Electronic Remittance Advice (ERA/835) Provider Guide Version Date: September 22, 2015

Transcription

1 Electronic Remittance Advice (ERA/835) Provider Guide Version Date: September 22, 2015 This document is a tool for understanding Martin s Point Generations Advantage and US Family Health Plan Electronic Remittance Advice (ERA/835 files). It maps industry standard remittance codes to the corresponding descriptions that appear on our 835 files. To search for a specific code, press your CTRL and F keys at the same time and type the code it into the Find box. Definitions: Claim Adjustment Reason Code (CARC): CARCs communicate an adjustment the reason why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. Not all CARCS have a corresponding RARC. In these situations, the CARC supplies sufficient information about the claim adjustment we have made. Remit Advice Reason Code (RARC): RARCs provide additional explanation for an adjustment already described by a CARC and may convey information about remittance processing. There are two types of RARCs, supplemental and informational. The majority of the RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by a CARC. The second type of RARC is informational; these RARCs are all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC. Martin s Point Rule Description: This column provides further information that corresponds to specific CARCS and pertains to our payment policies and rules. Our claims editing processes are closely aligned with correct coding and billing criteria established by the Centers for Medicare and Medicaid Services (CMS). There are some exceptions, usually based on our health plan benefit design. For example, our members have access to important preventive services such as annual physicals and eye exams at $0 copay. But overall, we adhere closely to Medicare claim editing practices. We also apply Medicare Local Coverage Determination (LCD) rules to claims for services rendered to Generations Advantage members in Maine and New Hampshire. (LCD rules do not apply to USFHP claims.) LCD rules can be found on the local carrier s website or by contacting them directly. Following are the local carriers for Maine and New Hampshire: o Medicare Parts A & B: National Government Services, Inc. o Durable Medical Equipment (DME): NHIC, Corp. If you receive a claim denial and, upon research and review of the documentation, you feel a corrected claim is in order, you may submit a corrected claim with the appropriate additional Before doing so, please review our electronic corrected claim guidelines at providers/claims. Electronic submission will speed processing time. Please be sure to include the claim number and the patient control number from the original claim to help ensure efficient reprocessing. For more information about Medicare coding and billing criteria, please visit

2 Questions? Please visit providers/claims or call CARC CARC Description Martin's Point Rule Description RARC RARC Description 1 Deductible Amount 915 REMIT deductibles 3 Co payment Amount 915 CMS pays covered clinical trial services. MP will make a payment if CMS costshare is more than the member s costshare as a MP member. CMS costshare for this claim is the same or less than the costshare for MP. Member is responsible for CMS costshare 3 Co payment Amount 915 A $10.00 co pay has been taken. A $10.00 cost share has been taken. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 245 Multiple surgeries claim submitted missing modifier 51 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 407 Modifier(s) is invalid for Medical Policy 4 The procedure code is inconsistent with the modifier used or a required modifier is missing Code 2 of a code pair allowed with modifier 4 The procedure code is inconsistent with the modifier used or a required modifier is missing Incorrect billing of modifier FB or FC 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing Mutually exclusive procedure allow with appropriate modifier 6168 Multiple medical visits, same date, needs condition code G (meh) Medicare E/M and Surgery without Modifier History 9242 (mem) Medicare E/M and Surgery without Modifier 9233 (LBM/LCM) Missing LCD Modifier 9203 (060MCA) Modifier CA billed with multiple procedures 9215 Incorrect billing of modifier FB or FC

3 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing Required modifier missing 9479 (040CCO/040hCCO) Component and comprehensive billed w/o mod 9474 (022IMO) HCPCS modifier invalid under OPPS 9509 (manm) Medicare Anesthesia Modifier Missing 9510 (mgt) Invalid Modifier Global Test Only Code 9511 (mic) Invalid Modifier Incident To Code 9512 (mpc) Invalid Modifier Professional Component Only Code 9513 (mps) Invalid Modifier Physician Service Code 9514 (mpi) Invalid Modifier Physician Interpretation Code 9515 (mtc) Invalid Modifier Technical Component Only Code 9469 (016MBP/017IBP) Invalid specification of bilateral procedure 9057 Inappropriate modifier combination 9058 (IMO) MODIFIER INVALID 6198 CLIENT CUSTOM EDIT 6184 Use of modifier CA with more than one procedure not allowed 6193 CLIENT CUSTOM EDIT 9060 Invalid patient gender for diagnosis code 9061 (M26) MOD 26 REQUIRED

4 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 5 The procedure code/bill type is inconsistent with the place of service. 5 The procedure code/bill type is inconsistent with the place of service. 5 The procedure code/bill type is inconsistent with the place of service. 5 The procedure code/bill type is inconsistent with the place of service. 5 The procedure code/bill type is inconsistent with the place of service. 5 The procedure code/bill type is inconsistent with the place of service. 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/ Modifier not appropriate 9105 (MIM) MEDICARE INAPPROPRIATE MODIFIER 817 Claim Check: Cross Provider Total Audit 915 Invalid Modifier Association 915 CMS guidelines for Modifier 55 not met. 915 Modifier required for CPT/HCPCS 915 Invalid CPT Modifier 915 This is a clinical trial claim and it is missing the required Modifier. 915 Incorrect billing of modifier FB or FC 915 MUP that would be allowed if modifier were present 915 Invalid modifier 179 Location specific term does NOT match claim 185 Location specific benefit does NOT match claim 9071 (OFS) OFFICE SETTING PROCEDURE 9074 POS not typical for procedure 662 Contract for service location on claim was not found 915 Rejected POS incompatible with procedure 6144 CLIENT CUSTOM EDIT 804 Claim Check: Age Conflict M78 M77 M77 Missing/incomplete/invalid HCPCS modifier. Missing/incomplete/invalid place of service. Missing/incomplete/invalid place of service.

5 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 6 The procedure/revenue code is inconsistent with the patients age. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/02 7 The procedure/revenue code is inconsistent with the patients gender. Changed as of 6/ Claim Check: Age Replacement 401 Age is invalid for Medical Policy 168 Member does NOT meet age criteria for term 915 Procedure and age conflict 915 Age invalid; not in range MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Benefit has age restrictions N129 Not eligible due to the patient's age. 915 Incorrect age for Nursery charges 915 Age Incorrect for Nursery Charges 6042 Sex invalid; not 1 or 2, M or F 6078 Procedure and sex conflict 806 Claim Check: Gender Conflict 807 Claim Check: Gender Replacement 6145 CLIENT CUSTOM EDIT 400 Gender is invalid for Medical Policy 9225 (BSX/LCG) Procedure Not Typical for Patient Sex 9168 (DPSC) Patient gender inconsistent with procedure 915 Procedure and sex conflict 915 Invalid sex N129 Not eligible due to the patient's age. MA39 Missing/incomplete/invalid gender.

6 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Changed as of 6/02 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Changed as of 6/02 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Changed as of 6/02 8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Changed as of 6/02 9 The diagnosis is inconsistent with the patient's age age conflict; patient's age and diagnosis are inconsistent 9 The diagnosis is inconsistent with the patient's age Age conflict; patient's age and diagnosis are inconsistent 9 The diagnosis is inconsistent with the patient's age (IAG/002IAG) Invalid patient age for diagnosis code 9 The diagnosis is inconsistent with the patient's age Patient age invalid for service 9 The diagnosis is inconsistent with the patient's age Patient age inconsistent with diagnosis 9 The diagnosis is inconsistent with the patient's age (DASC3) Patient gender and age inconsistent with diagnosis 9 The diagnosis is inconsistent with the patient's age (DDAS1) Patient age and diagnosis inconsistent 9 The diagnosis is inconsistent with the patient's age (DDAS2) Patient gender and diagnosis inconsistent 9 The diagnosis is inconsistent with the patient's age Patient age and gender inconsistent with diagnosis 9 The diagnosis is inconsistent with the patient's age. 915 age conflict; patient's age and diagnosis are inconsistent 9 The diagnosis is inconsistent with the patient's age. 915 patient's age and sex are inconsistent with the patient's dx 9 The diagnosis is inconsistent with the patient's age. 915 Age and sex conflict 9 The diagnosis is inconsistent with the patient's age. 915 Age conflict; patient's age and diagnosis are inconsistent 10 The diagnosis is inconsistent with the patient's gender. 915 Sex conflict; patient's sex Changed as of 2/00 and diagnosis are inconsistent 10 The diagnosis is inconsistent with the patient's gender. Changed as of 2/ Provider does not match required type 9224 Missing or invalid provider specialty 156 Provider type does NOT match type required by contract term 151 Non Contracted Service N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges. 915 Sex conflict; patient's sex and diagnosis are inconsistent

7 10 The diagnosis is inconsistent with the patient's gender Sex conflict; patient's sex Changed as of 2/00 and diagnosis are inconsistent 10 The diagnosis is inconsistent with the patient's gender Sex conflict; patient's sex Changed as of 2/00 and diagnosis are inconsistent 10 The diagnosis is inconsistent with the patient's gender (DASC2) Patient gender Changed as of 2/00 inconsistent with diagnosis 11 The diagnosis is inconsistent with the procedure. 815 Claim Check: Intensity of Service Audit 11 The diagnosis is inconsistent with the procedure. 816 Claim Check: Diag to Procedure Audit 11 The diagnosis is inconsistent with the procedure (LBI/LCI) Missing or Invalid LCD Diagnosis 11 The diagnosis is inconsistent with the procedure. 330 Invalid diagnosis code for benefit 11 The diagnosis is inconsistent with the procedure (LBI/LCI) Missing or Invalid LCD Diagnosis 13 The date of death precedes the date of service. 915 Services billed after date of death. MA39 Missing/incomplete/invalid gender. M25 The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. N115 This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at or if you do not have web access, you may contact the contractor to request a copy of the LCD. M64 Missing/incomplete/invalid other diagnosis. M64 Missing/incomplete/invalid other diagnosis.

8 13 The date of death precedes the date of service. 915 SERVICE RESPONSIBILITY OF LAB CORP ONLY 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/01 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. Changed as of 2/ UM is not for same Provider MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 606 UM Not found M62 Missing/incomplete/invalid treatment authorization code. 618 Provider's group does not match authorized group 622 Place of Service does not Match Authorized 617 Provider's specialty does not match authorized specialty 915 Prior authorization not for same member 915 Prior authorization not for same member. 915 Prior authorization is not for same provider. 915 Record does not meet criteria for any DRG in MDC 915 Record does not meet criteria for any DRG in MDC N54 Claim information is inconsistent with precertified/authorized services. N54 Claim information is inconsistent with precertified/authorized services. N95 This provider type/provider specialty may not bill this service. N54 Claim information is inconsistent with precertified/authorized services. N54 Claim information is inconsistent with precertified/authorized services. N54 Claim information is inconsistent with precertified/authorized services. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information

9 915 Invalid age in years on admission or age in days 915 Invalid age in years on admission or age in days 915 Inappropriate specification of bilateral procedure MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct MA41 Missing/incomplete/invalid admission type. M51 Missing/incomplete/invalid procedure code(s). 915 invalid admission source MA42 Missing/incomplete/invalid admission source. 915 Invalid nursery level MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid discharge status MA43 Missing/incomplete/invalid patient status. 915 Illogical principal diagnosis (PDX) 915 Invalid principal diagnosis (PDX) 915 Invalid date or fromdate > thrudate MA63 Missing/incomplete/invalid principal diagnosis. MA63 Missing/incomplete/invalid principal diagnosis. M52 Missing/incomplete/invalid "from" date(s) of service.

10 915 Invalid date or fromdate > thrudate MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid operation code M51 Missing/incomplete/invalid procedure code(s). 915 Invalid operation code MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid patient type MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Outpatient claim contains unacceptable errors 915 Outpatient claim contains unacceptable errors 915 From date greater than thru date 915 Invalid Outpatient Classification MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule. M52 MA130 Missing/incomplete/invalid "from" date(s) of service. Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct

11 915 Invalid Outpatient Classification N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule. 915 Condition code 21 M44 Missing/incomplete/invalid condition code. 915 Condition code 21 MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid from thru dates MA31 Missing/incomplete/invalid beginning and ending dates of the period billed. 915 Date out of OCE range MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Date out of OCE range N345 Date range not valid with units submitted. 915 Invalid procedure code M51 Missing/incomplete/invalid procedure code(s). 915 This is a clinical trial claim and it is missing the required diagnosis code. 915 Late charge/ corrected claim received. Denied to allow corrections. M64 Missing/incomplete/invalid other diagnosis. MA67 Correction to a prior claim.

12 915 Late charge/ corrected claim received. Denied to allow corrections. 915 No Charges Submitted on Claim Line 915 Code invalid; not found on table of valid ICD 9 CM codes 915 Invalid code, unnecessary 4th/5th digit 915 Invalid code missing 4th/5th digit N693 Alert: This reversal is due to a cancellation of the claim by the provider. M54 M76 M76 M76 Missing/incomplete/invalid total charges. Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. 915 Code invalid M76 Missing/incomplete/invalid diagnosis or condition. 915 Invalid code for dates, unnecessary 4th/5th digit 915 Invalid code for dates, missing 4th/5th digit 915 Invalid age in days at discharge M76 M76 MA130 Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct

13 915 Invalid age in days at discharge 915 Sex invalid; not 1 or 2, M or F 915 Code is duplicate of principal diagnosis 915 Code is duplicate of another secondary diagnosis 915 Diagnosis cannot be used as principal N50 Missing/incomplete/invalid discharge MA39 Missing/incomplete/invalid gender. M76 M76 Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. MA63 Missing/incomplete/invalid principal diagnosis. 915 E Code as principal MA63 Missing/incomplete/invalid principal diagnosis. 915 Manifestation code as principal 915 Non Specific code as principal MA63 Missing/incomplete/invalid principal diagnosis. MA63 Missing/incomplete/invalid principal diagnosis. 915 Questionable admission MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct

14 915 Questionable admission MA41 Missing/incomplete/invalid admission type. 915 Unacceptable principal diagnosis 915 Unacceptable principal diagnosis; requires secondary dx 915 Present On Admission indicator required but not submitted 915 Present On Admission indicator required but is not valid 915 A Present on Admission Indicator (POA) has been applied to a Diagnosis Code that does not require one per Medicare/Tricare OPPS guidelines 915 Code invalid; not found on table of valid ICD 9 CM codes 915 Invalid code, unnecessary 4th digit 915 Invalid code, missing 4th digit MA63 Missing/incomplete/invalid principal diagnosis. MA63 Missing/incomplete/invalid principal diagnosis. N434 Missing/Incomplete/Invalid Present on Admission indicator. N434 Missing/Incomplete/Invalid Present on Admission indicator. N434 Missing/Incomplete/Invalid Present on Admission indicator. M76 M76 M76 Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition.

15 915 Same Provider As Surgeon/Asst Surgeon Invalid 915 Same Provider As Surgeon/Asst Surgeon Invalid 915 Adjusted due to processing error 915 Adjusted due to processing error 915 Adjusted due to processing error QNXT 915 Adjusted due to processing error QNXT M80 Not covered when performed during the same session/date as a previously processed service for the patient. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct MA67 Correction to a prior claim. N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication. MA67 Correction to a prior claim. N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication. 915 Appeal MA67 Correction to a prior claim. 915 Appeal N691 Alert: This reversal is due to a patient submitted appeal. 915 Reconsideration MA67 Correction to a prior claim.

16 915 Reconsideration N690 Alert: This reversal is due to a provider submitted appeal. 915 Unable to determine which history claim to adjust based off the claim number provided and/or information provided. N380 The original claim has been processed, submit a corrected claim. 915 Claims Recovery Project N432 Adjustment based on a Recovery Audit. 915 Insufficient services on day of partial hospitalization. 915 Insufficient services on day of partial hospitalization. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct MA32 Missing/incomplete/invalid number of covered days during the billing period. 915 The member has not exhausted their Part A benefits. Martin s Point does not adhere to this limitation. Please submit a corrected inpatient claim with your room and board charges. M54 Missing/incomplete/invalid total charges. 915 Corrected Claim MA67 Correction to a prior claim. 915 Corrected Claim N694 Alert: This reversal is due to a resubmission/change to the claim by the provider. 915 No Assessment Date Submitted on Claim N309 Missing/incomplete/invalid assessment date.

17 915 Invalid value for OPCODE1 M45 Missing/incomplete/invalid occurrence code(s). 915 Invalid value for OPCODE1 MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid value for PATTYPE MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Invalid value for PATTYPE MA43 Missing/incomplete/invalid patient status. 915 Claim billed with two different individual NPI s 915 This is a clinical trial claim and it is missing the required clinical trial number 915 This is a clinical trial claim and it is missing the required Condition code. 915 Invalid Insured/Patient information submitted (Name, DOB, Gender, Member ID) 915 Rebill with a valid HIPPS code MA102 Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider. MA50 Missing/incomplete/invalid Investigational Device Exemption number for FDA approved clinical trial services. M44 Missing/incomplete/invalid condition code.

18 915 The procedure code billed is not recognized by Tricare. An alternate code is available. 915 The procedure code billed is not recognized by Medicare. An alternate code is available. 915 Denied Please provide a description of service 915 Description of Service & a Prior Authorization is Required M51 M51 Missing/incomplete/invalid procedure code(s). Missing/incomplete/invalid procedure code(s). N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure. N225 Incomplete/invalid documentation/orders/notes/summary/report/ chart. 915 Invalid Insured/Member ID N382 Missing/incomplete/invalid patient identifier. 915 Invalid Gender MA39 Missing/incomplete/invalid gender. 915 Invalid DOB MA52 Missing/incomplete/invalid date. 915 File with FFS Medicare First MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 File with FFS Medicare First N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.

19 915 Patient Name not matching name on file. 915 Provider termed from affiliation for DOS billed 915 Provider credentials required for reimbursement. 915 HCPC/CPT Code not Valid on a UB Claim 915 EOB needed from Primary Insurance 915 Accept Assignment Box 27 on claim needs to be completed. MA36 Missing/incomplete/invalid patient name. N198 Rendering provider must be affiliated with the pay to provider. M143 The provider must update license information with the payer. M20 N4 Missing/incomplete/invalid HCPCS. Missing/incomplete/invalid prior insurance carrier EOB. 915 EOB does not match claim N4 Missing/incomplete/invalid prior insurance carrier EOB. 915 Invalid units for modifier M53 Missing/incomplete/invalid days or units of service. 915 Payment included in composite rate N95 This provider type/provider specialty may not bill this service. 915 Invalid HCPCS code M20 Missing/incomplete/invalid HCPCS.

20 915 Invalid modifier for pricing M78 Missing/incomplete/invalid HCPCS modifier. 915 Invalid Admit Diagnosis MA65 Missing/incomplete/invalid admitting diagnosis. 915 Claim returned to provider for correction (RTP) 915 Invalid units for this modifier 915 ZIP code missing or inv (for Ambulance) 915 Invalid units for revenue code 915 Trauma response cc code without rev code 068X and CPT Claim lacks allowed procedure code 915 Claim lacks required radiolabeled product MA130 M53 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct Missing/incomplete/invalid days or units of service. MA29 Missing/incomplete/invalid provider name, city, state, or zip code. M53 Missing/incomplete/invalid days or units of service. N59 Please refer to your provider manual for additional program and provider N59 Please refer to your provider manual for additional program and provider M51 Missing/incomplete/invalid procedure code(s).

21 915 G0379 only allowed with G G0379 only allowed with G Revenue code not recognized by Medicare 915 Claim lacks required device code 915 Incorrect billing of blood and blood products 915 Incorrect billing of blood and blood products 915 Units greater than one for bilateral proc billed with mod Multiple observations overlap in time 915 Multiple observations overlap in time MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N357 Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met. M50 Missing/incomplete/invalid revenue code(s). N59 Please refer to your provider manual for additional program and provider MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N750 Incomplete/invalid Blood Gas Report. M53 Missing/incomplete/invalid days or units of service. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N20 Service not payable with other service rendered on the same date.

22 915 Code 2 of a code pair allowed with modifier M50 Missing/incomplete/invalid revenue code(s). 915 Invalid revenue code M50 Missing/incomplete/invalid revenue code(s). 915 Codes G0378 and G0379 only allowed with bill type 13x 915 Codes G0378 and G0379 only allowed with bill type 13x 915 Code 2 of a code pair that is not allowed by NCCI 915 Code 2 of a code pair that is not allowed by NCCI 915 Terminated bilateral procedure 915 implanted/administered not consistent with implant/procedure 915 Transf or blood product exchange w/o spec of blood product MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct MA30 Missing/incomplete/invalid type of bill. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N345 Date range not valid with units submitted. M51 Missing/incomplete/invalid procedure code(s). N59 Please refer to your provider manual for additional program and provider MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct

23 915 Transf or blood product exchange w/o spec of blood product 915 Obs rev code on line item with non obs HCPCS code 915 HCPC Code not Valid on a HCFA Claim 915 Revenue center requires HCPCS code 915 REMIT Claim with Enrollment Status Change 915 REMIT Claim with External Enrollment Coverage Type Change 915 REMIT LOI Records Added or Changed 915 REMIT E/R Claim reversed due to receipt of inpatient claim. 915 REMIT retro term enrollment 915 REMIT denied claim with valid enrollment N750 Incomplete/invalid Blood Gas Report. N59 Please refer to your provider manual for additional program and provider M20 M20 Missing/incomplete/invalid HCPCS. Missing/incomplete/invalid HCPCS. N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment. M2 Not paid separately when the patient is an inpatient. N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package

24 915 Pricing cannot be determined based on units billed 915 Servicing provider required on claim 915 Skin substitute application procedure without appropriate skin substitute product code 915 Resubmit With Operative Report/Medical Records 915 "Medical Records required, fax records to ATTN HMD" 915 A valid HCPC code available for NDC number. 915 ABA Therapy codes need to be billed on a separate claim. 915 ABA Therapy codes need to be billed on a separate claim. 915 Need breakout of Anesthesia time for the MD and CRNA M53 Missing/incomplete/invalid days or units of service. N257 Missing/incomplete/invalid billing provider/supplier primary identifier. M51 Missing/incomplete/invalid procedure code(s). N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N225 Incomplete/invalid documentation/orders/notes/summary/report/ chart. M20 Missing/incomplete/invalid HCPCS. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N61 Rebill services on separate claims. N29 Missing documentation/orders/notes/summary/report/ chart.

25 915 Service not rendered in place of service billed N38 Missing/incomplete/invalid place of service. 915 Incorrect Billing MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Incorrect Billing N34 Incorrect claim form/format for this service. 915 Bill with a valid J Code M20 Missing/incomplete/invalid HCPCS. 915 Incomplete claim form. M58 Missing/incomplete/invalid claim Resubmit claim after corrections. 915 Submit appropriate claim form 915 Non Contracted Code, Use corresponding S Code N34 Incorrect claim form/format for this service. M20 Missing/incomplete/invalid HCPCS. 915 EOB is Missing Information. N4 Missing/incomplete/invalid prior insurance carrier EOB. 915 Invoice does not match services billed N354 Incomplete/invalid invoice

26 915 Unable to determine patient responsibility based upon the submitted EOB. 915 Please resubmit with remit remark code key. 915 Invalid ICD9 Procedure Code 915 Invalid ICD 9 Diagnosis Code 915 Diagnosis not valid for Benefit N4 Missing/incomplete/invalid prior insurance carrier EOB. MA69 Missing/incomplete/invalid remarks. M51 M76 M76 Missing/incomplete/invalid procedure code(s). Missing/incomplete/invalid diagnosis or condition. Missing/incomplete/invalid diagnosis or condition. 915 Pay and Educate M17 Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions. 915 Pay and Educate N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges. 915 Service only payable as inpatient. 915 Explanation of Benefits illegible. Please submit legible Explanation of Benefits. N38 Missing/incomplete/invalid place of service.

27 915 The Medical Records Submitted are not for the Rendering Provider on the claim. 915 Resubmit claim with Medicare FQHC/Rural Health per diem rate sheet 915 Invalid Type of Bill for a Corrected Claim 915 Invalid Type of Bill for a Corrected Claim 915 Invalid billing. Please report the appropriate HCPCS G code. 915 Invalid/Missing occurrence code N225 Incomplete/invalid documentation/orders/notes/summary/report/ chart. N66 Missing/incomplete/invalid documentation. MA30 Missing/incomplete/invalid type of bill. MA67 Correction to a prior claim. M51 M44 Missing/incomplete/invalid procedure code(s). Missing/incomplete/invalid condition code. 915 Invalid Place of Service M77 Missing/incomplete/invalid place of service. 915 Invalid billing multiple service locations billed on one claim N93 A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim. 915 Paid Incorrect Provider MA67 Correction to a prior claim. 915 Paid Incorrect Provider N694 Alert: This reversal is due to a resubmission/change to the claim by the provider.

28 915 Invalid Approved Provider Service for Provider N95 This provider type/provider specialty may not bill this service. 915 Therapy Threshold not met MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Therapy Threshold not met N486 Incomplete/invalid Physical Therapy Certification. 915 Claim Doesn't have any Service Lines 915 Ambulance Run Report Doesn t match units billed on claim. 915 Patient not enrolled with plan. 915 CPT code invalid on DOS. 915 No response to COB inquiry. 915 Revenue code missing / invalid. M79 M53 Missing/incomplete/invalid charge. Missing/incomplete/invalid days or units of service. N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N245 Incomplete/invalid plan information for other insurance M50 Missing/incomplete/invalid revenue code(s).

29 915 DOS incorrect. MA52 Missing/incomplete/invalid date. 915 Incorrect Discharge Status Submitted 915 Treatment Authorization Needed N50 Missing/incomplete/invalid discharge M62 Missing/incomplete/invalid treatment authorization code. 915 Procedure code not on file. M51 Missing/incomplete/invalid procedure code(s). 915 Diagnosis code not on file. M64 Missing/incomplete/invalid other diagnosis. 915 Diagnostic Pointer Missing or Invalid 915 Member ID number invalid. 915 Category of service invalid. 915 Member not enrolled on DOS. 915 Member was not enrolled with this Medical Group on DOS. M64 Missing/incomplete/invalid other diagnosis. N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package

30 915 Resubmit claim with Medicare EOB. N4 Missing/incomplete/invalid prior insurance carrier EOB. 915 Resubmit with primary EOB. N4 Missing/incomplete/invalid prior insurance carrier EOB. 915 Primary Diagnosis Required MA63 Missing/incomplete/invalid principal diagnosis. 915 Triage only not life threatening. 915 Triage only not life threatening. 915 No Attending Physician ID (Outpatient) 915 Negative charge on claim line MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N358 Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted. M68 Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification. M54 Missing/incomplete/invalid total charges. 915 Invalid Admit Hour N46 Missing/incomplete/invalid admission hour. 915 Invalid Discharge Hour N317 Missing/incomplete/invalid discharge hour.

31 915 Claim Doesn't have any Service Lines 915 Provider requires a specialty code 915 PCP is solely responsible for services 915 PCP is solely responsible for services 915 Services are not eligible with diagnosis provided by physician. 915 Service is not related to direct treatment of an illness or injury. 915 Service is not related to direct treatment of an illness or injury. 915 Discharge Status Required for Inpatient and SNF Claims M79 Missing/incomplete/invalid charge. N270 Missing/incomplete/invalid other provider primary identifier. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N450 Covered only when performed by the primary treating physician or the designee. M76 Missing/incomplete/invalid diagnosis or condition. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N576 Services not related to the specific incident/claim/accident/loss being reported. MA43 Missing/incomplete/invalid patient status. 915 Missing Primary Diagnosis MA63 Missing/incomplete/invalid principal diagnosis.

32 915 Admit Type Required MA41 Missing/incomplete/invalid admission type. 915 Discharge Status Required MA43 Missing/incomplete/invalid patient status. 915 Member has no active enrollment on DOS N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package 915 Invalid CPT/HCPCS M20 Missing/incomplete/invalid HCPCS. 915 No Enrollment N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package 915 Invalid Accomodation Days MA32 Missing/incomplete/invalid number of covered days during the billing period. 915 Admit Date Required for Inpatient Claim 915 Attending Physician Required for Inpatient Claims MA31 Missing/incomplete/invalid beginning and ending dates of the period billed. N31 Missing/incomplete/invalid prescribing provider identifier. 915 Invalid Bill Type MA30 Missing/incomplete/invalid type of bill. 915 Revenue Code Requires HCPCS and/or Modifier M20 Missing/incomplete/invalid HCPCS.

33 915 Physicians Assistant requires Modifier 80 or 27 M78 Missing/incomplete/invalid HCPCS modifier. 915 CRNA requires Modifier AA M78 Missing/incomplete/invalid HCPCS modifier. 915 Invalid Line Date of Service MA52 Missing/incomplete/invalid date. 915 Invalid Start Date M52 Missing/incomplete/invalid "from" date(s) of service. 915 Invalid End Date M59 Missing/incomplete/invalid "to" date(s) of service. 915 Invalid Discharge Status MA43 Missing/incomplete/invalid patient status. 915 Invalid Revenue Code for Bill Type 915 Invalid HCPCS for Revenue Code 915 Transferred to Patient Advocates for processing; Expect payment determination from Patient Advocates 915 Rendering and billing provider NPIs cannot match M50 M20 Missing/incomplete/invalid revenue code(s). Missing/incomplete/invalid HCPCS. N196 Alert: Patient eligible to apply for other coverage which may be primary. N433 Resubmit this claim using only your National Provider Identifier (NPI)

34 915 No rendering provider NPI billed on HCFA N433 Resubmit this claim using only your National Provider Identifier (NPI) 915 Not valid for SNF N106 Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service. 915 Occurrence Code 55 and M44 Missing/incomplete/invalid condition code. the date of death must be present when patient discharge status 20, 40, 41, or 42 is present 915 Another service line for the same DOS is missing information to process this line 915 OPPS Claim Denial Return to Provider 915 OPPS Claim Denial Return to Provider 915 Resubmit Claim to OptumHealth 915 Resubmit Claim to OptumHealth MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N142 The original claim was denied. Resubmit a new claim, not a replacement claim. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N196 Alert: Patient eligible to apply for other coverage which may be primary. 915 No Enrollment N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package

35 915 NDC Number is missing or Invalid M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC). 915 Bill to Pharmacare MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct 915 Bill to Pharmacare N196 Alert: Patient eligible to apply for other coverage which may be primary. 915 Billing with invalid NPI for provider submitted on claim. 915 Mental Health NPI number Missing or invalid for Mental Health Services billed on claim. 915 The billing group NPI in Box 33A is not valid or missing for the dates of service on the claim. 915 Denied Benefit Requires submission by member 915 Denied Benefit Requires submission by member 915 Claim cannot be submitted with any negative charges N433 Resubmit this claim using only your National Provider Identifier (NPI) M57 Missing/incomplete/invalid provider identifier. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package M53 Missing/incomplete/invalid days or units of service.