Denial Codes Found on Explanations of Payment/Remittance ...

[Pages:22]Denial Codes Found on Explanations of Payment/Remittance Advice (EOPs/RA)

Denial Description Code

1 Services after auth end

2 Services prior to auth start 3 No auth on file 4 Max Days 5 Not member 6 Benefit Day Limit Exceeded. 7 No benefit 8 Not covered

9 Before eff date 10 Prior auth required 11 Not a benefit 12 Exceeds annual amount 13 Lifetime max 14 Visit limit 15 Dollar limit 16 Exceeds auth 17 Auth for different provider 18 Experimental

19 Mental Health 20 Not covered 21 Capitated 22 Hospice 23 Capitated 24 CompCare

26 Vision

27 Health and Wellness

Denial Language

The services were provided after the authorization was effective and are not covered benefits under this plan. The services were provided before the authorization was effective and are not covered benefits under this plan. There is no authorization on file for these services. This claim exceeds the maximum allowed days per benefit period Denied: No coverage effective at time of service. Benefit Day Limit Exceeded. The patient does not have benefits for this service under this Plan. The service provided is not a covered benefit under this plan. The date you received medical services on the above claim was prior to your effective date of eligibility with this Plan. Please submit your claim to the appropriate Plan. Utilization Management has denied prior authorization for this service. Not a benefit This claim exceeds the annual amount allowed for this benefit. This claim exceeds the lifetime maximum allowed for this benefit. This claim exceeds the visit limit allowed for this benefit. This claim exceeds the dollar limit allowed for this benefit. This services exceeds the number of services authorized. The authorization on file was issued to a different provider. Procedure has been determined as being experimental in nature. This claim is the responsibility of Bravo Health's Delegated Mental Health Vendor. This claim has been forwarded on your behalf. This service is not a covered benefit for this plan This is a capitated service. Hospice Member - Submit to Original Medicare This is a capitated service. Submit all Inpatient Mental Health to Comp Care This claim is the responsibility of Bravo Health's Delegated Vision Vendor. This claim has been forwarded on your behalf. This claim is the responsibility of Bravo Health's Delegated Health & Wellness Vendor. This claim has been forwarded on your behalf.

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Denial Description Code

28 Dental 29 Adjusted claim 30 Auth match 31 Not covered Medicare

32 Not covered benefit 33 POS 35 Per Diem 36 Facility 37 RUGS 38 Visit 39 Invalid revenue code

40 Invalid modifier 41 Invalid procedure code 42 Invalid ICD9 code

43 Par filing deadline exceeded

44 No detail 45 No EOB 46 No occurrence code 47 Correct occurrence span 48 Correct condition code

Duplicate Claim Line (Same 49 Member/DOS/CPT(REV)

Duplicate Mem/DOS/Pay 50 To/Rendering Phys/Charges

Invalid claim data found on IRF 51 claim.

Denial Language

This claim is the responsibility of Bravo Health's Delegated Dental Vendor. This claim has been forwarded on your behalf. This is an adjusted claim. The services billed do not match the services that were authorized on file. This service is not covered by Medicare. This service is not a covered benefit for this plan however the patient is not liable for payment as the Noncoverage provided to the patient did not comply with the program requirements Please resubmit this claim with the correct place of service. Services included in Per Diem Services included in facility fee Services included in RUGS rate Services included in visit rate Claim has been submitted with an invalid revenue code. Please resubmit a corrected claim. The modifier submitted on this claim is invalid for the date of service. Please resubmit claim with a valid modifier. The procedure code billed is not valid. Please resubmit this claim with a valid code. Please resubmit this claim with a valid ICD9 diagnosis code. All claims for participating providers must be submitted within 180 days of the date of service. This claim was submitted after the filing deadline. Please resubmit this claim with a detailed bill showing the charges and specific services for each date of service. Itemized bills can be faxed to 1(877)-788-2764 Please resubmit with EOB in order to complete processing of the claim. Please resubmit with corrected Occurrence Code on claim Please resubmit with corrected Occurrence Code Span on claim. Please resubmit with corrected Condition Code on claim.

Duplicate Claim Line (Same Member/DOS/CPT(REV)

Duplicate Mem/DOS/Pay To/Rendering Phys/Charges

Invalid claim data found on IRF claim.

Benefit Requires Contracted (PAR)

52 provider.

Benefit Requires Contracted (PAR) provider.

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Denial Code

53

54 55 56 57 58 59 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77

Description

Benefit requires non-contracted (NONPAR) provider. Service not within the scope of your contract. Incorrect value code Incorrect admission date Discharge status required Admission source required Incorrect patient status HIPPS RUGS DOS billed dollars HIPPS RUG requires rehab Submit EOB Duplicate service code Incorrect From DOS Incorrect To DOS Incorrect Admit Type Incorrect HIPPS code Incorrect IRF charges Incorrect Rev code/HCPC rate Invalid claim line units Annual benefit amount exceeded Lifetime benefit amount exceeded Individual Lifetime visits exceeded Not covered Benefit visit limit exceeded Benefit dollar limit exceeded

78 Excluded from provider contract Duplicate Mem/DOS/Service

79 Code/Pay To/Modifier

Denial Language

Benefit requires non-contracted (NONPAR) provider.

Service provided is not included within the scope of your contract. Please resubmit with corrected Value Code on claim Please resubmit with corrected Admission Date on claim Discharge status is required for inpatient and SNF claims. Admission source required Please resubmit with corrected patient status for bill type on claim HH PPS and RUGS DOS billed amount should not have a dollar amount. HIPPS RUG rate code requires rehabilitation therapy Please resubmit with a EOB in order to complete the processing of the claim Duplicate service code on same claim with no modifier. Please resubmit with corrected modifier on claim. Please resubmit with corrected From DOS on claim. Please resubmit with corrected TO DOS on claim. Please resubmit with a correct Admit Type on claim. Please resubmit with corrected HIPPS code on IRF claim. Please resubmit with corrected charges on IRF claim Please resubmit with corrected Revenue Code and HCPCS/Rate on claim Claim line units not equal to days reflected with span code 74 Annual benefit amount exceeded Lifetime benefit amount exceeded Individual Lifetime visits exceeded This service is not a covered benefit under the plan for this date of service. Benefit visit limit exceeded Benefit dollar limit exceeded This service is excluded from the Provider's contract. Reimbursement will be made only on services covered by the contract.

Duplicate Mem/DOS/Service Code/Pay To/Modifier

Dup mem/DOS/Svc Code/ Pay 80 To/Rend Phys/Mod

Duplicate member/DOS/Service Code/ Pay To/Rendering Physician/Modifier

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Denial Code

81

82 83

84

85

Description

One 0024 revenue code is permitted per claim Resubmit with appropriate diagnosis codes. Duplicate claim line Not covered/Not allowable by contract Duplicate Claim (Provider/Member/DOS)

86 No RAP

87 Unmatched HIPPS

88 No RAP 2 89 Invalid from date

The statement From date is a 90 required field.

91 Duplicate RAP

92 RAP date discrepancy Include rev and HCPC codes for

93 each service. HIPPS RUGS DOS not in time

94 period. 95 Not a member 96 Need EOB 97 Incorrect bill type 98 Incorrect number of units

Inpatient hospital days have been 99 exhausted. 100 Rebundled 101 Pre-op included

Denial Language

Per CMS guidelines, only one 0024 revenue code is permitted per claim

Please resubmit the claim with appropriate diagnosis codes. Duplicate claim line (same provider/member/DOS/CPT(REV)

Service not covered/Not allowable by contract for provider.

Duplicate Claim (Provider/Member/DOS) A Request for Anticipated Payment (RAP) has not yet been submitted for this episode. A RAP must be submitted before payment can be made on the final claim of the episode. The HIPPS code that was submitted on the RAP for this episode does not match the HIPPS code that was billed on the final claim. Please resubmit a corrected claim or RAP. A Request for Anticipated Payment (RAP) has not yet been submitted for this episode. A RAP must be submitted before payment can be made on the final claim of the episode. The From statement date must equal the date on the service line item. Please submit a corrected claim.

The statement From date is a required field. Please resubmit a corrected claim. A Request for Anticipated Payment (RAP) has already been submitted for this episode. A cancellation of the original RAP must be submitted before payment can be made on a corrected RAP. The statement From and Through date on the Request for Anticipated Payment (RAP) should be equal. Please submit a corrected claim.

Please resubmit the claim and include both valid revenue and HCPC codes for each service.

HIPPS RUGS Date of Service is not within the assessment modifier time period. Denied: No coverage effective at time of service. Please resubmit with an Explanation of Benefits from the primary insurance carrier Please resubmit this claim with a corrected bill type Please resubmit with the correct number of units on claim.

Inpatient hospital days have been exhausted. Two or more procedure codes were rebundled into one comprehensive code. Pre-Operative services are included in the surgical package.

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Denial Code 102

103 104 105

106 107

108 109 110

111 112 113 114 116 117

118 119

120 121 122 123 124 125 126 127 128

129

Description

Post-op included Medical visit is not separately reimbursable. One initial/3 years Duplicate claim.

Incidental Obsolete or invalid procedure code Multiple unit or multiple modifier denial. Unilateral/Bilateral procedure code Mutually exclusive Procedure does not require an Assistant Surgeon. Age range discrepancy Gender discrepancy Invalid diagnosis code OPPS Incorrect blood

Radiopharm G0739

Inc in Part A Need mod T or S Rev Code Mileage Invoice Total mismatch Diag required EOB required

Single HIPPS

Denial Language

Post-Operative services are included in the surgical package.

Medical visit is not separately reimbursable. Initial visit is only billed once per patient/provider every three years. Duplicate claim. Incidental service(s) to primary procedure do not require separate reimbursement - The patient is not liable for payment. Obsolete or invalid procedure code

Multiple unit or multiple modifier denial. Unilateral/Bilateral procedure code Two or more procedure codes are considered mutually exclusive.

Procedure does not require an Assistant Surgeon. Provider assigned an age-specific procedure to a patient whose age is outside of the designated age range. Provider assigned a gender-specific procedure to a patient of the opposite sex. Invalid diagnosis code The services reported on this claim are not separately reimbursable under OPPS. Line items billing for blood and products is incorrect. Please resubmit a corrected claim. Certain nuclear medicine procedures are performed with specific diagnostic radiopharmaceuticals. The required radiopharmaceutical is not present on the claim. Please resubmit corrected claim. G0379 must be billed in conjunction with G0378. The services billed on this claim are considered directly related to an inpatient admission and are not separately billable. These services are included in the Part A payment. Component of comprehensive procedure that would be allowed if appropriate modifier were present Medical visit on same day as a type T or S procedure without modifier 25. Please resubmit with corrected Revenue Code. Mileage included in base rate. Submit claim with invoice. Claim total does not match detail line total. Per CMS regulations this benefit requires specific diagnosis codes. The primary carrier's explanation of benefits is necessary to consider these services. Effective January 1, 2008, episodes paid under the refined HH PPS will be paid based on a single HIPPS code. Please submit a corrected claim.

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Denial Code 130 131 132 133 134 135

Description

Missing Modifier Rendering Provider POA SUBMITTED W/O NDC NUMBERS SUBMITTED W/INVALID NDC #S INVALID NDC NUMBER

136 NDC NUMBER(S) ILLEGIBLE

137 FIN and NPI mismatch 138 Acute Rehab 139 OON 140 Add On 141 Drug Coverage Only 142 Bundled Service 143 HIPPS 144 A8A9 146 Old 147 OPPS 148 CMS 149 Not enrolled 150 Not enrolled group

151 Bill on 1500 152 RUGS 153 DevCode 154 Report

155 Invalid

156 Excl 157 No RVU

Denial Language

Please resubmit with appropriate or missing modifier. Rendering Provider Required on Claim Please resubmit with a valid POA code Please resubmit with National Drug Code (NDC) numbers. Please resubmit with a valid National Drug Code (NDC) number. The number submitted is not valid. Please resubmit with a valid National Drug Code (NDC) number. The number submitted is not valid.

Please resubmit this claim with legible NDC numbers.

Our data indicates a FIN and NPI mismatch as billed. Please submit a corrected claim. This is an acute rehab admit. Please resubmit claim with the appropriate case mix group code. The benefit for this service is not covered out of network. Add-on billed without primary code. No Medical Coverage. Member has Drug Coverage Only. Bundled Service A HIPPS codes is required for this type of claim. Please resubmit with appropriate coding. Please resubmit claim with value codes A8 & A9 Services not billable for the Fiscal Year. Code not recognized by OPPS; alternate code for the same service may be available. Code not recognized by CMS; alternate code for the same service may be available. Member not enrolled on DOS. Member was not enrolled with this Medical Group on DOS . Resubmit ASC Claims on HCFA ASCs are required to submit claims on form CMS-1500. Please resubmit claim on appropriate form. Submit with RUGS code. Claim lacks required device code. Code is used for reporting performance measurements only. G/I- This service code is not valid for Medicare purposes. Medicare uses an alternate code for the reporting and payment of these services. Please resubmit claim with appropriate coding. E- This service code is excluded from the Physician fee schedule by regulation. No payment is made under the MPFS for this code. J- This code has no Relative Value Unit and no payment amount. The intent of this code is to facilitate the identification of anesthesia services only.

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Denial Code 158 159 160 161 162 163 164

Description

APC DRG Age Gender E Dx Gender Match Bilateral 2x

165 Bilateral 2xx

166 Mut Excl

167 No Mod 168 No Blood

169 Obs 170 HCPCS Req 171 Comp EM 172 Inv Rev 173 No Proc 176 Not covered 177 Max 178 Max copay 179 Cosurgeon 180 Credit 181 MedSurg 182 Skilled 183 Subacute 184 Telemetry 185 Obs 2 186 Per Diem 187 Obs Rate 188 Package

11/11/2013

Denial Language

Reimbursement for this service is included in the APC reimbursement. Payment for this service is included in the DRG rate. The diagnosis code includes an age range and the age is outside that range. The diagnosis code includes sex designation and the sex does not match. The first letter of the principle diagnosis code in an E. This edit is not applicable to the admit diagnosis. The sex of the patient does not match the sex designated for the procedure on the record. The same bilateral procedure code occurs two or more times on the same service date. The same bilateral procedure code occurs two or more times on the same service date or the same inherent bilateral procedure code occurs two or more times on the same service date. The procedure is one of a pair of mutually exclusive procedures in the NCCI table coded on the same day, where the use of a modifier is not appropriate. The procedure is identified as part of another procedure on the claim coded on the same day, where the use of a modifier is not appropriate. A blood transfusion or exchange is coded but no blood product is coded. A 762 (observation) revenue code is used with a HCPCS other than observation (99217-99220, 99234-99236, G0378, G0379). Revenue center requires HCPCS. Composite E/M conditions not met for observation and line item. Revenue code not recognized by Medicare. Claim lacks allowed procedure code. This is not a covered service. Maximum out of Pocket has been reached. Eligible Amounts have been paid at 100%. Maximum copay per diem has been satisfied for this benefit period. No copay per diem applied. Co-Surgeon Not Covered Credit applied for prior RAP payment This service has been down graded to Med/Surg Day This service has been down graded to Skilled Nursing This service has been down graded to Subacute This service has been down graded to Telemetry This service has been down graded to the Observation Rate This service is included in the In-patient Per Diem This service is included in the Observation Rate This service is included in the Package Price

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Denial Code 189 190 191 192 193 194 195 196 197 198 199

Description

Stoploss Unequal Missing Anes Time Missing CPT Mult Proc Mult Surg Non Par Timely Not Quest Lab Convenience Rebill Facility Payment

200 HH Claims 201 Self Admin 202 SNF Exhaustted 203 3 Units Blood 204 UR Denied Days 205 After Death

206 DRG Invalid 207 ER in 72 hrs 208 Inc in case 209 Inc in CMG 210 Denied Days 211 Spec Dx 212 Dup 213 Location 214 Adjust for Cap 215 BT 710 216 Excl 217 NotMember2

220 Qual

11/11/2013

Denial Language

This service is included in the Stop Loss Rate Itemized Bill not equaled to charges Please rebill. The service is billed is missing Anesthesia Time Units MISSING CPT CODE MULTIPLE PROCEDURES BILLED WITHOUT MODIFIER Multiple Surgery Reduction NON PAR PROVIDER TIMELY FILING NON QUEST LAB PROVIDER Patient convenience items are not covered under this benefit plan. REBILL USING MEDICARE G CODES Reimbursement for service is included in the payment made to the facility. Resubmit HH Claims on UB Home Health Agencies are required to submit claims on form CMS-1450, the UB-04. Please resubmit claim on appropriate form. Self administered drugs are not covered services under this plan. SKILLED NURSING DAYS EXHAUSTED The first three units of blood are not covered services under this plan. UR DENIED HOSPITAL DAYS This date of service is after the date of the patient's death. The DRG submitted on this claim is not valid for the fiscal year billed. Please resubmit claim with a corrected DRG. Emergency Room visits within 72 hours of an inpatient admission cannot be billed and reimbursed separately. This service is included in the Case Rate Reimbursement for this service in included in the CMG These hospital days have been denied by our Health Services Department. Payment for this benefit requires specific diagnosis codes per CMS guidelines. This is a duplicate of a claim that was previously adjudicated. Service Facility Location Required. This claim is an adjustment for services capitated incorrectly according to your contract. Payment for claims submitted using bill type 710 will be $0.00 as this is a non-payment claim. Excluded Service Not Covered Denied: No coverage effective at time of service. Physician Quality Reporting Indicator codes are for reporting purposes only and are not eligible for reimbursement.

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