requested 1180 M127 Override - Medical Records not received within timelines 1181 M127 Override - Medical Records does not support code billed 1194 A1 Override - Pre-Payment Review Process 1200 A1 Override - NCHealthchoice passthru billing 1201 A1 Override - Consumer now eligible for Innovations 1202 A1 Override - recoup-network Monitoring 1203 A1 Override - Invalid rendering taxonomy code 1205 A1 Override - Consumer deceased on date of service COB information submitted on claim and patient has no COB record 1209 A1 Override - TPI not received from Provider Override - Medical Records Requested Override - Medical Records not received within timelines Override - Medical Records does not support code billed NPI is invalid for the 3 way service billed Override - Incorrect code combination per NCCI Edit The taxonomy code for the attending provider is missing or invalid M76 ICD set is not valid for the discharge/through date N643 Ancillary services covered under per diem rate 1230 A1 N61 Multiple funding sources are not permitted for a single claim Readju - Auto Retro-COB Readju - Retro Target Population Update 1233 MA129 Readju - Clinician licensure updated Adjusted Against Patient Responsibility Trillium EOB Denial s

6 M143 Clinician not licensed to provide the service. Page 6 of M143 Clinician License not active and effective for date of service Units per claim exhausted Adjusted for units per claim limit Pay and Report: The Billing Provider Taxonomy is not associated with the Billing Provider NPI provided on the claim. The Billing Provider Taxonomy is not associated with the Billing Provider NPI provided on the claim. Pay and Report: The association of the Billing Provider Taxonomy to the Billing Provider NPI is not active and effective for the date of service. The association of the Billing Provider Taxonomy to the Billing Provider NPI is not active and effective for the date of service. Pay and Report: The Billing Provider Taxonomy is not active and effective for the date of service The Billing Provider Taxonomy is not active and effective for the date of service Pay and Report: The Rendering Provider Taxonomy is not associated with the Rendering Provider NPI provided on the claim. The Rendering Provider Taxonomy is not associated with the Rendering Provider NPI provided on the claim. Pay and Report: The association of the Rendering Provider Taxonomy to the Rendering Provider NPI is not active and effective for the date of service. The association of the Rendering Provider Taxonomy to the Rendering Provider NPI is not active and effective for the date of service The taxonomy code for the Rendering Provider is missing The Rendering Provider Taxonomy is not active and effective for the date of service The taxonomy code for the Attending Provider is missing The Attending Provider Taxonomy is not active and effective for the date of service Pay and Report: The Billing Provider Taxonomy is not associated with the Billing Provider Site provided on the claim. The Billing Provider Taxonomy is not associated with the Billing Provider Site provided on the claim. Pay and Report: The association of the Billing Provider Taxonomy to the Billing Provider Site is not active and effective for the date of service. The association of the Billing Provider Taxonomy to the Billing Provider Site is not active and effective for the date of service. Trillium EOB Denial s