Medicaid denial codes -- 1

1 Deductible Amount
2 Coinsurance Amount
3 Co-payment Amounts
4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 The procedure code/bill type is inconsistent with the place of service.
6 The procedure/revenue code is inconsistent with the patient's age.
7 The procedure/revenue code is inconsistent with the patient's gender.
8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, ordoes not apply to the billed services or provider.
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate
17 Payment adjusted because requested information was not provided or was insufficient incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate.
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility; spend down, waiting, or residency requirements.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
36 Balance does not exceed co-payment amount.
37 Balance does not exceed deductible.
38 Services not provided or authorized by designated (network/primary care) providers.
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
47 This (these) diagnosis (s) is (are) not covered, missing, or are invalid.
48 This (these) procedure(s) is (are) not covered.
49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a `medical necessity' by the payer.
51 These are non-covered services because this is a pre-existing condition
52 The referring/prescribing/rendering provider is not eligible torefer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case.
55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer.
57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Note: Changed as of 6/00
60 Charges for outpatient services with this proximity to inpatient services are not covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
63 Correction to a prior claim.
64 Denial reversed per Medical Review.
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood Deductible.
67 Lifetime reserve days
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs.
71 Primary Payer amount.
72 Coinsurance day
73 Administrative days.
74 Indirect Medical Education Adjustments.
75 Direct Medical Education Adjustments.
76 Disproportionate Share Adjustments.
78 Non-Covered days Room charge adjustment.
79 Cost Report days.
80 Outlier days.
85 Interest amount.
87 Transfer amount.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.

100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustments.
103 Provider promotional discount
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim.
108 Payment adjusted because rent/purchase guidelines were not met.
109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
113 Payment denied because service/procedure was provided outside the United States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.
116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
121 Indemnification adjustment.
122 Psychiatric reduction.
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
126 Deductible -- Major Medical
127 Coinsurance -- Major Medical
128 Newborn's services are covered in the mother's Allowance.
129 Payment denied - Prior processing information appears incorrect.
131 Claim specific negotiated discount.
132 Prearranged demonstration project adjustment.
133 The disposition of this claim/service is pending further review.
134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claims Adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
138 Claim/service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement - Subscriber is employed by the provider of services.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment e.g. preferred product/service.
145 Premium payment withholding
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
149 Lifetime benefit maximum has been reached for this service/benefit category.
150 Payment adjusted because the payer deems the information submitted does not support this level of service.
151 Payment adjusted because the payer deems the information submitted does not support this many services.
152 Payment adjusted because the payer deems the information submitted does not support this length of service.
153 Payment adjusted because the payer deems the information submitted does not support this dosage.
154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
155 This claim is denied because the patient refused the service/procedure.
156 Flexible spending account payments
157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
158 Payment denied/reduced because the service/procedure was provided outside of the
United States.
159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
160 Payment denied/reduced because injury/illness was the result of an activity that is benefit exclusion.
161 Provider performance bonus
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
163 Claim/Service adjusted because the attachment referenced on the claim was not received.
164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
165 Payment denied /reduced for absence of, or exceeded referral
166 These services were submitted after this payers responsibility for processing claims under this plan ended.
167 This (these) diagnosis is (are) not covered.
168 Payment denied as Service(s) have been considered under the patient's medical plan.
Benefits are not available under this dental plan
169 Payment adjusted because an alternate benefit has been provided
170 Payment is denied when performed/billed by this type of provider.
171 Payment is denied when performed/billed by this type of provider in this type of facility.
172 Payment is adjusted when performed/billed by a provider of this specialty
173 Payment adjusted because this service was not prescribed by a physician
174 Payment denied because this service was not prescribed prior to delivery
175 Payment denied because the prescription is incomplete
176 Payment denied because the prescription is not current
177 Payment denied because the patient has not met the required eligibility requirements
178 Payment adjusted because the patient has not met the required spends down requirements.
179 Payment adjusted because the patient has not met the required waiting requirements
180 Payment adjusted because the patient has not met the required residency requirements
181 Payment adjusted because this procedure code was invalid on the date of service
182 Payment adjusted because the procedure modifier was invalid on the date of service
183 The referring provider is not eligible to refer the service billed.
184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
185 The rendering provider is not eligible to perform the service billed.
186 Payment adjusted since the level of care changed
187 Health Savings account payments
188 This product/procedure is only covered when used according to FDA recommendations.
189 "Not otherwise classified" or "unlisted" procedure code was billed when there is a specific procedure code for this procedure/service.