pi 16 denial code descriptions

The AMA does not directly or indirectly practice medicine or dispense medical services. 168 Service(s) have been considered under the patients medical plan. End users do not act for or on behalf of the CMS. 199 Revenue code and Procedure code do not match. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). 55 Procedure/treatment is deemed experimental/investigational by the payer. An LCD provides a guide to assist in determining whether a particular item or service is covered. Applicable federal, state or local authority may cover the claim/service. Note Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. We receive many MSP claims with the incorrect insurance type reported. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Users must adhere to CMS Information Security Policies, Standards, and Procedures. 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Let's begin by going through some of the numerous remark codes with the CO16. The ADA is a third-party beneficiary to this Agreement. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. 174 Service was not prescribed prior to delivery. 32 Our records indicate that this dependent is not an eligible dependent as defined. NULL CO A1, 45 N54, M62 . Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. These materials contain Current Dental Terminology, (CDT), copyright 2020 American Dental Association (ADA). Applicable federal, state or local authority may cover the claim/service. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Beneficiary was inpatient on date of service billed. This license will terminate upon notice to you if you violate the terms of this license. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. Claim lacks indicator that x-ray is available for review.. Samoa, Guam, N. Mariana Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, Last Updated Tue, 28 Feb 2023 16:05:45 +0000. 240 The diagnosis is inconsistent with the patients birth weight. D7 Claim/service denied. Payment for this claim/service may have been provided in a previous payment. P12 Workers compensation jurisdictional fee schedule adjustment. PR 31 Claim denied as patient cannot be identified as our insured. 64 Denial reversed per Medical Review. Claim/service lacks information or has submission/billing error(s). D4 Claim/service does not indicate the period of time for which this will be needed. A6 Prior hospitalization or 30 day transfer requirement not met. Warning: you are accessing an information system that may be a U.S. Government information system. The scope of this license is determined by the AMA, the copyright holder. 128 Newborns services are covered in the mothers Allowance. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. 7 The procedure/revenue code is inconsistent with the patients gender. The three digit EOB on your remittance advice explains how L&I processed a bill, and how to make corrections if needed. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. P15 Workers Compensation Medical Treatment Guideline Adjustment. 31 Patient cannot be identified as our insured. Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS), Please follow the steps under claim submission for this error on the. All Rights Reserved. 2. All rights reserved. 178 Patient has not met the required spend down requirements. 167 This (these) diagnosis(es) is (are) not covered. 1. 107 The related or qualifying claim/service was not identified on this claim. This item or service does not meet the criteria for the category under which it was billed. HCPCS billed is included in payment/allowance for another service/procedure that was already adjudicated, HCPCS code billed is included in the payment/allowance for another service/procedure that has already been adjudicated. PDF ANSI REASON CODES - highmarkbcbswv.com 244 Payment reduced to zero due to litigation. A copy of this policy is available on the. 183 The referring provider is not eligible to refer the service billed. else{document.getElementById("usprov").href="/web/"+"jeb"+"/help/us-government-rights";}, Advance Beneficiary Notice of Noncoverage (ABN), Oral Anticancer Drugs and Oral Antiemetic Drugs, Transcutaneous Electrical Nerve Stimulators (TENS), Supplemental Medical Review Contractor (SMRC), Unified Program Integrity Contractor (UPIC), Provider Outreach and Education Advisory Group (POE AG), Healthcare Integrated General Ledger Accounting System (HIGLAS), Reason Code 16 | Remark Codes MA13 N265 N276, click here to see all U.S. Government Rights Provisions, American Hospital Association Online Store. PDF Denial Codes listed are from the national code set. view here. - CTACNY The use of the information system establishes user's consent to any and all monitoring and recording of their activities. P7 The applicable fee schedule/fee database does not contain the billed code. Same denial code can be adjustment as well as patient responsibility. Some examples of incorrect MSP insurance types are: Reporting MSP type 47 (liability) as a default code. W6 Referral not authorized by attending physician per regulatory requirement. Warning: you are accessing an information system that may be a U.S. Government information system. A4 Medicare Claim PPS Capital Day Outlier Amount. 202 Non-covered personal comfort or convenience services. This system is provided for Government authorized use only. This decision was based on a Local Coverage Determination (LCD). 231 Mutually exclusive procedures cannot be done in the same day/setting. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose. 5. 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. 158 Service/procedure was provided outside of the United States. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. 41 Discount agreed to in Preferred Provider contract. Applications are available at the AMA Web site, https://www.ama-assn.org. Item does not meet the criteria for the category under which it was billed. PR 2 Coinsurance Amount Members plan coinsurance rate applied to allowable benefit for the rendered service(s). About Claim Adjustment Group Codes Maintenance Request Status Maintenance Request Form 11/16/2022 Filter by code: Reset There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. PR 3 Co-payment Amount Copayment Members plan copayment applied to the allowable benefit for the rendered service(s). 223 Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Main equipment is missing therefore Medicare will not pay for supplies, Item(s) billed did not have a valid ordering physician name, Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS). Denial Code 185 defined as "The rendering provider is not eligible to perform the service billed". 30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Denial Code Resolution - JE Part B - Noridian Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service. PR 204 This service/equipment/drug is not covered under the patients current benefit plan. 251 The attachment/other documentation content received did not contain the content required to process this claim or service. B15 This service/procedure requires that a qualifying service/procedure be received and covered. 146 Diagnosis was invalid for the date(s) of service reported. 2. 212 Administrative surcharges are not covered. 242 Services not provided by network/primary care providers.Reason for this denial PR 242:If your Provider is Not Contracted for this members planSupplies or DME codes are only payable to Authorized DME ProvidersNon- Member ProviderNot covered benefit when using a Non-Contracted planAction : Waiting for Credentiall or to bill patient or to waive the balance as per Cleint instruction. 109 Claim/service not covered by this payer/contractor. To license the electronic data file of UB-04 Data Specifications, contact AHA at (312) 893-6816. 128 Newborn's services are covered in the mother's allowance. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. B18 This procedure code and modifier were invalid on the date of service. PDF EOB Description Rejection Group Reason Remark Code Receive Medicare's "Latest Updates" each week. End users do not act for or on behalf of the CMS. 4. Do you have any other denial codes on these codes like an M or N denial reason. 139 These codes describe why a claim or service line was paid differently than it was billed. 142 Monthly Medicaid patient liability amount. 170 Payment is denied when performed/billed by this type of provider. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THESE AGREEMENTS CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. To access a denial description, select the applicable Reason/Remark code found on Noridian's Remittance Advice. Denial Code CO 16 lacks information Remark Codes - Billing Executive When a CO16 rejection is issued, the first step is to examine any associated remark codes. 173 Service/equipment was not prescribed by a physician. AMA Disclaimer of Warranties and Liabilities No one likes to see insurance payers deny claims. PR 168 Payment denied as Service(s) have been considered under the patients medical plan. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. CMS Disclaimer Denial code - 29 Described as "TFL has expired". You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. D1 Claim/service denied. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Consult plan benefit documents/guidelines for information about restrictions for this service. This payment reflects the correct code. 147 Provider contracted/negotiated rate expired or not on file. 239 Claim spans eligible and ineligible periods of coverage. 141 Claim spans eligible and ineligible periods of coverage. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. 27 Expenses incurred after coverage terminated. Correct reporting of MSP type on electronic claims - fcso.com B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. 56 Procedure/treatment has not been deemed proven to be effective by the payer. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK LABELED "I Do Not Accept" AND EXIT FROM THIS COMPUTER SCREEN. Receive Medicare's "Latest Updates" each week. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. They include reason and remark codes that outline reasons for not covering patients' treatment costs. 25 Payment denied. Claim/service lacks information or has submission/billing error(s), Missing/incomplete/invalid procedure code(s), Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure, Item billed does not have base equipment on file. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. CPT is a trademark of the AMA. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) Missing/incomplete/invalid credentialing data. Missing/incomplete/invalid initial treatment date. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. CO 96- Non-Covered Charges Denial (Not covered under Providers Contract) When the billed Cpt/diagnosis code not listed under the provider's contract then it called Non covered under the provider's plan. Group Codes CO = Contractual Obligations CR = Corrections and Reversal OA = Other Adjustments PI = Payer Initiated Reductions PR = Patient Responsibility CDT is a trademark of the ADA. NULL CO 16, A1 MA66 044 Denied. pi 16 denial code descriptions. D8 Claim/service denied. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. Policy frequency limits may have been reached, per LCD. 197 Precertification/authorization/notification absent. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK LABELED "I Do Not Accept" AND EXIT FROM THIS COMPUTER SCREEN. 54 Multiple physicians/assistants are not covered in this case. 187 Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). PI Payer Initiated Reductions PR Patient Responsibility Reason Code Description 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. D19 Claim/Service lacks Physician/Operative or other supporting documentation. P10 Payment reduced to zero due to litigation. This Payer not liable forclaim or service/treatment. 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. 65 Procedure code was incorrect. They will help tell you how the claim is processed and if there is a balance, who is responsible for it. An allowance has been made for a comparable service. 204 This service/equipment/drug is not covered under the patients current benefit plan. PR B9 Services not covered because the patient is enrolled in a Hospice. 182 Procedure modifier was invalid on the date of service. OA Other Adjsutments Y2 Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. 133 The disposition of the claim/service is pending further review. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. P23 Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Ask the same questions as denial code - 5, but here check which procedure code submitted is incompatible with provider type. 155 Patient refused the service/procedure. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. Additional information will be sent following the conclusion of litigation. B20 Procedure/service was partially or fully furnished by another provider. Separately billed services/tests have been bundled as they are considered components of the same procedure. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement. Missing/incomplete/invalid rendering provider primary identifier. Reason Code 22 | Remark Codes MA04 - JA DME - Noridian Claim Adjustment Reason Codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Common Reasons for Denial This claim appears to be covered by a primary payer. PR 201 Workers Compensation case settled. 153 Payer deems the information submitted does not support this dosage. 116 The advance indemnification notice signed by the patient did not comply with 117 Transportation is only covered to the closest facility that can provide the necessary care. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. 9 The diagnosis is inconsistent with the patients age. The scope of this license is determined by the AMA, the copyright holder. Denial code 30 defined as 'Payment adjusted because the patient has not met the required spend down, eligibility, waiting, or residency requirements, Services not provided or authorized by designated providers. This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier, Misrouted claim. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Service Review Decision Reason Codes. Denial code 26 defined as "Services rendered prior to health care coverage". Note: The information obtained from this Noridian website application is as current as possible. The date of death precedes the date of service. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. An LCD provides a guide to assist in determining whether a particular item or service is covered, This decision was based on a Local Coverage Determination (LCD). P21 Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. The AMA is a third-party beneficiary to this license. Denial Codes in Medical Billing - Remit Codes List with solutions 139 Contracted funding agreement Subscriber is employed by the provider of services. Reproduced with permission. Separate payment is not allowed. Required fields are marked *. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. No fee schedules, basic unit, relative values or related listings are included in CDT. To be used for Property and Casualty only. 23 The impact of prior payer(s) adjudication including payments and/or adjustments. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Check to see the indicated modifier code with procedure code on the DOS is valid or not? Therefore, you have no reasonable expectation of privacy. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Select the Reason or Remark code link below to review supplier solutions to the denial and/or how to avoid the same denial in the future. 39 Services denied at the time authorization/pre-certification was requested. 159 Service/procedure was provided as a result of terrorism. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. 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 days supply. Denial Code described as "Claim/service not covered by this payer/contractor. The Washington Publishing Company publishes the CMS-approved Reason Codes and Remark Codes. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. If you choose not to accept the agreement, you will return to the Noridian Medicare home page. PI: Payor Initiated Reduction Start: 05/20/2018: PR: Patient Responsibility Start: 05/20/2018: Products. The definition of each is: CO (Contractual Obligations) is the amount between what you billed and the amount allowed by the payer when you are in-network with them. 1. PI Payer Initiated reductions D2 Claim lacks the name, strength, or dosage of the drug furnished. End Users do not act for or on behalf of the CMS. 111 Not covered unless the provider accepts assignment. Benefits are not available under this dental plan, PR 177 Payment denied because the patient has not met the required eligibility requirements, PR 200 Expenses incurred during lapse in coverage. Even if a provider has an individual NPI, it does not mean that his/her enrollment record is in PECOS and/or is active. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. This system is provided for Government authorized use only. An LCD provides a guide to assist in determining whether a particular item or service is covered. 258 Claim/service not covered when patient is in custody/incarcerated. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). Applications are available at the American Dental Association web site, http://www.ADA.org. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR). 156 Flexible spending account payments. Missing/incomplete/invalid procedure code(s). Completed physician financial relationship form not on file. For date of service submitted, beneficiary was enrolled in a Medicare Health Maintenance Organization (HMO). D5 Claim/service denied. 136 Failure to follow prior payers coverage rules. Medicare does not pay for this service/equipment/drug. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. All Rights Reserved. Denial codes are codes assigned by health care insurance companies to faulty insurance claims. Claim adjustment reason codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed.If there is no adjustment to a claim/line, then there is no . ANSI Reason & Remark Codes The Washington Publishing Company maintains a standard code set used industry wide to provide information regarding claim processing.. These materials contain Current Dental Terminology, (CDT), copyright 2020 American Dental Association (ADA). Missing/Invalid Molecular Diagnostic Services (MolDX) DEX Z-Code Identifier. Ask the same questions with representative as denial code - 5, but here check which procedure code submitted is incompatible with patient's gender. Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. you can get the help of coding Because in some cases you can Correct /add the valid code for the claim to be processed. This payment reflects the correct code. 46 This (these) service(s) is (are) not covered. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. 232 Institutional Transfer Amount. Procedure code billed is not correct/valid for the services billed or the date of service billed, This decision was based on a Local Coverage Determination (LCD). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. 124 Payer refund amount not our patient.

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