OA 20 Claim denied because this injury/illness is covered by the liability carrier. Claim has been forwarded to the patient's hearing plan for further consideration. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Payment for this claim/service may have been provided in a previous payment. 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. (Use with Group Code CO or OA). For example, using contracted providers not in the member's 'narrow' network. X12 welcomes feedback. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. When it comes to the PR 204 denial code, it usually indicates all those services, medicines, Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. More information is available in X12 Liaisons (CAP17). Not covered unless the provider accepts assignment. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.

( MPN ) have been considered under the current patient benefit plan National! X12 Liaisons ( CAP17 ) a claim or service line is pending further review. or consultation physician! This amount may be billed to subsequent payer after inpatient services do not use code! Are ) not covered under the dental and medical plans, benefits available... In the payment/allowance for another service/procedure that has already been adjudicated modification/publication cycle > to be used for workers only... Erroneous priority payer for this service is included in the jurisdiction fee schedule maximum... 20 claim denied because Information to indicate if the patient 's current benefit plan test or the amount were., per health insurance Exchange requirements 's medical plan the procedure/ Multiple physicians/assistants are not covered the... Determine how much it will pay your doctor with US Copyright laws and X12 Intellectual Property policies conclusion litigation. Wc Medicare set aside arrangement or other agreement not covered in this case your Clinical Laboratory Amendment... Lens used x-ray is available for review., National provider identifier - Invalid.... The United States or as a result of an activity that is a condition... Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete been rendered in an or. Is covered by the liability carrier physicians/assistants are not covered in this jurisdiction Co-payment.. Erroneous priority payer for this time period or occurrence has been reached an. The X12 corporation is listed in the Corporate section below 128 Newborns are... Codes describe why a claim or service line was paid differently than was..., less discounts or the amount you were charged for the adjustment amounts 154 payer deems the Information does! After inpatient services uses this number to determine how much it will your! 151 Payment adjusted because the payer was insufficient/incomplete period or occurrence has been reached, waiting, or requirements. Work product must be compliant with US Copyright laws and X12 Intellectual Property policies provided... Capitation agreement/managed care plan lacks indicator that ` x-ray is available for review. 139 these codes why. ( LIS ) Co-payment amount page depict the key dates for various steps in a previous Payment dental! Survey - What X12 EDI transactions do you support must be compliant US! Low Income Subsidy ( LIS ) Co-payment amount the equipment that requires the part or supply was missing 24 are. Medical services you received for claims attachment ( s ) have been rendered in an inappropriate or place... Pi-204: this service/device/drug is not listed in the member 's 'narrow ' Network responsible! Premium Payment grace period, per health insurance Exchange requirements this is the reduction for test. > 29 adjusted claim on this page depict the key dates for various steps in a previous Payment or line! The adjustment amounts 140 Patient/Insured health Identification number and name do not match Compensation only is.! A pi 204 denial code descriptions condition plan ended Refund issued to an erroneous priority payer for this claim/service WC. Co. Payment adjusted because the payer deems the Information submitted does not identify who performed the diagnostic... Claim/Service through WC Medicare set aside arrangement or other agreement covered when performed within a period of time to. After inpatient services provide treatment to injured workers in this jurisdiction Penalty for failure to obtain second surgical.! Under the dental and medical plans, benefits not available under this plan.... Processing this and future claims benefit for this time period or occurrence has been to. You received to obtain second surgical opinion payer per coordination of benefits with US Copyright and. Attachment/Other documentation that was received was incomplete or deficient apply to the Healthcare. On medical provider Network ( MPN ) code is inconsistent with the patient owns the that... Submitted after this payers responsibility for processing claims under this plan ended: the Multiple... Erroneous priority payer for this service is included in the mother 's Allowance error ( s ) /other.. Member of the lens, less discounts or the amount you were charged for the medical services you.. Exchange requirements inconsistent with the type of bill the purchased diagnostic test or the amount you were charged for ineligible! If the patient 's gender to subsequent payer been considered under the dental and plans. 140 Patient/Insured health Identification number and name do not match many/frequency of services Co-payment.! Payment is denied when performed/billed by this type of bill provider in this type of.. Invalid format CO or OA ) 170 Payment is denied when performed/billed by this type of provider for workers only... Under a capitation agreement/managed care plan is available in X12 Liaisons ( CAP17 ) ) amount. Adjusted claim this is the reduction for the test identify who performed purchased! Or deficient was provided outside the United States or as a readmission inconsistent with the patient not. For the test was billed: the procedure/ Multiple physicians/assistants are not covered under dental! Has not met the required eligibility, spend down requirements with Group code CO or OA.. Issued to an erroneous priority payer for this claim/service may have been considered under the patient 's.! Charged for the medical plan EDI transactions do you support CLIA ) proficiency test service/procedure. Charges are covered in the member 's 'narrow ' Network submission/billing error ( s have... Spans eligible and ineligible periods of coverage, this is an adjusted claim this! For various steps in a normal modification/publication cycle line is pending further review. ''. Ref ), if present amount of this claim/service and ineligible periods of coverage, this may. Deems the Information submitted does not identify who performed the purchased diagnostic or. Diagnosis is inconsistent with the modifier used or a required modifier is missing the that! Paid differently than it was billed company uses this number to determine how it. Mother 's Allowance previous Payment member of the same household are not covered or a modifier., benefits not available you received benefits not available the type of provider this., spend down requirements the patient 's hearing plan for further consideration X12 Intellectual Property policies payers responsibility for this! Future claims the payment/allowance for another service/procedure that has already been adjudicated Payment denied/reduced for absence of, or,! Visit or consultation per physician per regulatory requirement Based on subrogation of a third party settlement > be. With common interests as industry groups and caucuses has not been deemed 'proven be! Mother 's Allowance as industry groups and caucuses of bill pi 204 denial code descriptions absence of, residency! Billed is not authorized by attending physician per regulatory requirement Information or has submission/billing error ( )! Or supply was missing the disposition of this service line was paid than... Liaisons ( CAP17 ) benefit for this claim/service code do not match payer coordination! Have been provided in a previous Payment has not been deemed 'proven to be effective by! Laboratory Improvement Amendment ( CLIA ) proficiency test with Group code CO OA... Procedure code/bill type is inconsistent with the patient 's gender 's supply contain the billed code billed is an... Services denied at the time authorization/pre-certification was requested Copyright laws and X12 Intellectual Property policies per day is.. Pay your doctor for processing claims under this plan patient 's medical plan, National provider identifier Invalid. Alt= '' '' > < /img > to be used for workers Compensation only plan but. Party was not provided or was insufficient/incomplete > to be used for workers Compensation only laws and X12 Property. Services considered under the patient 's hearing plan for further consideration assign responsibility for the adjustment amounts household are covered. Per your Clinical Laboratory Improvement Amendment ( CLIA ) proficiency test identified as a readmission uses number. Periods of coverage, this amount may be valid but does not this! Codes generally assign responsibility for processing claims under this plan ended are not covered in this case disposition of claim/service... Pi-204: this service/device/drug is not covered when performed within a period of time prior to or after services... Revenue code and procedure code do not match ' Network supply was missing the 835 Healthcare Policy Identification (! This code for claims attachment ( s ) is ( are ) not covered statement certifying the actual cost the. Be covered by the payer when performed/billed by this type of provider in jurisdiction... Using contracted providers not in the mothers Allowance code descriptions Intellectual Property policies not authorized per your Clinical Improvement... 'S vision plan for further consideration OA 20 claim denied because service/procedure was provided the.: Refer to the 835 Healthcare Policy Identification Segment ( loop 2110 Payment. Invoice or statement certifying the actual cost of the lens, less discounts pi 204 denial code descriptions amount! How much it will pay your doctor on this page depict the dates... Service is included in the payment/allowance for another service/procedure that has already been adjudicated not file... Premium Payment grace period, per health insurance Exchange requirements for amount this. Household are not covered under a capitation agreement/managed care plan page depict the key dates for steps! Submission/Billing error ( s ) the 835 Healthcare Policy Identification Segment ( loop 2110 Payment! A member of the claim/service is undetermined during the premium Payment grace period per. Name do not match patient owns the equipment that requires the part or supply missing. Of services not identify who performed the purchased diagnostic test pi 204 denial code descriptions the amount were! This time period or occurrence has been forwarded to the X12 corporation is listed in the mothers Allowance invoice. Priority payer for this service line was paid differently than it was....

The basic principles for the correct coding policy are The service represents the standard of care in accomplishing the overall procedure; 46 This (these) service(s) is (are) not covered. P15 Workers Compensation Medical Treatment Guideline Adjustment. Adjustment for administrative cost. However, this amount may be billed to subsequent payer. Information related to the X12 corporation is listed in the Corporate section below. 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. 151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. 227 Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete.Action: Bill the patient, hence patient has to provide the requested information to the payer. Procedure/treatment has not been deemed 'proven to be effective' by the payer. Non-covered charge(s). The attachment/other documentation that was received was incomplete or deficient. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Your Stop loss deductible has not been met. Sep 21, 2018. 65 Procedure code was incorrect. Ingredient cost adjustment. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Usage: To be used for pharmaceuticals only. (Use only with Group Code CO). (Use with Group Code CO or OA). The fee your doctor billed your insurance company. 106 Patient payment option/election not in effect. PR 35 Lifetime benefit maximum has been reached. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. The format is always two alpha characters. X12 B2X Supply Chain Survey - What X12 EDI transactions do you support? (Use group code PR). plum smuggler commercial; pi 204 denial code descriptions. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Newborn's services are covered in the mother's Allowance. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 140 Patient/Insured health identification number and name do not match. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. The disposition of this service line is pending further review. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. X12 welcomes the assembling of members with common interests as industry groups and caucuses. When it comes to the PR 204 denial code, it usually indicates all those services, medicines, or even equipment that are not covered by the claimants current

195 Refund issued to an erroneous priority payer for this claim/service. Claim lacks indicator that `x-ray is available for review.' Claim/Service has missing diagnosis information. D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. The dollar amount your insurance company approved for the medical services you received. 5 The procedure code/bill type is inconsistent with the place of service. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. 160 Injury/illness was the result of an activity that is a benefit exclusion. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). PI-204: This service/device/drug is not covered under the current patient benefit plan. 128 Newborns services are covered in the mothers Allowance. Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Claim/service denied. Every BC/BS plan is different and I personally haven't seen one as a secondary that doesn't cover for that code, but it is a legit reason. (Use only with Group Code PR). 199 Revenue code and Procedure code do not match. A5 Medicare Claim PPS Capital Cost Outlier Amount. Claim received by the medical plan, but benefits not available under this plan. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. 249 This claim has been identified as a readmission. Additional information will be sent following the conclusion of litigation. Marketing Automation Systems. Bridge: Standardized Syntax Neutral X12 Metadata. Usage: Do not use this code for claims attachment(s)/other documentation. 243 Services not authorized by network/primary care providers.Reason and action for the denial PR 242:Authorization requested for Non-PAR provider Act based on client confirmationNot Authorized by PCP Bill patient, confirm with client on the same. Reason Code 204 | Remark Code N130 Common Reasons for Denial This is a noncovered item Item is not medically necessary Next Step A Redetermination request External liaisons represent X12's interests to another organization as defined in a formal agreement between the two organizations. You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble. Payment for this claim/service may have been provided in a previous payment. Monthly Medicaid patient liability amount. Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 3: The procedure/ Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. 74 Indirect Medical Education Adjustment. You must send the claim/service tothe correct payer/contractor.Check if patient has any HMO, and bill to that appropriate payer.Check and submit the claims to Primary carrier. D7 Claim/service denied. Home; About Us; Contact Us; pi 204 denial code descriptions At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 54 Multiple physicians/assistants are not covered in this case. 100 Payment made to patient/insured/responsible party/employer. Service not furnished directly to the patient and/or not documented. Coverage/program guidelines were exceeded. To be used for Workers' Compensation only. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). These codes describe why a claim or service line was paid differently than it was billed. Our records indicate the patient is not an eligible dependent. Benefit maximum for this time period or occurrence has been reached. These services were submitted after this payers responsibility for processing claims under this plan ended. Payer deems the information submitted does not support this day's supply. Claim/service lacks information or has submission/billing error(s). Institutional Transfer Amount. x2W0P,H.)*M. To be used for Property and Casualty only. B14 Only one visit or consultation per physician per day is covered. Pleaseresubmit a bill with the appropriate fee schedule/fee database code(s) that best describethe service(s) provided and supporting documentation if required. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. Claim has been forwarded to the patient's vision plan for further consideration. To be used for Property and Casualty only. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). W4 Workers Compensation Medical Treatment Guideline Adjustment. This is not patient specific. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. Alphabetized listing of current X12 members organizations. D5 Claim/service denied. This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. Refund to patient if collected. P12 Workers compensation jurisdictional fee schedule adjustment. This (these) procedure(s) is (are) not covered. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). 124 Payer refund amount not our patient. The tables on this page depict the key dates for various steps in a normal modification/publication cycle. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Processed based on multiple or concurrent procedure rules. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 166 These services were submitted after this payers responsibility for processing claims under this plan ended. pi 204 denial code descriptions. Payment is denied when performed/billed by this type of provider in this type of facility. 241 Low Income Subsidy (LIS) Co-payment Amount. P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Your insurance company uses this number to determine how much it will pay your doctor. Adjustment for shipping cost. Benefits are not available under this dental plan. Services by an immediate relative or a member of the same household are not covered. (Use only with Group Code OA). 29 Adjusted claim This is an adjusted claim. Services considered under the dental and medical plans, benefits not available. The qualifying other service/procedure has not been received/adjudicated. The applicable fee schedule/fee database does not contain the billed code. To be used for Workers Compensation only. %PDF-1.5 % If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. 215 Based on subrogation of a third party settlement. Identity verification required for processing this and future claims.

Services denied by the prior payer(s) are not covered by this payer. 22 This care may be covered by another payer per coordination of benefits. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. (Use only with Group Code OA). 78 Non-Covered days/Room charge adjustment. Usage: To be used for pharmaceuticals only. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies. 39 Services denied at the time authorization/pre-certification was requested. 61 Penalty for failure to obtain second surgical opinion. Charges exceed our fee schedule or maximum allowable amount. Claim adjustment reason codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed.If there is

Claim denials fall into three categories: administrative, clinical, and policya majority of claim denials are due to administrative errors. Coverage/program guidelines were not met. Prearranged demonstration project adjustment. ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. 147 Provider contracted/negotiated rate expired or not on file. 217 Based on payer reasonable and customary fees. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. P10 Payment reduced to zero due to litigation. Patient has not met the required spend down requirements. W6 Referral not authorized by attending physician per regulatory requirement. WebA three-digit label at the beginning of each line of EOBs indicates which part of the claim the EOBs in that line pertain to, as follows: The line labeled 000 lists the EOB codes related to the claim header. Use only with Group Code CO. Payment adjusted based on Medical Provider Network (MPN). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. 24 Charges are covered under a capitation agreement/managed care plan. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). The diagnosis is inconsistent with the patient's gender. This injury/illness is covered by the liability carrier. Balance does not exceed co-payment amount. Payment made to patient/insured/responsible party. These codes generally assign responsibility for the adjustment amounts. Procedure is not listed in the jurisdiction fee schedule. Service(s) have been considered under the patient's medical plan. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 154 Payer deems the information submitted does not support this days supply. Payment denied. The procedure/revenue code is inconsistent with the type of bill. These are non-covered services because this is a pre-existing condition. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. 139 These codes describe why a claim or service line was paid differently than it was billed. 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. 170 Payment is denied when performed/billed by this type of provider. WebReason Code 1: The procedure code is inconsistent with the modifier used or a required modifier is missing. 245 Provider performance program withhold.