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Edit Codes Summary
A list of edit codes and methods of correction.
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The following document contains common EOB codes that may appear on your MassHealth Remittance Advice. If the error(s) on the claim that caused it to deny can be corrected, the corrected claim can be resubmitted to MassHealth.
For more information on how to correct a claim, see Subchapter Part 6 of the Administrative and Billing Instructions in your provider manual. The MassHealth Provider Manuals are available in the Provider Library of the MassHealth Web site.
To quickly find an EOB code, press CTRL + F on your keyboard and type the four digit EOB code indicated on your MassHealth remittance advice into the search box.
|Edit Code |Description |Provider Action |
|203 |This EOB Code displayed because the MassHealth |Correct the member’s MassHealth ID |
|Member ID Number |Member’s ID was missing or invalid. |Resubmit claim with corrected information |
|Missing/Invalid | | |
|229 |This EOB Code displayed because the Admit Source|Correct the Admit Source |
|Source Admission Missing |on the claim is blank or invalid. |Resubmit claim with corrected information |
|231 |This EOB Code displayed for a group practice who|Add the NPI of the rendering provider onto the corresponding field [add in claim |
|Rendering Provider Number Is |did not list the rendering provider’s NPI on the|field] |
|Missing |claim. |Resubmit claim with corrected information |
|237 |This EOB Code displayed because the outpatient |Bill each outpatient date of service as a separate institutional claim |
|Outpatient Claims Cannot Span |institutional claim included multiple dates of |Resubmit claim with corrected information |
|Dates |service. | |
|241 |This EOB Code displayed because the accident |Select “Y” or “N” |
|Accident Indicator Is Invalid |indicator is not specified as “Y” or “N.” |If “Y” is selected, enter the reason for admission |
| | |If “N” is selected, admission reason is not required |
| | |Resubmit claim with corrected information |
|251 |This EOB Code displayed because the modifier is |Check Subchapter 6 for acceptable modifiers |
|First Modifier Not Covered |no longer accepted/active. |Resubmit claim with corrected information |
|257 |This EOB Code displayed because the place where |Refer to CMS for valid Place of Service Codes for Professional Claims |
|Place Of Service Is Invalid - |the service was rendered is invalid for the |Verify the place of service is indicated at the detail level of the claim |
|DTL |procedure code. |Resubmit claim with corrected information |
|Edit Code |Description |Provider Action |
|259 |This EOB Code displayed because the bill date is|Correct bill date in appropriate format MM/DD/YYYY |
|Date Billed Is Missing/Invalid |not in the correct format or not present on |Resubmit claim with corrected information |
| |claim. | |
|273 |This EOB displays because an institutional claim|If paper waiver provider and claim was sent on paper: |
|Type Of Bill Missing |was submitted without a type of bill code on the|Check field 4 of the UB-04 and refer to the UB-04 Billing Guide as the type of |
| |claim, which is required. |bill codes and UB-04 claim frequency type code values for specific provider types|
| | |are listed on the billing guide. |
| | |If electronic claim: |
| | |Verify that the type of bill code is being reported in the corresponding |
| | |loop/segment of the 837 file. |
| | |Refer to the 837I Billing Guide for details. |
|274 |This EOB Code displayed because bill code does |If paper waiver provider and claim was sent on paper: |
|Type Of Bill Code Invalid |not match provider type or method of claims |Check field 4 of the UB-04 and refer to the UB-04 Billing Guide as the type of |
| |submittal. |bill codes and UB-04 claim frequency type code values for specific provider types|
| | |are listed on the billing guide. |
| | | |
| | |If electronic claim: |
| | |Refer to 837I Billing Guide for correct bill code reported in the corresponding |
| | |loop/segment of the 837 file. |
| | |Resubmit claim with corrected information |
|277 |This EOB Code displayed because the Admit Hour |Correct Admit Hour for the member to correspond to the start time of the member’s|
|Admit Hour Invalid |listed on the claim does not correspond to the |visit |
| |start time of a member's visit. |Resubmit claim with corrected information |
|282 |This EOB Code displayed because the value code |Enter value code 80 with number of covered days for these provider types: Acute |
|Covered Days Missing |for covered days did not correspond with |Hospitals, Chronic Disease and Rehabilitation Hospitals, Psychiatric Inpatient |
| |provider types. |Hospitals, and Nursing Facilities |
| | |Resubmit claim with corrected information |
|Edit Code |Description |Provider Action |
|292 |This EOB Code displayed because the claim |Enter occurrence code into the Extended Services tab of the Provider Online |
|Revenue Code 185 Requires OSC =|included Revenue Code 185 without inclusion of |Service Center (POSC) if doing Direct Data Entry (DDE) |
|71 |occurrence code 71. |Enter the occurrence code into Loop 2300 Segment HI, if submitting 837I |
|Provider billing for MLOA | |Resubmit claim with corrected information |
|revenue code 185, Occurrence | | |
|code "71" is required. | | |
|301 |This EOB Code displayed because the number of |Validate the HSN-payer relationship |
|Payer Responsibility and COB |payers listed on the claim do not correspond to |If HSN is the primary payer, no other payers should be listed |
|Not Compatible |the member’s relationship with HSN. |If HSN is the secondary payer, there should be one other payer listed |
| | |If HSN is the tertiary payer, there should be two other payers listed |
| | |Resubmit claim with corrected information |
|302 |This EOB Code displayed because the SBR04 field |Complete the SBR04 field with one of the following valid values: “Prime,” |
|Insured Group Name (HSN Type) |is missing or invalid. |“Second,” “Partial,” “CA,” “BD,” or “MH” |
|is Invalid | |Resubmit claim with corrected information |
|304 |This EOB Code displayed because the segment |Validate the two segment fields to ensure claim type matches payer responsibility|
|Payer Responsibility and |fields SBR01 and SBR04 are not compatible. |sequence number code |
|Insured Group Name /Not | |HSN claim type (SBR04) is equal to Prime (P) and Payer Responsibility Sequence |
|Compatible | |Number Code (SBR01) should be P |
| | |HSN claim type (SBR04) is equal to Second (S) and Payer Responsibility |
| | |SBR01should be S |
| | |Partial/P, S, or |
| | |T, BD/P |
| | |CA/P |
| | |S or T, MH/P, S or T |
| | |Resubmit claim with corrected information |
|305 |This EOB Code displayed because CA/MH HSN claim |Add the G1 qualifier to REF01 in 2300 |
|G1 Ref Required when HSN |types require REF01 in 2300 to have a qualifier |Resubmit claim with corrected information |
|Insured Group Is CA Or MH |of G1 to report the claim type application | |
| |number. | |
|308 |This EOB displays when there is a mismatch |Confirm that the submitted benefit information on the claim is correct and |
|Aid Cat Must be HB when Insured|between the submitted benefit plan data for an |re-submit claim if necessary. |
|Group is BD |HSN claim and what the HSN eligibility system |Resubmit claim with corrected information, if applicable |
| |has for member eligibility. | |
|Edit Code |Description |Provider Action |
|309 |This EOB displays when there is a mismatch |Confirm that the submitted benefit information on the claim is correct |
|Aid CAT Must be HC or HD when |between the submitted benefit plan data for an |Resubmit claim with corrected information, if applicable |
|Insured Group is CA |HSN claim and what the HSN eligibility system | |
| |has for member eligibility. | |
|310 |This EOB displays when there is a mismatch |Confirm that the submitted benefit information on the claim is correct |
|Aid CAT Must be HA when Insured|between the submitted benefit plan data for an |Resubmit claim with corrected information, if applicable |
|Group is MH |HSN claim and what the HSN eligibility system | |
| |has for member eligibility. | |
|315 |This EOB Code displayed because the amount |Validate and enter the amount into 2300 |
|HSN Partial Clm Pat |listed in 2300 is missing. |Resubmit claim with corrected information |
|Responsibility Amt Not Present | | |
|320 |This EOB Code displayed because the Type of Bill|Validate and enter the TOB |
|HSN Claim TOB for HSN |(TOB) is missing, incomplete, or invalid. |Valid TOBs are 111, 117, 118, 131, 137, and 138 |
| | |Resubmit claim with corrected information |
|327 |This EOB Code displayed because the time limit |Resubmit claim with corrected information |
|HSN MH Claim Submission > 18 |for submission of claim has expired. | |
|Months From LDOS | | |
|330 |This EOB Code displayed because bad debt claim |Confirm 120 days has passed after the service was rendered |
|HSN BD Claim Submitted Before |was submitted prior to 120 days after the |Resubmit claim with corrected information |
| Detail |185 for MLOA days, was billed on multiple claim |all occurrence span codes (OSC) on that line and will systematically generate the|
|From And To DOS |lines. |total number of units |
| | |Resubmit claim with corrected information |
|494 |This EOB Code displayed because the medical |Confirm the MLOA or NMLOA dates correspond to the claim DOS |
|Occurrence Span LOA Dates Not |leave-of-absence (MLOA) days or nonmedical |Resubmit claim with corrected information |
|Within Claim Dates |leave-of-absence (NMLOA) dates are outside the | |
| |claim header billed Date of Service (DOS). | |
|498 |This EOB Code displayed because the occurrence |Validate the correct occurrence code from the List of Occurrences per billing |
|The Occurrence Code Is Invalid |code is incomplete or invalid. |guides |
| | |OR panel on the Provider Online Service Center (POSC) |
| | |Resubmit claim with corrected information |
|508 |This EOB Code displayed because the total billed|Review the claim total and the detail line billed amounts to confirm that they |
|Total Charge Does Not Equal The|amount does not add up to the billed amount on |match |
|Sum of All Details |each claim line. |Resubmit with corrected information |
|530 |This EOB Code displayed because the surgery date|Validate the surgery date listed |
|Surgery Date Is After The |is after the “to date of service” (TDOS). |Resubmit claim with corrected information |
|Discharge Date | | |
|550 |This EOB Code displayed because the claim |A denied claim cannot be adjusted, only resubmitted |
|Adjustment Failed |attempting to adjust was one of the following: |Use the most recently paid claim to adjust payment amount |
| |in a denied status |The type of bill for Institutional Claims, last digit for adjustments should be |
| |not the most recently paid ICN |“7” (replacement) |
| |billed with the incorrect type of bill | |
| | |Refer to the Paper Billing Guides & Billing Companion Guides |
|554 |This EOB Code displayed because the header date |Validate the header billed date compared to the date of service indicated |
|Header Billed Date Is Prior To |billed is prior to the first date of service. |Resubmit claim with corrected information |
|Dates Of Service | | |
|Edit Code |Description |Provider Action |
|569 |This EOB Code displayed the date of the accident|Validate the date of accident |
|Hdr Dte Of Accident Greater |is after the last date of service. |Resubmit claim with corrected information |
|Than Last Dte Of Serv | | |
|570 |This EOB Code displayed because the total number|Correct the number of days to equal the number of units billed for each Revenue |
|Header Total Days Less than |of days is less than the Revenue Code(s) number |Code(s) |
|Covered Days |of units billed. |Resubmit claim with corrected information |
|572 |This EOB Code displayed because total covered |Correct the units billed to match the covered days. For example, one unit is |
|Room And Board Days Conflict |days do not match the units billed on each claim|billed at the detail but two days are indicated as covered days |
| |line. |Resubmit claim with corrected information |
|575 |This EOB Code displayed because |Verify the surgery date(s) to the date of service billed |
|Surgery Dte Cannot Be Outside |(inpatient/outpatient) surgery date(s) are not |Resubmit claim with corrected information |
|HDR Dates Of Service |during the dates of services listed at the | |
| |header level. | |
|618 |This EOB Code displayed because outlier date is |Verify the corresponding occurrence code(s) |
|No Outlier Days for HSN |not within date range of claim header date span.|Verify outlier dates on claim header |
| | |Resubmit claim with corrected information |
|619 |This EOB Code displayed because the claim type |Verify the corresponding code(s) [SBR01 & SBR04] for benefit plan HSNI (HSN |
|Invalid Type of claim for HSNI |used is invalid. |Inpatient Outlier) |
| | |Resubmit claim with corrected information |
|620 |This EOB Code displayed because the outlier |Correct either the “From DOS” or the beginning outlier date |
|Occurrence Code 47 FDOS Is |start date in the claim's occurrence code |Resubmit claim with corrected information |
|Invalid For HSNI |segment is not 21 days after the header “From | |
| |DOS.” | |
|700 |This EOB Code displayed because the modifier for|Verify procedure code and corresponding modifier |
|Multiple Primary Endoscopic |the procedure code is inconsistent with the |Resubmit claim with corrected information |
|Families Cannot Be Bill |procedure or missing altogether. | |
|701 |This EOB Code displayed because the modifier for|Verify procedure code and corresponding modifier |
|No Primary Surgical Procedure |the procedure code is inconsistent with the |Resubmit claim with corrected information |
|Indicated |procedure or missing altogether. | |
|Edit Code |Description |Provider Action |
|703 |This EOB Code displayed because modifier (51) |Validate the procedure code the multiple surgery modifier (51) is used only on |
|Endo Family Mixed |was incorrectly used within the same family of |the endoscopic procedure(s) from a different family of codes, after the primary |
|Primary/Secondary |endoscopic codes. |family of endoscopies. |
| | |Refer to Endoscopy CMS Pricing Guidelines and Transmittal Letter PHY-127 (October|
| | |2009) for more information |
| | |Resubmit claim with corrected information |
|800 |This EOB code displayed because claim detail |Validate the NDC for the procedure code |
|HCPCS Requires NDC |procedure code is missing National Drug Code |Resubmit claim with corrected information |
| |(NDC). | |
|815 |This EOB Code displayed because the type of bill|Verify the type of bill and patient status match |
|Type Of Bill Must Match Patient|is does not match with the patient status |Type of Bill 111 or 114 and patient status is 30 OR |
|Status |indicated. |Type of bill is 112 or 113 and patient status is not 30 |
| | |Resubmit claim with corrected information |
|818 |This EOB code displays if the claim is billed |Verify attachments are present for review. |
|Special Handling 90 Day Waiver |for special handling (delay reason 11) without |Resubmit claim with corrected information |
| |an attachment(s). | |
|820 |This EOB code displayed because the national |Verify the NDC is in a 11-digit, 3-segment numeric format |
|NDC Given With No/Invalid Units|drug code (NDC) was missing/incomplete/or did |Refer to National Drug Code (NDC) Requirements for Physician-Administered |
|For HCPCS |not include the correct numeric format. |Medications for further information |
| | |Resubmit claim with corrected information |
|821 |This EOB code displayed because the claim |Verify the Unit of Measure Qualifier on invoice or package |
|NDC Given With No/Invalid |contained an incorrect Unit of Measure |Refer to National Drug Code (NDC) Requirements for Physician-Administered |
|Measurement For HCPCS |Qualifier. |Medications or the billing guide for further information |
| | |Resubmit claim with corrected information |
|828 |This EOB code displayed because the claim |This is an informational EOB code. No further action needs to be taken until |
|Claim / Appeal is Under Review |included the delay reason code 9 and claim |completion of adjudication |
| |receipt is between one and three years of last | |
| |DOS. | |
|Edit Code |Description |Provider Action |
|829 |This EOB Code displayed because the procedure |Check to see if a letter was received, detailing what attachment(s) is missing |
|NCCI Appeal/Special Handle |requires a manual review. The claim remains in |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative &|
|Under Review |suspend status until adjudication. A future RA |All Provider Bulletin 225: Special Circumstances for Electronic Claims for more |
| |will indicate final status. |information about the appeal process |
| | |Resubmit claim with corrected information |
|832 |This EOB Code displayed because member’s gender |Verify the member’s gender and the billed procedure |
|3M-Record Does Not Meet |does not correspond to the billed procedure |Resubmit claim with corrected information |
|Criteria For Any DRG |code. | |
|850 |This EOB Code displayed because the claim date |Determine whether claim eligible for 90-Day Waiver by referring to All Provider |
|Billing Deadline Exceeded - |of service at the claim detail level is over 90 |Bulletin 233: Revisions to the 90-Day Waiver Procedures and follow the guidelines|
|Detail |days from the bill date. |listed in the Submitting a 90-Day Waiver Request |
| | |Resubmit claim with corrected information |
|851 |This EOB Code displayed because the original |Determine whether claim eligible for 90-Day Waiver by referring to All Provider |
|Original Claim Deadline |claim was not received within the appropriate |Bulletin 233: Revisions to the 90-Day Waiver Procedures and follow the guidelines|
|Exceeded - Legacy 513 |timely filing limit. |listed in the Submitting a 90-Day Waiver Request |
| | |Resubmit claim with corrected information |
|852 |This EOB Code displayed because the claim date |Determine whether claim eligible for 90-Day Waiver by referring to All Provider |
|Billing Deadline Exceeded - |of service at the claim header level is over 90 |Bulletin 233: Revisions to the 90-Day Waiver Procedures and follow the guidelines|
|Header |days from the bill date. |listed in the Submitting a 90-Day Waiver Request |
| | |Resubmit claim with corrected information |
|853 |This EOB Code displayed because the claim was |For further information, see All Provider Bulletin 232: Revisions to the Final |
|Final Deadline Exceeded - |received over a year from the date of service. |Deadline Appeal Procedures |
|Detail | |Resubmit claim with corrected information, if applicable |
|855 |This EOB Code displayed because the claim was |For further information, see All Provider Bulletin 232: Revisions to the Final |
|Final Deadline Exceeded - |received over a year from the date of service. |Deadline Appeal Procedures |
|Header | |Resubmit claim with corrected information, if applicable |
|856 |This EOB Code displayed because the maximum |For further information, see All Provider Bulletin 232: Revisions to the Final |
|Final Deadline Exceeds 36 |timeframe to resolve the claim has been |Deadline Appeal Procedures |
|Months - Detail |exceeded. |Resubmit claim with corrected information, if applicable |
|Edit Code |Description |Provider Action |
|857 |This EOB Code displayed because the maximum |For further information, see All Provider Bulletin 232: Revisions to the Final |
|Final Deadline Exceeded 36 |timeframe to resolve the claim has been |Deadline Appeal Procedures |
|Months - Header |exceeded. |Resubmit claim with corrected information, if applicable |
|1000 |This EOB Code displayed because the billing |Verify the billing provider’s file is up to date with the correct NPI |
|Billing Prov ID Number Not on |provider NPI is not listed in the provider’s |Resubmit claim with corrected information, if applicable |
|File |file. | |
|1002 |This EOB Code displayed because the rendering |Verify the rendering provider was active with MassHealth at the time of the date |
|DTL Performing Prov Not Elig At|provider is not an enrolled MassHealth Provider |of service |
|Serv Loc For Prog |on the date of service rendered. |Resubmit claim with corrected information, if applicable |
|1003 |This EOB Code displayed because the billing |Verify the billing provider was active with MassHealth at the time of the date of|
|Billing Prov Not Elig At Serv |provider has no eligibility for any provider |service |
|Loc For Prog Billed |program. |Resubmit claim with corrected information |
|1007 |This EOB Code displayed because the rendering |Verify that rendering provider is enrolled/active provider with MassHealth |
|Detail Rendering Provider I.D. |provider ID is not on file or is not eligible to|Resubmit claim with corrected information |
|Not on File |bill for date of service. | |
|1010 |This EOB Code displayed because the rendering |Verify rendering provider is linked to the group and date of linkage effective at|
|Rendering Provider Not A Member|provider is not linked to the group practice |the time of services rendered |
|of Billing Group |billing. |Resubmit claim with corrected information |
|1012 |This EOB Code displayed because the rendering |Verify the rendering provider’s certified specialty is on file by checking their |
|Rendering Provider Specialty |provider’s file does not have the appropriate |profile on the Provider Online Service Center (POSC) |
|Not Eligible To Render |specialty code to render the procedure code. |Resubmit claim with corrected information |
|Procedure | | |
|1019 |This EOB Code displayed because procedure code |Please contact MassHealth Customer Service |
|No Provider LOC Rate On File |or procedure rate cannot be determined, or was |providersupport@ |
| |not on file, for the date of service/provider. |800-841-2900 |
|1051 |This EOB Code displayed because the rendering |Verify the rendering provider’s NPI/PIDSL is correct and the appropriate |
|Header Rendering Provider ID |provider’s NPI or Provider ID /Service Location |qualifier is used |
|Not Valid |is missing or invalid. |Resubmit claim with corrected information |
|Edit Code |Description |Provider Action |
|1066 |This EOB code displayed because the billing |The billing provider is not in a valid pay to status, further documentation may |
|Billing Provider Not A Valid |provider is not marked as a valid billing (pay |be required |
|Biller |to) provider on provider files. |For next steps, please contact MassHealth Customer Service at |
| | |providersupport@ |
| | |800-841-2900 |
|1067 |This edit posts when the rendering provider is |Confirm that the billing and rendering provider should be the same and should be |
|Rendering Equals Billing and |also the billing provider (such as a facility) |a pay provider, make corrections if necessary |
|Not a Valid Biller |and the provider is at a no-pay status. |If the provider numbers are correct and no corrections are necessary, contact |
| | |MassHealth Customer Service for further assistance on this denial at |
| | |providersupport@ |
| | |800-841-2900 |
|1080 |This EOB displayed because the ordering provider|Verify if ordering provider was inadvertently left off the claim |
|Ordering Provider Required |was not indicated on the claim. |Resubmit claim with corrected information |
|1081 |This EOB displayed because the ordering provider|Verify if ordering provider NPI was inadvertently left off the claim |
|NPI required for Ordering |NPI was not indicated on the claim. |Resubmit claim with corrected information |
|Provider | | |
|1082 |This EOB Code displayed because the ordering |Verify that ordering provider is enrolled/active provider with MassHealth |
|Ordering Provider NPI not on |provider NPI is not listed in the provider’s |Confirm correct ordering provider NPI listed on claim |
|file |file. |Resubmit claim with corrected information, if applicable |
|1083 |This EOB displayed because there are multiple |For more information, please contact MassHealth Customer Service |
|Mult Sak Prov Locs for Ordering|Provider ID/Service Locations associated with |providersupport@ |
|Provider |the ordering provider NPI. |800-841-2900 |
|1084 |This EOB displayed because the ordering provider|Verify that ordering provider is enrolled/active provider with MassHealth |
|Ordering Provider not actively |on claim is not actively enrolled with |Confirm correct ordering provider listed on claim |
|enrolled |MassHealth. |Resubmit claim with corrected information, if applicable |
|Edit Code |Description |Provider Action |
|1085 |This EOB displayed because the ordering provider|Refer to All Provider Bulletin 259: Ordering, Referring, and Prescribing Provider|
|Ordering Provider Not |on claim is not an eligible ordering provider |Requirements for eligible ordering provider types |
|Authorized to Order Services |type. |Resubmit claim with corrected information, if applicable |
|1100 |This EOB displayed because an adjustment claim |Resubmit claim with the most recent ICN |
|Adjust: Former ICN Incorrect |was submitted with the incorrect ICN. | |
|1121 |This EOB code displayed because the required |Review the form for accuracy. |
|Sterilization Form Incomplete |sterilization form attached to the claim was | |
| |missing information. | |
|1122 |This EOB code displayed because the required |Review form to ensure it meets the Sterilization Regulations |
|Sterilization Regs Not Met |sterilization form contained information which |Resubmit claim with corrected information |
| |did not meet regulations. | |
|1127 |This EOB code displayed because the required |The information is not consistent with regulations |
|Hysterectomy Regs Not Met |Hysterectomy Information Form contained | |
| |information which did not meet regulations. | |
|1130 |This EOB code displayed because the incorrect |Verify the correct form to use |
|Invalid Sterilization Form |form was submitted with the claim. Verify that |Resubmit claim with corrected information |
| |correct form has been used (age, most recent | |
| |version of the form, currently 5-09). | |
|1200 |This EOB displayed because the referring |Verify if referring provider was inadvertently left off the claim |
|Referring Provider Required |provider was not indicated on the claim. |Resubmit claim with corrected information |
|1201 |This EOB displayed because the ordering, |Verify if ordering, referring, or prescribing provider NPI was inadvertently left|
|NPI of Provider Required—HDR |referring, or prescribing provider NPI was not |off the claim |
| |indicated at the claim header level. |Resubmit claim with corrected information |
|1202 |This EOB displayed because the secondary |Verify if secondary referring provider NPI was inadvertently left off the claim |
|NPI of Referring Provider |referring provider NPI was not indicated at the |Resubmit claim with corrected information |
|Required 2—HDR |claim header level. | |
|Edit Code |Description |Provider Action |
|1204 |This EOB displayed because the secondary |Verify if secondary referring provider NPI was inadvertently left off the claim |
|NPI of Referring Provider |referring provider NPI was not indicated at the |Resubmit claim with corrected information |
|Required 2—DTL |claim detail level. | |
|1205 |This EOB Code displayed because the referring |Verify that referring provider is enrolled/active provider with MassHealth |
|Referring Provider NPI not on |provider NPI indicated at the claim header level|Confirm correct referring provider NPI listed on claim header |
|file – HDR |is not listed in the provider’s file. |Resubmit claim with corrected information, if applicable |
|1206 |This EOB Code displayed because the secondary |Verify that secondary referring provider is enrolled/active provider with |
|Referring Provider 2 NPI not on|referring provider NPI indicated at the claim |MassHealth |
|file – HDR |header level is not listed in the provider’s |Confirm correct secondary referring provider NPI listed on claim header |
| |file. |Resubmit claim with corrected information, if applicable |
|1207 |This EOB Code displayed because the referring |Verify that referring provider is enrolled/active provider with MassHealth |
|Referring Provider NPI not on |provider NPI indicated at the claim detail level|Confirm correct referring provider NPI listed on claim detail |
|file – DTL |is not listed in the provider’s file. |Resubmit claim with corrected information, if applicable |
|1208 |This EOB Code displayed because the secondary |Verify that secondary referring provider is enrolled/active provider with |
|Referring Provider 2 NPI not on|referring provider NPI indicated at the claim |MassHealth |
|file – DTL |detail level is not listed in the provider’s |Confirm correct secondary referring provider NPI listed on claim detail |
| |file. |Resubmit claim with corrected information, if applicable |
|1209 |This EOB displayed because there are multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Mult Sak Prov Locs for |Provider ID/Service Locations associated with |Customer Service |
|Referring Provider – HDR |the referring provider NPI indicated at the |providersupport@ |
| |claim header level. |800-841-2900 |
|1210 |This EOB displayed because there are multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Mult Sak Prov Locs for |Provider ID/Service Locations associated with |Customer Service |
|Referring Provider 2 – HDR |the secondary referring provider NPI indicated |providersupport@ |
| |at the claim header level. |800-841-2900 |
|Edit Code |Description |Provider Action |
|1211 |This EOB displayed because there are multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Mult Sak Prov Locs for |Provider ID/Service Locations associated with |Customer Service |
|Referring Provider – DTL |the referring provider NPI indicated at the |providersupport@ |
| |claim detail level. |800-841-2900 |
|1212 |This EOB displayed because there are multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Mult Sak Prov Locs for |Provider ID/Service Locations associated with |Customer Service |
|Referring Provider 2 – DTL |the secondary referring provider NPI indicated |providersupport@ |
| |at the claim detail level. |800-841-2900 |
|1213 |This EOB displayed because the referring |Verify that referring provider is enrolled/active provider with MassHealth |
|Referring Provider not actively|provider indicated at the claim header level is |Confirm correct referring provider is listed on claim header |
|enrolled – HDR |not actively enrolled with MassHealth. |Resubmit claim with corrected information, if applicable |
|1214 |This EOB displayed because the secondary |Verify that secondary referring provider is enrolled/active provider with |
|Referring Provider 2 not |referring provider indicated at the claim header|MassHealth |
|actively enrolled – HDR |level is not actively enrolled with MassHealth. |Confirm correct secondary referring provider is listed on claim header |
| | |Resubmit claim with corrected information, if applicable |
|1215 |This EOB displayed because the referring |Verify that referring provider is enrolled/active provider with MassHealth |
|Referring Provider not actively|provider indicated at the claim detail level is |Confirm correct referring provider listed on claim detail |
|enrolled – DTL |not actively enrolled with MassHealth. |Resubmit claim with corrected information, if applicable |
|1216 |This EOB displayed because the secondary |Verify that secondary referring provider is enrolled/active provider with |
|Referring Provider 2 not |referring provider indicated at the claim detail|MassHealth |
|actively enrolled – DTL |level is not actively enrolled with MassHealth. |Confirm correct secondary referring provider listed on claim detail |
| | |Resubmit claim with corrected information, if applicable |
|1217 |This EOB displayed because the referring |Refer to All Provider Bulletin 259: Ordering, Referring, and Prescribing Provider|
|Referring Provider Not |provider indicated at the claim header level is |Requirements for eligible referring provider types |
|Authorized to Refer – HDR |not an eligible referring provider type. |Resubmit claim with corrected information, if applicable |
|Edit Code |Description |Provider Action |
|1218 |This EOB displayed because the secondary |Refer to All Provider Bulletin 259: Ordering, Referring, and Prescribing Provider|
|Referring Provider 2 Not |referring provider indicated at the claim header|Requirements for eligible referring provider types |
|Authorized to Refer – HDR |level is not an eligible referring provider |Resubmit claim with corrected information, if applicable |
| |type. | |
|1219 |This EOB displayed because the referring |Refer to All Provider Bulletin 259: Ordering, Referring, and Prescribing Provider|
|Referring Provider Not |provider indicated at the claim detail level is |Requirements for eligible referring provider types |
|Authorized to Refer – DTL |not an eligible referring provider type. |Resubmit claim with corrected information, if applicable |
|1220 |This EOB displayed because the secondary |Refer to All Provider Bulletin 259: Ordering, Referring, and Prescribing Provider|
|Referring Provider 2 Not |referring provider indicated at the claim detail|Requirements for eligible referring provider types |
|Authorized to Refer – DTL |level is not an eligible referring provider |Resubmit claim with corrected information, if applicable |
| |type. | |
|1803 |This EOB code displayed because this claim |This EOB code is informational only if less than 60 days has passed since receipt|
|Recycle Mcare Part A Claim |suspended. Medicare crossover claims for |of Medicare payment |
| |dually eligible members that contain both |Submit claim electronically for Medicare noncovered days if one of the following |
| |Medicare covered and noncovered days are |occurred: |
| |automatically transmitted from the coordination |if 60 days passed since receipt of the Medicare payment, or |
| |of benefits contractor (COBC) to MassHealth for |the member has other insurance in addition to Medicare and MassHealth and the |
| |processing. MMIS systematically collects |claim has not appeared on a MassHealth remittance advice. |
| |Medicare Part B ancillary payments associated | |
| |with the inpatient stay. Medicare Part A and | |
| |Part B payments are deducted from the final | |
| |mid-stay crossover claim payment | |
|1804 |This EOB code displayed because the type of bill|Verify the TOB to use with the correct claim |
|Deny Medicare Part A Interim |(TOB) submitted with the claim was incomplete or|Do not use TOB 112 or TOB 113 with claim type A if provider type 70 or 73. |
|Stay Claims |invalid. |Resubmit the claim with the corrected information |
|1808 |This EOB code displayed because the patient |Verify the patient liability amount |
|Unable To Perform Crossover |liability amount listed was invalid, incomplete,|Resubmit claim with corrected information |
|Pricing- Header (Deny) |or missing at the header level. | |
|Edit Code |Description |Provider Action |
|1809 |This EOB code displayed because the patient |Verify the patient liability amount |
|Unable To Perform Crossover |liability amount listed was invalid, incomplete,|Resubmit claim with corrected information |
|Pricing- Detail(Deny) |or missing in the claim detail. | |
|1927 |This EOB code displayed because billing |Add the billing provider's NPI number |
|NPI Required For Billing Prov |provider's NPI was not included on the claim. |Resubmit claim with corrected information |
|1928 |This EOB code displayed because rendering |Add the rendering provider's NPI number |
|NPI Required For Performing |provider's NPI was not included on the claim. |Resubmit claim with corrected information |
|Prov | | |
|1945 |This EOB Code displayed because the billing |Please contact MassHealth Customer Service |
|Multi Sak Prov Locs for Billing|provider billed with a NPI linked to multiple |providersupport@ |
|Prov Spec |Provider ID/Service Locations (PIDSL) and the |800-841-2900 |
| |system cannot route to the correct PIDSL | |
|1946 |This EOB Code displayed because the rendering |Please contact MassHealth Customer Service |
|Multi Sak Prov Locs for |provider on the claim has multiple PID/SLs. This|providersupport@ |
|Performing Prov Spec |is unusual. Be sure to check provider file and |800-841-2900 |
| |make sure there are not multiple PID/SLs | |
| |attached to the NPI. | |
|1952 |This EOB code displayed because there are |Please contact MassHealth Customer Service |
|Mult Sak Prov Locs For DTL |multiple possible service locations |providersupport@ |
|Perfom Prov Spec |corresponding to the NPI. |800-841-2900 |
|2003 |This EOB Code displayed because the MassHealth |Verify the member’s eligibility on the POSC |
|Member Ineligible on Detail |member was not eligible on the date of service |Resubmit claim with corrected information if applicable |
|Date of Service |billed. | |
|2006 |This EOB Code displayed because the member’s |Correct/Verify the member’s 12-digit MassHealth ID is listed |
|Claims Submitted With Legacy |Social Security Number on the claim. |Resubmit claim with corrected information |
|Member ID | | |
|2007 |This EOB Code displayed because the member has |Verify the member’s eligibility on the POSC |
|Coverage Is Buy-In/Subsidy/QMB |no additional coverage other than MassHealth |Resubmit claim with corrected information, if applicable |
|not a Xover Claim |Buy-in, which is not a coverage type. MassHealth| |
| |Buy-in assists the member with paying their | |
| |Medicare Part B premiums. | |
|Edit Code |Description |Provider Action |
|2014 |This EOB code displayed because the member is |Confirm there was no gap in member's coverage for date(s) of service |
|Mental HLTH/Substance Abuse |Category of Assistance (COA) 35 and is not |If no gap, resubmit claim for date(s) of service that member was covered |
|Only, Bill Partnership |covered on date of service. |If there was a gap, claim cannot be resubmitted |
|2017 |This EOB Code displayed because the services |Verify member’s eligibility and managed care enrollment for date(s) of service |
|Member Services Covered By MCO |being billed are covered by the member’s managed|Resubmit claim to the appropriate MCO, if applicable |
|Plan |care plan (MCO). | |
|2018 |This EOB code displayed because the billed |Verify member’s eligibility on date of service |
|Member is enrolled in Hospice |procedure does not correspond to a member |MassHealth will only pay services rendered that are unrelated to the member’s |
| |enrolled with a hospice facility. |terminal illness |
| | |Contact hospice facility to confirm the member’s discharge date |
| | |Resubmit claim if unrelated to hospice stay |
|2043 |This EOB Code displayed because the member is |Verify member’s eligibility and managed care segment for date(s) of service |
|Member is on review |enrolled in SCO/ICO. |Resubmit claim to the member’s SCO/ICO plan, if applicable |
|2049 |This EOB Code displayed because the member is |Verify member’s eligibility and enrollment on date of service |
|LTC/Hospice Conflict |enrolled in hospice and a Long Term Care (LTC) |If hospice receives denial, confirm member discharged from LTC facility, submit |
| |claim is received. |hospice election form and resubmit claim |
| | |If LTC receives denial, confirm member discharged from hospice, complete SC-1 and|
| | |resubmit claim |
|2502 |This EOB Code displayed because the member has |Check member’s eligibility and verify if other insurance is active. Notify |
|Member Covered By Other |another insurance listed on file. |MassHealth Customer Service if other insurance is no longer active |
|Insurance | |If other insurance is correct, verify the appropriate carrier code is entered on |
| | |claim |
| | |Once other insurance information is updated using the correct carrier code |
| | |listed, resubmit claim with corrected information |
|2505 |This EOB code displayed because the member is |Confirm that Medicare has properly adjudicated the claim |
|Member covered by Medicare-Deny|covered by Medicare. Medicare must adjudicate |Resubmit claim with corrected Coordination of Benefits (COB) |
| |the claim before it can be billed to MassHealth.| |
|Edit Code |Description |Provider Action |
|2509 |This EOB code displayed because the member is |Confirm that Medicare has properly adjudicated the claim |
|Member Covered By Medicare B |covered by Medicare. Medicare must adjudicate |Resubmit claim with corrected Coordination of Benefits (COB) |
|(Pharmacy) |the claim before it can be billed to MassHealth.| |
|2514 |This EOB code displayed because the third party |Verify the TPL adjudication date is present and in the correct format |
|TPL Adjudication Date Not |liability (TPL) payer adjudication date is not |Resubmit claim with corrected information |
|Present Header |present at the claim header level. | |
|2525 |This EOB code displayed because the member is |Confirm that Medicare has properly adjudicated the claim |
|Member covered by Medicare-Deny|covered by Medicare. Medicare must adjudicate |Resubmit claim with corrected Coordination of Benefits (COB) |
| |the claim before it can be billed to MassHealth.| |
|2526 |This EOB code displayed because the third party |Confirm payer paid amount and the adjustment reason code(s) are listed on claim |
|Zero TPL Amount And No Adj Rsn |liability (TPL) paid amount is zero or blank and|Resubmit claim with corrected information |
|Code - Header |there is no valid adjustment reason code present| |
| |at the claim header. | |
|2527 |This EOB code displayed because the third party |Confirm payer paid amount and the adjustment reason code(s) are listed on claim |
|Zero TPL Amount And No Adj Rsn |liability (TPL) payer paid amount is zero or |Resubmit claim with corrected information |
|Code-Detail |blank and there is no valid adjustment reason | |
| |code present at the claim detail level. | |
|2528 |This EOB code displayed because the member has |Refer to Nursing Facility Bulletin 133: Update to Third-Party-Liability Claim |
|Potential Medicare A in First |active Medicare Part A coverage, and date of |Submissions |
|100 Days |service on claim is within 100 days of date of |Verify the COB detail for Medicare Part A |
| |admission, and the claim does not contain |Resubmit claim with corrected information |
| |Coordination of Benefits (COB) details | |
| |pertaining to Medicare Part A coverage. | |
|2542 |This EOB code displayed because a professional |Incorrect claim type was submitted |
|Medicare Payment Or Patient |claim was submitted detailing Medicare B |Complete crossover claim only if Medicare paid |
|Responsibility is > 0 |payment. |Resubmit claim with correct claim type |
|Edit Code |Description |Provider Action |
|2543 |This EOB code displayed because an institutional|Incorrect claim type was submitted |
|Medicare Payment Or Patient |claim was submitted detailing Medicare B |Complete crossover claim only if Medicare paid |
|Responsibility is > 0 |payment. |Resubmit claim with correct claim type |
|2545 |This EOB code displayed because the claim at the|Verify the claim amounts at both the detail line and claim level. The total claim|
|Header and Detail COB Payments |detail line and the claim level do not equal |charge amount must balance the sum of all detail line charge amounts |
|Do Not Balance |each other. |Resubmit claim with corrected information |
|2546 |This EOB code displayed because the claim at |Verify the claim amounts at both the detail line and claim level. This means that|
|Detail COB Payments Do Not |both the detail line and the claim level do not |the total claim charge amount must balance to the sum of all detail line charge |
|Balance |equal each other. |amounts |
| | |Resubmit claim with corrected information |
|2548 |This EOB code displayed because the claim has a |Verify the non-covered amount and the billed amount at the header level |
|Non Covered Amt Is Not Equal To|non-covered amount at the header, and the |Resubmit claim with corrected information |
|Billed |non-covered amount is not equal to the billed | |
| |amount at the header. | |
|2555 |This EOB code displayed because the claim filing|Verify the carrier code. When using MA or MB, the carrier code should be 0084000 |
|Invalid filing |indicator of either MA (Medicare Part A) or MB |(Medicare Part A) or 0085000 (Medicare Part B) |
|Indicator/Carrier Combination |(Medicare Part B) and the carrier code do not |Resubmit claim with corrected information |
| |correspond to each other. | |
|2556 |This EOB code displayed because the member has |Refer to Nursing Facility Bulletin 133: Update to Third-Party-Liability Claim |
|Potential Medicare C in First |an active Medicare Advantage plan (Part C), the |Submissions |
|100 Days |date of service on the claim is within 100 days |Verify the COB detail for Medicare Advantage plan |
| |of the date of admission, and the claim does not|Resubmit claim with corrected information |
| |contain Coordination of Benefits (COB) details | |
| |pertaining to Medicare Advantage plan. | |
|2557 |This EOB code displayed because the member has |Refer to Nursing Facility Bulletin 133: Update to Third-Party-Liability Claim |
|Potential Private Insurance in |active other insurance coverage, the date of |Submissions |
|First 100 Days |service on the claim is within 100 days of the |Verify the COB detail for other insurance |
| |date of admission, and the claim does not |Resubmit claim with corrected information |
| |contain COB details pertaining to other | |
| |insurance coverage. | |
|Edit Code |Description |Provider Action |
|2560 |This EOB code displayed because at least two |Verify the correct EOB/adjudication date for all carriers. The remittance date |
|Duplicate EOB Dates at the |carriers have the same EOB date on the claim |should not match either the EOB date of any other insurer or the service date(s) |
|Detail |header. |on the claim |
| | |Resubmit claim with corrected information |
|2564 |This EOB code displayed because the claim is a |Verify the member’s TPL information |
|Member Has Supplemental |crossover B or C claim, and the member has |Resubmit claim with corrected information |
|Insurance - Detail |Supplemental Third Party Liability (TPL) | |
| |coverage that is not indicated on the claim. | |
|2566 |This EOB code displayed because the claim is a |Verify the member’s TPL information |
|Member Has Medicare Supp INS |Part A crossover, and the member has |Resubmit claim with corrected information |
| |Supplemental Third Party Liability (TPL) | |
| |coverage that is not indicated on the claim. | |
|2568 |This EOB code displayed because provider not |This EOB code is informational. The following providers are authorized to use a |
|Claim Has Non-Covered Amt, DTL |authorized to submit ‘total non-covered’ amount |"total non-covered amount" when reporting specific TPL exception conditions. |
|is Not Eligible |for specific third-party-liability (TPL) |Details of submitting claims with TPL are outlined in the respective provider |
| |exception conditions. |manual. |
| | |Acute Inpatient Hospitals |
| | |Chronic Disease and Rehabilitation Inpatient Hospitals |
| | |Community Health Centers |
| | |Home Health Agencies |
| | |Mental Health Centers |
| | |Nursing Facilities |
| | |Psychiatric Inpatient Hospitals |
|2592 |This EOB displays when TPL has denied a line and|Confirm that TPL has properly adjudicated this claim |
|Detail/Commercial/Deny Edit |MassHealth does not accept the denial reason. |Resubmit the claim with corrected COB information (if applicable) |
|from TPL Deny Table | | |
|2593 |This EOB displays when Medicare has denied a |Confirm that Medicare has properly adjudicated this claim |
|Detail/Medicare/Deny Edit from |line and MassHealth does not accept the denial |Resubmit the claim with corrected COB information (if applicable) |
|TPL Deny Table |reason. | |
|2594 |This EOB displays when MassHealth has suspended |Provider should wait until the claim fully adjudicates with MassHealth |
|Detail/Commercial/Suspend Edit |a line after TPL adjudication. |Resubmit the claim with corrected COB information (if applicable) |
|from TPL Deny Table | | |
|Edit Code |Description |Provider Action |
|2595 |This EOB displays when MassHealth has suspended |Provider should wait until the claim fully adjudicates with MassHealth |
|Detail/Medicare/Suspend Edit |a line after Medicare adjudication |Resubmit the claim with corrected COB information (if applicable) |
|from TPL Deny Table | | |
|2596 |This EOB is informational only. |No further action is necessary unless there are changes to report |
|Header/Commercial/Pay Edit from| | |
|TPL Deny Table | | |
|2597 |This EOB is informational only. |No further action is necessary unless there are changes to report |
|Header/Medicare/Pay Edit from | | |
|TPL Deny Table | | |
|2598 |This EOB displays when TPL has denied a line and|Confirm that TPL has properly adjudicated this claim |
|Header/Commercial/Deny Edit |MassHealth does not accept the denial reason. |Resubmit the claim with corrected COB information (if applicable) |
|from TPL Deny Table | | |
|2599 |This EOB displays when Medicare has denied a |Confirm that Medicare has properly adjudicated this claim |
|Header/Medicare/Deny Edit From |line and MassHealth does not accept the denial |Resubmit the claim with corrected COB information (if applicable) |
|The TPL Deny Table |reason. | |
|2614 |This EOB code displayed because the member was |Verify there was no gap in member’s coverage for DOS. If YES, split claim |
|Managed Care Service Should Be |not covered on date of service. |accordingly |
|Paid By MassHealth BHVL HLTH | |Resubmit via DDE with Delay Reason Code 11 (Other), using the Attachment tab, |
| | |include a cover letter, medical records, and RA with 2614 denial |
| | |These claims will appear in a suspense status on RA with Edit 829 (NCCI |
| | |Appeal/Special Handle under Review). A decision will be reflected when claim |
| | |appears processed on subsequent RA |
| | | |
| | |Massachusetts Acute Inpatient Hospitals must submit the following documentation |
| | |to MassHealth for review of Edit 2614: |
| | |Cover letter: Include patient name, MH ID number, date of service, hospital |
| | |contact person, hospital contact phone number and a brief description why |
| | |MassHealth needs to review the claim |
| | |RA showing the 2614 denial |
| | |Medical records (only the following should be submitted) |
| | |Fact sheet |
| | |Emergency department history and physical exam |
| | |Admission history and physical exam |
| | |Social worker/Case management notes |
| | |Admission orders |
| | |Discharge summary |
| | |Consultation notes |
|Edit Code |Description |Provider Action |
|2616 |This EOB code displayed because the procedure is|Check all Diagnosis, Procedure, Revenue, NDC, ICD-10 codes billed on the claim to|
|Service Not Reimbursable by |not covered by the member’s coverage type. |verify they are NOT covered by the member’s coverage type. If the procedure |
|Medical Assistance Program | |code(s) are related to Mental Health/Substance abuse, the claim must be billed to|
| | |MBHP |
| | |Resubmit claim with corrected information, if applicable |
|2617 |This EOB Code displayed because the procedure |Resubmit the claim with a general written report or a discharge summary for |
|Procedure Requires Review of |code requires supporting documentation to be |individual consideration (I.C.) |
|Report |attached to the claim. |Consult Subchapter 6 in the MassHealth Provider Manual for additional |
| | |information. |
|2626 |This EOB Code displayed because either the |For questions on reasons for 90-day waiver denial, please contact MassHealth |
|Request for 90 Day Waiver |stated reason for request was not backed up with|Customer Service at |
|Denied |supporting documentation or the stated reason |providersupport@ |
| |was not appropriate. |800-841-2900 |
|2628 |This EOB Code displayed because either the |For questions about Preadmission Screening, please contact Permedion at |
|Medical Necessity Denial By |stated reason for request was not backed up with|1-877-735-7416 |
|Prepayment Review |supporting documentation or the stated reason |Fax: 1-877-735-7415 |
| |was not appropriate. | |
|2802 |This EOB Code displayed because the member was |Verify member's eligibility |
|No Benefit Program for Member |not eligible for MassHealth on date of service. |Resubmit claim with corrected information, if applicable |
|Found | | |
|3003 |This EOB Code displayed because the Prior |Refer to Subchapter 6 of the Provider Manual for which procedure codes need a PA |
|Procedure Code Requires PA |Authorization (PA) number was not indicated on |Verify the PA number on the claim is correct |
| |the claim |Resubmit claim with corrected information |
|3009 |This EOB Code displayed because the Prior |Verify the PA number on the claim is correct |
|PA Number Not On The Database |Authorization (PA) number listed is incomplete |Resubmit claim with corrected information |
| |or incorrect. | |
|3015 |This EOB Code displayed because there is a |Confirm that modifier(s) on claim detail line exactly match the modifier(s) on |
|Modifier on Claim and PA |discrepancy between the PA modifier(s) and |the PA |
|Mismatch |modifier(s) listed on the claim. |Resubmit claim with corrected information |
|Edit Code |Description |Provider Action |
|3023 |This EOB Code displayed because PAS for |Confirm the correct occurrence code is listed(occurrence code 21 or 22) |
|Invalid Rate ID/Pymt Type Combo|Administrative Days (AD) was not submitted with |Resubmit claim with corrected information |
| |the appropriate occurrence code 21 (UR Notice | |
| |Received) or 22 (Active Care Ended). | |
|3024 |This EOB Code displayed because the Hospital |Resubmit claim with Hospital Level of Care and Administrative Days on separate |
|Line Item Not Found For Pas |Level of Care and Administrative Days, were |claims |
|Number |billed on the same claim. This EOB Code also |Verify the PAS is approved for Administrative Days |
| |displays if the Administrative Days are not | |
| |approved on the PAS. | |
|3032 |This EOB Code displayed because the inpatient |Verify if PAS was inadvertently left off the claim |
|PAS Is Required |elective admission claim was submitted without a|Resubmit with corrected information |
| |PAS number. | |
|3035 |This EOB Code displayed because inpatient claim |This EOB Code is informational only. This claim will automatically suspend for up|
|Claim Selected for Pre-Payment |was submitted with 3 or less covered days. |to 85 days |
|Review | |If inpatient stay is approved, the claim will adjudicate to paid status |
| | |If the inpatient stay is not approved, the claim will adjudicate to denied status|
|3041 |This EOB Code displayed because there is a |Confirm that the PIDSL on claim detail line exactly matches the PIDSL on the PA |
|Prov# On Claim And PA Mismatch |discrepancy between the Provider ID Service |Resubmit claim with corrected information |
| |Location (PIDSL) and the PA. | |
|3109 |This EOB Code displayed because the available |Confirm the PA units and/or dollars remaining on the PA. A new PA may be |
|PA Units and/or Dollars |units/dollars on the Prior Authorization (PA) |required. If there are still units available on the PA, advise the Provider to |
|Presently Exhausted |are exhausted. |rebill the claim. |
| | |Resubmit claim with corrected information |
|3120 |This EOB Code displayed because the referral |Verify there is a referral on file for the member |
|Referral Required on Claim |number was not indicated on the claim. |Resubmit claim with corrected information |
|3122 |This EOB Code displayed because the referral |Obtain a new referral from the members PCC provider |
|No More Units Available on |does not have units/visits remaining. |Resubmit claim with corrected information |
|Referral | | |
|3124 |This EOB Code displayed because the billing or |Obtain a new referral from the members PCC provider |
|Rendering Provider Does Not |rendering provider on the claim does not match |Resubmit claim with corrected information |
|Match Referral Auth |the referral. | |
|Edit Code |Description |Provider Action |
|3125 |This EOB Code displayed because the member ID on|Verify the member ID on claim/referral is correct |
|Recipient In Claim Does Not |the referral does not match the member ID on |Resubmit claim with corrected information (or with updated referral) |
|Match Referral |claim. | |
|3126 |This EOB Code displayed because the date of |Obtain a new referral from the members PCC Provider |
|Service Date is Outside |service billed is outside the referral |Resubmit claim with corrected information |
|Referral Auth |authorization period. | |
|3300 |This EOB Code displayed because the injection |Verify the NDC is in a 11-digit, 3-segment numeric format |
|JCODE Given With Invalid NDC |procedure (JCODE) was billed with an |For more information refer to the National Drug Code (NDC) Requirements for |
| |invalid/incorrect NDC Code. |Physician- Administered Medications |
| | |Resubmit claim with corrected information |
|3314 |This EOB Code displayed because the place of |Verify the appropriate modifier is used when billing for professional service |
|POS invalid for Radiology |service (POS) listed is Inpatient, Outpatient, |Refer to Subchapter 6 for more information |
| |ER setting, and modifier 26 was not indicated on|Resubmit claim with corrected information |
| |a professional claim. | |
|4013 |This EOB Code displayed because the service code|Refer to Subchapter 6 of the appropriate Provider Manual for procedure code |
|Procedure Code Is Not Covered |entered on the claim was not valid for the date |listing |
|For Date Service |of service. |Resubmit claim with corrected information |
|4014 |This EOB Code displayed because the procedure |Please contact MassHealth Customer Service at 800-841-2900 |
|No Pricing Segment On File |code may not have the proper rate on file. | |
|4019 |This EOB Code displayed because the procedure |Refer to Subchapter 6 of the appropriate Provider Manual for any attachment |
|Procedure Code Requires |code requires supporting documentation (i.e. |requirements |
|Attachment |operative notes). |Resubmit claim with corrected information |
|4021 |This EOB Code displayed because the services |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Procedure Not Covered for |delivered to the member are not covered under |benefit plan covered services |
|Benefit Plan |their benefit plan. |Resubmit claim with corrected information |
|4036 |This EOB Code displayed because the procedure |Refer to Subchapter 6 of the appropriate Provider Manual for billable codes |
|Prov Contract POS Restriction |code is restricted to specific place of service |Contact MassHealth Customer Service at 800-841-2900 if code is billable under the|
|on Procedure |(POS) based on the rendering provider. |provider contract |
|4037 |This EOB Code displayed because the procedure is|Refer to Subchapter 6 of the appropriate Provider Manual for billable codes |
|Procedure Code vs Diagnosis |restricted to specific diagnosis codes based on |Contact MassHealth Customer Service at 800-841-2900 if code is billable under the|
|Restriction |the rendering provider. |provider contract |
|Edit Code |Description |Provider Action |
|4038 |This EOB Code displayed because the emergency |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Non-Emergency on Limited BP |indicator was set to No. |benefit plan covered services. MassHealth Limited does not pay for non-emergency |
| | |claims |
| | |Resubmit claim with corrected information, if applicable |
|4039 |This EOB code is informational only. The |Review claim and claim information for accuracy and resubmit if necessary |
|Diagnosis Cannot Be Used As |principal diagnosis cannot be used as a primary | |
|Principal Diagnosis |diagnosis. | |
|4066 |This EOB Code displayed because the ICD |Resubmit claim with corrected information |
|ICD9-CM Procedure/Diagnosis |procedure is submitted on the claim where none | |
|Restriction |of the submitted diagnoses are compatible. | |
|4140 |This EOB Code displayed because the billing |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Benefit Plan Bill Type |provider is not allowed to bill the procedure |benefit plan covered services |
|Restriction On Procedure |for the members plan. |Members with certain benefit plans (i.e. EAEDC) may only receive services at |
| | |specified provider locations |
|4141 |This EOB Code displayed because the rendering |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Benefit Plan Perf PR Type |provider is not allowed to bill the procedure |benefit plan covered services |
|Restriction On Procedure |for the members plan. |Members with certain benefit plans (i.e. EAEDC) may only receive services at |
| | |specified provider locations |
|4142 |This EOB Code displayed because the billing |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Benefit Plan Bill Pr Type |provider is not allowed to bill the revenue for |benefit plan covered services |
|Restriction On Revenue |the members plan. |Members with certain benefit plans (i.e. EAEDC) may only receive services at |
| | |specified provider locations |
|4143 |This EOB Code displayed because the rendering |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Benefit Plan Perf Pr Type |provider is not allowed to bill the revenue for |benefit plan covered services |
|Restriction On Revenue |the members plan. |Resubmit claim with corrected information |
|4149 |This EOB Code displayed because the billing |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Prov Contract Bill Pr Typ |provider type is not allowed to bill for the |benefit plan covered services |
|Restriction On Procedure |procedure code. |Resubmit claim with corrected information |
|Edit Code |Description |Provider Action |
|4150 |This EOB Code displayed because the rendering |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Prov Contract Perf PR Typ |provider type is not allowed to bill for the |benefit plan covered services |
|Restriction On Procedure |procedure code. |Resubmit claim with corrected information |
|4151 |This EOB Code displayed because the billing |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Prov Contract Bill PR Typ |provider type is not allowed to bill the revenue|benefit plan covered services |
|Restriction On Revenue |code. |Resubmit claim with corrected information |
|4152 |This EOB Code displayed because the rendering |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Prov Contract Perf PR Typ |provider type is not allowed to bill for the |benefit plan covered services |
|Restriction On Revenue |revenue code. |Resubmit claim with corrected information |
|4170 |This EOB Code displayed because the units billed|This edit is informational only |
|Units Billed Greater Than |is greater than the units allowed for the |The units billed were greater than what is allowed for the procedure code |
|Allowed |procedure code. | |
|4171 |This EOB Code displayed because the units billed|Verify the units billed correspond to the units allowed for the procedure code |
|Units Billed Less Than Allowed |are less than the units allowed for the |Resubmit claim with corrected information |
| |procedure code. | |
|4185 |This EOB displays when a diagnosis is used for |Check the diagnosis submitted in sequences 7-24 for accuracy and verify that the |
|7 - 24 Diag Code Not Covered |sequence 7-24 and they are invalid to use for |correct diagnoses were used for the dates of service being billed |
|For Date Of Service |the Date of Service (DOS) billed. |Resubmit with any corrections if applicable |
|4188 |This EOB Code displayed because the primary |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Diag not covered on DO |diagnosis code is not allowed for the date of |of service |
|Professional Claims |service. |Resubmit claim with corrected information, if applicable |
|4189 |This EOB Code displayed because the diagnosis |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Second Diag Code Not Covered |code is not allowed for the date of service. |of service |
|For DOS | |Resubmit claim with corrected information, if applicable |
|4190 |This EOB Code displayed because the diagnosis |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Third Diag Code Not Covered For|code is not allowed for the date of service. |of service |
|DOS | |Resubmit claim with corrected information, if applicable |
|4191 |This EOB Code displayed because the diagnosis |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Fourth Diag Code Not Covered |code is not allowed for the date of service. |of service |
|For DOS | |Resubmit claim with corrected information, if applicable |
|Edit Code |Description |Provider Action |
|4192 |This EOB Code displayed because the diagnosis |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Fifth Diag Code Not Covered For|code is not allowed for the date of service. |of service |
|DOS | |Resubmit claim with corrected information, if applicable |
|4193 |This EOB Code displayed because the diagnosis |Verify that the submitted diagnosis code is billable as primary for the date(s) |
|Sixth Diag Code Not Covered For|code is not allowed for the date of service. |of service |
|DOS | |Resubmit claim with corrected information, if applicable |
|4194 |This EOB displays when a diagnosis is used for |Check the diagnosis submitted in sequences 7-24 for accuracy and verify that the |
|7-24 Diag Code Not Covered For |sequence 7-24 and they are invalid to use for |correct diagnoses were used for the dates of service being billed |
|DOS |the Date of Service (DOS) billed. |Resubmit with any corrections if applicable |
|4207 |This EOB Code displayed because an active CLIA |If applicable, submit CLIA certification to MassHealth PEC Unit via uploading to |
|CLIA Number Not On File For |number is not on file for the date of service. |POSC |
|Dates Of Service | |After update is processed, resubmit claim with corrected information |
|4209 |This EOB displays when a procedure/modifier |If information reported on the claim is accurate, please contact MassHealth |
|No Pricing Segment For |combination does not yield a proper pricing |Customer Service at |
|Procedure/Modifier Combinat |segment. |providersupport@ |
| | |800-841-2900 |
|4215 |This EOB Code displayed because the CLIA number |If applicable, submit CLIA certification to MassHealth PEC Unit via uploading to |
|CLIA Number Terminated |is not active for the date of service. |POSC |
| | |After update is processed, resubmit claim with corrected information |
|4227 |This EOB Code displays because the revenue code |Refer to Subchapters 1 through 3: Administrative and Billing Regulations for |
|Revenue Not Covered For Benefit|is not allowed for the member's plan. |benefit plan covered services |
|Plan | |Members with certain benefit plans (i.e. EAEDC, Limited) may have restrictions on|
| | |covered services |
|4240 |This EOB Code displayed because the procedure |Verify the procedure is submitted on separate claim lines for each date of |
|Procedure Must Be Billed |code cannot be billed using a from/through date |service |
|Separately |of service. |Resubmit claim with corrected information |
|4250 |This EOB Code displayed because the billing or |Refer to Subchapter 6 of the appropriate Provider Manual for billable codes |
|Reimbursement Rule Prov Type |rendering provider type is not allowed for |If the code is billable under the provider contract, please contact MassHealth |
|Restriction |reimbursement for the procedure code. |Customer Service at |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|4252 |This EOB Code displayed because the diagnosis |Verify the diagnosis code is allowed for the ICD-10 version |
|13-24, Admit or Emerg Diagnosis|code related to the reason for visit (admitting,|Resubmit claim with corrected information |
|Code Not on File |external injury, patient reason) is not allowed | |
| |for the ICD version. | |
|4257 |This EOB Code displayed because the modifier is |Please contact MassHealth Customer Service |
|Provider Contract Modifier |not allowed with the procedure code. |providersupport@ |
|Restriction On Procedure | |800-841-2900 |
|4270 |This EOB Code displayed because the ICD version |Confirm the diagnosis code is the appropriate version (ICD-9 or ICD-10) based on |
|ICD Version Invalid for DOS – |(ICD-9 or ICD-10) used for the diagnosis code is|date of service |
|Diagnosis |not valid for the date of service or discharge |Resubmit claim with corrected information |
| |date. | |
|4271 |This EOB Code displayed because the 837 batch |Ensure that proper qualifiers are being reported appropriately |
|Mixed ICD Versions – Diagnosis |qualifier does not correspond to the correct ICD|837 Batch |
| |version (ICD-9 or ICD-10) used for reporting the|Valid ICD-9 qualifiers are BK, BF, BJ, PR, and BN |
| |diagnosis code. |Valid ICD-10 qualifiers are ABK, ABF, ABJ, APR, and ABN |
| | |DDE |
| | |On the ICD Version panel select the radio button corresponding to the ICD Version|
| | |for the claim. |
| | |Resubmit claim with corrected information |
|4312 |This EOB Code displayed because the primary |Please contact MassHealth Customer Service |
|Prov Contract Prim Dtl Diag |diagnosis is not compatible with the procedure |providersupport@ |
|Restrict On Procedure |code for the billing/rendering provider. |800-841-2900 |
|4371 |This EOB Code displayed because the type of |Please contact MassHealth Customer Service |
|Benefit Plan Claim Type |claim (e.g. crossover, inpatient, and |providersupport@ |
|Restriction On Procedure |outpatient) is not compatible with member’s |800-841-2900 |
| |coverage and procedure code. | |
|4374 |This EOB Code displayed because the revenue code|Please contact MassHealth Customer Service |
|Benefit Plan Claim Type |cannot be billed on this type of claim (e.g. |providersupport@ |
|Restriction On revenue |crossover, inpatient, and outpatient) for the |800-841-2900 |
| |member’s coverage type. | |
|4801 |This EOB Code displayed because the procedure |This is informational only |
|Procedure Not Covered By |code on the claim is not billable by the |Refer to Subchapter 6 of the provider manual for more information |
|Provider Contract |rendering/billing provider. | |
|Edit Code |Description |Provider Action |
|4825 |This EOB Code displayed because Holiday, Weekend|Please contact MassHealth Customer Service |
|Mixed Holiday/Weekend/Weekday |& Weekday dates are billed span dates. |providersupport@ |
|Dates | |800-841-2900 |
|4831 |This EOB Code displayed because the rates are |Please contact MassHealth Customer Service |
|No Reimbursement Rule For |not on file for the service provided. |providersupport@ |
|Service | |800-841-2900 |
|5000 |This EOB Code displayed because there is another|This is informational only |
|Exact Duplicate - Inpatient |Inpatient claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Claim |service and provider) in paid status. | |
|5002 |This EOB Code displayed because there is an |Verify member records to confirm accurate admission hour was captured |
|Conflict - Inpatient vs |inpatient or outpatient claim that conflicts |If information reported on the claim is accurate, please Contact MassHealth |
|Outpatient |with an inpatient or outpatient claim for the |Customer Service |
| |same member & date of service |providersupport@ |
| | |800-841-2900 |
|5004 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate - Inpatient |Inpatient claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Claim/ LTC Crossover A |service and provider) in paid status. | |
|5006 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate - Physician |crossover claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Crossover |service and provider) in paid status. | |
|5009 Conflict-Long Term Care vs|This EOB Code displayed because there is a LTC |Verify there is no crossover payment or claim previously submitted |
|Crossover A |or crossover claim that conflicts with an LTC or|If payment not received, please contact MassHealth Customer Service |
| |crossover claim for the same member & date of |providersupport@ |
| |service. |800-841-2900 |
|5010 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate - Outpatient |outpatient claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Claim |service and provider) in paid status. | |
|5032 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate - Outpatient |outpatient claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Procedures |service and provider) in paid status. | |
|Edit Code |Description |Provider Action |
|5044 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate - Physician |physician claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Claim |service and provider) in paid status. | |
|5045 |This EOB Code displayed because there is another|Verify the services billed were not paid under a different PIDSL |
|Suspect Duplicate - Physician |claim for the same member, same DOS, same |If verified payment under another PIDSL has not been issued, please contact |
|Claim - Different Prov |procedures, different provider. |MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|5046 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate Outpatient |outpatient claim (for the same member, date of |Review your billing history for member to confirm payment was received |
|Procedures (Clinic) |service and provider) in paid status. | |
|5052 |This EOB Code displayed because there is another|This is information only |
|Exact Duplicate Long-Term-Care |LTC claim (for the same member, date of service |Review your billing history for member to confirm payment was received |
| |and provider) in paid status. | |
|5065 |This EOB Code displayed because there is a HHA |Verify there is no payment or claim previously submitted |
|Conflict: Home Health vs. |or outpatient claim that conflicts with a Home |If payment not received, please contact MassHealth Customer Service |
|Outpatient |Health or outpatient claim for the same member &|providersupport@ |
| |date of service |800-841-2900 |
|5067 |This EOB Code displayed because there is a Home |Verify there is no payment or claim previously submitted |
|Conflict: Home Health vs. |Health or crossover claim that conflicts with a |If payment not received, please contact MassHealth Customer Service |
|Crossover B |HHA or crossover claim for the same member & |providersupport@ |
| |date of service. |800-841-2900 |
|5067 |This EOB Code displayed because there is a Home |Verify there is no payment or claim previously submitted |
|Conflict: Home Health vs. |Health or crossover claim that conflicts with a |If payment not received, please contact MassHealth Customer Service |
|Crossover A |HHA or crossover claim for the same member & |providersupport@ |
| |date of service. |800-841-2900 |
|5069 |This EOB Code displayed because there is a Home |Verify there is no payment or claim previously submitted |
|Conflict: Home Health vs. |Health or crossover claim that conflicts with a |If payment not received, please contact MassHealth Customer Service |
|Crossover C |HHA or crossover claim for the same member & |providersupport@ |
| |date of service |800-841-2900 |
|Edit Code |Description |Provider Action |
|5079 |This EOB displays when a claim is received for |Confirm that the member is no longer in Long Term Care and is properly coded in |
|Conflict: : LTC vs. Physician |emergency response systems installed in home, |MMIS |
|(S5160 & S5161) Same DOS |but the member is in a Long Term Care facility. |Resubmit claim if necessary (LTC information updated, etc.) |
|5081 |This EOB Code displayed because the same |Verify there is no payment or claim previously submitted |
|Conflict: ASC Facility VS OPD |surgical procedure code, either an ASC facility |If payment not received, please contact MassHealth Customer Service |
|Facility |or an OPD facility can bill on same DOS, but not|providersupport@ |
| |both. This audit is for provider type 80 (Acute |800-841-2900 |
| |Outpatient) and 84 (Ambulatory Surgery Center). | |
| |Claim types that will conflict are Physician (M)| |
| |vs. Outpatient (O) OR Physician Crossover (B) | |
| |vs. Outpatient Crossover (C). | |
|5083 |This EOB Code displayed because same surgical |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|Limit 1 Surgical Code With |procedure was used by different rendering |For more information, please call MassHealth Customer Service |
|Different Mod Per Day |providers without a modifier. |providersupport@ |
| | |800-841-2900 |
|5085 |This EOB Code displayed because the same |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|One Primary Assist Surgery Per |rendering providers billed surgical procedures |For more information, please call MassHealth Customer Service |
|Day |as the primary assistant surgical code. |providersupport@ |
| | |800-841-2900 |
|5095 |This EOB Code displayed because there are |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|Bilateral Surgery 1 Of Same |multiple bilateral procedure codes billed on the|For more information, please call MassHealth Customer Service |
|Procedure Code Per Day |same date of service. |providersupport@ |
| | |800-841-2900 |
|5096 |This EOB Code displayed because the services |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative |
|NCCI Conflict With Adjusted Oth|billed do not meet the NCCI guidelines set forth|which describes the NCCI process and All Provider Bulletin 227: Modifier Coverage|
|Serv Prev Paid |by CMS. |and National Correct Coding Initiative (NCCI) Updates for updates on the NCCI |
| | |process |
| | |For more information refer to the website @ The National Correct |
| | |Coding Initiative in Medicaid |
|Edit Code |Description |Provider Action |
|5927 |This EOB Code displayed because the services |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative |
|NCCI Another Service Prev Paid |billed do not meet the NCCI guidelines set forth|which describes the NCCI process and All Provider Bulletin 227: Modifier Coverage|
|Same Claim |by CMS. |and National Correct Coding Initiative (NCCI) Updates for updates on the NCCI |
| | |process |
| | |For more information refer to the website @ The National Correct |
| | |Coding Initiative in Medicaid |
|5928 |This EOB Code displayed because the services |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative |
|NCCI Another Service Prev Paid |billed do not meet the NCCI guidelines set forth|which describes the NCCI process and All Provider Bulletin 227: Modifier Coverage|
|Other Claim |by CMS. |and National Correct Coding Initiative (NCCI) Updates for updates on the NCCI |
| | |process |
| | |For more information refer to the website @ The National Correct |
| | |Coding Initiative in Medicaid |
|5929 |This EOB Code displayed because the services |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative |
|NCCI Conflict With Other |billed do not meet the NCCI guidelines set forth|which describes the NCCI process and All Provider Bulletin 227: Modifier Coverage|
|Service Prev Paid |by CMS. |and National Correct Coding Initiative (NCCI) Updates for updates on the NCCI |
| | |process |
| | |For more information refer to the website @ The National Correct |
| | |Coding Initiative in Medicaid |
|5930 |This EOB Code displayed because the services |Refer to All Provider Bulletin 209: Medicaid National Correct Coding Initiative |
|MUE Units Exceeded |billed do not meet the NCCI guidelines set forth|which describes the NCCI process and All Provider Bulletin 227: Modifier Coverage|
| |by CMS. A Medically Unlikely Edit (MUE) is a |and National Correct Coding Initiative (NCCI) Updates for updates on the NCCI |
| |Medicare unit of service claim edit applied to |process |
| |medical claims against a procedure code for |For more information refer to the website @ The National Correct |
| |medical services rendered by one |Coding Initiative in Medicaid |
| |provider/supplier to one patient on one day. | |
|6000 |This EOB Code displayed because the services |Refer to Subchapter 6 of the provider manual regarding attachment requirements |
|Manual Pricing Required |provided requires supporting documentation |Resubmit claim with attachment(s) |
| |attached to claim (i.e. invoices, operative | |
| |notes, etc.) | |
|6006 |The EOB Code displayed because an outpatient |Confirm that the member is tied to hospice on the date of service |
|Unable To Price Hospice LOC |hospice claim with LOC pricing and the member is|If so, please contact MassHealth Customer Service |
|Claim |not coded, or the provider has no rate on file. |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|6010 |This EOB Code displayed because two or more |Refer to Subchapter 4 of provider manual re: Surgery & Services |
|Multiple Surgeries/Visits |surgeries within the global time period. |If you feel you received this denial in error, contact MassHealth Customer |
|Within Global Period | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|6020 |This EOB Code displayed because the 20 MLOA days|Verify MLOA Days billed |
|MLOA Days Exceeds Max |per inpatient hospital stay in an acute, chronic|Resubmit claim with corrected information, if applicable |
| |disease, psychiatric, or rehabilitation hospital| |
| |prior to September 1, 2014 when the MLOA days | |
| |max was increased. | |
|6215 |This EOB Code displayed because an inpatient |Suspended Claims: Provide required information via email to |
|HCAC Claim Eligible for Cost |claim was submitted with Health Care Acquired |EHS.HCACOutlierClaimReview@state.ma.us before 5/19/2016: |
|Outlier Payment |Condition(s) present and requires additional |In email subject line reference: hospital name and suspended claim’s 13-digit ICN|
| |information in order to calculate an outlier | |
| |payment. |Indicate which medical services have any charges that represent or resulted from |
| | |an HCAC |
| | |Revise charges to show what they would have been had the HCAC(s) not occurred |
| | |Provide name of HCAC(s) |
| | |Briefly indicate the rationale for determining revised charges. |
| | | |
| | |Denied Claims: Resubmit claim via POSC indicating the following information as a |
| | |claim attachment: |
| | |Hospital name and suspended claim’s 13-digit ICN. |
| | |Which medical services have any charges that represent or resulted from an HCAC |
| | |Revised charges showing what they would have been had the HCAC(s) not occurred |
| | |Name of the HCAC(s) |
| | |Rationale for determining revised charges |
|8005 |This EOB Code displayed because two |Verify when the service was rendered to the member |
|Contraceptive Injectable 3Mth. |Depro-Provera procedures were submitted within |Resubmit claim with corrected information, if applicable |
|Depro-Provera |3-months. | |
|8011 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|2 Monural Code V5241 Dispensing|for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|Fees In 5 Years |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|8016 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|Orthotics 2 Units In 1 Year |for each member per year on these types of |procedure code limits |
|From DOS |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8025 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|Home Health PT LIM 20 Visits |for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|(100 Units) 12 Months |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8026 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|Home Health OT LIM 20 Visits |for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|(100 Units) 12 Months |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8027 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|Home Health ST LIM 35 Visits |for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|(140 Units) 12 Months |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8028 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|DME 1 Unit In 1 Calendar Month |for each member per year on these types of |procedure code limits |
| |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8038 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|DME Limits 31 units in 1 |for each member per year on these types of |procedure code limits |
|calendar month |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|8069 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|DME Limits 1 Unit 5 Years |for each member per year on these types of |procedure code limits |
|(Purchase Only) |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8091 |This EOB Code displayed a procedure code was |Confirm the procedure was billed with modifier 26 or TC |
|Modifier 26 or TC Required for |billed that requires modifier 26 and/or TC. |Resubmit claim with corrected information |
|Group 4113 | | |
|8092 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|Orthotic - Prosthetic - Limit 4|for each member per year on these types of |procedure code limits |
|Units/Member/Yr |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8121 |This EOB displayed because more than 1 unit for |Confirm all records and check for previously paid claims |
|Adult Day Care Service S5102 |adult daycare service is being submitted. |If you feel you received this denial in error, contact MassHealth Customer |
|Limit 1 Per Day | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8122 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|Limit 1 in 5 Years on Month of |for each member per year on these types of |procedure code limits |
|Capped Rental |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8123 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|2ND & 3RD Months Capped Rental |for each member per year on these types of |procedure code limits |
|- Limit 2 in 5 Years |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|8124 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|10 Months Capped Rental Allow |for each member per year on these types of |procedure code limits |
|Limit 10 IN 5 Years |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8125 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|Various Repair & Mobility Codes|for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|Require a Modifier |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8126 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual to confirm procedure code limits |
|Modifier Required for Codes |for each member per year on these types of |If you feel you received this denial in error, contact MassHealth Customer |
|A4450, A4452 AND A5120 |services. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8127 |This EOB Code displayed because there are more |Verify each date of service is billed on a separate line |
|Transportation T2003 Limit- 2 |than two one way trips billed on the same detail|Resubmit claim with corrected information |
|One Way Trips Day |line. | |
|8131 |This EOB displayed because DME rentals should |Confirm that this service has not already been billed for the month in question |
|DME Limit One Unit Per Month - |only be billed once per month. |If you feel you received this denial in error, contact MassHealth Customer |
|Rental Only | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8133 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|DME Conflict: Purchase Vs |for each member per year on these types of |procedure code limits |
|Rental In 3 Years |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|8139 |This EOB Code displayed because there are limits|Refer to Subchapter 4 of provider manual & DME Coverage Guideline tool to confirm|
|DME Conflict: Purchase Vs |for each member per year on these types of |procedure code limits |
|Rental In 5 Years |services. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8152 |This EOB displayed because h2014 was billed |Confirm that services have not already been billed for the day in question |
|H2014 Day Habilitation Limit 24|for more than 24 units in one day. |If you feel you received this denial in error, contact MassHealth Customer |
|Units Per Day | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8158 |This EOB Code displayed because procedure code |Confirm the appropriate claim type was used for this procedure |
|Service Cannot be Billed on a |T1015 was billed on a Professional Crossover |Resubmit claim with corrected information, if applicable |
|Prof XOVER |Claim Type B. | |
|8175 |This EOB Code displayed because there were |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|Serv Provd Day Of Procedure |services provided during the global payment |After reviewing the regulations and need more information, please contact |
|Included In Fee Amount |timeframe. |MassHealth Customer Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8176 |This EOB Code displayed because there were |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|Serv Provd Day Before And 10 |services provided during the global payment |After reviewing the regulations and need more information, please contact |
|Day Global Included |timeframe. |MassHealth Customer Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8177 |This EOB Code displayed because there were |Refer to Subchapter 4 of provider manual related to Surgery & Services |
|Serv Provd Day Before And 90 |services provided during the global payment |After reviewing the regulations and need more information, please contact |
|Day Global Included |timeframe |MassHealth Customer Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|Edit Code |Description |Provider Action |
|8250 |This EOB Code displayed because multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Invalid Combination Of |procedures were billed that should not have been|Customer Service |
|Procedures |billed together, such as Hospital procedures and|providersupport@ |
| |lab tests. |800-841-2900 |
|8252 |This EOB Code displayed because multiple |For more information, please contact MassHealth Customer Service MassHealth |
|Invalid Combination Of |procedures were billed that should not have been|Customer Service |
|Procedures |billed together, such as Hospital procedures and|providersupport@ |
| |lab tests. |800-841-2900 |
|8253 |The provider cannot bill for a visit and a |Refer to All Provider Bulletin 209:Medicaid National Correct Coding Initiative |
|Visit & Surgery Not Allowed |surgery on the same date of service unless the |and All Provider Bulletin 227:Modifier Coverage and National Correct Coding |
|Same Day/Same POS |visit is separately identifiable from the |Initiative (NCCI) Updates |
| |procedure done. |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8255 |This EOB code displayed because chiropractor |This EOB code is informational |
|Chiropractor Manipulation / |manipulations or visits were billed for more |Chiropractor manipulation or visit is limited to one per day |
|Visit = 1 Per Day |than one day. | |
|8256 |This EOB code displayed because the maximum |This EOB code is informational |
|Chiropractor Manipulation / |number of office visits/chiropractic |Chiropractor services are limited to a total of 20 office visits or chiropractic |
|Visit 20 Per Cal Year |manipulative treatments have been exceeded. |manipulative treatments, or any combination of office visits and chiropractic |
| | |manipulative treatments, up to a total of 20, per member per calendar year |
|8261 |This EOB code displayed because the Municipal |Confirm the proper hours were billed |
|10 Hours PDN Per Day For 22 |Medicaid Private Duty Nurse billable hours were |If you feel you received this denial in error, contact MassHealth Customer |
|School Days |exceeded. |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8262 |This EOB code displayed because school based |This EOB code is informational |
|Muni Medicaid Procs Conflict |municipal Medicaid procedures were billed on the|Procedure code T1018 cannot be billed on the same date as codes for therapy by a |
|With Therapy |same date as therapy procedures. |non- municipal provider |
|8263 |This EOB code displayed because more than one |This EOB code is informational |
|Lab Unrinalysis Conflict W Each|lab urinalysis was billed on the same day. |Multiple procedure codes cannot be billed on the same date. Only one lab |
|Other On Same Day | |urinalysis can be billed per day |
|Edit Code |Description |Provider Action |
|8270 |This EOB code displayed because speech therapy |This EOB code is informational |
|Speech Therapy Codes Limit 1 Hr|billed for more than one hour (4 units) |Multiple procedure codes cannot be billed on the same date for a total more than |
|(4 Units) Per Day | |one hour |
|8271 |This EOB code displayed because more than one |This EOB code is informational |
|Antepartum Care Limit 1 Of |procedure code (either 59425 or 59426) was |Antepartum care is limited to the use of only one code per year |
|Either Code Per Year |billed in a year. Antepartum care limits one of | |
| |either code per year. | |
|8274 |This EOB code displayed because the number of |This EOB code is informational |
|2 Monaural Hearing Aids In 5 |units exceed 2 in 5 years. |Codes are limited to two units in five years |
|Years | | |
|8275 |This EOB Code displayed because the number of |This EOB code is informational |
|1 Binaural Hearing Aid In 5 |units exceed 1 in 5 years. |Refer to subchapter 4 of you Provider Manual to confirm limits |
|Years | |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8276 |This EOB Code displayed because the number of |This EOB code is informational |
|1 Dispensing Fee In 5 Yrs |units exceed 1 in 5 years. |Refer to subchapter 4 of your Provider Manual to confirm limits |
|(Bilateral) | |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8277 |This EOB Code displayed because an evaluation |Refer to All Provider Bulletin 227: Modifier Coverage and National Correct Coding|
|Eval & Mangmnt Conflicts W/ |visit and a procedure rendered on the same date |Initiative (NCCI) Updates for more information |
|Treatment Prec Sa |of service unless the visit is separately |Any further questions, please contact MassHealth Customer Service |
| |identifiable from the procedure done. |providersupport@ |
| | |800-841-2900 |
|8281 |This EOB code displayed because the maximum |This EOB code is informational only |
|Diapers Limit 248 Per Memb/Per |number of diapers dispensed per calendar month |A member is allowed a maximum of 248 diapers a month; confirm the amount of units|
|Cal Month |have been exceeded. |approved on PA |
|Edit Code |Description |Provider Action |
|8297 |This EOB code displayed because the maximum |This EOB code is informational only. |
|Psych Inpatient Limit 30 |number of inpatient consecutive days have been |For further information, refer to Subchapter 4 of the Psychiatric Inpatient |
|Consectv Days Per Admit |exceeded. |Hospital Manual, see Regulation 425.410(B) on service limitations for members |
| | |aged 21 through 64 |
|8302 |This EOB code displayed when the number of units|This EOB code is informational only |
|Adult & Group Foster Care-Limit|for procedure codes H0043 or S5140 exceed 31 | |
|31 Units / Calendar Month |units per month. | |
|8304 |This EOB displayed because multiple lab codes |Refer to: Community Health Center Bulletin 74: Drug Screen/Quantitative Drug Test|
|Lab Conflict w/Each Other on |that were incompatible with each other were |Claim Edit; Drug Screens Performed For Residential Monitoring or Independent |
|the Same Day |billed in the same day. |Clinical Laboratory Bulletin 9: Drug Screen/Quantitative Drug Test Claim Edit; |
| | |Drug Screens Performed For Residential Monitoring |
| | |If you feel you received this denial in error, contact MassHealth Customer |
| | |Service MassHealth Customer Service |
| | |providersupport@ |
| | |800-841-2900 |
|8309 |This EOB displayed because a comprehensive LAB |Comprehensive lab codes that contain the codes referenced will not be paid |
|Lab Panel Code 80053 |code (80053) which includes services described |separately |
|Comprehensive Metabolic Panel |in the following series of CPT codes was billed:|If you feel you received this denial in error, contact MassHealth Customer |
| |82040, 82247, 82310, 82374, 82435, 82565, 82947,|Service MassHealth Customer Service |
| |84075, 84132, 84155, 84295, 84450, 84460, and |providersupport@ |
| |84520. |800-841-2900 |
|9918 |This EOB is informational only. It denotes the |No action is necessary |
|Pricing Adjustment - Max Fee |reduction in payment from the billed amount and | |
|Pricing Applied |the approved payment rate per the fee schedule. | |
|9928 |This EOB is informational only. It denotes the |No action is necessary |
|COB-TPL Cost Savings |reduction in payment from the billed amount and | |
| |the approved payment rate per the fee schedule. | |
4153 • Edit Codes Summary Created: 09/11/2009 Proprietary & Confidential
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