# RemarkCode RemarkCodeDescription

1 M1 X-ray not taken within the past 12 months or near enough to the start of treatment. Start: 01/01/199
2 M10 Equipment purchases are limited to the first or the tenth month of medical necessity. Start: 01/01/19
3 M11 We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, o
11 M111 We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray tak
12 M112 Reimbursement for this item is based on the single payment amount required under the DMEPOS Co
13 M113 Our records indicate that this patient began using this item/service prior to the current contract perio
14 M114 This service was processed in accordance with rules and guidelines under the DMEPOS Competitive B
15 M115 This item is denied when provided to this patient by a non-contract or non-demonstration supplier. S
16 M116 Processed under a demonstration project or program. Project or program is ending and additional se
17 M117 Not covered unless submitted via electronic claim. Start: 01/01/1997 | Last Modified: 06/30/2003 No
18 M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC). Start: 01/01/1997 | L
4 M12 Service not performed on equipment approved by the FDA for this purpose. Start: 01/01/1997
19 M12 Diagnostic tests performed by a physician must indicate whether purchased services are included o
20 M121 We pay for this service only when performed with a covered cryosurgical ablation. Start: 01/01/1997
21 M122 Missing/incomplete/invalid level of subluxation. Start: 01/01/1997 | Last Modified: 02/28/2006 Note
22 M123 Missing/incomplete/invalid name, strength, or dosage of the drug furnished. Start: 01/01/1997 | Last
23 M124 Missing indication of whether the patient owns the equipment that requires the part or supply. Start
24 M125 Missing/incomplete/invalid information on the period of time for which the service/supply/equipmen
25 M126 Missing/incomplete/invalid individual lab codes included in the test. Start: 01/01/1997 | Last Modifie
26 M127 Missing patient medical record for this service. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes
27 M129 Missing/incomplete/invalid indicator of x-ray availability for review. Start: 01/01/1997 | Last Modifie
5 M13 Information supplied supports a break in therapy. However, the medical information we have for this
28 M13 Only one initial visit is covered per specialty per medical group. Start: 01/01/1997 | Last Modified: 06
29 M130 Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of i
30 M131 Missing physician financial relationship form. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (
31 M132 Missing pacemaker registration form. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modifie
32 M133 Claim did not identify who performed the purchased diagnostic test or the amount you were charged
33 M134 Performed by a facility/supplier in which the provider has a financial interest. Start: 01/01/1997 | Las
34 M135 Missing/incomplete/invalid plan of treatment. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes:
35 M136 Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician. St
36 M137 Part B coinsurance under a demonstration project or pilot program. Start: 01/01/1997 | Last Modifie
37 M138 Patient identified as a demonstration participant but the patient was not enrolled in the demonstrati
38 M139 Denied services exceed the coverage limit for the demonstration. Start: 01/01/1997
6 M14 Information supplied supports a break in therapy. A new capped rental period will begin with delivery
39 M14 No separate payment for an injection administered during an office visit, and no payment for a full offi
40 M141 Missing physician certified plan of care. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modifi
41 M142 Missing American Diabetes Association Certificate of Recognition. Start: 01/01/1997 | Last Modified:
42 M143 The provider must update license information with the payer. Start: 01/01/1997 | Last Modified: 12/
43 M144 Pre-/post-operative care payment is included in the allowance for the surgery/procedure. Start: 01/0
7 M15 Information supplied does not support a break in therapy. The medical information we have for this p
44 M15 Separately billed services/tests have been bundled as they are considered components of the same p
8 M16 Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%. Start: 01/0
45 M16 Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure
9 M17 We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of t
46 M17 Alert: Payment approved as you did not know, and could not reasonably have been expected to know
10 M18 DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.
47 M18 Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF)
48 M19 Missing oxygen certification/re-certification. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
49 M2 Not paid separately when the patient is an inpatient. Start: 01/01/1997
50 M20 Missing/incomplete/invalid HCPCS. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified
51 M21 Missing/incomplete/invalid place of residence for this service/item provided in a home. Start: 01/01/
52 M22 Missing/incomplete/invalid number of miles traveled. Start: 01/01/1997 | Last Modified: 02/28/2003
53 M23 Missing invoice. Start: 01/01/1997 | Last Modified: 08/01/2005 Notes: (Modified 8/1/05)
54 M24 Missing/incomplete/invalid number of doses per vial. Start: 01/01/1997 | Last Modified: 02/28/2003
55 M25 The information furnished does not substantiate the need for this level of service. If you believe the s
56 M26 The information furnished does not substantiate the need for this level of service. If you have collecte
57 M27 Alert: The patient has been relieved of liability of payment of these items and services under the limi
58 M28 This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise a
59 M29 Missing operative note/report. Start: 01/01/1997 | Last Modified: 07/01/2008 Notes: (Modified 2/28
60 M3 Equipment is the same or similar to equipment already being used. Start: 01/01/1997
61 M30 Missing pathology report. Start: 01/01/1997 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04, 2/
62 M31 Missing radiology report. Start: 01/01/1997 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04, 2/
63 M32 Alert: This is a conditional payment made pending a decision on this service by the patient's primary
64 M36 This is the 11th rental month. We cannot pay for this until you indicate that the patient has been give
65 M37 Not covered when the patient is under age 35. Start: 01/01/1997 | Last Modified: 03/08/2011 Notes:
66 M38 Alert: The patient is liable for the charges for this service as they were informed in writing before the
67 M39 Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you
68 M4 Alert: This is the last monthly installment payment for this durable medical equipment. Start: 01/01/1
69 M40 Claim must be assigned and must be filed by the practitioner's employer. Start: 01/01/1997
70 M41 We do not pay for this as the patient has no legal obligation to pay for this. Start: 01/01/1997
71 M42 The medical necessity form must be personally signed by the attending physician. Start: 01/01/1997
72 M44 Missing/incomplete/invalid condition code. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
73 M45 Missing/incomplete/invalid occurrence code(s). Start: 01/01/1997 | Last Modified: 12/02/2004 Note
74 M46 Missing/incomplete/invalid occurrence span code(s). Start: 01/01/1997 | Last Modified: 12/02/2004
75 M47 Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including
76 M49 Missing/incomplete/invalid value code(s) or amount(s). Start: 01/01/1997 | Last Modified: 02/28/200
77 M5 Monthly rental payments can continue until the earlier of the 15th month from the first rental month
78 M50 Missing/incomplete/invalid revenue code(s). Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
79 M51 Missing/incomplete/invalid procedure code(s). Start: 01/01/1997 | Last Modified: 12/02/2004 Notes
80 M52 Missing/incomplete/invalid "from" date(s) of service. Start: 01/01/1997 | Last Modified: 02/28/2003
81 M53 Missing/incomplete/invalid days or units of service. Start: 01/01/1997 | Last Modified: 02/28/2003 N
82 M54 Missing/incomplete/invalid total charges. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Mo
83 M55 We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral
84 M56 Missing/incomplete/invalid payer identifier. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
85 M59 Missing/incomplete/invalid "to" date(s) of service. Start: 01/01/1997 | Last Modified: 02/28/2003 No
86 M6 Alert: You must furnish and service this item for any period of medical need for the remainder of the
87 M60 Missing Certificate of Medical Necessity. Start: 01/01/1997 | Last Modified: 08/01/2004 Notes: (Mod
88 M61 We cannot pay for this as the approval period for the FDA clinical trial has expired. Start: 01/01/1997
89 M62 Missing/incomplete/invalid treatment authorization code. Start: 01/01/1997 | Last Modified: 02/28/
90 M64 Missing/incomplete/invalid other diagnosis. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
91 M65 One interpreting physician charge can be submitted per claim when a purchased diagnostic test is ind
92 M66 Our records indicate that you billed diagnostic tests subject to price limitations and the procedure co
93 M67 Missing/incomplete/invalid other procedure code(s). Start: 01/01/1997 | Last Modified: 12/02/2004
94 M69 Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
95 M7 No rental payments after the item is purchased, or after the total of issued rental payments equals th
 96 M70 Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but ple
97 M71 Total payment reduced due to overlap of tests billed. Start: 01/01/1997
98 M73 The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. R
99 M74 This service does not qualify for a HPSA/Physician Scarcity bonus payment. Start: 01/01/1997 | Last M
100 M75 Multiple automated multichannel tests performed on the same day combined for payment. Start: 01
101 M76 Missing/incomplete/invalid diagnosis or condition. Start: 01/01/1997 | Last Modified: 02/28/2003 No
102 M77 Missing/incomplete/invalid/inappropriate place of service. Start: 01/01/1997 | Last Modified: 03/14/
103 M79 Missing/incomplete/invalid charge. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified
104 M8 We do not accept blood gas tests results when the test was conducted by a medical supplier or taken
105 M80 Not covered when performed during the same session/date as a previously processed service for the
106 M81 You are required to code to the highest level of specificity. Start: 01/01/1997 | Last Modified: 02/01/
107 M82 Service is not covered when patient is under age 50. Start: 01/01/1997
108 M83 Service is not covered unless the patient is classified as at high risk. Start: 01/01/1997
109 M84 Medical code sets used must be the codes in effect at the time of service. Start: 01/01/1997 | Last M
110 M85 Subjected to review of physician evaluation and management services. Start: 01/01/1997
111 M86 Service denied because payment already made for same/similar procedure within set time frame. Sta
112 M87 Claim/service(s) subjected to CFO-CAP prepayment review. Start: 01/01/1997
113 M89 Not covered more than once under age 40. Start: 01/01/1997
114 M9 Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a
115 M90 Not covered more than once in a 12 month period. Start: 01/01/1997
116 M91 Lab procedures with different CLIA certification numbers must be billed on separate claims. Start: 01/
117 M93 Information supplied supports a break in therapy. A new capped rental period began with delivery of
118 M94 Information supplied does not support a break in therapy. A new capped rental period will not begin.
119 M95 Services subjected to Home Health Initiative medical review/cost report audit. Start: 01/01/1997
120 M96 The technical component of a service furnished to an inpatient may only be billed by that inpatient fa
121 M97 Not paid to practitioner when provided to patient in this place of service. Payment included in the rei
122 M99 Missing/incomplete/invalid Universal Product Number/Serial Number. Start: 01/01/1997 | Last Modi
123 MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. To
124 MA02 Alert: If you do not agree with this determination, you have the right to appeal. You must file a writte
125 MA04 Secondary payment cannot be considered without the identity of or payment information from the p
126 MA07 Alert: The claim information has also been forwarded to Medicaid for review. Start: 01/01/1997 | Las
127 MA08 Alert: Claim information was not forwarded because the supplemental coverage is not with a Mediga
128 MA09 Claim submitted as unassigned but processed as assigned in accordance with our current assignment
129 MA10 Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment t
130 MA10 Missing/incomplete/invalid date of current illness or symptoms. Start: 01/01/1997 | Last Modified: 0
131 MA10 Hemophilia Add On. Start: 01/01/1997
132 MA10 PIP (Periodic Interim Payment) claim. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modifie
133 MA10 Paper claim contains more than three separate data items in field 19. Start: 01/01/1997
134 MA10 Paper claim contains more than one data item in field 23. Start: 01/01/1997
135 MA10 Claim processed in accordance with ambulatory surgical guidelines. Start: 01/01/1997
145 MA12 You have not established that you have the right under the law to bill for services furnished by the pe
146 MA12 Missing/incomplete/invalid CLIA certification number. Start: 01/01/1997 | Last Modified: 02/28/2003
147 MA12 Missing/incomplete/invalid x-ray date. Start: 01/01/1997 | Last Modified: 12/02/2004 Notes: (Modifi
148 MA12 Missing/incomplete/invalid initial treatment date. Start: 01/01/1997 | Last Modified: 12/02/2004 No
149 MA12 Your center was not selected to participate in this study, therefore, we cannot pay for these services.
150 MA12 Per legislation governing this program, payment constitutes payment in full. Start: 01/01/1997
151 MA12 Pancreas transplant not covered unless kidney transplant performed. Start: 10/12/2001
152 MA12 Missing/incomplete/invalid FDA approval number. Start: 10/12/2001 | Last Modified: 03/30/2005 No
153 MA13 Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (pa
154 MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because
155 MA131 Physician already paid for services in conjunction with this demonstration claim. You must have the p
156 MA132 Adjustment to the pre-demonstration rate. Start: 10/12/2001
157 MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay. Start: 10
158 MA134 Missing/incomplete/invalid provider number of the facility where the patient resides. Start: 10/12/20
159 MA14 Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside
160 MA15 Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the
161 MA16 The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Feder
162 MA17 We are the primary payer and have paid at the primary rate. You must contact the patient's other ins
163 MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any q
164 MA19 Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you subm
165 MA20 Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral
166 MA21 SSA records indicate mismatch with name and sex. Start: 01/01/1997
167 MA22 Payment of less than $1.00 suppressed. Start: 01/01/1997
168 MA23 Demand bill approved as result of medical review. Start: 01/01/1997
169 MA24 Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period. Start: 01/01
170 MA25 A patient may not elect to change a hospice provider more than once in a benefit period. Start: 01/01
171 MA26 Alert: Our records indicate that you were previously informed of this rule. Start: 01/01/1997 | Last M
172 MA27 Missing/incomplete/invalid entitlement number or name shown on the claim. Start: 01/01/1997 | La
173 MA28 Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for informatio
174 MA30 Missing/incomplete/invalid type of bill. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modifi
175 MA31 Missing/incomplete/invalid beginning and ending dates of the period billed. Start: 01/01/1997 | Last
176 MA32 Missing/incomplete/invalid number of covered days during the billing period. Start: 01/01/1997 | Las
177 MA33 Missing/incomplete/invalid noncovered days during the billing period. Start: 01/01/1997 | Last Modi
178 MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. Start: 01/01/1997 |
179 MA35 Missing/incomplete/invalid number of lifetime reserve days. Start: 01/01/1997 | Last Modified: 02/2
180 MA36 Missing/incomplete/invalid patient name. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Mo
181 MA37 Missing/incomplete/invalid patient's address. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes:
182 MA39 Missing/incomplete/invalid gender. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified
183 MA40 Missing/incomplete/invalid admission date. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
184 MA41 Missing/incomplete/invalid admission type. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (M
185 MA42 Missing/incomplete/invalid admission source. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes:
186 MA43 Missing/incomplete/invalid patient status. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Mo
187 MA44 Alert: No appeal rights. Adjudicative decision based on law. Start: 01/01/1997 | Last Modified: 04/01
188 MA45 Alert: As previously advised, a portion or all of your payment is being held in a special account. Start:
189 MA46 The new information was considered but additional payment will not be issued. Start: 01/01/1997 | L
190 MA47 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for
191 MA48 Missing/incomplete/invalid name or address of responsible party or primary payer. Start: 01/01/1997
192 MA50 Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number. Start:
193 MA53 Missing/incomplete/invalid Competitive Bidding Demonstration Project identification. Start: 01/01/1
194 MA54 Physician certification or election consent for hospice care not received timely. Start: 01/01/1997
195 MA55 Not covered as patient received medical health care services, automatically revoking his/her election
196 MA56 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for
197 MA57 Patient submitted written request to revoke his/her election for religious non-medical health care ser
198 MA58 Missing/incomplete/invalid release of information indicator. Start: 01/01/1997 | Last Modified: 02/2
199 MA59 Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days
200 MA60 Missing/incomplete/invalid patient relationship to insured. Start: 01/01/1997 | Last Modified: 02/28/
201 MA61 Missing/incomplete/invalid social security number. Start: 01/01/1997 | Last Modified: 03/01/2018 N
202 MA62 Alert: This is a telephone review decision. Start: 01/01/1997 | Last Modified: 08/01/2007 Notes: (Mo
203 MA63 Missing/incomplete/invalid principal diagnosis. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes
204 MA64 Our records indicate that we should be the third payer for this claim. We cannot process this claim un
205 MA65 Missing/incomplete/invalid admitting diagnosis. Start: 01/01/1997 | Last Modified: 02/28/2003 Note
206 MA66 Missing/incomplete/invalid principal procedure code. Start: 01/01/1997 | Last Modified: 12/02/2004
207 MA67 Correction to a prior claim. Start: 01/01/1997
208 MA68 Alert: We did not crossover this claim because the secondary insurance information on the claim was
209 MA69 Missing/incomplete/invalid remarks. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified
210 MA70 Missing/incomplete/invalid provider representative signature. Start: 01/01/1997 | Last Modified: 02/
211 MA71 Missing/incomplete/invalid provider representative signature date. Start: 01/01/1997 | Last Modified
212 MA72 Alert: The patient overpaid you for these assigned services. You must issue the patient a refund withi
213 MA73 Informational remittance associated with a Medicare demonstration. No payment issued under fee-f
214 MA74 Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or return
215 MA75 Missing/incomplete/invalid patient or authorized representative signature. Start: 01/01/1997 | Last M
216 MA76 Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is p
217 MA77 Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference
218 MA79 Billed in excess of interim rate. Start: 01/01/1997
219 MA80 Informational notice. No payment issued for this claim with this notice. Payment issued to the hospit
220 MA81 Missing/incomplete/invalid provider/supplier signature. Start: 01/01/1997 | Last Modified: 02/28/20
221 MA83 Did not indicate whether we are the primary or secondary payer. Start: 01/01/1997 | Last Modified:
222 MA84 Patient identified as participating in the National Emphysema Treatment Trial but our records indicat
223 MA88 Missing/incomplete/invalid insured's address and/or telephone number for the primary payer. Start:
224 MA89 Missing/incomplete/invalid patient's relationship to the insured for the primary payer. Start: 01/01/1
225 MA90 Missing/incomplete/invalid employment status code for the primary insured. Start: 01/01/1997 | Las
226 MA91 Alert: This determination is the result of the appeal you filed. Start: 01/01/1997 | Last Modified: 07/0
227 MA92 Missing plan information for other insurance. Start: 01/01/1997 | Last Modified: 02/01/2004 Notes: (
228 MA93 Non-PIP (Periodic Interim Payment) claim. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Mo
229 MA94 Did not enter the statement "Attending physician not hospice employee" on the claim form to certify
230 MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a M
231 MA97 Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial
232 MA99 Missing/incomplete/invalid Medigap information. Start: 01/01/1997 | Last Modified: 02/28/2003 No
233 N1 Alert: You may appeal this decision in writing within the required time limits following receipt of this
234 N10 Adjustment based on the findings of a review organization/professional consult/manual adjudication
237 N103 Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when
238 N104 This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medi
239 N105 This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Pal
240 N106 Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded service
241 N107 Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. Th
242 N108 Missing/incomplete/invalid upgrade information. Start: 01/31/2002 | Last Modified: 02/28/2003 Not
243 N109 Alert: This claim/service was chosen for complex review. Start: 02/28/2002 | Last Modified: 07/01/20
244 N11 Denial reversed because of medical review. Start: 01/01/2000
245 N110 This facility is not certified for film mammography. Start: 02/28/2002
246 N111 No appeal right except duplicate claim/service issue. This service was included in a claim that has bee
247 N112 This claim is excluded from your electronic remittance advice. Start: 02/28/2002
248 N113 Only one initial visit is covered per physician, group practice or provider. Start: 04/16/2002 | Last Mo
249 N114 During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended am
250 N115 This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist i
251 N116 This payment is being made conditionally because the service was provided in the home, and it is pos
252 N117 This service is paid only once in a patient's lifetime. Start: 07/30/2002 | Last Modified: 06/30/2003 N
253 N118 This service is not paid if billed more than once every 28 days. Start: 07/30/2002
254 N119 This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive d
255 N12 Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled i
256 N120 Payment is subject to home health prospective payment system partial episode payment adjustment
257 N121 Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiar
258 N122 Add-on code cannot be billed by itself. Start: 09/12/2002 | Last Modified: 08/01/2005 Notes: (Modifi
259 N123 This is a split service and represents a portion of the units from the originally submitted service. Start
260 N124 Payment has been denied for the/made only for a less extensive service/item because the informatio
261 N125 Payment has been (denied for the/made only for a less extensive) service/item because the informati
262 N126 Social Security Records indicate that this individual has been deported. This payer does not cover item
263 N127 This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please
264 N128 This amount represents the prior to coverage portion of the allowance. Start: 10/31/2002
265 N129 Not eligible due to the patient's age. Start: 10/31/2002 | Last Modified: 08/01/2007 Notes: (Modified
266 N13 Payment based on professional/technical component modifier(s). Start: 01/01/2000
267 N130 Consult plan benefit documents/guidelines for information about restrictions for this service. Start: 1
268 N131 Total payments under multiple contracts cannot exceed the allowance for this service. Start: 10/31/2
269 N132 Alert: Payments will cease for services rendered by this US Government debarred or excluded provid
270 N133 Alert: Services for predetermination and services requesting payment are being processed separately
271 N134 Alert: This represents your scheduled payment for this service. If treatment has been discontinued, p
272 N135 Record fees are the patient's responsibility and limited to the specified co-payment. Start: 10/31/200
273 N136 Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consum
274 N137 Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, a
275 N138 Alert: In the event you disagree with the Dental Advisor's opinion and have additional information re
276 N139 Alert: Under 32 CFR 199.13, a non-participating provider is not an appropriate appealing party. There
277 N140 Alert: You have not been designated as an authorized OCONUS provider therefore are not considered
278 N141 The patient was not residing in a long-term care facility during all or part of the service dates billed. S
279 N142 The original claim was denied. Resubmit a new claim, not a replacement claim. Start: 10/31/2002
280 N143 The patient was not in a hospice program during all or part of the service dates billed. Start: 10/31/20
281 N144 The rate changed during the dates of service billed. Start: 10/31/2002
282 N146 Missing screening document. Start: 10/31/2002 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04
283 N147 Long term care case mix or per diem rate cannot be determined because the patient ID number is mi
284 N148 Missing/incomplete/invalid date of last menstrual period. Start: 10/31/2002
285 N149 Rebill all applicable services on a single claim. Start: 10/31/2002
286 N15 Services for a newborn must be billed separately. Start: 01/01/2000
287 N150 Missing/incomplete/invalid model number. Start: 10/31/2002
288 N151 Telephone contact services will not be paid until the face-to-face contact requirement has been met.
289 N152 Missing/incomplete/invalid replacement claim information. Start: 10/31/2002
290 N153 Missing/incomplete/invalid room and board rate. Start: 10/31/2002
291 N154 Alert: This payment was delayed for correction of provider's mailing address. Start: 10/31/2002 | Las
292 N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance inform
293 N156 Alert: The patient is responsible for the difference between the approved treatment and the elective
294 N157 Transportation to/from this destination is not covered. Start: 02/28/2003 | Last Modified: 02/01/200
295 N158 Transportation in a vehicle other than an ambulance is not covered. Start: 02/28/2003
296 N159 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. S
297 N16 Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage. Star
298 N160 The patient must choose an option before a payment can be made for this procedure/ equipment/ su
299 N161 This drug/service/supply is covered only when the associated service is covered. Start: 02/28/2003
300 N162 Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laborato
301 N163 Medical record does not support code billed per the code definition. Start: 02/28/2003
302 N167 Charges exceed the post-transplant coverage limit. Start: 02/28/2003
303 N170 A new/revised/renewed certificate of medical necessity is needed. Start: 02/28/2003
304 N171 Payment for repair or replacement is not covered or has exceeded the purchase price. Start: 02/28/2
305 N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item. Sta
306 N173 No qualifying hospital stay dates were provided for this episode of care. Start: 02/28/2003
307 N174 This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amou
308 N175 Missing review organization approval. Start: 02/28/2003 | Last Modified: 02/29/2008 Notes: (Modifie
309 N176 Services provided aboard a ship are covered only when the ship is of United States registry and is in U
310 N177 Alert: We did not send this claim to patient's other insurer. They have indicated no additional payme
311 N178 Missing pre-operative images/visual field results. Start: 02/28/2003 | Last Modified: 11/01/2013 Not
312 N179 Additional information has been requested from the member. The charges will be reconsidered upon
313 N180 This item or service does not meet the criteria for the category under which it was billed. Start: 02/28
314 N181 Additional information is required from another provider involved in this service. Start: 02/28/2003 |
315 N182 This claim/service must be billed according to the schedule for this plan. Start: 02/28/2003
316 N183 Alert: This is a predetermination advisory message, when this service is submitted for payment additi
317 N184 Rebill technical and professional components separately. Start: 02/28/2003
318 N185 Alert: Do not resubmit this claim/service. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Mod
319 N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Fa
320 N187 Alert: You may request a review in writing within the required time limits following receipt of this noti
321 N188 The approved level of care does not match the procedure code submitted. Start: 02/28/2003
322 N189 Alert: This service has been paid as a one-time exception to the plan's benefit restrictions. Start: 02/2
323 N19 Procedure code incidental to primary procedure. Start: 01/01/2000
324 N190 Missing contract indicator. Start: 02/28/2003 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04) R
325 N191 The provider must update insurance information directly with payer. Start: 02/28/2003
326 N192 Patient is a Medicaid/Qualified Medicare Beneficiary. Start: 02/28/2003
327 N193 Specific federal/state/local program may cover this service through another payer. Start: 02/28/2003
328 N194 Technical component not paid if provider does not own the equipment used. Start: 02/25/2003
329 N195 The technical component must be billed separately. Start: 02/25/2003
330 N196 Alert: Patient eligible to apply for other coverage which may be primary. Start: 02/25/2003 | Last Mo
331 N197 The subscriber must update insurance information directly with payer. Start: 02/25/2003
332 N198 Rendering provider must be affiliated with the pay-to provider. Start: 02/25/2003
333 N199 Additional payment/recoupment approved based on payer-initiated review/audit. Start: 02/25/2003
334 N2 This allowance has been made in accordance with the most appropriate course of treatment provisio
335 N20 Service not payable with other service rendered on the same date. Start: 01/01/2000
336 N200 The professional component must be billed separately. Start: 02/25/2003
337 N202 Additional information/explanation will be sent separately. Start: 06/30/2003 | Last Modified: 03/14/
338 N203 Missing/incomplete/invalid anesthesia time/units. Start: 06/30/2003 | Last Modified: 03/14/2014 No
339 N204 Services under review for possible pre-existing condition. Send medical records for prior 12 months S
340 N205 Information provided was illegible. Start: 06/30/2003 | Last Modified: 03/14/2014 Notes: (Modified 3
341 N206 The supporting documentation does not match the information sent on the claim. Start: 06/30/2003
342 N207 Missing/incomplete/invalid weight. Start: 06/30/2003 | Last Modified: 11/18/2005 Notes: (Modified
343 N208 Missing/incomplete/invalid DRG code. Start: 06/30/2003 | Last Modified: 03/14/2014 Notes: (Modifi
344 N209 Missing/incomplete/invalid taxpayer identification number (TIN). Start: 06/30/2003 | Last Modified:
345 N21 Alert: Your line item has been separated into multiple lines to expedite handling. Start: 01/01/2000 |
346 N210 Alert: You may appeal this decision. Start: 06/30/2003 | Last Modified: 03/14/2014 Notes: (Modified
347 N211 Alert: You may not appeal this decision. Start: 06/30/2003 | Last Modified: 03/14/2014 Notes: (Modi
348 N212 Charges processed under a Point of Service benefit . Start: 02/01/2004 | Last Modified: 03/14/2014 N
349 N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information. Start: 04/01/2
350 N214 Missing/incomplete/invalid history of the related initial surgical procedure(s). Start: 04/01/2004 | Las
351 N215 Alert: A payer providing supplemental or secondary coverage shall not require a claims determination
352 N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our b
353 N217 We pay only one site of service per provider per claim. Start: 08/01/2004 | Last Modified: 03/14/201
354 N218 You must furnish and service this item for as long as the patient continues to need it. We can pay for
355 N219 Payment based on previous payer's allowed amount. Start: 08/01/2004
356 N22 Alert: This procedure code was added/changed because it more accurately describes the services ren
357 N220 Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms a
358 N221 Missing Admitting History and Physical report. Start: 08/01/2004
359 N222 Incomplete/invalid Admitting History and Physical report. Start: 08/01/2004
360 N223 Missing documentation of benefit to the patient during initial treatment period. Start: 08/01/2004
361 N224 Incomplete/invalid documentation of benefit to the patient during initial treatment period. Start: 08/
363 N226 Incomplete/invalid American Diabetes Association Certificate of Recognition. Start: 08/01/2004
364 N227 Incomplete/invalid Certificate of Medical Necessity. Start: 08/01/2004
365 N228 Incomplete/invalid consent form. Start: 08/01/2004
366 N229 Incomplete/invalid contract indicator. Start: 08/01/2004
367 N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or max
368 N230 Incomplete/invalid indication of whether the patient owns the equipment that requires the part or su
369 N231 Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or t
370 N232 Incomplete/invalid itemized bill/statement. Start: 08/01/2004 | Last Modified: 07/01/2008 Notes: (M
371 N233 Incomplete/invalid operative note/report. Start: 08/01/2004 | Last Modified: 07/01/2008 Notes: (Mo
372 N234 Incomplete/invalid oxygen certification/re-certification. Start: 08/01/2004
373 N235 Incomplete/invalid pacemaker registration form. Start: 08/01/2004
374 N236 Incomplete/invalid pathology report. Start: 08/01/2004
375 N237 Incomplete/invalid patient medical record for this service. Start: 08/01/2004
376 N238 Incomplete/invalid physician certified plan of care. Start: 08/01/2004 | Last Modified: 03/14/2014 No
377 N239 Incomplete/invalid physician financial relationship form. Start: 08/01/2004
378 N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information. Start: 01/01/2000 |
379 N240 Incomplete/invalid radiology report. Start: 08/01/2004
380 N241 Incomplete/invalid review organization approval. Start: 08/01/2004 | Last Modified: 02/29/2008 Not
381 N242 Incomplete/invalid radiology film(s)/image(s). Start: 08/01/2004 | Last Modified: 07/01/2008 Notes:
382 N243 Incomplete/invalid/not approved screening document. Start: 08/01/2004
383 N244 Incomplete/Invalid pre-operative images/visual field results. Start: 08/01/2004 | Last Modified: 11/01
384 N245 Incomplete/invalid plan information for other insurance . Start: 08/01/2004 | Last Modified: 03/14/2
385 N246 State regulated patient payment limitations apply to this service. Start: 12/02/2004
386 N247 Missing/incomplete/invalid assistant surgeon taxonomy. Start: 12/02/2004
387 N248 Missing/incomplete/invalid assistant surgeon name. Start: 12/02/2004
388 N249 Missing/incomplete/invalid assistant surgeon primary identifier. Start: 12/02/2004
389 N25 This company has been contracted by your benefit plan to provide administrative claims payment ser
390 N250 Missing/incomplete/invalid assistant surgeon secondary identifier. Start: 12/02/2004
391 N251 Missing/incomplete/invalid attending provider taxonomy. Start: 12/02/2004
392 N252 Missing/incomplete/invalid attending provider name. Start: 12/02/2004
393 N253 Missing/incomplete/invalid attending provider primary identifier. Start: 12/02/2004
394 N254 Missing/incomplete/invalid attending provider secondary identifier. Start: 12/02/2004
395 N255 Missing/incomplete/invalid billing provider taxonomy. Start: 12/02/2004
396 N256 Missing/incomplete/invalid billing provider/supplier name. Start: 12/02/2004
397 N257 Missing/incomplete/invalid billing provider/supplier primary identifier. Start: 12/02/2004
398 N258 Missing/incomplete/invalid billing provider/supplier address. Start: 12/02/2004
399 N259 Missing/incomplete/invalid billing provider/supplier secondary identifier. Start: 12/02/2004
400 N26 Missing itemized bill/statement. Start: 01/01/2000 | Last Modified: 07/01/2008 Notes: (Modified 2/2
401 N260 Missing/incomplete/invalid billing provider/supplier contact information. Start: 12/02/2004
402 N261 Missing/incomplete/invalid operating provider name. Start: 12/02/2004
403 N262 Missing/incomplete/invalid operating provider primary identifier. Start: 12/02/2004
404 N263 Missing/incomplete/invalid operating provider secondary identifier. Start: 12/02/2004
405 N264 Missing/incomplete/invalid ordering provider name. Start: 12/02/2004
406 N265 Missing/incomplete/invalid ordering provider primary identifier. Start: 12/02/2004
407 N266 Missing/incomplete/invalid ordering provider address. Start: 12/02/2004
408 N267 Missing/incomplete/invalid ordering provider secondary identifier. Start: 12/02/2004
409 N268 Missing/incomplete/invalid ordering provider contact information. Start: 12/02/2004
410 N269 Missing/incomplete/invalid other provider name. Start: 12/02/2004
411 N27 Missing/incomplete/invalid treatment number. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes
412 N270 Missing/incomplete/invalid other provider primary identifier. Start: 12/02/2004
413 N271 Missing/incomplete/invalid other provider secondary identifier. Start: 12/02/2004
414 N272 Missing/incomplete/invalid other payer attending provider identifier. Start: 12/02/2004
415 N273 Missing/incomplete/invalid other payer operating provider identifier. Start: 12/02/2004
416 N274 Missing/incomplete/invalid other payer other provider identifier. Start: 12/02/2004
417 N275 Missing/incomplete/invalid other payer purchased service provider identifier. Start: 12/02/2004
418 N276 Missing/incomplete/invalid other payer referring provider identifier. Start: 12/02/2004
419 N277 Missing/incomplete/invalid other payer rendering provider identifier. Start: 12/02/2004
420 N278 Missing/incomplete/invalid other payer service facility provider identifier. Start: 12/02/2004
421 N279 Missing/incomplete/invalid pay-to provider name. Start: 12/02/2004
422 N28 Consent form requirements not fulfilled. Start: 01/01/2000
423 N280 Missing/incomplete/invalid pay-to provider primary identifier. Start: 12/02/2004
424 N281 Missing/incomplete/invalid pay-to provider address. Start: 12/02/2004
425 N282 Missing/incomplete/invalid pay-to provider secondary identifier. Start: 12/02/2004
426 N283 Missing/incomplete/invalid purchased service provider identifier. Start: 12/02/2004
427 N284 Missing/incomplete/invalid referring provider taxonomy. Start: 12/02/2004
428 N285 Missing/incomplete/invalid referring provider name. Start: 12/02/2004
429 N286 Missing/incomplete/invalid referring provider primary identifier. Start: 12/02/2004
430 N287 Missing/incomplete/invalid referring provider secondary identifier. Start: 12/02/2004
431 N288 Missing/incomplete/invalid rendering provider taxonomy. Start: 12/02/2004
432 N289 Missing/incomplete/invalid rendering provider name. Start: 12/02/2004
434 N290 Missing/incomplete/invalid rendering provider primary identifier. Start: 12/02/2004
435 N291 Missing/incomplete/invalid rendering provider secondary identifier. Start: 12/02/2004 | Last Modifie
436 N292 Missing/incomplete/invalid service facility name. Start: 12/02/2004
437 N293 Missing/incomplete/invalid service facility primary identifier. Start: 12/02/2004
438 N294 Missing/incomplete/invalid service facility primary address. Start: 12/02/2004
439 N295 Missing/incomplete/invalid service facility secondary identifier. Start: 12/02/2004
440 N296 Missing/incomplete/invalid supervising provider name. Start: 12/02/2004
441 N297 Missing/incomplete/invalid supervising provider primary identifier. Start: 12/02/2004
442 N298 Missing/incomplete/invalid supervising provider secondary identifier. Start: 12/02/2004
443 N299 Missing/incomplete/invalid occurrence date(s). Start: 12/02/2004
444 N3 Missing consent form. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) Rela
445 N30 Patient ineligible for this service. Start: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 6/3
446 N300 Missing/incomplete/invalid occurrence span date(s). Start: 12/02/2004
447 N301 Missing/incomplete/invalid procedure date(s). Start: 12/02/2004
448 N302 Missing/incomplete/invalid other procedure date(s). Start: 12/02/2004
449 N303 Missing/incomplete/invalid principal procedure date. Start: 12/02/2004
450 N304 Missing/incomplete/invalid dispensed date. Start: 12/02/2004
451 N305 Missing/incomplete/invalid accident date. Start: 12/02/2004
452 N306 Missing/incomplete/invalid acute manifestation date. Start: 12/02/2004
453 N307 Missing/incomplete/invalid adjudication or payment date. Start: 12/02/2004
454 N308 Missing/incomplete/invalid appliance placement date. Start: 12/02/2004
455 N309 Missing/incomplete/invalid assessment date. Start: 12/02/2004
456 N31 Missing/incomplete/invalid prescribing provider identifier. Start: 01/01/2000 | Last Modified: 12/02/
457 N310 Missing/incomplete/invalid assumed or relinquished care date. Start: 12/02/2004
458 N311 Missing/incomplete/invalid authorized to return to work date. Start: 12/02/2004
459 N312 Missing/incomplete/invalid begin therapy date. Start: 12/02/2004
460 N313 Missing/incomplete/invalid certification revision date. Start: 12/02/2004
461 N314 Missing/incomplete/invalid diagnosis date. Start: 12/02/2004
462 N315 Missing/incomplete/invalid disability from date. Start: 12/02/2004
463 N316 Missing/incomplete/invalid disability to date. Start: 12/02/2004
464 N317 Missing/incomplete/invalid discharge hour. Start: 12/02/2004
465 N318 Missing/incomplete/invalid discharge or end of care date. Start: 12/02/2004
466 N319 Missing/incomplete/invalid hearing or vision prescription date. Start: 12/02/2004
467 N32 Claim must be submitted by the provider who rendered the service. Start: 01/01/2000 | Last Modifie
468 N320 Missing/incomplete/invalid Home Health Certification Period. Start: 12/02/2004
469 N321 Missing/incomplete/invalid last admission period. Start: 12/02/2004
470 N322 Missing/incomplete/invalid last certification date. Start: 12/02/2004
471 N323 Missing/incomplete/invalid last contact date. Start: 12/02/2004
472 N324 Missing/incomplete/invalid last seen/visit date. Start: 12/02/2004
473 N325 Missing/incomplete/invalid last worked date. Start: 12/02/2004
474 N326 Missing/incomplete/invalid last x-ray date. Start: 12/02/2004
475 N327 Missing/incomplete/invalid other insured birth date. Start: 12/02/2004)
476 N328 Missing/incomplete/invalid Oxygen Saturation Test date. Start: 12/02/2004
477 N329 Missing/incomplete/invalid patient birth date. Start: 12/02/2004
478 N33 No record of health check prior to initiation of treatment. Start: 01/01/2000
479 N330 Missing/incomplete/invalid patient death date. Start: 12/02/2004
480 N331 Missing/incomplete/invalid physician order date. Start: 12/02/2004
481 N332 Missing/incomplete/invalid prior hospital discharge date. Start: 12/02/2004
482 N333 Missing/incomplete/invalid prior placement date. Start: 12/02/2004
483 N334 Missing/incomplete/invalid re-evaluation date. Start: 12/02/2004 | Last Modified: 03/14/2014 Notes
484 N335 Missing/incomplete/invalid referral date. Start: 12/02/2004
485 N336 Missing/incomplete/invalid replacement date. Start: 12/02/2004
486 N337 Missing/incomplete/invalid secondary diagnosis date. Start: 12/02/2004
487 N338 Missing/incomplete/invalid shipped date. Start: 12/02/2004
488 N339 Missing/incomplete/invalid similar illness or symptom date. Start: 12/02/2004
489 N34 Incorrect claim form/format for this service. Start: 01/01/2000 | Last Modified: 11/18/2005 Notes: (M
490 N340 Missing/incomplete/invalid subscriber birth date. Start: 12/02/2004
491 N341 Missing/incomplete/invalid surgery date. Start: 12/02/2004
492 N342 Missing/incomplete/invalid test performed date. Start: 12/02/2004
493 N343 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date. Start: 1
494 N344 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date. Start: 1
495 N345 Date range not valid with units submitted. Start: 03/30/2005
496 N346 Missing/incomplete/invalid oral cavity designation code. Start: 03/30/2005
497 N347 Your claim for a referred or purchased service cannot be paid because payment has already been ma
498 N348 You chose that this service/supply/drug would be rendered/supplied and billed by a different practiti
499 N349 The administration method and drug must be reported to adjudicate this service. Start: 08/01/2005
500 N35 Program integrity/utilization review decision. Start: 01/01/2000
501 N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an
502 N351 Service date outside of the approved treatment plan service dates. Start: 08/01/2005
503 N352 Alert: There are no scheduled payments for this service. Submit a claim for each patient visit. Start: 0
504 N353 Alert: Benefits have been estimated, when the actual services have been rendered, additional payme
505 N354 Incomplete/invalid invoice. Start: 08/01/2005 | Last Modified: 03/14/2014 Notes: (Modified 3/14/20
506 N355 Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and
507 N356 Not covered when performed with, or subsequent to, a non-covered service. Start: 08/01/2005 | Las
508 N357 Time frame requirements between this service/procedure/supply and a related service/procedure/su
509 N358 Alert: This decision may be reviewed if additional documentation as described in the contract or plan
510 N359 Missing/incomplete/invalid height. Start: 11/18/2005
511 N36 Claim must meet primary payer's processing requirements before we can consider payment. Start: 01
512 N360 Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determi
513 N362 The number of Days or Units of Service exceeds our acceptable maximum. Start: 11/18/2005
514 N363 Alert: in the near future we are implementing new policies/procedures that would affect this determ
515 N364 Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts. Star
517 N366 Requested information not provided. The claim will be reopened if the information previously reques
518 N367 Alert: The claim information has been forwarded to a Consumer Spending Account processor for revi
519 N368 You must appeal the determination of the previously adjudicated claim. Start: 04/01/2006
520 N369 Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
521 N37 Missing/incomplete/invalid tooth number/letter. Start: 01/01/2000 | Last Modified: 02/28/2003 Not
522 N370 Billing exceeds the rental months covered/approved by the payer. Start: 08/01/2006
523 N371 Alert: title of this equipment must be transferred to the patient. Start: 08/01/2006
524 N372 Only reasonable and necessary maintenance/service charges are covered. Start: 08/01/2006
525 N373 It has been determined that another payer paid the services as primary when they were not the prim
526 N374 Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required. S
527 N375 Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility. S
528 N376 Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE. St
529 N377 Payment based on a processed replacement claim. Start: 12/01/2006 | Last Modified: 11/05/2007 No
530 N378 Missing/incomplete/invalid prescription quantity. Start: 12/01/2006
531 N379 Claim level information does not match line level information. Start: 12/01/2006
532 N380 The original claim has been processed, submit a corrected claim. Start: 04/01/2007
533 N381 Alert: Consult our contractual agreement for restrictions/billing/payment information related to thes
534 N382 Missing/incomplete/invalid patient identifier. Start: 04/01/2007
535 N383 Not covered when deemed cosmetic. Start: 04/01/2007 | Last Modified: 03/08/2011 Notes: (Modifie
536 N384 Records indicate that the referenced body part/tooth has been removed in a previous procedure. Sta
537 N385 Notification of admission was not timely according to published plan procedures. Start: 04/01/2007 |
538 N386 This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage d
539 N387 Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits
540 N388 Missing/incomplete/invalid prescription number. Start: 08/01/2007 | Last Modified: 03/14/2014 Not
541 N389 Duplicate prescription number submitted. Start: 08/01/2007
542 N39 Procedure code is not compatible with tooth number/letter. Start: 01/01/2000
543 N390 This service/report cannot be billed separately. Start: 08/01/2007 | Last Modified: 07/01/2008 Notes
544 N391 Missing emergency department records. Start: 08/01/2007
545 N392 Incomplete/invalid emergency department records. Start: 08/01/2007
546 N393 Missing progress notes/report. Start: 08/01/2007 | Last Modified: 07/01/2008 Notes: (Modified 7/1/
547 N394 Incomplete/invalid progress notes/report. Start: 08/01/2007 | Last Modified: 07/01/2008 Notes: (Mo
548 N395 Missing laboratory report. Start: 08/01/2007
549 N396 Incomplete/invalid laboratory report. Start: 08/01/2007
550 N397 Benefits are not available for incomplete service(s)/undelivered item(s). Start: 08/01/2007
551 N398 Missing elective consent form. Start: 08/01/2007
552 N399 Incomplete/invalid elective consent form. Start: 08/01/2007
553 N4 Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. Start: 01/01/2000 | Last Modified: 03/06/
554 N40 Missing radiology film(s)/image(s). Start: 01/01/2000 | Last Modified: 07/01/2008 Notes: (Modified 2
555 N400 Alert: Electronically enabled providers should submit claims electronically. Start: 08/01/2007
556 N401 Missing periodontal charting. Start: 08/01/2007
557 N402 Incomplete/invalid periodontal charting. Start: 08/01/2007
558 N403 Missing facility certification. Start: 08/01/2007
559 N404 Incomplete/invalid facility certification. Start: 08/01/2007
560 N405 This service is only covered when the donor's insurer(s) do not provide coverage for the service. Start
561 N406 This service is only covered when the recipient's insurer(s) do not provide coverage for the service. St
562 N407 You are not an approved submitter for this transmission format. Start: 08/01/2007
563 N408 This payer does not cover deductibles assessed by a previous payer. Start: 08/01/2007
564 N409 This service is related to an accidental injury and is not covered unless provided within a specific time
565 N410 Not covered unless the prescription changes. Start: 08/01/2007 | Last Modified: 03/08/2011 Notes: (
566 N418 Misrouted claim. See the payer's claim submission instructions. Start: 08/01/2007
567 N419 Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change. St
568 N42 Missing mental health assessment. Start: 01/01/2000 | Last Modified: 11/01/2014
569 N420 Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits o
570 N421 Claim payment was the result of a payer's retroactive adjustment due to a review organization decisi
571 N422 Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive
572 N423 Claim payment was the result of a payer's retroactive adjustment due to a non standard program. Sta
573 N424 Patient does not reside in the geographic area required for this type of payment. Start: 08/01/2007
574 N425 Statutorily excluded service(s). Start: 08/01/2007
575 N426 No coverage when self-administered. Start: 08/01/2007
576 N427 Payment for eyeglasses or contact lenses can be made only after cataract surgery. Start: 08/01/2007
577 N428 Not covered when performed in this place of service. Start: 08/01/2007 | Last Modified: 03/08/2011
578 N429 Not covered when considered routine. Start: 08/01/2007 | Last Modified: 03/08/2011 Notes: (Modifi
579 N43 Bed hold or leave days exceeded. Start: 01/01/2000
580 N430 Procedure code is inconsistent with the units billed. Start: 11/05/2007
581 N431 Not covered with this procedure. Start: 11/05/2007 | Last Modified: 03/08/2011 Notes: (Modified 3/
582 N432 Alert: Adjustment based on a Recovery Audit. Start: 11/05/2007 | Last Modified: 07/01/2015 Notes:
583 N433 Resubmit this claim using only your National Provider Identifier (NPI). Start: 02/29/2008 | Last Modifi
584 N434 Missing/Incomplete/Invalid Present on Admission indicator. Start: 07/01/2008
585 N435 Exceeds number/frequency approved /allowed within time period without support documentation. S
586 N436 The injury claim has not been accepted and a mandatory medical reimbursement has been made. Sta
587 N437 Alert: If the injury claim is accepted, these charges will be reconsidered. Start: 07/01/2008
588 N438 This jurisdiction only accepts paper claims. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Mo
589 N439 Missing anesthesia physical status report/indicators. Start: 07/01/2008
590 N440 Incomplete/invalid anesthesia physical status report/indicators. Start: 07/01/2008
591 N441 This missed/cancelled appointment is not covered. Start: 07/01/2008 | Last Modified: 07/15/2013 No
592 N442 Payment based on an alternate fee schedule. Start: 07/01/2008
593 N443 Missing/incomplete/invalid total time or begin/end time. Start: 07/01/2008
594 N444 Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' C
595 N445 Missing document for actual cost or paid amount. Start: 07/01/2008
596 N446 Incomplete/invalid document for actual cost or paid amount. Start: 07/01/2008
597 N447 Payment is based on a generic equivalent as required documentation was not provided. Start: 07/01/
598 N448 This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangemen
599 N449 Payment based on a comparable drug/service/supply. Start: 07/01/2008
600 N45 Payment based on authorized amount. Start: 01/01/2000
601 N450 Covered only when performed by the primary treating physician or the designee. Start: 07/01/2008
602 N451 Missing Admission Summary Report. Start: 07/01/2008
603 N452 Incomplete/invalid Admission Summary Report. Start: 07/01/2008
604 N453 Missing Consultation Report. Start: 07/01/2008
605 N454 Incomplete/invalid Consultation Report. Start: 07/01/2008
606 N455 Missing Physician Order. Start: 07/01/2008
607 N456 Incomplete/invalid Physician Order. Start: 07/01/2008
608 N457 Missing Diagnostic Report. Start: 07/01/2008
609 N458 Incomplete/invalid Diagnostic Report. Start: 07/01/2008
610 N459 Missing Discharge Summary. Start: 07/01/2008
611 N46 Missing/incomplete/invalid admission hour. Start: 01/01/2000
612 N460 Incomplete/invalid Discharge Summary. Start: 07/01/2008
613 N461 Missing Nursing Notes. Start: 07/01/2008
614 N462 Incomplete/invalid Nursing Notes. Start: 07/01/2008
615 N463 Missing support data for claim. Start: 07/01/2008
616 N464 Incomplete/invalid support data for claim. Start: 07/01/2008
617 N465 Missing Physical Therapy Notes/Report. Start: 07/01/2008
618 N466 Incomplete/invalid Physical Therapy Notes/Report. Start: 07/01/2008
619 N467 Missing Tests and Analysis Report. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3
620 N468 Incomplete/invalid Report of Tests and Analysis Report. Start: 07/01/2008
621 N469 Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Imp
622 N47 Claim conflicts with another inpatient stay. Start: 01/01/2000
623 N470 This payment will complete the mandatory medical reimbursement limit. Start: 07/01/2008
624 N471 Missing/incomplete/invalid HIPPS Rate Code. Start: 07/01/2008
625 N472 Payment for this service has been issued to another provider. Start: 07/01/2008
626 N473 Missing certification. Start: 07/01/2008
627 N474 Incomplete/invalid certification. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/1
628 N475 Missing completed referral form. Start: 07/01/2008
629 N476 Incomplete/invalid completed referral form. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (M
630 N477 Missing Dental Models. Start: 07/01/2008
631 N478 Incomplete/invalid Dental Models. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3
632 N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). Start: 07/01
633 N48 Claim information does not agree with information received from other insurance carrier. Start: 01/0
634 N480 Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer). S
635 N481 Missing Models. Start: 07/01/2008
636 N482 Incomplete/invalid Models. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/14/20
639 N485 Missing Physical Therapy Certification. Start: 07/01/2008
640 N486 Incomplete/invalid Physical Therapy Certification. Start: 07/01/2008
641 N487 Missing Prosthetics or Orthotics Certification. Start: 07/01/2008
642 N488 Incomplete/invalid Prosthetics or Orthotics Certification. Start: 07/01/2008 | Last Modified: 03/14/20
643 N489 Missing referral form. Start: 07/01/2008
644 N49 Court ordered coverage information needs validation. Start: 01/01/2000
645 N490 Incomplete/invalid referral form. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/
646 N491 Missing/Incomplete/Invalid Exclusionary Rider Condition. Start: 07/01/2008
647 N492 Alert: A network provider may bill the member for this service if the member requested the service a
648 N493 Missing Doctor First Report of Injury. Start: 07/01/2008
649 N494 Incomplete/invalid Doctor First Report of Injury. Start: 07/01/2008
650 N495 Missing Supplemental Medical Report. Start: 07/01/2008
651 N496 Incomplete/invalid Supplemental Medical Report. Start: 07/01/2008
652 N497 Missing Medical Permanent Impairment or Disability Report. Start: 07/01/2008
653 N498 Incomplete/invalid Medical Permanent Impairment or Disability Report. Start: 07/01/2008
654 N499 Missing Medical Legal Report. Start: 07/01/2008
655 N5 EOB received from previous payer. Claim not on file. Start: 01/01/2000
656 N50 Missing/incomplete/invalid discharge information. Start: 01/01/2000 | Last Modified: 02/28/2003 No
657 N500 Incomplete/invalid Medical Legal Report. Start: 07/01/2008
658 N501 Missing Vocational Report. Start: 07/01/2008
659 N502 Incomplete/invalid Vocational Report. Start: 07/01/2008
660 N503 Missing Work Status Report. Start: 07/01/2008
661 N504 Incomplete/invalid Work Status Report. Start: 07/01/2008
662 N505 Alert: This response includes only services that could be estimated in real-time. No estimate will be p
663 N506 Alert: This is an estimate of the member's liability based on the information available at the time the
664 N507 Plan distance requirements have not been met. Start: 11/01/2008
665 N508 Alert: This real-time claim adjudication response represents the member responsibility to the provide
666 N509 Alert: A current inquiry shows the member's Consumer Spending Account contains sufficient funds to
667 N51 Electronic interchange agreement not on file for provider/submitter. Start: 01/01/2000
668 N510 Alert: A current inquiry shows the member's Consumer Spending Account does not contain sufficient
669 N511 Alert: Information on the availability of Consumer Spending Account funds to cover the member liabi
670 N512 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to t
671 N513 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to th
672 N516 Records indicate a mismatch between the submitted NPI and EIN. Start: 03/01/2009
673 N517 Resubmit a new claim with the requested information. Start: 03/01/2009
674 N518 No separate payment for accessories when furnished for use with oxygen equipment. Start: 03/01/20
675 N519 Invalid combination of HCPCS modifiers. Start: 07/01/2009
676 N52 Patient not enrolled in the billing provider's managed care plan on the date of service. Start: 01/01/2
677 N520 Alert: Payment made from a Consumer Spending Account. Start: 07/01/2009
678 N521 Mismatch between the submitted provider information and the provider information stored in our sy
679 N522 Duplicate of a claim processed, or to be processed, as a crossover claim. Start: 11/01/2009 | Last Mo
680 N523 The limitation on outlier payments defined by this payer for this service period has been met. The ou
681 N524 Based on policy this payment constitutes payment in full. Start: 03/01/2010
682 N525 These services are not covered when performed within the global period of another service. Start: 03
683 N526 Not qualified for recovery based on employer size. Start: 03/01/2010
684 N527 We processed this claim as the primary payer prior to receiving the recovery demand. Start: 03/01/20
685 N528 Patient is entitled to benefits for Institutional Services only. Start: 03/01/2010 | Last Modified: 07/01
686 N529 Patient is entitled to benefits for Professional Services only. Start: 03/01/2010 | Last Modified: 07/01
687 N53 Missing/incomplete/invalid point of pick-up address. Start: 01/01/2000 | Last Modified: 02/28/2003
688 N530 Not Qualified for Recovery based on enrollment information. Start: 03/01/2010 | Last Modified: 07/0
689 N531 Not qualified for recovery based on direct payment of premium. Start: 03/01/2010
690 N532 Not qualified for recovery based on disability and working status. Start: 03/01/2010
691 N533 Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.
692 N534 This is an individual policy, the employer does not participate in plan sponsorship. Start: 07/01/2010
693 N535 Payment is adjusted when procedure is performed in this place of service based on the submitted pro
694 N536 We are not changing the prior payer's determination of patient responsibility, which you may collect,
695 N537 We have examined claims history and no records of the services have been found. Start: 07/01/2010
696 N538 A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to
697 N539 Alert: We processed appeals/waiver requests on your behalf and that request has been denied. Start
698 N54 Claim information is inconsistent with pre-certified/authorized services. Start: 01/01/2000
699 N540 Payment adjusted based on the interrupted stay policy. Start: 11/01/2010
700 N541 Mismatch between the submitted insurance type code and the information stored in our system. Sta
701 N542 Missing income verification. Start: 03/08/2011
702 N543 Incomplete/invalid income verification. Start: 03/08/2011 | Last Modified: 03/14/2014 Notes: (Modifi
703 N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match
704 N545 Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx)
705 N546 Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program
706 N547 A refund request (Frequency Type Code 8) was processed previously. Start: 03/06/2012
707 N548 Alert: patient's calendar year deductible has been met. Start: 03/06/2012
708 N549 Alert: patient's calendar year out-of-pocket maximum has been met. Start: 03/06/2012
709 N55 Procedures for billing with group/referring/performing providers were not followed. Start: 01/01/200
710 N550 Alert: You have not responded to requests to revalidate your provider/supplier enrollment informatio
711 N551 Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program. Start: 0
712 N552 Payment adjusted to reverse a previous withhold/bonus amount. Start: 03/06/2012
713 N554 Missing/Incomplete/Invalid Family Planning Indicator. Start: 07/01/2012 | Last Modified: 03/14/2014
714 N555 Missing medication list. Start: 07/01/2012
715 N556 Incomplete/invalid medication list. Start: 07/01/2012
716 N557 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in
717 N558 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in
718 N559 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in
719 N56 Procedure code billed is not correct/valid for the services billed or the date of service billed. Start: 01
720 N560 The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim
721 N561 The bundled claim originally submitted for this episode of care includes related readmissions. You ma
722 N562 The provider number of your incoming claim does not match the provider number on the processed
723 N563 Missing required provider/supplier issuance of advance patient notice of non-coverage. The patient i
724 N564 Patient did not meet the inclusion criteria for the demonstration project or pilot program. Start: 11/0
725 N565 Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable
726 N566 Alert: This procedure code requires functional reporting. Future claims containing this procedure cod
727 N567 Not covered when considered preventative. Start: 03/01/2013
728 N568 Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV
729 N569 Not covered when performed for the reported diagnosis. Start: 03/01/2013
730 N57 Missing/incomplete/invalid prescribing date. Start: 01/01/2000 | Last Modified: 12/02/2004 Notes: (
731 N570 Missing/incomplete/invalid credentialing data. Start: 03/01/2013 | Last Modified: 03/14/2014 Notes
732 N571 Alert: Payment will be issued quarterly by another payer/contractor. Start: 03/01/2013
733 N572 This procedure is not payable unless appropriate non-payable reporting codes and associated modifie
734 N573 Alert: You have been overpaid and must refund the overpayment. The refund will be requested sepa
735 N574 Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer.
736 N575 Mismatch between the submitted ordering/referring provider name and the ordering/referring provi
737 N576 Services not related to the specific incident/claim/accident/loss being reported. Start: 07/15/2013
738 N577 Personal Injury Protection (PIP) Coverage. Start: 07/15/2013
739 N578 Coverages do not apply to this loss. Start: 07/15/2013
740 N579 Medical Payments Coverage (MPC). Start: 07/15/2013
741 N58 Missing/incomplete/invalid patient liability amount. Start: 01/01/2000 | Last Modified: 02/28/2003 N
742 N580 Determination based on the provisions of the insurance policy. Start: 07/15/2013
743 N581 Investigation of coverage eligibility is pending. Start: 07/15/2013
744 N582 Benefits suspended pending the patient's cooperation. Start: 07/15/2013
745 N583 Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person. St
746 N584 Not covered based on the insured's noncompliance with policy or statutory conditions. Start: 07/15/2
747 N585 Benefits are no longer available based on a final injury settlement. Start: 07/15/2013
748 N586 The injured party does not qualify for benefits. Start: 07/15/2013
749 N587 Policy benefits have been exhausted. Start: 07/15/2013
750 N588 The patient has instructed that medical claims/bills are not to be paid. Start: 07/15/2013
751 N589 Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxic
752 N59 Please refer to your provider manual for additional program and provider information. Start: 01/01/2
753 N590 Missing independent medical exam detailing the cause of injuries sustained and medical necessity of
754 N591 Payment based on an Independent Medical Examination (IME) or Utilization Review (UR). Start: 07/1
755 N592 Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial pres
756 N593 Not covered based on failure to attend a scheduled Independent Medical Exam (IME). Start: 07/15/2
757 N594 Records reflect the injured party did not complete an Application for Benefits for this loss. Start: 07/1
758 N595 Records reflect the injured party did not complete an Assignment of Benefits for this loss. Start: 07/1
759 N596 Records reflect the injured party did not complete a Medical Authorization for this loss. Start: 07/15/
760 N597 Adjusted based on a medical/dental provider's apportionment of care between related injuries and o
761 N598 Health care policy coverage is primary. Start: 07/15/2013
762 N599 Our payment for this service is based upon a reasonable amount pursuant to both the terms and con
763 N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare w
764 N600 Adjusted based on the applicable fee schedule for the region in which the service was rendered. Star
765 N601 In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law pa
766 N602 Adjusted based on the Redbook maximum allowance. Start: 07/15/2013
767 N603 This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Inju
768 N604 In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to t
769 N605 This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DR
770 N606 The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedu
771 N607 Service provided for non-compensable condition(s). Start: 07/15/2013
772 N608 The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region,
773 N609 80% of the provider's billed amount is being recommended for payment according to Act 6. Start: 07
774 N61 Rebill services on separate claims. Start: 01/01/2000
775 N610 Alert: Payment based on an appropriate level of care. Start: 07/15/2013
776 N611 Claim in litigation. Contact insurer for more information. Start: 07/15/2013
777 N612 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.
778 N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their en
779 N614 Alert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 21
780 N615 Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of th
781 N616 Alert: This enrollee is in the first month of the advance premium tax credit grace period. Start: 07/15/
782 N617 This enrollee is in the second or third month of the advance premium tax credit grace period. Start: 0
783 N618 Alert: This claim will automatically be reprocessed if the enrollee pays their premiums. Start: 07/15/2
784 N619 Coverage terminated for non-payment of premium. Start: 07/15/2013
785 N62 Dates of service span multiple rate periods. Resubmit separate claims. Start: 01/01/2000 | Last Modi
786 N620 Alert: This procedure code is for quality reporting/informational purposes only. Start: 07/15/2013
787 N621 Charges for Jurisdiction required forms, reports, or chart notes are not payable. Start: 07/15/2013
788 N622 Not covered based on the date of injury/accident. Start: 07/15/2013
789 N623 Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate
790 N624 The associated Workers' Compensation claim has been withdrawn. Start: 07/15/2013
791 N625 Missing/Incomplete/Invalid Workers' Compensation Claim Number. Start: 07/15/2013
792 N626 New or established patient E/M codes are not payable with chiropractic care codes. Start: 07/15/201
794 N628 Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowe
795 N629 Reviews/documentation/notes/summaries/reports/charts not requested. Start: 07/15/2013
796 N63 Rebill services on separate claim lines. Start: 01/01/2000
797 N630 Referral not authorized by attending physician. Start: 07/15/2013
798 N631 Medical Fee Schedule does not list this code. An allowance was made for a comparable service. Start
800 N633 Additional anesthesia time units are not allowed. Start: 07/15/2013
801 N634 The allowance is calculated based on anesthesia time units. Start: 07/15/2013
802 N635 The Allowance is calculated based on the anesthesia base units plus time. Start: 07/15/2013
803 N636 Adjusted because this is reimbursable only once per injury. Start: 07/15/2013
804 N637 Consultations are not allowed once treatment has been rendered by the same provider. Start: 07/15
805 N638 Reimbursement has been made according to the home health fee schedule. Start: 07/15/2013
806 N639 Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule. Start:
807 N64 The "from" and "to" dates must be different. Start: 01/01/2000
808 N640 Exceeds number/frequency approved/allowed within time period. Start: 07/15/2013
809 N641 Reimbursement has been based on the number of body areas rated. Start: 07/15/2013
810 N642 Adjusted when billed as individual tests instead of as a panel. Start: 07/15/2013
811 N643 The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee sched
812 N644 Reimbursement has been made according to the bilateral procedure rule. Start: 07/15/2013
813 N645 Mark-up allowance. Start: 07/15/2013 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
814 N646 Reimbursement has been adjusted based on the guidelines for an assistant. Start: 07/15/2013
815 N647 Adjusted based on diagnosis-related group (DRG). Start: 07/15/2013
816 N648 Adjusted based on Stop Loss. Start: 07/15/2013
817 N649 Payment based on invoice. Start: 07/15/2013
818 N65 Procedure code or procedure rate count cannot be determined, or was not on file, for the date of ser
819 N650 This policy was not in effect for this date of loss. No coverage is available. Start: 07/15/2013
820 N651 No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss. Start
821 N652 The date of service is before the date of loss. Start: 07/15/2013
822 N653 The date of injury does not match the reported date of loss. Start: 07/15/2013
823 N654 Adjusted based on achievement of maximum medical improvement (MMI). Start: 07/15/2013
824 N655 Payment based on provider's geographic region. Start: 07/15/2013
825 N656 An interest payment is being made because benefits are being paid outside the statutory requiremen
826 N657 This should be billed with the appropriate code for these services. Start: 07/15/2013
827 N658 The billed service(s) are not considered medical expenses. Start: 07/15/2013
828 N659 This item is exempt from sales tax. Start: 07/15/2013
829 N660 Sales tax has been included in the reimbursement. Start: 07/15/2013
830 N661 Documentation does not support that the services rendered were medically necessary. Start: 07/15/2
831 N662 Alert: Consideration of payment will be made upon receipt of a final bill. Start: 07/15/2013
832 N663 Adjusted based on an agreed amount. Start: 07/15/2013
833 N664 Adjusted based on a legal settlement. Start: 07/15/2013
834 N665 Services by an unlicensed provider are not reimbursable. Start: 07/15/2013
835 N666 Only one evaluation and management code at this service level is covered during the course of care.
836 N667 Missing prescription. Start: 07/15/2013 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
837 N668 Incomplete/invalid prescription. Start: 07/15/2013 | Last Modified: 03/14/2014 Notes: (Modified 3/1
838 N669 Adjusted based on the Medicare fee schedule. Start: 07/15/2013
839 N67 Professional provider services not paid separately. Included in facility payment under a demonstratio
840 N670 This service code has been identified as the primary procedure code subject to the Medicare Multiple
841 N671 Payment based on a jurisdiction cost-charge ratio. Start: 07/15/2013
842 N672 Alert: Amount applied to Health Insurance Offset. Start: 07/15/2013
843 N673 Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or
844 N674 Not covered unless a pre-requisite procedure/service has been provided. Start: 07/15/2013
845 N675 Additional information is required from the injured party. Start: 07/15/2013
846 N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule. Start: 07/15/2013
847 N677 Alert: Films/Images will not be returned. Start: 11/01/2013
848 N678 Missing post-operative images/visual field results. Start: 11/01/2013
849 N679 Incomplete/Invalid post-operative images/visual field results. Start: 11/01/2013
850 N68 Prior payment being cancelled as we were subsequently notified this patient was covered by a demo
851 N680 Missing/Incomplete/Invalid date of previous dental extractions. Start: 11/01/2013
852 N681 Missing/Incomplete/Invalid full arch series. Start: 11/01/2013
853 N682 Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance. Start: 11/01/2013
854 N683 Missing/Incomplete/Invalid prior treatment documentation. Start: 11/01/2013
855 N684 Payment denied as this is a specialty claim submitted as a general claim. Start: 11/01/2013
856 N685 Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code. Start: 11/01/2013
857 N686 Missing/incomplete/Invalid questionnaire needed to complete payment determination. Start: 11/01/
858 N687 Alert: This reversal is due to a retroactive disenrollment. Start: 11/01/2013 | Last Modified: 03/14/20
859 N688 Alert: This reversal is due to a medical or utilization review decision. Start: 11/01/2013 | Last Modifie
860 N689 Alert: This reversal is due to a retroactive rate change. Start: 11/01/2013 | Last Modified: 03/14/2014
861 N69 PPS (Prospective Payment System) code changed by claims processing system. Start: 01/01/2000 | La
862 N690 Alert: This reversal is due to a provider submitted appeal. Start: 11/01/2013 | Last Modified: 03/14/2
863 N691 Alert: This reversal is due to a patient submitted appeal. Start: 11/01/2013 | Last Modified: 03/14/20
864 N692 Alert: This reversal is due to an incorrect rate on the initial adjudication. Start: 11/01/2013 | Last Mod
865 N693 Alert: This reversal is due to a cancellation of the claim by the provider. Start: 11/01/2013 | Last Mod
866 N694 Alert: This reversal is due to a resubmission/change to the claim by the provider. Start: 11/01/2013
867 N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudic
868 N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive ad
869 N697 Alert: This reversal is due to a payer's retroactive contract incentive program adjustment. Start: 11/0
870 N698 Alert: This reversal is due to non-payment of the Health Insurance Exchange premiums by the end of
871 N699 Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program. Start:
872 N7 Alert: Processing of this claim/service has included consideration under Major Medical provisions. Sta
873 N70 Consolidated billing and payment applies. Start: 01/01/2000 | Last Modified: 11/05/2007 Notes: (Mo
875 N70 Payment adjusted based on the Value-based Payment Modifier. Start: 03/01/2014
876 N70 Decision based on review of previously adjudicated claims or for claims in process for the same/simil
877 N70 This service is incompatible with previously adjudicated claims or claims in process. Start: 03/01/2014
878 N70 Alert: You may not appeal this decision but can resubmit this claim/service with corrected informatio
879 N70 Incomplete/invalid documentation. Start: 03/01/2014
880 N70 Missing documentation. Start: 03/01/2014
881 N70 Incomplete/invalid orders. Start: 03/01/2014
882 N70 Missing orders. Start: 03/01/2014
883 N70 Incomplete/invalid notes. Start: 03/01/2014
874 N700 Payment adjusted based on the Electronic Health Records (EHR) Incentive Program. Start: 03/01/201
884 N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance se
885 N71 Missing notes. Start: 03/01/2014
886 N71 Incomplete/invalid summary. Start: 03/01/2014
887 N71 Missing summary. Start: 03/01/2014
888 N71 Incomplete/invalid report. Start: 03/01/2014
889 N71 Missing report. Start: 03/01/2014
890 N71 Incomplete/invalid chart. Start: 03/01/2014
891 N71 Missing chart. Start: 03/01/2014
892 N71 Incomplete/Invalid documentation of face-to-face examination. Start: 03/01/2014
893 N71 Missing documentation of face-to-face examination. Start: 03/01/2014
894 N71 Penalty applied based on plan requirements not being met. Start: 03/01/2014
895 N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical rec
896 N72 Alert: The patient overpaid you. You may need to issue the patient a refund for the difference betwe
897 N72 This service is only covered when performed as part of a clinical trial. Start: 03/01/2014
898 N72 Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or it
899 N72 Patient must use Liability set-aside (LSA) funds to pay for the medical service or item. Start: 03/01/20
900 N72 Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item. Start: 03/01/
901 N72 A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagn
902 N72 A conditional payment is not allowed. Start: 03/01/2014
903 N72 A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diag
904 N72 A workers' compensation insurer has reported having ongoing responsibility for medical services (OR
905 N72 Missing patient medical/dental record for this service. Start: 11/01/2014
917 N74 Resubmit with multiple claims, each claim covering services provided in only one calendar month. Sta
918 N740 The member's Consumer Spending Account does not contain sufficient funds to cover the member's
919 N741 This is a site neutral payment. Start: 03/01/2015
920 N742 Alert: This claim was processed based on one or more ICD-9 codes. The transition to ICD-10 is require
921 N743 Adjusted because the services may be related to an employment accident. Start: 03/01/2015
922 N744 Adjusted because the services may be related to an auto/other accident. Start: 03/01/2015 | Last Mo
923 N745 Missing Ambulance Report. Start: 03/01/2015
924 N746 Incomplete/invalid Ambulance Report. Start: 03/01/2015
925 N747 This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides. Sta
926 N748 Adjusted because the related hospital charges have not been received. Start: 03/01/2015
927 N749 Missing Blood Gas Report. Start: 03/01/2015
928 N75 Missing/incomplete/invalid tooth surface information. Start: 01/01/2000 | Last Modified: 02/28/200
929 N750 Incomplete/invalid Blood Gas Report. Start: 03/01/2015
930 N751 Adjusted because the drug is covered under a Medicare Part D plan. Start: 03/01/2015
931 N752 Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC). Start: 03/01/2015
932 N753 Missing/incomplete/invalid Attachment Control Number. Start: 07/01/2015
933 N754 Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form. Sta
934 N755 Missing/incomplete/invalid ICD Indicator on the 1500 Claim Form. Start: 07/01/2015
935 N756 Missing/incomplete/invalid point of drop-off address. Start: 07/01/2015
936 N757 Adjusted based on the Federal Indian Fees schedule (MLR). Start: 07/01/2015
937 N758 Adjusted based on the prior authorization decision. Start: 07/01/2015
938 N76 Missing/incomplete/invalid number of riders. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (
939 N77 Missing/incomplete/invalid designated provider number. Start: 01/01/2000 | Last Modified: 02/28/2
940 N78 The necessary components of the child and teen checkup (EPSDT) were not completed. Start: 01/01/
941 N787 Alert: Under 42 CFR 410.43, an eligible Partial Hospitalization Program (PHP) patient/beneficiary requ
942 N788 Alert: The third-party administrator/review organization did not receive the required information. Sta
943 N79 Service billed is not compatible with patient location information. Start: 01/01/2000
944 N8 Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this clai
945 N80 Missing/incomplete/invalid prenatal screening information. Start: 01/01/2000 | Last Modified: 02/28
946 N800 Only one service date is allowed per claim. Start: 03/01/2018
947 N801 Services performed in a Medicare participating or CAH facility under a self-insured tribal Group Healt
948 N802 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in
949 N803 Submission of the claim for the service rendered is the responsibility of the Contracted Medical Grou
950 N804 Alert: The claim/service was processed through the Outpatient Code Editor (OCE). Start: 07/01/2018
951 N805 Alert: The claim/service was processed through the Correct Code Editor (CCE). Start: 07/01/2018
952 N806 Payment is included in the Global transplant allowance. Start: 07/01/2018
953 N807 Payment adjustment based on the Merit-based Incentive Payment System (MIPS). Start: 07/01/2018
954 N808 Not covered for this provider type / provider specialty. Start: 07/01/2018
955 N81 Procedure billed is not compatible with tooth surface code. Start: 01/01/2000
956 N82 Provider must accept insurance payment as payment in full when a third party payer contract specifi
957 N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration project. Start: 01/
958 N84 Alert: Further installment payments are forthcoming. Start: 01/01/2000 | Last Modified: 04/01/2007
959 N85 Alert: This is the final installment payment. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (M
960 N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the tre
961 N87 Home use of biofeedback therapy is not covered. Start: 01/01/2000
962 N88 Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this
963 N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but form
964 N9 Adjustment represents the estimated amount a previous payer may pay. Start: 01/01/2000 | Last Mo
965 N90 Covered only when performed by the attending physician. Start: 01/01/2000
966 N91 Services not included in the appeal review. Start: 01/01/2000
967 N92 This facility is not certified for digital mammography. Start: 01/01/2000
968 N93 A separate claim must be submitted for each place of service. Services furnished at multiple sites may
969 N94 Claim/Service denied because a more specific taxonomy code is required for adjudication. Start: 01/0
970 N95 This provider type/provider specialty may not bill this service. Start: 07/31/2001 | Last Modified: 02/
971 N96 Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or s
972 N97 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes
973 N98 Patient must have had a successful test stimulation in order to support subsequent implantation. Bef
974 N99 Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical re
 t of treatment. Start: 01/01/1997
edical necessity. Start: 01/01/1997
or use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug. Start: 01/01/1997
ent refuses to have an x-ray taken. Start: 01/01/1997
required under the DMEPOS Competitive Bidding Program for the area where the patient resides. Start: 01/01/1997 | Last Modified: 11/0
rior to the current contract period for the DMEPOS Competitive Bidding Program. Start: 01/01/1997 | Last Modified: 11/05/2007 Notes: (M
nder the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your l
r non-demonstration supplier. Start: 01/01/1997 | Last Modified: 11/05/2007 Notes: (Modified 11/5/2007)
ram is ending and additional services may not be paid under this project or program. Start: 01/01/1997 | Last Modified: 03/08/2011 Note
| Last Modified: 06/30/2003 Notes: (Modified 6/30/03)
ode (NDC). Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 2/28/03, 4/1/04)
urpose. Start: 01/01/1997
urchased services are included on the claim. Start: 01/01/1997
gical ablation. Start: 01/01/1997
Last Modified: 02/28/2006 Notes: (Modified 2/28/03)
nished. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
equires the part or supply. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to N230
ch the service/supply/equipment will be needed. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
ast Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to N237
tart: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modified 2/28/03, 6/30/03)
cal information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a re
01/01/1997 | Last Modified: 06/30/2007 Notes: (Modified 6/30/03)
s discounts, and/or the type of intraocular lens used. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to
t Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to N239
ed: 02/28/2003 Notes: (Modified 2/28/03) Related to N235
or the amount you were charged for the test. Start: 01/01/1997
nterest. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)
st Modified: 02/28/2003 Notes: (Modified 2/28/03)
d or evaluated by a physician. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
tart: 01/01/1997 | Last Modified: 11/01/2012 Notes: (Modified 11/1/12)
not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants. Start: 01/01/199
rt: 01/01/1997
al period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service. Start: 0
isit, and no payment for a full office visit if the patient only received an injection. Start: 01/01/1997
ified: 02/28/2003 Notes: (Modified 2/28/03) Related to N238
rt: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to N226
01/01/1997 | Last Modified: 12/01/2006 Notes: (Modified 12/1/06)
e surgery/procedure. Start: 01/01/1997
al information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a red
ered components of the same procedure. Separate payment is not allowed. Start: 01/01/1997
ent exceeded 36.5%. Start: 01/01/1997
oncerning this policy/procedure/decision. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Reactivated 4/1/04, Modified 11/18/05
n. You must send 25 percent of the teleconsultation payment to the referring practitioner. Start: 01/01/1997
bly have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charg
o services the patient's zip code. Start: 01/01/1997
or a Skilled Nursing Facility (SNF) is considered to be a patient's home. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modified 6/3
 Modified: 02/28/2003 Notes: (Modified 2/28/03) Related to N234

: 02/28/2003 Notes: (Modified 2/28/03)

rovided in a home. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
s: (Modified 8/1/05)
97 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
el of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been
el of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for t
ems and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, inc
is exhausted or not otherwise available. Start: 01/01/1997
/01/2008 Notes: (Modified 2/28/03, 7/1/2008) Related to N233
tart: 01/01/1997
004 Notes: (Modified 8/1/04, 2/28/03) Related to N236
004 Notes: (Modified 8/1/04, 2/28/03) Related to N240
ervice by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service
e that the patient has been given the option of changing the rental to a purchase. Start: 01/01/1997
st Modified: 03/08/2011 Notes: (Modified 3/8/11)
e informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charge
nce notice of non-coverage you provided the patient did not comply with program requirements. Start: 01/01/1997 | Last Modified: 07/01
edical equipment. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
yer. Start: 01/01/1997
r this. Start: 01/01/1997
ng physician. Start: 01/01/1997
Modified: 02/28/2003 Notes: (Modified 2/28/03)
ast Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N299
97 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N300
s exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Numb
1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
onth from the first rental month, or the month when the equipment is no longer needed. Start: 01/01/1997
Modified: 02/28/2003 Notes: (Modified 2/28/03)
ast Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N301
97 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
7 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
odified: 02/28/2003 Notes: (Modified 2/28/03)
dministered with a covered oral anti-cancer drug. Start: 01/01/1997
Modified: 02/28/2003 Notes: (Modified 2/28/03)
| Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
l need for the remainder of the reasonable useful lifetime of the equipment. Start: 01/01/1997 | Last Modified: 03/01/2009 Notes: (Modi
dified: 08/01/2004 Notes: (Modified 8/1/04, 6/30/03) Related to N227
l has expired. Start: 01/01/1997
1/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
Modified: 02/28/2003 Notes: (Modified 2/28/03)
purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician. Start: 01/01/1997
mitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitatio
97 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N302
y the modified procedure code. Start: 01/01/1997 | Last Modified: 02/01/2004 Notes: (Modified 2/1/04)
ssued rental payments equals the purchase price. Start: 01/01/1997
PCS code for processing, but please continue to submit the NDC on future claims for this item. Start: 01/01/1997 | Last Modified: 08/01/2

nal component of this service. Rebill as separate professional and technical components. Start: 01/01/1997 | Last Modified: 08/01/2004 N
ment. Start: 01/01/1997 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04)
ombined for payment. Start: 01/01/1997 | Last Modified: 11/05/2007 Notes: (Modified 11/5/07)
| Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
01/1997 | Last Modified: 03/14/2014 Notes: (Modified 2/28/03, 3/1/2014, 3/14/2014)
d: 02/28/2003 Notes: (Modified 2/28/03)
d by a medical supplier or taken while the patient is on oxygen. Start: 01/01/1997
iously processed service for the patient. Start: 01/01/1997 | Last Modified: 10/31/2002 Notes: (Modified 10/31/02)
01/1997 | Last Modified: 02/01/2004 Notes: (Modified 2/1/04)

art: 01/01/1997
vice. Start: 01/01/1997 | Last Modified: 03/14/2014 Notes: (Modified 2/1/04, 3/14/2014)
s. Start: 01/01/1997
edure within set time frame. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

hoice of changing the rental to a purchase agreement. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

ed on separate claims. Start: 01/01/1997

al period began with delivery of this equipment. Start: 01/01/1997
ped rental period will not begin. Start: 01/01/1997
ort audit. Start: 01/01/1997
nly be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed
ice. Payment included in the reimbursement issued the facility. Start: 01/01/1997
r. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to c
to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice. Start: 01/01/1997 | Last Modi
payment information from the primary payer. The information was either not reported or was illegible. Start: 01/01/1997
review. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
al coverage is not with a Medigap plan, or you do not participate in Medicare. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Mod
nce with our current assignment/participation agreement. Start: 01/01/1997 | Last Modified: 11/01/2014
must refund the overpayment to the patient. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
: 01/01/1997 | Last Modified: 03/14/2014 Notes: (Modified 2/28/03, 3/30/05, 3/14/2014)

ed: 06/30/2003 Notes: (Modified 6/30/03)

Start: 01/01/1997

tart: 01/01/1997
for services furnished by the person(s) that furnished this (these) service(s). Start: 01/01/1997
997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
fied: 12/02/2004 Notes: (Modified 12/2/04)
| Last Modified: 12/02/2004 Notes: (Modified 12/2/04)
e cannot pay for these services. Start: 01/01/1997
in full. Start: 01/01/1997
Start: 10/12/2001
| Last Modified: 03/30/2005 Notes: (Modified 2/28/03, 3/30/05)
 nts not reported with the PR (patient responsibility) group code. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
peal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. Start: 10/1
ation claim. You must have the physician withdraw that claim and refund the payment before we can process your claim. Start: 10/12/200

side the inpatient stay. Start: 10/12/2001

patient resides. Start: 10/12/2001
alth plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this
eceive a separate notice for the other services reported. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703. Start: 01/01/1997
st contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment. Start: 01/01/1997
upplemental insurer. Send any questions regarding supplemental benefits to them. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes:
ect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to
elated to the use of an urethral catheter for convenience or the control of incontinence. Start: 01/01/1997 | Last Modified: 06/30/2003 N

ame benefit period. Start: 01/01/1997 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)
in a benefit period. Start: 01/01/1997
rule. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
he claim. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
cept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to a
ified: 02/28/2003 Notes: (Modified 2/28/03)
billed. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
g period. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
d. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
illing period. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
1/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
odified: 02/28/2003 Notes: (Modified 2/28/03)
t Modified: 02/28/2003 Notes: (Modified 2/28/03)
d: 02/28/2003 Notes: (Modified 2/28/03)
Modified: 02/28/2003 Notes: (Modified 2/28/03)
Modified: 02/28/2003 Notes: (Modified 2/28/03)
st Modified: 02/28/2003 Notes: (Modified 2/28/03)
Modified: 02/28/2003 Notes: (Modified 2/28/03)
01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
held in a special account. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
be issued. Start: 01/01/1997 | Last Modified: 03/01/2009 Notes: (Modified 3/1/2009)
patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payme
primary payer. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
r or Clinical Trial number. Start: 01/01/1997 | Last Modified: 03/01/2014 Notes: (Modified 2/28/03, 3/1/2014)
ect identification. Start: 01/01/1997 | Last Modified: 02/01/2004 Notes: (Modified 2/1/04)
ed timely. Start: 01/01/1997
atically revoking his/her election to receive religious non-medical health care services. Start: 01/01/1997
patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payme
ous non-medical health care services. Start: 01/01/1997
/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this
01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
7 | Last Modified: 03/01/2018 Notes: (Modified 2/28/03, 3/1/2018)
odified: 08/01/2007 Notes: (Modified 4/1/07, 8/1/07)
ast Modified: 02/28/2003 Notes: (Modified 2/28/03)
We cannot process this claim until we have received payment information from the primary and secondary payers. Start: 01/01/1997
Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
997 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N303

ce information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and ti
ed: 02/28/2003 Notes: (Modified 2/28/03)
01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
tart: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patien
No payment issued under fee-for-service Medicare as patient has elected managed care. Start: 01/01/1997
as either lost, damaged or returned. Start: 01/01/1997 | Last Modified: 07/01/2015 Notes: (Modified 7/1/15)
ature. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
y or hospice when physician is performing care plan oversight services. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2
within 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as

e. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project. Start: 01/01/1997
1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
rt: 01/01/1997 | Last Modified: 08/01/2005 Notes: (Modified 8/1/05)
ent Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Con
ber for the primary payer. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
he primary payer. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
insured. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03).
1/01/1997 | Last Modified: 07/01/2015 Notes: (Modified 7/1/15)
t Modified: 02/01/2004 Notes: (Modified 2/1/04) Related to N245
odified: 06/30/2003 Notes: (Modified 6/30/03)
yee" on the claim form to certify that the rendering physician is not an employee of the hospice. Start: 01/01/1997 | Last Modified: 08/01/
ut patient is not enrolled in a Medicare managed care plan. Start: 01/01/1997
contract number or clinical trial registry number. Start: 01/01/1997 | Last Modified: 02/29/2008 Notes: (Modified 2/29/08)
| Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
e limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statu
nal consult/manual adjudication/medical advisor/dental advisor/peer review. Start: 01/01/2000 | Last Modified: 03/01/2015 Notes: (Mod
l, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he
ou can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. Start: 01/29/2002
er claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic
ents (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this s
billed on the inpatient claim. They cannot be billed separately as outpatient services. Start: 01/31/2002
Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
/2002 | Last Modified: 07/01/2015 Notes: (Modified 3/1/2009, 7/1/15)

included in a claim that has been previously billed and adjudicated. Start: 02/28/2002

er. Start: 04/16/2002 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

ed on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the subm
LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms
ovided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home hea
| Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

as spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days. Start: 07/30/2002 | Last Modifi
does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge tha
al episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode. Start: 08/09/2002 | Last Modifi
pe of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay. Start: 09/09/2002 | Last Modified: 08/0
fied: 08/01/2005 Notes: (Modified 8/1/05)
iginally submitted service. Start: 09/24/2002
ice/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for
vice/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected a
d. This payer does not cover items and services furnished to individuals who have been deported. Start: 10/17/2002
rica (UMWA) beneficiary. Please submit claims to them. Start: 10/31/2007 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04
e. Start: 10/31/2002
d: 08/01/2007 Notes: (Modified 8/1/07)
rt: 01/01/2000
trictions for this service. Start: 10/31/2002 | Last Modified: 11/01/2009 Notes: (Modified 4/1/07, 7/1/08, 11/1/09)
e for this service. Start: 10/31/2002
nt debarred or excluded provider after the 30 day grace period as previously notified. Start: 10/31/2002 | Last Modified: 04/01/2007 Note
t are being processed separately. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
tment has been discontinued, please contact Customer Service. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
d co-payment. Start: 10/31/2002
a, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548. Start: 10/31/2002 | Last Modified: 04/01/2007
l with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without
d have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insuran
propriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in w
der therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her represen
art of the service dates billed. Start: 10/31/2002
ent claim. Start: 10/31/2002
vice dates billed. Start: 10/31/2002

1/2004 Notes: (Modified 8/1/04) Related to N243

use the patient ID number is missing, incomplete, or invalid on the assignment request. Start: 10/31/2002

tact requirement has been met. Start: 10/31/2002

address. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

se submit other insurance information for our records. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
oved treatment and the elective treatment. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
003 | Last Modified: 02/01/2004 Notes: (Modified 2/1/04)
tart: 02/28/2003
atient is not in the ambulance. Start: 02/28/2003
ed on a higher percentage. Start: 01/01/2000
r this procedure/ equipment/ supply/ service. Start: 02/28/2003 | Last Modified: 02/01/2004 Notes: (Modified 2/1/04)
is covered. Start: 02/28/2003
ty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of pay
Start: 02/28/2003

art: 02/28/2003
e purchase price. Start: 02/28/2003
ng any updated service/item. Start: 02/28/2003
re. Start: 02/28/2003
atient liability is limited to amounts shown in the adjustments under group 'PR'. Start: 02/28/2003
fied: 02/29/2008 Notes: (Modified 8/1/04, 2/29/08) Related to N241
United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the servic
e indicated no additional payment can be made. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Modified 6/30/03, 4/1/07)
Last Modified: 11/01/2013 Notes: (Modified 8/1/04, 11/1/13) Related to N244
arges will be reconsidered upon receipt of that information. Start: 02/28/2003
which it was billed. Start: 02/28/2003
this service. Start: 02/28/2003 | Last Modified: 12/01/2006 Notes: (Modified 12/1/06)
an. Start: 02/28/2003
is submitted for payment additional documentation as specified in plan documents will be required to process benefits. Start: 02/28/2003

odified: 04/01/2007 Notes: (Modified 4/1/07)

e nearest Military Treatment Facility (MTF) for assistance. Start: 02/28/2003
mits following receipt of this notice by following the instructions included in your contract or plan benefit documents. Start: 02/28/2003 |
itted. Start: 02/28/2003
s benefit restrictions. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

2004 Notes: (Modified 8/1/04) Related to N229

Start: 02/28/2003

nother payer. Start: 02/28/2003

nt used. Start: 02/25/2003

ary. Start: 02/25/2003 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

r. Start: 02/25/2003
02/25/2003
review/audit. Start: 02/25/2003 | Last Modified: 08/01/2006 Notes: (Modified 8/1/06)
ate course of treatment provision of the plan. Start: 01/01/2000
art: 01/01/2000

30/2003 | Last Modified: 03/14/2014 Notes: (Modified 4/1/07, 11/1/09, 3/14/2014)

| Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
al records for prior 12 months Start: 06/30/2003
: 03/14/2014 Notes: (Modified 3/14/2014)
on the claim. Start: 06/30/2003 | Last Modified: 03/06/2012 Notes: (Modified 3/6/12)
d: 11/18/2005 Notes: (Modified 11/18/05)
fied: 03/14/2014 Notes: (Modified 3/14/2014)
rt: 06/30/2003 | Last Modified: 07/01/2008 Notes: (Modified 7/1/08)
te handling. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (Modified 8/1/05, 4/1/07)
d: 03/14/2014 Notes: (Modified 4/1/07, 3/14/2014)
dified: 03/14/2014 Notes: (Modified 4/1/07, 3/14/2014)
4 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
atus information. Start: 04/01/2004 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
edure(s). Start: 04/01/2004 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
t require a claims determination for this service from a primary payer as a condition of making its own claims determination. Start: 04/01/
enrolled in this portion of our benefit package. Start: 04/01/2004 | Last Modified: 03/14/2014 Notes: (Modified 3/1/2010, 3/14/2014)
004 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
nues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual. Start: 08/0

rately describes the services rendered. Start: 01/01/2000 | Last Modified: 07/01/2015 Notes: (Modified 10/31/02, 2/28/03, 7/1/15)
e department to obtain forms and instructions for filing a provider dispute. Start: 08/01/2004 | Last Modified: 04/01/2007 Notes: (Modifi

ent period. Start: 08/01/2004

tial treatment period. Start: 08/01/2004
gnition. Start: 08/01/2004

with other carriers and/or maximum benefit provisions. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (Modified 8/13/01, 4/1/07
ment that requires the part or supply. Start: 08/01/2004
he lens, less discounts, and/or the type of intraocular lens used. Start: 08/01/2004
Modified: 07/01/2008 Notes: (Modified 7/1/08)
odified: 07/01/2008 Notes: (Modified 7/1/08)

| Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

nformation. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

Last Modified: 02/29/2008 Notes: (Modified 2/29/08)

st Modified: 07/01/2008 Notes: (Modified 7/1/08)

/01/2004 | Last Modified: 11/01/2013 Notes: (Modified 11/1/2013)

1/2004 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
t: 12/02/2004

: 12/02/2004
ministrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on
art: 12/02/2004

rt: 12/02/2004
tart: 12/02/2004
r. Start: 12/02/2004

fier. Start: 12/02/2004

7/01/2008 Notes: (Modified 2/28/03, 7/1/2008) Related to N232
tion. Start: 12/02/2004

rt: 12/02/2004
tart: 12/02/2004

t: 12/02/2004

art: 12/02/2004
art: 12/02/2004

ast Modified: 02/28/2003 Notes: (Modified 2/28/03)

: 12/02/2004
Start: 12/02/2004
Start: 12/02/2004
rt: 12/02/2004
dentifier. Start: 12/02/2004
Start: 12/02/2004
Start: 12/02/2004
tifier. Start: 12/02/2004

12/02/2004

t: 12/02/2004
rt: 12/02/2004

t: 12/02/2004
art: 12/02/2004

rt: 12/02/2004
Start: 12/02/2004 | Last Modified: 11/01/2010

12/02/2004

art: 12/02/2004
Start: 12/02/2004

3 Notes: (Modified 2/28/03) Related to N228

6/30/2003 Notes: (Modified 6/30/03)

01/2000 | Last Modified: 12/02/2004 Notes: (Modified 12/2/04)

12/02/2004
12/02/2004

12/02/2004
tart: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

ast Modified: 03/14/2014 Notes: (Modified 3/14/2014)

Modified: 11/18/2005 Notes: (Modified 11/18/05)

 or (TENS) trial start date. Start: 12/02/2004
or (TENS) trial end date. Start: 12/02/2004

e payment has already been made for this same service to another provider by a payment contractor representing the payer. Start: 03/30
and billed by a different practitioner/supplier. Start: 08/01/2005
this service. Start: 08/01/2005

e Classified (NOC) code or for an Unlisted/By Report procedure. Start: 08/01/2005 | Last Modified: 07/01/2008 Notes: (Modified 7/1/08)
art: 08/01/2005
m for each patient visit. Start: 08/01/2005 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
een rendered, additional payment will be considered based on the submitted claim. Start: 08/01/2005 | Last Modified: 04/01/2007 Notes
/2014 Notes: (Modified 3/14/2014)
ases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notifi
service. Start: 08/01/2005 | Last Modified: 03/08/2011 Notes: (Modified 3/8/11)
d a related service/procedure/supply have not been met. Start: 11/18/2005
described in the contract or plan benefit documents is submitted. Start: 11/18/2005 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

can consider payment. Start: 01/01/2000

ting benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim. Start: 11/18/2005
mum. Start: 11/18/2005
es that would affect this determination. Start: 11/18/2005 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
d/or coinsurance amounts. Start: 11/18/2005 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
e information previously requested is submitted within one year after the date of this denial notice. Start: 04/01/2006
ding Account processor for review; for example, flexible spending account or health savings account. Start: 04/01/2006 | Last Modified: 0
m. Start: 04/01/2006
g to state legislation/regulation. Start: 04/01/2006
Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
art: 08/01/2006
: 08/01/2006
ered. Start: 08/01/2006
ry when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf. Start: 12/01/2006
Remittance Advice is required. Start: 12/01/2006
termine dependent eligibility. Start: 12/01/2006
ry coverage may be TRICARE. Start: 12/01/2006
| Last Modified: 11/05/2007 Notes: (Modified 11/5/07)

12/01/2006
t: 04/01/2007
ment information related to these charges.Start: 04/01/2007 | Last Modified: 07/01/2015 Notes: (Modified 7/1/15)

ed: 03/08/2011 Notes: (Modified 3/8/11)

ved in a previous procedure. Start: 04/01/2007
procedures. Start: 04/01/2007 | Last Modified: 11/05/2007 Notes: (Modified 11/5/07)
. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www
yment of supplemental benefits. We did not forward the claim information. Start: 04/01/2007 | Last Modified: 03/01/2009 Notes: (Modifi
Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
ast Modified: 07/01/2008 Notes: (Modified 7/1/08)

/01/2008 Notes: (Modified 7/1/08)

odified: 07/01/2008 Notes: (Modified 7/1/08)

s). Start: 08/01/2007

01/2000 | Last Modified: 03/06/2012 Notes: (Modified 2/28/03, 3/6/2012)

07/01/2008 Notes: (Modified 2/1/04, 7/1/08) Related to N242
cally. Start: 08/01/2007

e coverage for the service. Start: 08/01/2007

vide coverage for the service. Start: 08/01/2007
: 08/01/2007
Start: 08/01/2007
s provided within a specific time frame from the date of the accident. Start: 08/01/2007
t Modified: 03/08/2011 Notes: (Modified 3/8/11)\
08/01/2007
e to a retroactive rate change. Start: 08/01/2007
: 11/01/2014
e to a Coordination of Benefits or Third Party Liability Recovery. Start: 08/01/2007
e to a review organization decision. Start: 08/01/2007 | Last Modified: 05/08/2008 Notes: (Modified 2/29/08, typo fixed 5/8/08)
e to a payer's contract incentive program. Start: 08/01/2007 | Last Modified: 05/08/2008 Notes: (Typo fixed 5/8/08)
e to a non standard program. Start: 08/01/2007
of payment. Start: 08/01/2007

ract surgery. Start: 08/01/2007

07 | Last Modified: 03/08/2011 Notes: (Modified 3/8/11)
fied: 03/08/2011 Notes: (Modified 3/8/11)

03/08/2011 Notes: (Modified 3/8/11)

t Modified: 07/01/2015 Notes: (Modified 7/1/15)
Start: 02/29/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

thout support documentation. Start: 07/01/2008

mbursement has been made. Start: 07/01/2008
ed. Start: 07/01/2008
Modified: 03/14/2014 Notes: (Modified 3/14/2014)
: 07/01/2008
| Last Modified: 07/15/2013 Notes: (Modified 7/15/2013)

with the Division of Workers' Compensation. Start: 07/01/2008

was not provided. Start: 07/01/2008

cted/legislated fee arrangement. Start: 07/01/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

he designee. Start: 07/01/2008

03/14/2014 Notes: (Modified 3/14/2014)

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Start: 07/01/2008

mit. Start: 07/01/2008

3/14/2014 Notes: (Modified 3/14/2014)

Modified: 03/14/2014 Notes: (Modified 3/14/2014)

: 03/14/2014 Notes: (Modified 3/14/2014)

e Secondary Payer). Start: 07/01/2008
er insurance carrier. Start: 01/01/2000
or Medicare Secondary Payer). Start: 07/01/2008

/2014 Notes: (Modified 3/14/2014)

/2008 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

03/14/2014 Notes: (Modified 3/14/2014)

member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge. Start

ort. Start: 07/01/2008

| Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

real-time. No estimate will be provided for the services that could not be estimated in real-time. Start: 11/01/2008 | Last Modified: 03/01
mation available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim

ber responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Co
ount contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account w
Start: 01/01/2000
ount does not contain sufficient funds to cover the Member's liability for this claim/service. Actual payment from the Consumer Spending
funds to cover the member liability on this claim/service is not available at this time. Start: 11/01/2008
ed real-time without change to the adjudication. Start: 11/01/2008
ed real-time with a change to the adjudication. Start: 11/01/2008
rt: 03/01/2009

ygen equipment. Start: 03/01/2009

e date of service. Start: 01/01/2000

der information stored in our system. Start: 11/01/2009

m. Start: 11/01/2009 | Last Modified: 03/01/2010
ce period has been met. The outlier payment otherwise applicable to this claim has not been paid. Start: 03/01/2010

riod of another service. Start: 03/01/2010

ecovery demand. Start: 03/01/2010

01/2010 | Last Modified: 07/01/2010 Notes: (Modified 7/1/10)
01/2010 | Last Modified: 07/01/2010 Notes: (Modified 7/1/10)
00 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
3/01/2010 | Last Modified: 07/01/2010 Notes: (Modified 7/1/10)
t: 03/01/2010
rt: 03/01/2010
nsured tribal Group Health Plan. Start: 07/01/2010
sponsorship. Start: 07/01/2010
vice based on the submitted procedure code and place of service. Start: 07/01/2010
nsibility, which you may collect, as this service is not covered by us. Start: 07/01/2010
been found. Start: 07/01/2010
these services/supplies/drugs to its patients/residents. Start: 07/01/2010
request has been denied. Start: 07/01/2010
es. Start: 01/01/2000

mation stored in our system. Start: 11/01/2010

ified: 03/14/2014 Notes: (Modified 3/14/2014)

g provider that does not match our system record. Unless corrected this will not be paid in the future. Start: 07/01/2011 | Last Modified:
the Electronic Prescribing (eRx) Incentive Program. Start: 07/01/2011
scribing (eRx) Incentive Program. Start: 07/01/2011
Start: 03/06/2012

Start: 03/06/2012
e not followed. Start: 01/01/2000
r/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future.
ality Reporting Program. Start: 03/06/2012
rt: 03/06/2012
012 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

ust be filed to the Payer/Plan in whose service area the specimen was collected. Start: 07/01/2012
ust be filed to the Payer/Plan in whose service area the equipment was received. Start: 07/01/2012
ust be filed to the Payer/Plan in whose service area the Ordering Physician is located. Start: 07/01/2012
e date of service billed. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
the Notice of Admission. A claim was not received. Start: 11/01/2012
es related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission. Start: 11/01/2012
vider number on the processed Notice of Admission (NOA) for this bundled payment. Start: 11/01/2012
e of non-coverage. The patient is not liable for payment for this service. Start: 11/01/2012 Notes: Related to M39
ect or pilot program. Start: 11/01/2012
ims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed. Start: 11/01/2012 | La
ms containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed. S

the Bundled Payment Model IV initiative. Start: 03/01/2013

Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N304

ast Modified: 03/14/2014 Notes: (Modified 3/14/2014)
Start: 03/01/2013
ng codes and associated modifiers are submitted. Start: 03/01/2013 | Last Modified: 07/01/2014
e refund will be requested separately by another payer/contractor. Start: 03/01/2013
ialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/ref
and the ordering/referring provider name stored in our records. Start: 07/15/2013
g reported. Start: 07/15/2013

0 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

07/15/2013

not an eligible injured person. Start: 07/15/2013

tutory conditions. Start: 07/15/2013
art: 07/15/2013

. Start: 07/15/2013
motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug. Start: 07/15/
ider information. Start: 01/01/2000 | Last Modified: 11/01/2009 Notes: (Modified 4/1/07, 11/1/09)
tained and medical necessity of services rendered. Start: 07/15/2013
ization Review (UR). Start: 07/15/2013
ount allowed for the initial prescription. Start: 07/15/2013
dical Exam (IME). Start: 07/15/2013
Benefits for this loss. Start: 07/15/2013
Benefits for this loss. Start: 07/15/2013
ation for this loss. Start: 07/15/2013
e between related injuries and other unrelated medical/dental conditions/injuries. Start: 07/15/2013 | Last Modified: 11/01/2013

suant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fau
re than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B. Start: 01/01/20
h the service was rendered. Start: 07/15/2013
Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Haw

les for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage. Start: 07/15/2013
ee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or
gnosis Related Groups (APR-DRG), pursuant to Regulation 68. Start: 07/15/2013
rkers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

are Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6. Start: 07/15/2013
ent according to Act 6. Start: 07/15/2013 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

ured workers in this jurisdiction. Start: 07/15/2013

er that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accura
Identification Segment (loop 2110 Service Payment Information). Start: 07/15/2013
redit is in the grace period of three consecutive months for non-payment of premium. Under 45 CFR 156.270, a Qualified Health Plan issu
redit grace period. Start: 07/15/2013
tax credit grace period. Start: 07/15/2013
s their premiums. Start: 07/15/2013
 . Start: 01/01/2000 | Last Modified: 03/08/2011 Notes: (Modified 3/8/11)
oses only. Start: 07/15/2013
ot payable. Start: 07/15/2013

mental/excessive/inappropriate. Start: 07/15/2013

art: 07/15/2013
tart: 07/15/2013
tic care codes. Start: 07/15/2013
d test or treatment is disallowed. Start: 07/15/2013
sted. Start: 07/15/2013

for a comparable service. Start: 07/15/2013

time. Start: 07/15/2013

the same provider. Start: 07/15/2013

hedule. Start: 07/15/2013
tion facilities fee schedule. Start: 07/15/2013

art: 07/15/2013
Start: 07/15/2013

n the applicable state fee schedule. Start: 07/15/2013

rule. Start: 07/15/2013
otes: (Modified 3/14/2014)
istant. Start: 07/15/2013

as not on file, for the date of service/provider. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
ble. Start: 07/15/2013
icy at the time of the loss. Start: 07/15/2013

MMI). Start: 07/15/2013

utside the statutory requirement. Start: 07/15/2013

art: 07/15/2013

edically necessary. Start: 07/15/2013

bill. Start: 07/15/2013
ered during the course of care. Start: 07/15/2013
Notes: (Modified 3/14/2014)
3/14/2014 Notes: (Modified 3/14/2014)

payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient w
subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule. Start: 07/15/2013

m or an outpatient factor and/or fee schedule amount. Start: 07/15/2013

ded. Start: 07/15/2013

e Schedule. Start: 07/15/2013

patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the fac
: 11/01/2013

tenance. Start: 11/01/2013

m. Start: 11/01/2013

ent determination. Start: 11/01/2013

/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
tart: 11/01/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
g system. Start: 01/01/2000 | Last Modified: 07/01/2012 Notes: (Modified 6/30/03, 7/1/12)
1/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
on. Start: 11/01/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
er. Start: 11/01/2013 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
he provider. Start: 11/01/2013
nformation on the initial adjudication. Start: 11/01/2013
Liability Recovery retroactive adjustment. Start: 11/01/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (M
rogram adjustment. Start: 11/01/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)
change premiums by the end of the premium payment grace period, resulting in loss of coverage. Start: 11/01/2013 | Last Modified: 03/1
PQRS) Incentive Program. Start: 03/01/2014
er Major Medical provisions. Start: 01/01/2000 | Last Modified: 07/15/2013 Notes: (Modified 7/15/13)
odified: 11/05/2007 Notes: (Modified 2/28/02, 11/5/07)
: 03/01/2014
ms in process for the same/similar type of services. Start: 03/01/2014
ms in process. Start: 03/01/2014
ervice with corrected information if warranted. Start: 03/01/2014 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)
ntive Program. Start: 03/01/2014
ratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of

: 03/01/2014

rs. Not supported by clinical records. Start: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)
refund for the difference between the patient's payment and the amount shown as patient responsibility on this notice. Start: 03/01/2014
Start: 03/01/2014
pay for the medical service or item. Start: 03/01/2014
service or item. Start: 03/01/2014
cal service or item. Start: 03/01/2014
cal services (ORM) for this diagnosis. Start: 03/01/2014

ical services (ORM) for this diagnosis. Start: 03/01/2014

nsibility for medical services (ORM) for this diagnosis. Start: 03/01/2014

in only one calendar month. Start: 01/01/2000

nt funds to cover the member's liability for this claim/service. Start: 03/01/2015

he transition to ICD-10 is required by October 1, 2015, for health care providers, health plans, and clearinghouses. More information can b
dent. Start: 03/01/2015
ent. Start: 03/01/2015 | Last Modified: 03/01/2017 Notes: (Modified 3/1/2017)

n where the patient resides. Start: 03/01/2015

d. Start: 03/01/2015

000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

Start: 03/01/2015
C). Start: 03/01/2015

fier on the 1500 Claim Form. Start: 07/01/2015

art: 07/01/2015

t Modified: 02/28/2003 Notes: (Modified 2/28/03)

1/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
re not completed. Start: 01/01/2000
m (PHP) patient/beneficiary requires a minimum of 20 hours of PHP services per week, as evidenced in the plan of care. PHP services must
ve the required information. Start: 03/01/2017 | Last Modified: 07/01/2018 Notes: (Modified 11/1/2017, 7/1/2018)
rt: 01/01/2000
ot forwarded. Resubmit this claim to this payer to provide adequate data for adjudication. Start: 01/01/2000
/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

a self-insured tribal Group Health Plan, in accordance with Federal Regulation 42 CFR 136. Start: 03/01/2018
ust be filed to the Payer/Plan in whose service area the Rendering Physician is located. Start: 03/01/2018
of the Contracted Medical Group or Hospital. Start: 03/01/2018
Editor (OCE). Start: 07/01/2018
or (CCE). Start: 07/01/2018

stem (MIPS). Start: 07/01/2018

hird party payer contract specifies full reimbursement. Start: 01/01/2000

emonstration project. Start: 01/01/2000
00 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07, 8/1/07)
Modified: 04/01/2007 Notes: (Modified 4/1/07, 8/1/07)
biofeedback training for the treatment of urinary incontinence to be covered. Start: 01/01/2000

are notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain
e than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice. Start: 01
pay. Start: 01/01/2000 | Last Modified: 11/18/2005 Notes: (Modified 11/18/05)

s furnished at multiple sites may not be billed in the same claim. Start: 01/01/2000
red for adjudication. Start: 01/01/2000
7/31/2001 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)
avioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthes
urologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above thre
rt subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater imp
ng diary data such that clinical results of the implant procedure can be properly evaluated. Start: 08/24/2001
01/01/1997

01/1997 | Last Modified: 11/05/2007 Notes: (Modified 11/5/07)

Modified: 11/05/2007 Notes: (Modified 11/5/07)
these projects, contact your local contractor. Start: 01/01/1997 | Last Modified: 11/05/2007 Notes: (Modified 8/1/06, 11/5/07)

st Modified: 03/08/2011 Notes: (Modified 2/1/04, 3/15/11)

odified 2/28/03)

d payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment. Start: 01/01/199

(Modified 2/28/03) Related to N231

participants. Start: 01/01/1997

or this item or service. Start: 01/01/1997

payment for this item at a reduced level, and a new capped rental period will not begin. Start: 01/01/1997

ed 4/1/04, Modified 11/18/05, 4/1/07)

ure, you will be liable for charges for the same service(s) under the same or similar conditions. Start: 01/01/1997 | Last Modified: 04/01/2

/30/2003 Notes: (Modified 6/30/03)

ould not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in
ceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiv
patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constit

tional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for th

o be responsible for the charges. Start: 01/01/1997 | Last Modified: 07/01/2015 Notes: (Modified 7/1/15)
1/1997 | Last Modified: 07/01/2015 Notes: (Modified 2/1/04, 4/1/07, 11/1/09, 11/1/12, 7/1/15) Related to N563

CCN), Document Control Number (DCN). Start: 01/01/1997 | Last Modified: 07/01/2015 Notes: (Modified 2/28/03, 7/1/15)

fied: 03/01/2009 Notes: (Modified 4/1/07, 3/1/2009)

: 01/01/1997
nent is subject to price limitations. Please submit the technical and professional components of this service as separate line items. Start: 01
1997 | Last Modified: 08/01/2007 Notes: (Modified 4/1/2007, 8/1/07)

| Last Modified: 08/01/2004 Notes: (Modified 8/1/04)

: (Modified 4/1/07)

ursement. If not already billed, you should bill us for the professional component only. Start: 01/01/1997

t process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of t
Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 12/29/05, 8/1/06, 4/1/07)
: 01/01/1997

fied: 04/01/2007 Notes: (Modified 4/1/07)

007 Notes: (Modified 4/1/07)
orrect information. Start: 10/12/2001
s your claim. Start: 10/12/2001

fied of this, we are paying this time. In the future, we will not pay you for non-plan services. Start: 01/01/1997 | Last Modified: 08/01/2007
es: (Modified 4/1/07)

ment. Start: 01/01/1997

Modified: 04/01/2007 Notes: (Modified 4/1/07)
ur secondary claim directly to that insurer. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
| Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

ation. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by recei

atient is responsible for payment. Start: 01/01/1997

atient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount. Start: 01/0

s patient responsibility on this notice. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
payers. Start: 01/01/1997

nsurer to assure correct and timely routing of the claim. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

of the amount shown as patient responsibility and as paid to the patient on this notice. Start: 01/01/1997 | Last Modified: 04/01/2007 Not

2/28/2003 Notes: (Modified 2/28/03, 2/1/04)

nts and the amount shown as patient responsibility on this notice. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/0

on project. Start: 01/01/1997

or this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy. Start: 01/01/199

1/1997 | Last Modified: 08/01/2005 Notes: (Reactivated 4/1/04, Modified 8/1/05)

dified 2/29/08)

ocuments or jurisdiction statutes. Refer to the URL provided in the ERA for the payer website to access the appeals process guidelines. Sta
fied: 03/01/2015 Notes: (Modified 10/31/02, 7/1/08, 7/15/13, 3/1/2015)
shed to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personall
ww.cms.gov. Start: 01/29/2002 | Last Modified: 07/01/2010 Notes: (Modified 10/31/02, 7/1/10)
EDI information for electronic claims processing. Start: 01/29/2002
ther than the patient for this service. Start: 01/31/2002

chedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calcu
policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. S
nt is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be

tart: 07/30/2002 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)

f the portion of the charge that would have been covered by Medicare. Start: 01/01/2000 | Last Modified: 08/01/2007 Notes: (Modified 8
tart: 08/09/2002 | Last Modified: 06/30/2003 Notes: (Modified 6/30/03)
09/2002 | Last Modified: 08/01/2004 Notes: (Modified 8/1/04, 6/30/03)

/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnishe
e/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this no

es: (Modified 8/1/04

ast Modified: 04/01/2007 Notes: (Modified 4/1/07)

007 Notes: (Modified 4/1/07)

2 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rend
the subscriber's dental insurance carrier for a second Independent Dental Advisor Review. Start: 10/31/2002 | Last Modified: 04/01/2007
determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, sub
ting, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this lette

s: (Modified 4/1/07)

fied 2/1/04)
on will result in a denial of payment in the near future. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

States must provide the service. Start: 02/28/2003

ified 6/30/03, 4/1/07)

ess benefits. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

cuments. Start: 02/28/2003 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

ms determination. Start: 04/01/2004 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
fied 3/1/2010, 3/14/2014)

r coverage manual. Start: 08/01/2004

31/02, 2/28/03, 7/1/15)

ed: 04/01/2007 Notes: (Modified 4/1/07)

tes: (Modified 8/13/01, 4/1/07)

espect to claims processed on behalf of your benefit plan. Start: 01/01/2000

enting the payer. Start: 03/30/2005

08 Notes: (Modified 7/1/08)

t Modified: 04/01/2007 Notes: (Modified 4/1/07)

or this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the servi

2007 Notes: (Modified 4/1/07)

dary claim. Start: 11/18/2005 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

04/01/2006 | Last Modified: 07/01/2008 Notes: (Modified 4/1/07, 11/5/07, 7/1/08)

your behalf. Start: 12/01/2006

this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy
ed: 03/01/2009 Notes: (Modified 3/1/2009)
8, typo fixed 5/8/08)
ble for the billed charge. Start: 07/01/2008

1/2008 | Last Modified: 03/01/2017 Notes: (Modified 3/1/2017)

be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment. Start: 11/01/2008

electronically or in the mail. Contact the insurer if there are any questions. Start: 11/01/2008 | Last Modified: 03/01/2017 Notes: (Modifie
Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment process

from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payme
 07/01/2011 | Last Modified: 03/14/2014 Notes: (Modified 3/14/2014)

ment hold in the near future. Start: 03/06/2012

eadmission. Start: 11/01/2012

ocessed. Start: 11/01/2012 | Last Modified: 03/01/2013 Notes: (Modified 3/1/13)

or the claim to be processed. Start: 11/01/2012

ate or contact the ordering/referring provider. Start: 07/15/2013

he use of a drug. Start: 07/15/2013

Modified: 11/01/2013

de as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual
edicare Part B. Start: 01/01/2000 | Last Modified: 02/28/2003 Notes: (Modified 2/28/03)

Scale System applicable to Hawaii. Start: 07/15/2013

uant to Regulation 83 and / or Appendix 17-C of 11 NYCRR. Start: 07/15/2013

with Section 4 of ORS 742.524. Start: 07/15/2013

. Start: 07/15/2013

bmitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corre

0, a Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace p
cility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of t

n the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another in

3/14/2014)

with claim/service reversal. (Modified 3/14/2014)

versal. (Modified 3/14/2014)
01/2013 | Last Modified: 03/14/2014 Notes: To be used with claim/service reversal. (Modified 3/14/2014)

fied 3/14/2014)
assignment for these types of claims. Start: 01/01/2000 | Last Modified: 06/30/2003 Notes: (Modified 2/21/02, 6/30/03)

this notice. Start: 03/01/2014

ouses. More information can be found at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html Start: 03/01/2015

an of care. PHP services must be furnished in accordance with the plan of care. Start: 03/01/2017

ed billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be
is remittance advice. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

at implantation with anesthesia can occur. Start: 08/24/2001

anifestations of the above three indications are excluded. Start: 08/24/2001
te a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries. Start: 08/24/2001
fied 8/1/06, 11/5/07)

s equipment. Start: 01/01/1997

1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

 tified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review
atient within 30 days of receiving this notice.The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The s
nable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not cov

f an additional payment for this service. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

28/03, 7/1/15)

s separate line items. Start: 01/01/1997

write to us within 120 days of the date you received this notice, unless you have a good reason for being late. Start: 01/01/1997 | Last Mod
06, 4/1/07)
7 | Last Modified: 08/01/2007 Notes: (Modified 4/1/07, 8/1/07)

ruction, are conferred by receipt of this notice. Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)

ng charge amount. Start: 01/01/1997

es: (Modified 4/1/07)

ast Modified: 04/01/2007 Notes: (Modified 4/1/07)

/2007 Notes: (Modified 4/1/07)

discrepancy. Start: 01/01/1997

ppeals process guidelines. Start: 01/01/2000 | Last Modified: 07/01/2018 Notes: (Modified 2/28/03, 4/1/07, 7/15/13, 7/1/18)

aw, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the

for the blended payment calculation will be. Start: 05/30/2002

o request a copy of the LCD. Start: 05/30/2002 | Last Modified: 07/01/2010 Notes: (Modified 4/1/04, 7/1/10)
and supplies, such as this, be included in the home health agency's (HHA's) payment. This payment will need to be recouped from you if w

8/01/2007 Notes: (Modified 8/1/07)

the service/item was furnished that we would not pay for it, and the patient agreed to pay. Start: 09/26/2002
hin 30 days of receiving this notice.The requirements for a refund are in $1834(a)(18) of the Social Security Act (and in $$1834(j)(4) and 18

which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority. Start: 10/31/2002 | Last
2 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
ointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiograp
submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subs
s: (Modified 4/1/07)
e were likely to deny the service, and the patient signed a statement agreeing to pay for the service.If you come within either exception, o

e contractor to request a copy of the NCD. Start: 04/01/2007 | Last Modified: 07/01/2010 Notes: (Modified 7/1/2010)
t: 11/01/2008

d: 03/01/2017 Notes: (Modified 3/1/2017)

t the time of payment processing. Start: 11/01/2008

services at the time of payment processing. Start: 11/01/2008

e, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community an

nrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future. Start: 07/15/2013

the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grac
other location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility no

ou by the patient or another insurer for this claim must be refunded to the payer within 30 days. Start: 01/01/2000
/02, 6/30/03)

html Start: 03/01/2015

This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode

g diaries. Start: 08/24/2001

writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon applica
y Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject
o know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determin
Start: 01/01/1997 | Last Modified: 04/01/2007 Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 4/1/07)
, 7/15/13, 7/1/18)

ocal government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The pro
d to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care. Start: 06/30/

Act (and in $$1834(j)(4) and 1879(h) by cross-reference to $1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly an

ority. Start: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 8/1/04, 2/28/03, 4/1/07)

ou disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this
evant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter. Start: 10/31/2002 | Last Modifie
ome within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should req
ent levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and othe

7/15/2013

d and third months of the grace period. Start: 07/15/2013 | Last Modified: 03/01/2017 Notes: (Modified 3/1/2017)
were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demons
eatment under a HHA episode of care. Start: 01/01/2000 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
 appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any d
opriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice,
g both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of t
tion of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate. Start: 10/31/2001 | Last Modified:
 episode of care. Start: 06/30/2002

t suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from t

n 90 days from the date of this letter. Start: 10/31/2002 | Last Modified: 03/01/2017 Notes: (Modified 4/1/07, 3/1/2017)
art: 10/31/2002 | Last Modified: 04/01/2007 Notes: (Modified 4/1/07)
for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should i
insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this se
from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim
 om him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. Star
ny questions about this notice, please contact this office. Start: 01/01/1997 | Last Modified: 11/05/2007 Notes: (Modified 10/1/02, 6/30/0
st be filed within 120 days of the date you receive this notice. You must make the request through this office. Start: 01/01/1997 | Last Mo
10/31/2001 | Last Modified: 11/01/2013 Notes: (Modified 6/30/03, 7/1/12, 11/1/13)
alties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office. Start: 09/26/20

7, 3/1/2017)
ur request for review should include any additional information necessary to support your position.If you request an appeal within 30 day
rvice. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which th
ation facility on the new claim. Start: 01/01/2000
m you as an overpayment. Start: 01/01/1997 | Last Modified: 11/01/2010 Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07, 11/1/10)
es: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)
e. Start: 01/01/1997 | Last Modified: 08/01/2007 Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)
act this office. Start: 09/26/2002 | Last Modified: 08/01/2005 Notes: (Modified 8/1/05. Also refer to N356)
quest an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of
edule for the locale in which the services were rendered. Start: 07/15/2013
, 8/1/05, 11/5/07, 11/1/10)
until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the
e any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfa
n 15 days of receiving the unfavorable review decision.The law also permits you to request an appeal at any time within 120 days of the da
time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of t
han 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the p
en a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination.The patien
the determination.The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a r
t he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also
and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days S
bout a refund within 30 days Start: 08/01/2005 | Last Modified: 04/01/2007 Notes: (Modified 11/18/05, Modified 4/1/07)
# RemarkCode
136 MA11
137 MA11
138 MA11
139 MA11
140 MA11
141 MA11
142 MA11
143 MA11
144 MA11
235 N100
236 N102
362 N225
433 N29
516 N365
637 N483
638 N484
793 N627
799 N632
906 N73
907 N73
908 N73
909 N73
910 N73
911 N73
912 N73
913 N73
914 N73
915 N73
916 N73
RemarkCodeDescription
Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purcha
Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address. Start: 01/01/1
Missing/incomplete/invalid group practice information. Start: 01/01/1997 | Last Modified: 02/28/2003 Notes: (Modified 2/28
Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims canno
Missing/incomplete/invalid information on where the services were furnished. Start: 01/01/1997 | Last Modified: 02/28/2003
Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Profe
Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home o
This claim has been assessed a $1.00 user fee. Start: 01/01/1997
Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a fa
PPS (Prospect Payment System) code corrected during adjudication. Start: 09/14/2001 | Last Modified: 06/30/2003 Notes: (M
This claim has been denied without reviewing the medical/dental record because the requested records were not received or
Incomplete/invalid documentation/orders/notes/summary/report/chart. Start: 08/01/2004 | Stop: 03/01/2016 | Last Modifie
Missing documentation/orders/notes/summary/report/chart. Start: 01/01/2000 | Stop: 03/01/2016 | Last Modified: 03/01/20
This procedure code is not payable. It is for reporting/information purposes only. Start: 04/01/2006 | Stop: 07/01/2014 Notes
Missing Periodontal Charts. Start: 07/01/2008 | Stop: 05/01/2015 | Last Modified: 11/01/2014 Notes: (Modified 11/1/2014)
Incomplete/invalid Periodontal Charts. Start: 07/01/2008 | Stop: 05/01/2015 | Last Modified: 11/01/2014 Notes: (Modified 3/
Service not payable per managed care contract. Start: 07/15/2013 | Stop: 07/01/2014 Notes: Consider Use CARC 256
According to the Official Medical Fee Schedule this service has a relative value of zero and therefore no payment is due. Start:
Incomplete/invalid patient medical/dental record for this service. Start: 11/01/2014
Incomplete/Invalid mental health assessment. Start: 11/01/2014
Services performed at an unlicensed facility are not reimbursable. Start: 11/01/2014
Regulatory surcharges are paid directly to the state. Start: 11/01/2014
The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or inju
The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or inju
Adjustment without review of medical/dental record because the requested records were not received or were not received ti
Incomplete/invalid Sleep Study Report. Start: 03/01/2015
Missing Sleep Study Report. Start: 03/01/2015
Incomplete/invalid Vein Study Report. Start: 03/01/2015
Missing Vein Study Report. Start: 03/01/2015
Status
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
DEACTIVATED
REMARK CODE
M100
M102
M103
M104
M105
M107
M109
MA100
MA103
MA106
MA107
MA108
MA109
MA110
MA111
MA112
MA113
MA114
MA115
MA116
MA117
MA118
MA120
MA121
MA122
MA123
MA125
MA126
MA128
N411
N412
N413
N414
N415
N416
N417
N701
N702
N703
N704
N705
N706
N707
N708
N709
N710
N711
N712
N713
N714
N715
N716
N717
N718
N719
N720
N721
N722
N723
N724
N725
N726
N727
N728
N729
N730
N731
N732
N733
N734
N736
N737
N738
N739
N759
N760
N761
N762
N763
N764
N765
N766
N767
N768
N769
N770
N771
N772
N773
N774
N775
N776
N777
N778
N779
N780
N781
N782
N783
N784
N785
N786
N789
N790
N791
N792
N794
N795
N796
N797
N798
N799
N809
N810
N811
N812
N815
N816
N817
N818
N819
N820
N821
N822
N823
N824
N825
N826
N827
N828
N829
N830
N831
N832
N833
N834
N835
N836
N837
N838
N839
N840
N841
N842
N843
N844
N845
N846
N847
N848
N849
N850
N851
N852
N853
N854
N855
N856
N857
N858
N859
N860
N861
N862
N863
N864
N865
N866
N867
N868
N869
N870
N871
N872
N873
N874
N875
N876
N877
N878
N879
N880
N881
N882
N883
N884
N885
N886
N887
N888
N889
N890
N891
N892
N893
N894
N895
N896
N897
N898
N899
N900
N901
N902
N903
N904
N905
N906
N907
N908
N909
N910
N911
DESCRIPTION
We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of admi
Service not performed on equipment approved by the FDA for this purpose.
Information supplied supports a break in therapy. However, the medical information we have for this patient does not suppor
Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This i
Information supplied does not support a break in therapy. The medical information we have for this patient does not support
Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.
We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation paym
Missing/incomplete/invalid date of current illness or symptoms.
Hemophilia Add On.
PIP (Periodic Interim Payment) claim.
Paper claim contains more than three separate data items in field 19.
Paper claim contains more than one data item in field 23.
Claim processed in accordance with ambulatory surgical guidelines.
Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purcha
Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.
Missing/incomplete/invalid group practice information.
Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims canno
Missing/incomplete/invalid information on where the services were furnished.
Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Profe
Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home o
This claim has been assessed a $1.00 user fee.
Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a fa
Missing/incomplete/invalid CLIA certification number.
Missing/incomplete/invalid x-ray date.
Missing/incomplete/invalid initial treatment date.
Your center was not selected to participate in this study, therefore, we cannot pay for these services.
Per legislation governing this program, payment constitutes payment in full.
Pancreas transplant not covered unless kidney transplant performed.
Missing/incomplete/invalid FDA approval number.
This service is allowed one time in a 6-month period.
This service is allowed 2 times in a 12-month period.
This service is allowed 2 times in a benefit year.
This service is allowed 4 times in a 12-month period.
This service is allowed 1 time in an 18-month period.
This service is allowed 1 time in a 3-year period.
This service is allowed 1 time in a 5-year period.
Payment adjusted based on the Value-based Payment Modifier.
Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.
This service is incompatible with previously adjudicated claims or claims in process.
Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.
Incomplete/invalid documentation.
Missing documentation.
Incomplete/invalid orders.
Missing orders.
Incomplete/invalid notes.
Missing notes.
Incomplete/invalid summary.
Missing summary.
Incomplete/invalid report.
Missing report.
Incomplete/invalid chart.
Missing chart.
Incomplete/Invalid documentation of face-to-face examination.
Missing documentation of face-to-face examination.
Penalty applied based on plan requirements not being met.
Alert: The patient overpaid you. You may need to issue the patient a refund for the difference between the patient's payment
This service is only covered when performed as part of a clinical trial.
Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item.
Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.
Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.
A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
A conditional payment is not allowed.
A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
A workers' compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.
Missing patient medical/dental record for this service.
Incomplete/invalid patient medical/dental record for this service.
Incomplete/Invalid mental health assessment.
Services performed at an unlicensed facility are not reimbursable.
Regulatory surcharges are paid directly to the state.
The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or inju
Incomplete/invalid Sleep Study Report.
Missing Sleep Study Report.
Incomplete/invalid Vein Study Report.
Missing Vein Study Report.
Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.
This facility is not authorized to receive payment for the service(s).
This provider is not authorized to receive payment for the service(s).
This facility is not certified for Tomosynthesis (3-D) mammography.
The demonstration code is not appropriate for this claim; resubmit without a demonstration code.
Missing/incomplete/invalid Hematocrit (HCT) value.
This payer does not cover coinsurance assessed by a previous payer.
This payer does not cover co-payment assessed by a previous payer.
The Medicaid state requires provider to be enrolled in the member's Medicaid state program prior to any claim benefits being
Incomplete/invalid initial evaluation report.
A lateral diagnosis is required.
The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the in
Alert: Under Federal law you cannot charge more than the limiting charge amount.
Alert: Rebill urgent/emergent and ancillary services separately.
Drug supplied not obtained from specialty vendor.
Alert: Refer to your Third Party Processor Agreement for specific information on fees associated with this payment type.
Payment adjusted based on x-ray radiograph on film.
This service is not a covered Telehealth service.
Missing Assignment of Benefits Indicator.
Missing Primary Care Physician Information.
Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is
Missing/incomplete/invalid end therapy date.
Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This
Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. Th
Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected copayment. This
Missing comprehensive procedure code.
Missing current radiology film/images.
Benefit limitation for the orthodontic active and/or retention phase of treatment.
Clinical Trial is not a covered benefit.
Provider/supplier not accredited for product/service.
Missing history & physical report.
Incomplete/invalid history & physical report.
Payment adjusted based on type of technology used.
Item must be resubmitted as a purchase.
Missing/incomplete/invalid Hemoglobin (Hb or Hgb) value.
Missing/incomplete/invalid date qualifier.
Submit a void request for the original claim and resubmit a new claim.
Submitted identifier must be an individual identifier, not group identifier.
Alert: The fee schedule amount for this service was adjusted based on prior competitive bidding rates. For more information,
Alert: Due to federal, state or local disaster declaration, this claim has been processed at the in-network level of benefit. At th
Missing Federal Sequestration Reduction from Prior Payer.
The start service date through end service date cannot span greater than 18 months.
Missing/Incomplete/Invalid NDC Unit Count
Missing/Incomplete/Invalid NDC Unit of Measure
Alert: Applicable laboratories are required to collect and report private payor data and report that data to CMS between Janu
Claims Dates of Service do not match Electronic Visit Verification System.
Patient not enrolled in Electronic Visit Verification System.
Electronic Visit Verification System units do not meet requirements of visit.
Electronic Visit Verification System visit not found.
Missing procedure modifier(s).
Incomplete/Invalid procedure modifier(s).
Electronic Visit Verification (EVV) data must be submitted through EVV Vendor.
Early intervention guidelines were not met.
Patient did not meet the inclusion criteria for the Medicare Shared Savings Program.
Missing/Incomplete/Invalid Federal Information Processing Standard (FIPS) Code.
Alert: Payment is suppressed due to a contracted funding.
Missing/incomplete/invalid Diagnostics Exchange Z-Code Identifier.
Alert: The charge[s] for this service was processed in accordance with Federal/ State, Balance Billing/ No Surprise Billing regula
You have not responded to requests to revalidate your provider/supplier enrollment information.
Duplicate occurrence code/occurrence span code.
Patient share of cost waived.
Jurisdiction exempt from sales and health tax charges.
Unrelated Service/procedure/treatment is reduced. The balance of this charge is the patient's responsibility.
Provider W9 or Payee Registration not on file.
Alert: Missing modifier was added.
Alert: Service/procedure postponed due to a federal, state, or local mandate/disaster declaration. Any amounts applied to ded
The procedure code was added/changed because the level of service exceeds the compensable condition(s).
Worker's compensation claim filed with a different state.
Alert: North Dakota Administrative Rule 92-01-02-50.3.
Alert: Patient cannot be billed for charges.
Missing/incomplete/invalid Core-Based Statistical Area (CBSA) code.
This claim, or a portion of this claim, was processed in accordance with the Nebraska Legislative LB997 July 24, 2020 - Out of N
Alert: Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act.
National Drug Code (NDC) supplied does not correspond to the HCPCs/CPT billed.
National Drug Code (NDC) billed is obsolete.
National Drug Code (NDC) billed cannot be associated with a product.
Missing Tooth Clause: Tooth missing prior to the member effective date.
Missing/incomplete/invalid narrative explaining/describing this service/treatment.
Payment reduced because services were furnished by a therapy assistant.
The pay-to and rendering provider tax identification numbers (TINs) do not match
The number of modalities performed per session exceeds our acceptable maximum.
Alert: If you have primary other health insurance (OHI) coverage that has denied services, you must exhaust all appeal levels w
This coverage is subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
This coverage is not subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
This claim has been adjusted/reversed. Refund any collected copayment to the member.
Alert: State regulations relating to an Out of Network Medical Emergency Care Act were applied to the processing of this claim
Alert: The Federal No Surprise Billing Act was applied to the processing of this claim. Payment amounts are eligible for dispute
Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).
Alert: Mismatch between the submitted Patient Liability/Share of Cost and the amount on record for this recipient.
Alert: Member cost share is in compliance with the No Surprises Act, and is calculated using the lesser of the QPA or billed cha
Alert: This claim is subject to the No Surprises Act (NSA). The amount paid is the final out-of-network rate and was calculated
Alert: This claim is subject to the No Surprises Act provisions that apply to emergency services.
Alert: This claim is subject to the No Surprises Act provisions that apply to nonemergency services furnished by nonparticipatin
Alert: This claim is subject to the No Surprises Act provisions that apply to services furnished by nonparticipating providers of a
Alert: Cost sharing was calculated based on a specified state law, in accordance with the No Surprises Act.
Alert: Cost sharing was calculated based on an All-Payer Model Agreement, in accordance with the No Surprises Act.
Alert: Cost sharing was calculated based on the qualifying payment amount, in accordance with the No Surprises Act.
Alert: In accordance with the No Surprises Act, cost sharing was based on the billed amount because the billed amount was lo
Alert: This initial payment was calculated based on a specified state law, in accordance with the No Surprises Act.
Alert: This final payment was calculated based on a specified state law, in accordance with the No Surprises Act.
Alert: This final payment was calculated based on an All-Payer Model Agreement, in accordance with the No Surprises Act.
Alert: This final payment was determined through open negotiation, in accordance with the No Surprises Act.
Alert: This final payment equals the amount selected as the out-of-network rate by a Federal Independent Dispute Resolution
Alert: This item or service is covered under the plan. This is a notice of denial of payment provided in accordance with the No
Alert: This initial payment is provided in accordance with the No Surprises Act. The provider or facility may initiate open negoti
Alert: The provider or facility specified that notice was provided and consent to balance bill obtained, but notice and consent w
Alert: The notice and consent to balance bill, and to be charged out-of-network cost sharing, that was obtained from the patie
Original claim closed due to changes in submitted data. Adjustment claim will be processed under a new claim number.
Client Obligation, patient responsibility for Home & Community Based Services (HCBS)
Alert: The out-of-network payment and cost sharing amounts were based on the plan's allowance because the provider or fac
Alert: Processed according to state law
Alert: The No Surprises Act may apply to this claim. Please contact payer for instructions on how to submit information regard
Alert: This claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-network payment requirem
Alert: A Health
Providers Care Claim Request
not participating for Additional
in the Medicare Information
Advantage (277
Plan have RFAI)
the righthas been sent.
to appeal if the plan has partially or fully denied pay
Once we receive the completed forms, we will give you a decision on your appeal within 60 calendar days.
Alert: An electronic request for additional information has been sent for this claim.
Alert: This claim was originally processed in real-time, and we sent a real-time 835 response.
Electronic Visit Verification Data Element Requirements were not met.
The maximum allowable payment for this service/procedure was paid by the primary insurance. No further payment due.
The claim does not meet the criteria for acceptable use of the Delay Reason Code.
Missing/incomplete/invalid child medical evaluation form/checklist.
Alert: These payments are made subject to a reservation of rights for the Payor to recoup or otherwise recover all or part of th
Processed based on a negotiated fee schedule for a specialty drug program.
Missing/incomplete/invalid trauma activation sheet.
Missing/incomplete/invalid proof of member payment.
Missing/incomplete/invalid Resource Utilization Group(s) (RUG) code(s).
Missing Initial Evaluation Report.
Missing Therapy Notes/Report.
Incomplete/Invalid Therapy Notes/Report.
Missing Health Risk Assessment (HRA).
Incomplete/Invalid Health Risk Assessment (HRA).
The transportation vendor is responsible for this claim.
Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies fu
Service is not covered when patient is under age 45.
No refund because this claim has been identified as 340B-eligible with a ceiling price lower than the maximum fair price.
No refund because this drug has been prospectively purchased at the maximum fair price.
Refund amount has been calculated using a methodology that differs from the Standard Default Refund Amount calculation ((
A refund cannot be provided for this claim at this time. Contact the manufacturer directly regarding your eligibility.
This claim cannot be reimbursed by the manufacturer until the Part D plan submits corrected prescription drug event data to C
t this claim after you have notified this office of your correct TIN.
mount the provider collected over the identified PR amount must be refunded to the patient within applicable Federal/State timeframes. P
nder the No Surprises Act, and balance billing is prohibited.
o Surprises Act, and balance billing is prohibited.

on on behalf of the patient through the payer’s internal appeals and external review processes.
hin 60 calendar days after the date of the remittance advice. For the plan to review the appeal, the plan will need a completed signed Wai
ayor's obligation to make these payments.
e Federal/State timeframes. Payment amounts are eligible for dispute pursuant to any Federal/State documented appeal/grievance proce
need a completed signed Waiver of Liability Statement. To obtain a Waiver of Liability form, please contact your Medicare Advantage Plan
mented appeal/grievance process(es).
your Medicare Advantage Plan.
SL No. REMARK CDESCRIPTION
1 M1 X-ray not taken within the past 12 months or near enough to the start of treatment.
2 M2 Not paid separately when the patient is an inpatient.
3 M3 Equipment is the same or similar to equipment already being used.
4 M4 Alert: This is the last monthly installment payment for this durable medical equipment.
5 M5 Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or
6 M6 Alert: You must furnish and service this item for any period of medical need for the remainder of the rea
7 M7 No rental payments after the item is purchased, returned or after the total of issued rental payments eq
8 M8 We do not accept blood gas tests results when the test was conducted by a medical supplier or taken wh
9 M9 Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a pu
10 M10 Equipment purchases are limited to the first or the tenth month of medical necessity.
11 M11 DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.
12 M12 Diagnostic tests performed by a physician must indicate whether purchased services are included on the
13 M13 Only one initial visit is covered per specialty per medical group.
14 M14 No separate payment for an injection administered during an office visit, and no payment for a full office
15 M15 Separately billed services/tests have been bundled as they are considered components of the same proc
16 M16 Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/de
17 M17 Alert: Payment approved as you did not know, and could not reasonably have been expected to know, th
18 M18 Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is c
19 M19 Missing oxygen certification/re-certification.
20 M20 Missing/incomplete/invalid HCPCS.
21 M21 Missing/incomplete/invalid place of residence for this service/item provided in a home.
22 M22 Missing/incomplete/invalid number of miles traveled.
23 M23 Missing invoice.
24 M24 Missing/incomplete/invalid number of doses per vial.
25 M25 The
The information
information furnished
furnished does
does not
not substantiate
substantiate the
the need
need for
for this
this level
level of
of service.
service. If
If you
you believe the serva
have collected
26 M26 The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section spec
27 M27 Alert: The patient has been relieved of liability of payment of these items and services under the limitati
28 M28 This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise avai
29 M29 Missing operative note/report.
30 M30 Missing pathology report.
31 M31 Missing radiology report.
32 M32 Alert: This is a conditional payment made pending a decision on this service by the patient's primary pay
33 M36 This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given t
34 M37 Not covered when the patient is under age 35.
35 M38 Alert: The patient is liable for the charges for this service as they were informed in writing before the ser
36 M39 Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you pro
37 M40 Claim must be assigned and must be filed by the practitioner's employer.
38 M41 We do not pay for this as the patient has no legal obligation to pay for this.
39 M42 The medical necessity form must be personally signed by the attending physician.
40 M44 Missing/incomplete/invalid condition code.
41 M45 Missing/incomplete/invalid occurrence code(s).
42 M46 Missing/incomplete/invalid occurrence span code(s).
43 M47 Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, bu
44 M49 Missing/incomplete/invalid value code(s) or amount(s).
45 M50 Missing/incomplete/invalid revenue code(s).
46 M51 Missing/incomplete/invalid procedure code(s).
47 M52 Missing/incomplete/invalid 'from' date(s) of service.
48 M53 Missing/incomplete/invalid days or units of service.
49 M54 Missing/incomplete/invalid total charges.
50 M55 We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti
51 M56 Missing/incomplete/invalid payer identifier.
52 M59 Missing/incomplete/invalid 'to' date(s) of service.
53 M60 Missing Certificate of Medical Necessity.
54 M61 We cannot pay for this as the approval period for the FDA clinical trial has expired.
55 M62 Missing/incomplete/invalid treatment authorization code.
56 M64 Missing/incomplete/invalid other diagnosis.
57 M65 One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indica
58 M66 Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code s
59 M67 Missing/incomplete/invalid other procedure code(s).
60 M69 Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
61 M70 Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please
62 M71 Total payment reduced due to overlap of tests billed.
63 M73 The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebil
64 M74 This service does not qualify for a HPSA/Physician Scarcity bonus payment.
65 M75 Multiple automated multichannel tests performed on the same day combined for payment.
66 M76 Missing/incomplete/invalid diagnosis or condition.
67 M77 Missing/incomplete/invalid/inappropriate place of service.
68 M79 Missing/incomplete/invalid charge.
69 M80 Not covered when performed during the same session/date as a previously processed service for the pati
70 M81 You are required to code to the highest level of specificity.
71 M82 Service is not covered when patient is under age 50.
72 M83 Service is not covered unless the patient is classified as at high risk.
73 M84 Medical code sets used must be the codes in effect at the time of service.
74 M85 Subjected to review of physician evaluation and management services.
75 M86 Service denied because payment already made for same/similar procedure within set time frame.
76 M87 Claim/service(s) subjected to CFO-CAP prepayment review.
77 M89 Not covered more than once under age 40.
78 M90 Not covered more than once in a 12 month period.
79 M91 Lab procedures with different CLIA certification numbers must be billed on separate claims.
80 M93 Information supplied supports a break in therapy. A new capped rental period began with delivery of thi
81 M94 Information supplied does not support a break in therapy. A new capped rental period will not begin.
82 M95 Services subjected to Home Health Initiative medical review/cost report audit.
83 M96 The technical component of a service furnished to an inpatient may only be billed by that inpatient facili
84 M97 Not paid to practitioner when provided to patient in this place of service. Payment included in the reimb
85 M99 Missing/incomplete/invalid Universal Product Number/Serial Number.
86 M100 We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or wi
87 M102 Service not performed on equipment approved by the FDA for this purpose.
88 M103 Information supplied supports a break in therapy. However, the medical information we have for this pa
89 M104 Information supplied supports a break in therapy. A new capped rental period will begin with delivery of
90 M105 Information supplied does not support a break in therapy. The medical information we have for this pati
91 M107 Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.
92 M109 We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the
93 M111 We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.
94 M112 Reimbursement for this item is based on the single payment amount required under the DMEPOS Comp
95 M113 Our records indicate that this patient began using this item/service prior to the current contract period f
 96 M114 This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidd
97 M115 This item is denied when provided to this patient by a non-contract or non-demonstration supplier.
98 M116 Processed under a demonstration project or program. Project or program is ending and additional servic
99 M117 Not covered unless submitted via electronic claim.
100 M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
101 M121 We pay for this service only when performed with a covered cryosurgical ablation.
102 M122 Missing/incomplete/invalid level of subluxation.
103 M123 Missing/incomplete/invalid name, strength, or dosage of the drug furnished.
104 M124 Missing indication of whether the patient owns the equipment that requires the part or supply.
105 M125 Missing/incomplete/invalid information on the period of time for which the service/supply/equipment w
106 M126 Missing/incomplete/invalid individual lab codes included in the test.
107 M127 Missing patient medical record for this service.
108 M129 Missing/incomplete/invalid indicator of x-ray availability for review.
109 M130 Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intra
110 M131 Missing physician financial relationship form.
111 M132 Missing pacemaker registration form.
112 M133 Claim did not identify who performed the purchased diagnostic test or the amount you were charged for
113 M134 Performed by a facility/supplier in which the provider has a financial interest.
114 M135 Missing/incomplete/invalid plan of treatment.
115 M136 Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.
116 M137 Part B coinsurance under a demonstration project or pilot program.
117 M138 Patient identified as a demonstration participant but the patient was not enrolled in the demonstration a
118 M139 Denied services exceed the coverage limit for the demonstration.
119 M141 Missing physician certified plan of care.
120 M142 Missing American Diabetes Association Certificate of Recognition.
121 M143 The provider must update license information with the payer.
122 M144 Pre-/post-operative care payment is included in the allowance for the surgery/procedure.
123 MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. To ma
124 MA02 Alert: If you do not agree with this determination, you have the right to appeal. You must file a written re
125 MA04 Secondary payment cannot be considered without the identity of or payment information from the prim
126 MA07 Alert: The claim information has also been forwarded to Medicaid for review.
127 MA08 Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap p
128 MA09 Alert: Claim submitted as unassigned but processed as assigned in accordance with our current assignme
129 MA10 Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to th
130 MA12 You have not established that you have the right under the law to bill for services furnished by the perso
131 MA13 Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patie
132 MA14 Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside tha
133 MA15 Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the oth
134 MA16 The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal B
135 MA17 We are the primary payer and have paid at the primary rate. You must contact the patient's other insure
136 MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any que
137 MA19 Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitt
138 MA20 Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral cat
139 MA21 SSA records indicate mismatch with name and sex.
140 MA22 Payment of less than $1.00 suppressed.
141 MA23 Demand bill approved as result of medical review.
142 MA24 Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.
143 MA25 A patient may not elect to change a hospice provider more than once in a benefit period.
144 MA26 Alert: Our records indicate that you were previously informed of this rule.
145 MA27 Missing/incomplete/invalid entitlement number or name shown on the claim.
146 MA28 Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information o
147 MA30 Missing/incomplete/invalid type of bill.
148 MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.
149 MA32 Missing/incomplete/invalid number of covered days during the billing period.
150 MA33 Missing/incomplete/invalid non-covered days during the billing period.
151 MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
152 MA35 Missing/incomplete/invalid number of lifetime reserve days.
153 MA36 Missing/incomplete/invalid patient name.
154 MA37 Missing/incomplete/invalid patient's address.
155 MA39 Missing/incomplete/invalid gender.
156 MA40 Missing/incomplete/invalid admission date.
157 MA41 Missing/incomplete/invalid admission type.
158 MA42 Missing/incomplete/invalid admission source.
159 MA43 Missing/incomplete/invalid patient status.
160 MA44 Alert: No appeal rights. Adjudicative decision based on law.
161 MA45 Alert: As previously advised, a portion or all of your payment is being held in a special account.
162 MA46 Alert: The new information was considered but additional payment will not be issued.
163 MA47 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for ser
164 MA48 Missing/incomplete/invalid name or address of responsible party or primary payer.
165 MA50 Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.
166 MA53 Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
167 MA54 Physician certification or election consent for hospice care not received timely.
168 MA55 Not covered as patient received medical health care services, automatically revoking his/her election to
169 MA56 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for ser
170 MA57 Patient submitted written request to revoke his/her election for religious non-medical health care servic
171 MA58 Missing/incomplete/invalid release of information indicator.
172 MA59 Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for
173 MA60 Missing/incomplete/invalid patient relationship to insured.
174 MA61 Missing/incomplete/invalid social security number.
175 MA62 Alert: This is a telephone review decision.
176 MA63 Missing/incomplete/invalid principal diagnosis.
177 MA64 Our records indicate that we should be the third payer for this claim. We cannot process this claim until
178 MA65 Missing/incomplete/invalid admitting diagnosis.
179 MA66 Missing/incomplete/invalid principal procedure code.
180 MA67 Alert: Correction to a prior claim.
181 MA68 Alert: We did not crossover this claim because the secondary insurance information on the claim was inc
182 MA69 Missing/incomplete/invalid remarks.
183 MA70 Missing/incomplete/invalid provider representative signature.
184 MA71 Missing/incomplete/invalid provider representative signature date.
185 MA72 Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 3
186 MA73 Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-s
187 MA74 Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or returned
188 MA75 Missing/incomplete/invalid patient or authorized representative signature.
189 MA76 Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is perf
190 MA77 Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference be
191 MA79 Billed in excess of interim rate.
192 MA80 Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital b
193 MA81 Missing/incomplete/invalid provider/supplier signature.
194 MA83 Did not indicate whether we are the primary or secondary payer.
195 MA84 Patient identified as participating in the National Emphysema Treatment Trial but our records indicate th
196 MA88 Missing/incomplete/invalid insured's address and/or telephone number for the primary payer.
197 MA89 Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
198 MA90 Missing/incomplete/invalid employment status code for the primary insured.
199 MA91 Alert: This determination is the result of the appeal you filed.
200 MA92 Missing plan information for other insurance.
201 MA93 Non-PIP (Periodic Interim Payment) claim.
202 MA94 Did not enter the statement 'Attending physician not hospice employee' on the claim form to certify tha
203 MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medic
204 MA97 Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial reg
205 MA99 Missing/incomplete/invalid Medigap information.
206 MA100 Missing/incomplete/invalid date of current illness or symptoms.
207 MA103 Hemophilia Add On.
208 MA106 PIP (Periodic Interim Payment) claim.
209 MA107 Paper claim contains more than three separate data items in field 19.
210 MA108 Paper claim contains more than one data item in field 23.
211 MA109 Claim processed in accordance with ambulatory surgical guidelines.
212 MA110 Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside
213 MA111 Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and ad
214 MA112 Missing/incomplete/invalid group practice information.
215 MA113 Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Serv
216 MA114 Missing/incomplete/invalid information on where the services were furnished.
217 MA115 Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rende
218 MA116 Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were
219 MA117 This claim has been assessed a $1.00 user fee.
220 MA118 Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible
221 MA120 Missing/incomplete/invalid CLIA certification number.
222 MA121 Missing/incomplete/invalid x-ray date.
223 MA122 Missing/incomplete/invalid initial treatment date.
224 MA123 Your center was not selected to participate in this study, therefore, we cannot pay for these services.
225 MA125 Per legislation governing this program, payment constitutes payment in full.
226 MA126 Pancreas transplant not covered unless kidney transplant performed.
227 MA128 Missing/incomplete/invalid FDA approval number.
228 MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because th
229 MA131 Physician already paid for services in conjunction with this demonstration claim. You must have the phys
230 MA132 Adjustment to the pre-demonstration rate.
231 MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.
232 MA134 Missing/incomplete/invalid provider number of the facility where the patient resides.
233 N1 Alert: You may appeal this decision in writing within the required time limits following receipt of this noti
234 N2 This allowance has been made in accordance with the most appropriate course of treatment provision o
235 N3 Missing consent form.
236 N4 Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.
237 N5 EOB received from previous payer. Claim not on file.
238 N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare woul
239 N7 Alert: Processing of this claim/service has included consideration under Major Medical provisions.
240 N8 Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim t
241 N9 Adjustment represents the estimated amount a previous payer may pay.
242 N10 Adjustment based on the findings of a review organization/professional consult/manual adjudication/me
243 N11 Denial reversed because of medical review.
244 N12 Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in th
245 N13 Payment based on professional/technical component modifier(s).
246 N15 Services for a newborn must be billed separately.
247 N16 Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.
248 N19 Procedure code incidental to primary procedure.
249 N20 Service not payable with other service rendered on the same date.
250 N21 Alert: Your line item has been separated into multiple lines to expedite handling.
251 N22 Alert: This procedure code was added/changed because it more accurately describes the services render
252 N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximu
253 N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
254 N25 This company has been contracted by your benefit plan to provide administrative claims payment servic
255 N26 Missing itemized bill/statement.
256 N27 Missing/incomplete/invalid treatment number.
257 N28 Consent form requirements not fulfilled.
258 N30 Patient ineligible for this service.
259 N31 Missing/incomplete/invalid prescribing provider identifier.
260 N32 Claim must be submitted by the provider who rendered the service.
261 N33 No record of health check prior to initiation of treatment.
262 N34 Incorrect claim form/format for this service.
263 N35 Program integrity/utilization review decision.
264 N36 Claim must meet primary payer's processing requirements before we can consider payment.
265 N37 Missing/incomplete/invalid tooth number/letter.
266 N39 Procedure code is not compatible with tooth number/letter.
267 N40 Missing radiology film(s)/image(s).
268 N42 Missing mental health assessment.
269 N43 Bed hold or leave days exceeded.
270 N45 Payment based on authorized amount.
271 N46 Missing/incomplete/invalid admission hour.
272 N47 Claim conflicts with another inpatient stay.
273 N48 Claim information does not agree with information received from other insurance carrier.
274 N49 Court ordered coverage information needs validation.
275 N50 Missing/incomplete/invalid discharge information.
276 N51 Electronic interchange agreement not on file for provider/submitter.
277 N52 Patient not enrolled in the billing provider's managed care plan on the date of service.
278 N53 Missing/incomplete/invalid point of pick-up address.
279 N54 Claim information is inconsistent with pre-certified/authorized services.
280 N55 Procedures for billing with group/referring/performing providers were not followed.
281 N56 Procedure code billed is not correct/valid for the services billed or the date of service billed.
282 N57 Missing/incomplete/invalid prescribing date.
283 N58 Missing/incomplete/invalid patient liability amount.
284 N59 Alert: Please refer to your provider manual for additional program and provider information.
285 N61 Rebill services on separate claims.
286 N62 Dates of service span multiple rate periods. Resubmit separate claims.
287 N63 Rebill services on separate claim lines.
288 N64 The 'from' and 'to' dates must be different.
289 N65 Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service
290 N67 Professional provider services not paid separately. Included in facility payment under a demonstration p
291 N68 Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstr
292 N69 Alert: PPS (Prospective Payment System) code changed by claims processing system.
293 N70 Consolidated billing and payment applies.
294 N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance servic
295 N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical record
296 N74 Resubmit with multiple claims, each claim covering services provided in only one calendar month.
297 N75 Missing/incomplete/invalid tooth surface information.
298 N76 Missing/incomplete/invalid number of riders.
299 N77 Missing/incomplete/invalid designated provider number.
300 N78 The necessary components of the child and teen checkup (EPSDT) were not completed.
301 N79 Service billed is not compatible with patient location information.
302 N80 Missing/incomplete/invalid prenatal screening information.
303 N81 Procedure billed is not compatible with tooth surface code.
304 N82 Provider must accept insurance payment as payment in full when a third party payer contract specifies f
305 N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration project.
306 N84 Alert: Further installment payments are forthcoming.
307 N85 Alert: This is the final installment payment.
308 N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatm
309 N87 Home use of biofeedback therapy is not covered.
310 N88 Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this pa
311 N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but format
312 N90 Covered only when performed by the attending physician.
313 N91 Services not included in the appeal review.
314 N92 This facility is not certified for digital mammography.
315 N93 A separate claim must be submitted for each place of service. Services furnished at multiple sites may no
316 N94 Claim/Service denied because a more specific taxonomy code is required for adjudication.
317 N95 This provider type/provider specialty may not bill this service.
318 N96 Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surg
319 N97 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes wi
320 N98 Patient must have had a successful test stimulation in order to support subsequent implantation. Before
321 N99 Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical resu
322 N103 Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the
323 N104 This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicar
324 N105 This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palme
325 N106 Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) c
326 N107 Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They
327 N108 Missing/incomplete/invalid upgrade information.
328 N109 Alert: This claim/service was chosen for complex review.
329 N110 This facility is not certified for film mammography.
330 N111 No appeal right except duplicate claim/service issue. This service was included in a claim that has been p
331 N112 This claim is excluded from your electronic remittance advice.
332 N113 Only one initial visit is covered per physician, group practice or provider.
333 N114 During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amou
334 N115 This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in de
335 N116 Alert: This payment is being made conditionally because the service was provided in the home, and it is p
336 N117 This service is paid only once in a patient's lifetime.
337 N118 This service is not paid if billed more than once every 28 days.
338 N119 This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days
339 N120 Payment is subject to home health prospective payment system partial episode payment adjustment. Pa
340 N121 Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries
341 N122 Add-on code cannot be billed by itself.
342 N123 Alert: This is a split service and represents a portion of the units from the originally submitted service.
343 N124 Payment
Payment hashas been
been denied
(deniedfor
forthe/made
the/madeonly
onlyfor
foraaless
lessextensive
extensive)service/item
service/itembecause
becausethe
theinformation
informationfu
344 N125 The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in §§1834(j)(4) and 187
345 N126 Social Security Records indicate that this individual has been deported. This payer does not cover items a
346 N127 This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please su
347 N128 This amount represents the prior to coverage portion of the allowance.
348 N129 Not eligible due to the patient's age.
349 N130 Consult plan benefit documents/guidelines for information about restrictions for this service.
350 N131 Total payments under multiple contracts cannot exceed the allowance for this service.
351 N132 Alert: Payments will cease for services rendered by this US Government debarred or excluded provider a
352 N133 Alert: Services for predetermination and services requesting payment are being processed separately.
353 N134 Alert: This represents your scheduled payment for this service. If treatment has been discontinued, pleas
354 N135 Record fees are the patient's responsibility and limited to the specified co-payment.
355 N136 Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer
356 N137 Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, actin
357 N138 Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relativ
358 N139 Alert: Under 32 CFR 199.13, a non-participating provider is not an appropriate appealing party. Therefor
359 N140 Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an
360 N141 The patient was not residing in a long-term care facility during all or part of the service dates billed.
361 N142 The original claim was denied. Resubmit a new claim, not a replacement claim.
362 N143 The patient was not in a hospice program during all or part of the service dates billed.
363 N144 The rate changed during the dates of service billed.
364 N146 Missing screening document.
365 N147 Long term care case mix or per diem rate cannot be determined because the patient ID number is missin
366 N148 Missing/incomplete/invalid date of last menstrual period.
367 N149 Rebill all applicable services on a single claim.
368 N150 Missing/incomplete/invalid model number.
369 N151 Telephone contact services will not be paid until the face-to-face contact requirement has been met.
370 N152 Missing/incomplete/invalid replacement claim information.
371 N153 Missing/incomplete/invalid room and board rate.
372 N154 Alert: This payment was delayed for correction of provider's mailing address.
373 N155 Alert: Our records do not indicate that other insurance is on file. Please submit other insurance informati
374 N156 Alert: The patient is responsible for the difference between the approved treatment and the elective tre
375 N157 Transportation to/from this destination is not covered.
376 N158 Transportation in a vehicle other than an ambulance is not covered.
377 N159 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.
378 N160 The patient must choose an option before a payment can be made for this procedure/ equipment/ supp
379 N161 This drug/service/supply is covered only when the associated service is covered.
380 N162 Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory C
381 N163 Medical record does not support code billed per the code definition.
382 N167 Charges exceed the post-transplant coverage limit.
383 N170 A new/revised/renewed certificate of medical necessity is needed.
384 N171 Payment for repair or replacement is not covered or has exceeded the purchase price.
385 N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.
386 N173 No qualifying hospital stay dates were provided for this episode of care.
387 N174 This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts
388 N175 Missing review organization approval.
389 N176 Services provided aboard a ship are covered only when the ship is of United States registry and is in Unit
390 N177 Alert: We did not send this claim to patient's other insurer. They have indicated no additional payment c
391 N178 Missing pre-operative images/visual field results.
392 N179 Additional information has been requested from the member. The charges will be reconsidered upon rec
393 N180 This item or service does not meet the criteria for the category under which it was billed.
394 N181 Additional information is required from another provider involved in this service.
395 N182 This claim/service must be billed according to the schedule for this plan.
396 N183 Alert: This is a predetermination advisory message, when this service is submitted for payment additiona
397 N184 Rebill technical and professional components separately.
398 N185 Alert: Do not resubmit this claim/service.
399 N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facilit
400 N187 Alert: You may request a review in writing within the required time limits following receipt of this notice
401 N188 The approved level of care does not match the procedure code submitted.
402 N189 Alert: This service has been paid as a one-time exception to the plan's benefit restrictions.
403 N190 Missing contract indicator.
404 N191 The provider must update insurance information directly with payer.
405 N192 Alert: Patient is a Medicaid/Qualified Medicare Beneficiary.
406 N193 Alert: Specific federal/state/local program may cover this service through another payer.
407 N194 Technical component not paid if provider does not own the equipment used.
408 N195 The technical component must be billed separately.
409 N196 Alert: Patient eligible to apply for other coverage which may be primary.
410 N197 The subscriber must update insurance information directly with payer.
411 N198 Rendering provider must be affiliated with the pay-to provider.
412 N199 Additional payment/recoupment approved based on payer-initiated review/audit.
413 N200 The professional component must be billed separately.
414 N202 Alert: Additional information/explanation will be sent separately.
415 N203 Missing/incomplete/invalid anesthesia time/units.
416 N204 Services under review for possible pre-existing condition. Send medical records for prior 12 months
417 N205 Information provided was illegible.
418 N206 The supporting documentation does not match the information sent on the claim.
419 N207 Missing/incomplete/invalid weight.
420 N208 Missing/incomplete/invalid DRG code.
421 N209 Missing/incomplete/invalid taxpayer identification number (TIN).
422 N210 Alert: You may appeal this decision.
423 N211 Alert: You may not appeal this decision.
424 N212 Charges processed under a Point of Service benefit.
425 N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information.
426 N214 Missing/incomplete/invalid history of the related initial surgical procedure(s).
427 N215 Alert: A payer providing supplemental or secondary coverage shall not require a claims determination fo
428 N216 We do not offer coverage for this type of service or the patient is not enrolled in this portion of our bene
429 N217 We pay only one site of service per provider per claim.
430 N218 You must furnish and service this item for as long as the patient continues to need it. We can pay for ma
431 N219 Payment based on previous payer's allowed amount.
432 N220 Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and
433 N221 Missing Admitting History and Physical report.
434 N222 Incomplete/invalid Admitting History and Physical report.
435 N223 Missing documentation of benefit to the patient during initial treatment period.
436 N224 Incomplete/invalid documentation of benefit to the patient during initial treatment period.
437 N226 Incomplete/invalid American Diabetes Association Certificate of Recognition.
438 N227 Incomplete/invalid Certificate of Medical Necessity.
439 N228 Incomplete/invalid consent form.
440 N229 Incomplete/invalid contract indicator.
441 N230 Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supp
442 N231 Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the t
443 N232 Incomplete/invalid itemized bill/statement.
444 N233 Incomplete/invalid operative note/report.
445 N234 Incomplete/invalid oxygen certification/re-certification.
446 N235 Incomplete/invalid pacemaker registration form.
447 N236 Incomplete/invalid pathology report.
448 N237 Incomplete/invalid patient medical record for this service.
449 N238 Incomplete/invalid physician certified plan of care.
450 N239 Incomplete/invalid physician financial relationship form.
451 N240 Incomplete/invalid radiology report.
452 N241 Incomplete/invalid review organization approval.
453 N242 Incomplete/invalid radiology film(s)/image(s).
454 N243 Incomplete/invalid/not approved screening document.
455 N244 Incomplete/Invalid pre-operative images/visual field results.
456 N245 Incomplete/invalid plan information for other insurance.
457 N246 State regulated patient payment limitations apply to this service.
458 N247 Missing/incomplete/invalid assistant surgeon taxonomy.
459 N248 Missing/incomplete/invalid assistant surgeon name.
460 N249 Missing/incomplete/invalid assistant surgeon primary identifier.
461 N250 Missing/incomplete/invalid assistant surgeon secondary identifier.
462 N251 Missing/incomplete/invalid attending provider taxonomy.
463 N252 Missing/incomplete/invalid attending provider name.
464 N253 Missing/incomplete/invalid attending provider primary identifier.
465 N254 Missing/incomplete/invalid attending provider secondary identifier.
466 N255 Missing/incomplete/invalid billing provider taxonomy.
467 N256 Missing/incomplete/invalid billing provider/supplier name.
468 N257 Missing/incomplete/invalid billing provider/supplier primary identifier.
469 N258 Missing/incomplete/invalid billing provider/supplier address.
470 N259 Missing/incomplete/invalid billing provider/supplier secondary identifier.
471 N260 Missing/incomplete/invalid billing provider/supplier contact information.
472 N261 Missing/incomplete/invalid operating provider name.
473 N262 Missing/incomplete/invalid operating provider primary identifier.
474 N263 Missing/incomplete/invalid operating provider secondary identifier.
475 N264 Missing/incomplete/invalid ordering provider name.
476 N265 Missing/incomplete/invalid ordering provider primary identifier.
477 N266 Missing/incomplete/invalid ordering provider address.
478 N267 Missing/incomplete/invalid ordering provider secondary identifier.
479 N268 Missing/incomplete/invalid ordering provider contact information.
480 N269 Missing/incomplete/invalid other provider name.
481 N270 Missing/incomplete/invalid other provider primary identifier.
482 N271 Missing/incomplete/invalid other provider secondary identifier.
483 N272 Missing/incomplete/invalid other payer attending provider identifier.
484 N273 Missing/incomplete/invalid other payer operating provider identifier.
485 N274 Missing/incomplete/invalid other payer other provider identifier.
486 N275 Missing/incomplete/invalid other payer purchased service provider identifier.
487 N276 Missing/incomplete/invalid other payer referring provider identifier.
488 N277 Missing/incomplete/invalid other payer rendering provider identifier.
489 N278 Missing/incomplete/invalid other payer service facility provider identifier.
490 N279 Missing/incomplete/invalid pay-to provider name.
491 N280 Missing/incomplete/invalid pay-to provider primary identifier.
492 N281 Missing/incomplete/invalid pay-to provider address.
493 N282 Missing/incomplete/invalid pay-to provider secondary identifier.
494 N283 Missing/incomplete/invalid purchased service provider identifier.
495 N284 Missing/incomplete/invalid referring provider taxonomy.
496 N285 Missing/incomplete/invalid referring provider name.
497 N286 Missing/incomplete/invalid referring provider primary identifier.
498 N287 Missing/incomplete/invalid referring provider secondary identifier.
499 N288 Missing/incomplete/invalid rendering provider taxonomy.
500 N289 Missing/incomplete/invalid rendering provider name.
501 N290 Missing/incomplete/invalid rendering provider primary identifier.
502 N291 Missing/incomplete/invalid rendering provider secondary identifier.
503 N292 Missing/incomplete/invalid service facility name.
504 N293 Missing/incomplete/invalid service facility primary identifier.
505 N294 Missing/incomplete/invalid service facility primary address.
506 N295 Missing/incomplete/invalid service facility secondary identifier.
507 N296 Missing/incomplete/invalid supervising provider name.
508 N297 Missing/incomplete/invalid supervising provider primary identifier.
509 N298 Missing/incomplete/invalid supervising provider secondary identifier.
510 N299 Missing/incomplete/invalid occurrence date(s).
511 N300 Missing/incomplete/invalid occurrence span date(s).
512 N301 Missing/incomplete/invalid procedure date(s).
513 N302 Missing/incomplete/invalid other procedure date(s).
514 N303 Missing/incomplete/invalid principal procedure date.
515 N304 Missing/incomplete/invalid dispensed date.
516 N305 Missing/incomplete/invalid injury/accident date.
517 N306 Missing/incomplete/invalid acute manifestation date.
518 N307 Missing/incomplete/invalid adjudication or payment date.
519 N308 Missing/incomplete/invalid appliance placement date.
520 N309 Missing/incomplete/invalid assessment date.
521 N310 Missing/incomplete/invalid assumed or relinquished care date.
522 N311 Missing/incomplete/invalid authorized to return to work date.
523 N312 Missing/incomplete/invalid begin therapy date.
524 N313 Missing/incomplete/invalid certification revision date.
525 N314 Missing/incomplete/invalid diagnosis date.
526 N315 Missing/incomplete/invalid disability from date.
527 N316 Missing/incomplete/invalid disability to date.
528 N317 Missing/incomplete/invalid discharge hour.
529 N318 Missing/incomplete/invalid discharge or end of care date.
530 N319 Missing/incomplete/invalid hearing or vision prescription date.
531 N320 Missing/incomplete/invalid Home Health Certification Period.
532 N321 Missing/incomplete/invalid last admission period.
533 N322 Missing/incomplete/invalid last certification date.
534 N323 Missing/incomplete/invalid last contact date.
535 N324 Missing/incomplete/invalid last seen/visit date.
536 N325 Missing/incomplete/invalid last worked date.
537 N326 Missing/incomplete/invalid last x-ray date.
538 N327 Missing/incomplete/invalid other insured birth date.
539 N328 Missing/incomplete/invalid Oxygen Saturation Test date.
540 N329 Missing/incomplete/invalid patient birth date.
541 N330 Missing/incomplete/invalid patient death date.
542 N331 Missing/incomplete/invalid physician order date.
543 N332 Missing/incomplete/invalid prior hospital discharge date.
544 N333 Missing/incomplete/invalid prior placement date.
545 N334 Missing/incomplete/invalid re-evaluation date.
546 N335 Missing/incomplete/invalid referral date.
547 N336 Missing/incomplete/invalid replacement date.
548 N337 Missing/incomplete/invalid secondary diagnosis date.
549 N338 Missing/incomplete/invalid shipped date.
550 N339 Missing/incomplete/invalid similar illness or symptom date.
551 N340 Missing/incomplete/invalid subscriber birth date.
552 N341 Missing/incomplete/invalid surgery date.
553 N342 Missing/incomplete/invalid test performed date.
554 N343 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.
555 N344 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.
556 N345 Date range not valid with units submitted.
557 N346 Missing/incomplete/invalid oral cavity designation code.
558 N347 Your claim for a referred or purchased service cannot be paid because payment has already been made f
559 N348 You chose that this service/supply/drug would be rendered/supplied and billed by a different practitione
560 N349 The administration method and drug must be reported to adjudicate this service.
561 N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Un
562 N351 Service date outside of the approved treatment plan service dates.
563 N352 Alert: There are no scheduled payments for this service. Submit a claim for each patient visit.
564 N353 Alert: Benefits have been estimated, when the actual services have been rendered, additional payment w
565 N354 Incomplete/invalid
The law also permitsinvoice.
you to request an appeal at any time within 120 days of the date you receive this n
566 N355 The patient has received a separate notice of this denial decision. The notice advises that he/she may be
567 N356 Not covered when performed with, or subsequent to, a non-covered service.
568 N357 Time frame requirements between this service/procedure/supply and a related service/procedure/supp
569 N358 Alert: This decision may be reviewed if additional documentation as described in the contract or plan be
570 N359 Missing/incomplete/invalid height.
571 N360 Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determinati
572 N362 The number of Days or Units of Service exceeds our acceptable maximum.
573 N363 Alert: in the near future we are implementing new policies/procedures that would affect this determinati
574 N364 Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts.
575 N366 Requested information not provided. The claim will be reopened if the information previously requested
576 N367 Alert: The claim information has been forwarded to a Consumer Spending Account processor for review;
577 N368 You must appeal the determination of the previously adjudicated claim.
578 N369 Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
579 N370 Billing exceeds the rental months covered/approved by the payer.
580 N371 Alert: title of this equipment must be transferred to the patient.
581 N372 Only reasonable and necessary maintenance/service charges are covered.
582 N373 It has been determined that another payer paid the services as primary when they were not the primary
583 N374 Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.
584 N375 Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.
585 N376 Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.
586 N377 Payment based on a processed replacement claim.
587 N378 Missing/incomplete/invalid prescription quantity.
588 N379 Claim level information does not match line level information.
589 N380 The original claim has been processed, submit a corrected claim.
590 N381 Alert: Consult our contractual agreement for restrictions/billing/payment information related to these ch
591 N382 Missing/incomplete/invalid patient identifier.
592 N383 Not covered when deemed cosmetic.
593 N384 Records indicate that the referenced body part/tooth has been removed in a previous procedure.
594 N385 Notification of admission was not timely according to published plan procedures.
595 N386 This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage deter
596 N387 Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. W
597 N388 Missing/incomplete/invalid prescription number.
598 N389 Duplicate prescription number submitted.
599 N390 This service/report cannot be billed separately.
600 N391 Missing emergency department records.
601 N392 Incomplete/invalid emergency department records.
602 N393 Missing progress notes/report.
603 N394 Incomplete/invalid progress notes/report.
604 N395 Missing laboratory report.
605 N396 Incomplete/invalid laboratory report.
606 N397 Benefits are not available for incomplete service(s)/undelivered item(s).
607 N398 Missing elective consent form.
608 N399 Incomplete/invalid elective consent form.
609 N400 Alert: Electronically enabled providers should submit claims electronically.
610 N401 Missing periodontal charting.
611 N402 Incomplete/invalid periodontal charting.
612 N403 Missing facility certification.
613 N404 Incomplete/invalid facility certification.
614 N405 This service is only covered when the donor's insurer(s) do not provide coverage for the service.
615 N406 This service is only covered when the recipient's insurer(s) do not provide coverage for the service.
616 N407 You are not an approved submitter for this transmission format.
617 N408 This payer does not cover deductibles assessed by a previous payer.
618 N409 This service is related to an accidental injury and is not covered unless provided within a specific time fra
619 N410 Not covered unless the prescription changes.
620 N411 This service is allowed one time in a 6-month period.
621 N412 This service is allowed 2 times in a 12-month period.
622 N413 This service is allowed 2 times in a benefit year.
623 N414 This service is allowed 4 times in a 12-month period.
624 N415 This service is allowed 1 time in an 18-month period.
625 N416 This service is allowed 1 time in a 3-year period.
626 N417 This service is allowed 1 time in a 5-year period.
627 N418 Misrouted claim. See the payer's claim submission instructions.
628 N419 Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.
629 N420 Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Th
630 N421 Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.
631 N422 Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive pro
632 N423 Claim payment was the result of a payer's retroactive adjustment due to a non standard program.
633 N424 Patient does not reside in the geographic area required for this type of payment.
634 N425 Statutorily excluded service(s).
635 N426 No coverage when self-administered.
636 N427 Payment for eyeglasses or contact lenses can be made only after cataract surgery.
637 N428 Not covered when performed in this place of service.
638 N429 Not covered when considered routine.
639 N430 Procedure code is inconsistent with the units billed.
640 N431 Not covered with this procedure.
641 N432 Alert: Adjustment based on a Recovery Audit.
642 N433 Resubmit this claim using only your National Provider Identifier (NPI).
643 N434 Missing/Incomplete/Invalid Present on Admission indicator.
644 N435 Exceeds number/frequency approved /allowed within time period without support documentation.
645 N436 The injury claim has not been accepted and a mandatory medical reimbursement has been made.
646 N437 Alert: If the injury claim is accepted, these charges will be reconsidered.
647 N438 This jurisdiction only accepts paper claims.
648 N439 Missing anesthesia physical status report/indicators.
649 N440 Incomplete/invalid anesthesia physical status report/indicators.
650 N441 This missed/cancelled appointment is not covered.
651 N442 Payment based on an alternate fee schedule.
652 N443 Missing/incomplete/invalid total time or begin/end time.
653 N444 Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Comp
654 N445 Missing document for actual cost or paid amount.
655 N446 Incomplete/invalid document for actual cost or paid amount.
656 N447 Payment is based on a generic equivalent as required documentation was not provided.
657 N448 This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.
658 N449 Payment based on a comparable drug/service/supply.
659 N450 Covered only when performed by the primary treating physician or the designee.
660 N451 Missing Admission Summary Report.
661 N452 Incomplete/invalid Admission Summary Report.
662 N453 Missing Consultation Report.
663 N454 Incomplete/invalid Consultation Report.
664 N455 Missing Physician Order.
665 N456 Incomplete/invalid Physician Order.
666 N457 Missing Diagnostic Report.
667 N458 Incomplete/invalid Diagnostic Report.
668 N459 Missing Discharge Summary.
669 N460 Incomplete/invalid Discharge Summary.
670 N461 Missing Nursing Notes.
671 N462 Incomplete/invalid Nursing Notes.
672 N463 Missing support data for claim.
673 N464 Incomplete/invalid support data for claim.
674 N465 Missing Physical Therapy Notes/Report.
675 N466 Incomplete/invalid Physical Therapy Notes/Report.
676 N467 Missing Tests and Analysis Report.
677 N468 Incomplete/invalid Report of Tests and Analysis Report.
678 N469 Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improve
679 N470 This payment will complete the mandatory medical reimbursement limit.
680 N471 Missing/incomplete/invalid HIPPS Rate Code.
681 N472 Payment for this service has been issued to another provider.
682 N473 Missing certification.
683 N474 Incomplete/invalid certification.
684 N475 Missing completed referral form.
685 N476 Incomplete/invalid completed referral form.
686 N477 Missing Dental Models.
687 N478 Incomplete/invalid Dental Models.
688 N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
689 N480 Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
690 N481 Missing Models.
691 N482 Incomplete/invalid Models.
692 N485 Missing Physical Therapy Certification.
693 N486 Incomplete/invalid Physical Therapy Certification.
694 N487 Missing Prosthetics or Orthotics Certification.
695 N488 Incomplete/invalid Prosthetics or Orthotics Certification.
696 N489 Missing referral form.
697 N490 Incomplete/invalid referral form.
698 N491 Missing/Incomplete/Invalid Exclusionary Rider Condition.
699 N492 Alert: A network provider may bill the member for this service if the member requested the service and
700 N493 Missing Doctor First Report of Injury.
701 N494 Incomplete/invalid Doctor First Report of Injury.
702 N495 Missing Supplemental Medical Report.
703 N496 Incomplete/invalid Supplemental Medical Report.
704 N497 Missing Medical Permanent Impairment or Disability Report.
705 N498 Incomplete/invalid Medical Permanent Impairment or Disability Report.
706 N499 Missing Medical Legal Report.
707 N500 Incomplete/invalid Medical Legal Report.
708 N501 Missing Vocational Report.
709 N502 Incomplete/invalid Vocational Report.
710 N503 Missing Work Status Report.
711 N504 Incomplete/invalid Work Status Report.
712 N505 Alert: This response includes only services that could be estimated in real-time. No estimate will be prov
713 N506 Alert: This is an estimate of the member's liability based on the information available at the time the esti
714 N507 Plan distance requirements have not been met.
715 N508 Alert: This real-time claim adjudication response represents the member responsibility to the provider fo
716 N509 Alert: A current inquiry shows the member's Consumer Spending Account contains sufficient funds to co
717 N510 Alert: A current inquiry shows the member's Consumer Spending Account does not contain sufficient fun
718 N511 Alert: Information on the availability of Consumer Spending Account funds to cover the member liability
719 N512 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the
720 N513 Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the ad
721 N516 Records indicate a mismatch between the submitted NPI and EIN.
722 N517 Resubmit a new claim with the requested information.
723 N518 No separate payment for accessories when furnished for use with oxygen equipment.
724 N519 Invalid combination of HCPCS modifiers.
725 N520 Alert: Payment made from a Consumer Spending Account.
726 N521 Mismatch between the submitted provider information and the provider information stored in our syste
727 N522 Duplicate of a claim processed, or to be processed, as a crossover claim.
728 N523 The limitation on outlier payments defined by this payer for this service period has been met. The outlier
729 N524 Based on policy this payment constitutes payment in full.
730 N525 These services are not covered when performed within the global period of another service.
731 N526 Not qualified for recovery based on employer size.
732 N527 We processed this claim as the primary payer prior to receiving the recovery demand.
733 N528 Patient is entitled to benefits for Institutional Services only.
734 N529 Patient is entitled to benefits for Professional Services only.
735 N530 Not Qualified for Recovery based on enrollment information.
736 N531 Not qualified for recovery based on direct payment of premium.
737 N532 Not qualified for recovery based on disability and working status.
738 N533 Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.
739 N534 This is an individual policy, the employer does not participate in plan sponsorship.
740 N535 Payment is adjusted when procedure is performed in this place of service based on the submitted proced
741 N536 We are not changing the prior payer's determination of patient responsibility, which you may collect, as
742 N537 We have examined claims history and no records of the services have been found.
743 N538 A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its
744 N539 Alert: We processed appeals/waiver requests on your behalf and that request has been denied.
745 N540 Payment adjusted based on the interrupted stay policy.
746 N541 Mismatch between the submitted insurance type code and the information stored in our system.
747 N542 Missing income verification.
748 N543 Incomplete/invalid income verification.
749 N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our
750 N545 Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Inc
751 N546 Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.
752 N547 A refund request (Frequency Type Code 8) was processed previously.
753 N548 Alert: Patient's calendar year deductible has been met.
754 N549 Alert: Patient's calendar year out-of-pocket maximum has been met.
755 N550 Alert: You have not responded to requests to revalidate your provider/supplier enrollment information.
756 N551 Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.
757 N552 Payment adjusted to reverse a previous withhold/bonus amount.
758 N554 Missing/Incomplete/Invalid Family Planning Indicator.
759 N555 Missing medication list.
760 N556 Incomplete/invalid medication list.
761 N557 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in who
762 N558 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in who
763 N559 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in who
764 N560 The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim w
765 N561 The bundled claim originally submitted for this episode of care includes related readmissions. You may re
766 N562 The provider number of your incoming claim does not match the provider number on the processed Noti
767 N563 Alert: Missing required provider/supplier issuance of advance patient notice of non-coverage. The patien
768 N564 Patient did not meet the inclusion criteria for the demonstration project or pilot program.
769 N565 Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable rep
770 N566 Alert: This procedure code requires functional reporting. Future claims containing this procedure code m
771 N567 Not covered when considered preventative.
772 N568 Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initi
773 N569 Not covered when performed for the reported diagnosis.
774 N570 Missing/incomplete/invalid credentialing data.
775 N571 Alert: Payment will be issued quarterly by another payer/contractor.
776 N572 This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers
777 N573 Alert: You have been overpaid and must refund the overpayment. The refund will be requested separate
778 N574 Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Ple
779 N575 Mismatch between the submitted ordering/referring provider name and the ordering/referring provider
780 N576 Services not related to the specific incident/claim/accident/loss being reported.
781 N577 Personal Injury Protection (PIP) Coverage.
782 N578 Coverages do not apply to this loss.
783 N579 Medical Payments Coverage (MPC).
784 N580 Determination based on the provisions of the insurance policy.
785 N581 Investigation of coverage eligibility is pending.
786 N582 Benefits suspended pending the patient's cooperation.
787 N583 Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.
788 N584 Not covered based on the insured's noncompliance with policy or statutory conditions.
789 N585 Benefits are no longer available based on a final injury settlement.
790 N586 The injured party does not qualify for benefits.
791 N587 Policy benefits have been exhausted.
792 N588 The patient has instructed that medical claims/bills are not to be paid.
793 N589 Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicate
794 N590 Missing independent medical exam detailing the cause of injuries sustained and medical necessity of ser
795 N591 Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).
796 N592 Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescrip
797 N593 Not covered based on failure to attend a scheduled Independent Medical Exam (IME).
798 N594 Records reflect the injured party did not complete an Application for Benefits for this loss.
799 N595 Records reflect the injured party did not complete an Assignment of Benefits for this loss.
800 N596 Records reflect the injured party did not complete a Medical Authorization for this loss.
801 N597 Adjusted based on a medical/dental provider's apportionment of care between related injuries and othe
802 N598 Health care policy coverage is primary.
803 N599 Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditi
804 N600 Adjusted based on the applicable fee schedule for the region in which the service was rendered.
805 N601 In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law paym
806 N602 Adjusted based on the Redbook maximum allowance.
807 N603 This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury P
808 N604 In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the
809 N605 This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG),
810 N606 The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (
811 N607 Service provided for non-compensable condition(s).
812 N608 The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, spe
813 N609 80% of the provider's billed amount is being recommended for payment according to Act 6.
814 N610 Alert: Payment based on an appropriate level of care.
815 N611 Claim in litigation. Contact insurer for more information.
816 N612 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.
817 N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrol
818 N614 Alert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 2110 S
819 N615 Alert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three
820 N616 Alert: This enrollee is in the first month of the advance premium tax credit grace period.
821 N617 This enrollee is in the second or third month of the advance premium tax credit grace period.
822 N618 Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.
823 N619 Coverage terminated for non-payment of premium.
824 N620 Alert: This procedure code is for quality reporting/informational purposes only.
825 N621 Charges for Jurisdiction required forms, reports, or chart notes are not payable.
826 N622 Not covered based on the date of injury/accident.
827 N623 Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.
828 N624 The associated Workers' Compensation claim has been withdrawn.
829 N625 Missing/Incomplete/Invalid Workers' Compensation Claim Number.
830 N626 New or established patient E/M codes are not payable with chiropractic care codes.
831 N628 Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.
832 N629 Reviews/documentation/notes/summaries/reports/charts not requested.
833 N630 Referral not authorized by attending physician.
834 N631 Medical Fee Schedule does not list this code. An allowance was made for a comparable service.
835 N633 Additional anesthesia time units are not allowed.
836 N634 The allowance is calculated based on anesthesia time units.
837 N635 The Allowance is calculated based on the anesthesia base units plus time.
838 N636 Adjusted because this is reimbursable only once per injury.
839 N637 Consultations are not allowed once treatment has been rendered by the same provider.
840 N638 Reimbursement has been made according to the home health fee schedule.
841 N639 Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.
842 N640 Exceeds number/frequency approved/allowed within time period.
843 N641 Reimbursement has been based on the number of body areas rated.
844 N642 Adjusted when billed as individual tests instead of as a panel.
845 N643 The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule
846 N644 Reimbursement has been made according to the bilateral procedure rule.
847 N645 Mark-up allowance.
848 N646 Reimbursement has been adjusted based on the guidelines for an assistant.
849 N647 Adjusted based on diagnosis-related group (DRG).
850 N648 Adjusted based on Stop Loss.
851 N649 Payment based on invoice.
852 N650 This policy was not in effect for this date of loss. No coverage is available.
853 N651 No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.
854 N652 The date of service is before the date of loss.
855 N653 The date of injury does not match the reported date of loss.
856 N654 Adjusted based on achievement of maximum medical improvement (MMI).
857 N655 Payment based on provider's geographic region.
858 N656 An interest payment is being made because benefits are being paid outside the statutory requirement.
859 N657 This should be billed with the appropriate code for these services.
860 N658 The billed service(s) are not considered medical expenses.
861 N659 This item is exempt from sales tax.
862 N660 Sales tax has been included in the reimbursement.
863 N661 Documentation does not support that the services rendered were medically necessary.
864 N662 Alert: Consideration of payment will be made upon receipt of a final bill.
865 N663 Adjusted based on an agreed amount.
866 N664 Adjusted based on a legal settlement.
867 N665 Services by an unlicensed provider are not reimbursable.
868 N666 Only one evaluation and management code at this service level is covered during the course of care.
869 N667 Missing prescription.
870 N668 Incomplete/invalid prescription.
871 N669 Adjusted based on the Medicare fee schedule.
872 N670 This service code has been identified as the primary procedure code subject to the Medicare Multiple Pr
873 N671 Payment based on a jurisdiction cost-charge ratio.
874 N672 Alert: Amount applied to Health Insurance Offset.
875 N673 Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee
876 N674 Not covered unless a pre-requisite procedure/service has been provided.
877 N675 Additional information is required from the injured party.
878 N676 Service does not qualify for payment under the Outpatient Facility Fee Schedule.
879 N677 Alert: Films/Images will not be returned.
880 N678 Missing post-operative images/visual field results.
881 N679 Incomplete/Invalid post-operative images/visual field results.
882 N680 Missing/Incomplete/Invalid date of previous dental extractions.
883 N681 Missing/Incomplete/Invalid full arch series.
884 N682 Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.
885 N683 Missing/Incomplete/Invalid prior treatment documentation.
886 N684 Payment denied as this is a specialty claim submitted as a general claim.
887 N685 Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.
888 N686 Missing/incomplete/Invalid questionnaire needed to complete payment determination.
889 N687 Alert: This reversal is due to a retroactive disenrollment.
890 N688 Alert: This reversal is due to a medical or utilization review decision.
891 N689 Alert: This reversal is due to a retroactive rate change.
892 N690 Alert: This reversal is due to a provider submitted appeal.
893 N691 Alert: This reversal is due to a patient submitted appeal.
894 N692 Alert: This reversal is due to an incorrect rate on the initial adjudication.
895 N693 Alert: This reversal is due to a cancellation of the claim by the provider.
896 N694 Alert: This reversal is due to a resubmission/change to the claim by the provider.
897 N695 Alert: This reversal is due to incorrect patient financial responsibility information on the initial adjudicati
898 N696 Alert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjus
899 N697 Alert: This reversal is due to a payer's retroactive contract incentive program adjustment.
900 N698 Alert: This reversal is due to non-payment of the health insurance premiums (Health Insurance Exchange
901 N699 Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.
902 N700 Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.
903 N701 Payment adjusted based on the Value-based Payment Modifier.
904 N702 Decision based on review of previously adjudicated claims or for claims in process for the same/similar ty
905 N703 This service is incompatible with previously adjudicated claims or claims in process.
906 N704 Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if
907 N705 Incomplete/invalid documentation.
908 N706 Missing documentation.
909 N707 Incomplete/invalid orders.
910 N708 Missing orders.
911 N709 Incomplete/invalid notes.
912 N710 Missing notes.
913 N711 Incomplete/invalid summary.
914 N712 Missing summary.
915 N713 Incomplete/invalid report.
916 N714 Missing report.
917 N715 Incomplete/invalid chart.
918 N716 Missing chart.
919 N717 Incomplete/Invalid documentation of face-to-face examination.
920 N718 Missing documentation of face-to-face examination.
921 N719 Penalty applied based on plan requirements not being met.
922 N720 Alert: The patient overpaid you. You may need to issue the patient a refund for the difference between t
923 N721 This service is only covered when performed as part of a clinical trial.
924 N722 Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item.
925 N723 Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.
926 N724 Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.
927 N725 A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis
928 N726 A conditional payment is not allowed.
929 N727 A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnos
930 N728 A workers' compensation insurer has reported having ongoing responsibility for medical services (ORM)
931 N729 Missing patient medical/dental record for this service.
932 N730 Incomplete/invalid patient medical/dental record for this service.
933 N731 Incomplete/Invalid mental health assessment.
934 N732 Services performed at an unlicensed facility are not reimbursable.
935 N733 Regulatory surcharges are paid directly to the state.
936 N734 The patient is eligible for these medical services only when unable to work or perform normal activities d
937 N736 Incomplete/invalid Sleep Study Report.
938 N737 Missing Sleep Study Report.
939 N738 Incomplete/invalid Vein Study Report.
940 N739 Missing Vein Study Report.
941 N740 The member's Consumer Spending Account does not contain sufficient funds to cover the member's liab
942 N741 This is a site neutral payment.
943 N743 Adjusted because the services may be related to an employment accident.
944 N744 Adjusted because the services may be related to an auto/other accident.
945 N745 Missing Ambulance Report.
946 N746 Incomplete/invalid Ambulance Report.
947 N747 This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.
948 N748 Adjusted because the related hospital charges have not been received.
949 N749 Missing Blood Gas Report.
950 N750 Incomplete/invalid Blood Gas Report.
951 N751 Adjusted because the patient is covered under a Medicare Part D plan.
952 N752 Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).
953 N753 Missing/incomplete/invalid Attachment Control Number.
954 N754 Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.
955 N755 Missing/incomplete/invalid ICD Indicator.
956 N756 Missing/incomplete/invalid point of drop-off address.
957 N757 Adjusted based on the Federal Indian Fees schedule (MLR).
958 N758 Adjusted based on the prior authorization decision.
959 N759 Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2
 960 N760 This facility is not authorized to receive payment for the service(s).
961 N761 This provider is not authorized to receive payment for the service(s).
962 N762 This facility is not certified for Tomosynthesis (3-D) mammography.
963 N763 The demonstration code is not appropriate for this claim; resubmit without a demonstration code.
964 N764 Missing/incomplete/invalid Hematocrit (HCT) value.
965 N765 This payer does not cover coinsurance assessed by a previous payer.
966 N766 This payer does not cover co-payment assessed by a previous payer.
967 N767 The Medicaid state requires provider to be enrolled in the member's Medicaid state program prior to an
968 N768 Incomplete/invalid initial evaluation report.
969 N769 A lateral diagnosis is required.
970 N770 The adjustment request received from the provider has been processed. Your original claim has been ad
971 N771 Alert: Under Federal law you cannot charge more than the limiting charge amount.
972 N772 Alert: Rebill urgent/emergent and ancillary services separately.
973 N773 Drug supplied not obtained from specialty vendor.
974 N774 Alert: Refer to your Third Party Processor Agreement for specific information on fees associated with thi
975 N775 Payment adjusted based on x-ray radiograph on film.
976 N776 This service is not a covered Telehealth service.
977 N777 Missing Assignment of Benefits Indicator.
978 N778 Missing Primary Care Physician Information.
979 N779 Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit onc
980 N780 Missing/incomplete/invalid end therapy date.
981 N781 Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully colle
982 N782 Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully colle
983 N783 Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully colle
984 N784 Missing comprehensive procedure code.
985 N785 Missing current radiology film/images.
986 N786 Benefit limitation for the orthodontic active and/or retention phase of treatment.
987 N787 Alert: Under 42 CFR 410.43, an eligible Partial Hospitalization Program (PHP) patient/beneficiary requires
988 N788 Alert: The third-party administrator/review organization did not receive the required information.
989 N789 Clinical Trial is not a covered benefit.
990 N790 Provider/supplier not accredited for product/service.
991 N791 Missing history & physical report.
992 N792 Incomplete/invalid history & physical report.
993 N794 Payment adjusted based on type of technology used.
994 N795 Item must be resubmitted as a purchase.
995 N796 Missing/incomplete/invalid Hemoglobin (Hb or Hgb) value.
996 N797 Missing/incomplete/invalid date qualifier.
997 N798 Submit a void request for the original claim and resubmit a new claim.
998 N799 Submitted identifier must be an individual identifier, not group identifier.
999 N800 Only one service date is allowed per claim.
1000 N801 Services performed in a Medicare participating or CAH facility under a self-insured tribal Group Health Pl
1001 N802 This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in who
1002 N803 Submission of the claim for the service rendered is the responsibility of the Contracted Medical Group or
1003 N804 Alert: The claim/service was processed through the Outpatient Code Editor (OCE).
1004 N805 Alert: The claim/service was processed through the Correct Code Editor (CCE).
1005 N806 Payment is included in the Global transplant allowance.
1006 N807 Payment adjustment based on the Merit-based Incentive Payment System (MIPS).
1007 N808 Not covered for this provider type / provider specialty.
1008 N809 Alert: The fee schedule amount for this service was adjusted based on prior competitive bidding rates. Fo
1009 N810 Alert: Due to federal, state or local disaster declaration, this claim has been processed at the in-network
1010 N811 Missing Federal Sequestration Reduction from Prior Payer.
1011 N812 The start service date through end service date cannot span greater than 18 months.
1012 N815 Missing/Incomplete/Invalid NDC Unit Count
1013 N816 Missing/Incomplete/Invalid NDC Unit of Measure
1014 N817 Alert: Applicable laboratories are required to collect and report private payor data and report that data t
1015 N818 Claims Dates of Service do not match Electronic Visit Verification System.
1016 N819 Patient not enrolled in Electronic Visit Verification System.
1017 N820 Electronic Visit Verification System units do not meet requirements of visit.
1018 N821 Electronic Visit Verification System visit not found.
1019 N822 Missing procedure modifier(s).
1020 N823 Incomplete/Invalid procedure modifier(s).
1021 N824 Electronic Visit Verification (EVV) data must be submitted through EVV Vendor.
1022 N825 Early intervention guidelines were not met.
1023 N826 Patient did not meet the inclusion criteria for the Medicare Shared Savings Program.
1024 N827 Missing/Incomplete/Invalid Federal Information Processing Standard (FIPS) Code.
1025 N828 Alert: Payment is suppressed due to a contracted funding.
1026 N829 Missing/incomplete/invalid Diagnostics Exchange Z-Code Identifier.
1027 N830 Alert: The charge[s] for this service was processed in accordance with Federal/ State, Balance Billing/ No
1028 N831 You have not responded to requests to revalidate your provider/supplier enrollment information.
1029 N832 Duplicate occurrence code/occurrence span code.
1030 N833 Patient share of cost waived.
1031 N834 Jurisdiction exempt from sales and health tax charges.
1032 N835 Unrelated Service/procedure/treatment is reduced. The balance of this charge is the patient's responsib
1033 N836 Provider W9 or Payee Registration not on file.
1034 N837 Alert: Missing modifier was added.
1035 N838 Alert: Service/procedure postponed due to a federal, state, or local mandate/disaster declaration. Any a
1036 N839 The procedure code was added/changed because the level of service exceeds the compensable conditio
1037 N840 Worker's compensation claim filed with a different state.
1038 N841 Alert: North Dakota Administrative Rule 92-01-02-50.3.
1039 N842 Alert: Patient cannot be billed for charges.
1040 N843 Missing/incomplete/invalid Core-Based Statistical Area (CBSA) code.
1041 N844 This claim, or a portion of this claim, was processed in accordance with the Nebraska Legislative LB997 Ju
1042 N845 Alert: Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act.
1043 N846 National Drug Code (NDC) supplied does not correspond to the HCPCs/CPT billed.
1044 N847 National Drug Code (NDC) billed is obsolete.
1045 N848 National Drug Code (NDC) billed cannot be associated with a product.
1046 N849 Missing Tooth Clause: Tooth missing prior to the member effective date.
1047 N850 Missing/incomplete/invalid narrative explaining/describing this service/treatment.
1048 N851 Payment reduced because services were furnished by a therapy assistant.
1049 N852 The pay-to and rendering provider tax identification numbers (TINs) do not match
1050 N853 The number of modalities performed per session exceeds our acceptable maximum.
1051 N854 Alert: If you have primary other health insurance (OHI) coverage that has denied services, you must exha
1052 N855 This coverage is subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
1053 N856 This coverage is not subject to the exclusive jurisdiction of ERISA (1974), U.S.C. SEC 1001.
1054 N857 This claim has been adjusted/reversed. Refund any collected copayment to the member.
1055 N858 Alert: State regulations relating to an Out of Network Medical Emergency Care Act were applied to the p
1056 N859 Alert: The Federal No Surprise Billing Act was applied to the processing of this claim. Payment amounts a
1057 N860 Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the me
1058 N861 Alert: Mismatch between the submitted Patient Liability/Share of Cost and the amount on record for this
1059 N862 Alert: Member cost share is in compliance with the No Surprises Act, and is calculated using the lesser of
1060 N863 Alert: This claim is subject to the No Surprises Act (NSA). The amount paid is the final out-of-network rat
1061 N864 Alert: This claim is subject to the No Surprises Act provisions that apply to emergency services.
1062 N865 Alert: This claim is subject to the No Surprises Act provisions that apply to nonemergency services furnis
1063 N866 Alert: This claim is subject to the No Surprises Act provisions that apply to services furnished by nonparti
1064 N867 Alert: Cost sharing was calculated based on a specified state law, in accordance with the No Surprises Ac
1065 N868 Alert: Cost sharing was calculated based on an All-Payer Model Agreement, in accordance with the No Su
1066 N869 Alert: Cost sharing was calculated based on the qualifying payment amount, in accordance with the No S
1067 N870 Alert: In accordance with the No Surprises Act, cost sharing was based on the billed amount because the
1068 N871 Alert: This initial payment was calculated based on a specified state law, in accordance with the No Surp
1069 N872 Alert: This final payment was calculated based on a specified state law, in accordance with the No Surpri
1070 N873 Alert: This final payment was calculated based on an All-Payer Model Agreement, in accordance with the
1071 N874 Alert: This final payment was determined through open negotiation, in accordance with the No Surprises
1072 N875 Alert: This final payment equals the amount selected as the out-of-network rate by a Federal Independe
1073 N876 Alert: This item or service is covered under the plan. This is a notice of denial of payment provided in acc
1074 N877 Alert: This initial payment is provided in accordance with the No Surprises Act. The provider or facility m
1075 N878 Alert: The provider or facility specified that notice was provided and consent to balance bill obtained, bu
1076 N879 Alert: The notice and consent to balance bill, and to be charged out-of-network cost sharing, that was ob
1077 N880 Original claim closed due to changes in submitted data. Adjustment claim will be processed under a new
1078 N881 Client Obligation, patient responsibility for Home & Community Based Services (HCBS)
1079 N882 Alert: The out-of-network payment and cost sharing amounts were based on the plan's allowance becau
1080 N883 Alert: Processed according to state law
1081 N884 Alert: The No Surprises Act may apply to this claim. Please contact payer for instructions on how to subm
1082 N885 Alert: This claim was not processed in accordance with the No Surprises Act cost-sharing or out-of-netwo
1083 N886 Alert: A Health
Providers Care Claim Request
not participating for Additional
in the Medicare Information
Advantage (277
Plan have RFAI)
the righthas been sent.
to appeal if the plan has partia
1084 N887 Once we receive the completed forms, we will give you a decision on your appeal within 60 calendar day
1085 N888 Alert: An electronic request for additional information has been sent for this claim.
1086 N889 Alert: This claim was originally processed in real-time, and we sent a real-time 835 response.
1087 N890 Electronic Visit Verification Data Element Requirements were not met.
1088 N891 The maximum allowable payment for this service/procedure was paid by the primary insurance. No furth
1089 N892 The claim does not meet the criteria for acceptable use of the Delay Reason Code.
1090 N893 Missing/incomplete/invalid child medical evaluation form/checklist.
1091 N894 Alert: These payments are made subject to a reservation of rights for the Payor to recoup or otherwise r
1092 N895 Processed based on a negotiated fee schedule for a specialty drug program.
1093 N896 Missing/incomplete/invalid trauma activation sheet.
1094 N897 Missing/incomplete/invalid proof of member payment.
1095 N898 Missing/incomplete/invalid Resource Utilization Group(s) (RUG) code(s).
1096 N899 Missing Initial Evaluation Report.
1097 N900 Missing Therapy Notes/Report.
1098 N901 Incomplete/Invalid Therapy Notes/Report.
1099 N902 Missing Health Risk Assessment (HRA).
1100 N903 Incomplete/Invalid Health Risk Assessment (HRA).
1101 N904 The transportation vendor is responsible for this claim.
1102 N905 Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for ser
1103 N906 Service is not covered when patient is under age 45.
1104 N907 No refund because this claim has been identified as 340B-eligible with a ceiling price lower than the max
1105 N908 No refund because this drug has been prospectively purchased at the maximum fair price.
1106 N909 Refund amount has been calculated using a methodology that differs from the Standard Default Refund
1107 N910 A refund cannot be provided for this claim at this time. Contact the manufacturer directly regarding your
1108 N911 This claim cannot be reimbursed by the manufacturer until the Part D plan submits corrected prescriptio
l equipment.
from the first rental month, or the month when the equipment is no longer needed.
d for the remainder of the reasonable useful lifetime of the equipment.
of issued rental payments equals the purchase price.
a medical supplier or taken while the patient is on oxygen.
of changing the rental to a purchase agreement.

ices the patient's zip code.

d services are included on the claim.

nd no payment for a full office visit if the patient only received an injection.
components of the same procedure. Separate payment is not allowed.
rning this policy/procedure/decision.
ave been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges fo
killed Nursing Facility (SNF) is considered to be a patient's home.

ed in a home.

service.
service. If
If you
you believe the service
have collected should have
any amount frombeen fully covered
the patient for thisaslevel
billed, or if you didamount
of service/any not know andexceeds
that could not
thereasonably havefor
limiting charge been
theexp
les
2CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil mo
and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including
hausted or not otherwise available.

e by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from
t the patient has been given the option of changing the rental to a purchase.

rmed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges.
otice of non-coverage you provided the patient did not comply with program requirements.

t for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (D
stered with a covered oral anti-cancer drug.

hased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.
tions and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. P

modified procedure code.

ode for processing, but please continue to submit the NDC on future claims for this item.

mponent of this service. Rebill as separate professional and technical components.

ned for payment.

y processed service for the patient.

e within set time frame.

separate claims.
riod began with delivery of this equipment.
ental period will not begin.

e billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you
Payment included in the reimbursement issued the facility.

e immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.

formation we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduce
riod will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.
ormation we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced
ceeded 36.5%.
must send 25 percent of the teleconsultation payment to the referring practitioner.
efuses to have an x-ray taken.
red under the DMEPOS Competitive Bidding Program for the area where the patient resides.
o the current contract period for the DMEPOS Competitive Bidding Program.
 he DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local c
-demonstration supplier.
s ending and additional services may not be paid under this project or program.

es the part or supply.

e service/supply/equipment will be needed.

ounts, and/or the type of intraocular lens used.

amount you were charged for the test.

valuated by a physician.

nrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.

ery/procedure.
may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to condu
peal. You must file a written request for an appeal within 180 days of the date you receive this notice.
ent information from the primary payer. The information was either not reported or was illegible.

erage is not with a Medigap plan, or you do not participate in Medicare.

nce with our current assignment/participation agreement.
refund the overpayment to the patient.
ervices furnished by the person(s) that furnished this (these) service(s).
ot reported with the PR (patient responsibility) group code.
lan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time.
e a separate notice for the other services reported.
epartment of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.
tact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.
emental insurer. Send any questions regarding supplemental benefits to them.
valid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that i
d to the use of an urethral catheter for convenience or the control of incontinence.

benefit period.
benefit period.
 ssignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appea

in a special account.
t be issued.
ent not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.

linical Trial number.

entification.

y revoking his/her election to receive religious non-medical health care services.

ent not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, b
on-medical health care services.

ent a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notic

annot process this claim until we have received payment information from the primary and secondary payers.

ormation on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely

the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient resp
ayment issued under fee-for-service Medicare as patient has elected managed care.
her lost, damaged or returned.

hospice when physician is performing care plan oversight services.

n 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as patie
yment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.

rial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact J
r the primary payer.
mary payer.

n the claim form to certify that the rendering physician is not an employee of the hospice.
tient is not enrolled in a Medicare managed care plan.
act number or clinical trial registry number.

were performed by an outside entity or if no purchased tests are included on the claim.
ming laboratory's name and address.

per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending cor

here the service(s) were rendered in a Health Professional Shortage Area (HPSA).
ether laboratory services were performed at home or in an institution.

urnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Coinsurance and/or deductible are applica

nnot pay for these services.

rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.
claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.

he inpatient stay.

ts following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes. R
ourse of treatment provision of the plan.

an the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.
ajor Medical provisions.
warded. Resubmit this claim to this payer to provide adequate data for adjudication.

nsult/manual adjudication/medical advisor/dental advisor/peer review.

not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that wou

n a higher percentage.

y describes the services rendered.

other carriers and/or maximum benefit provisions.

strative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behal

consider payment.

surance carrier.

e of service.

e of service billed.

vider information.
 t on file, for the date of service/provider.
ment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was e
nt was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility.

y services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claim
ot supported by clinical records.
ly one calendar month.

t completed.

arty payer contract specifies full reimbursement.

nstration project.

edback training for the treatment of urinary incontinence to be covered.

otice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain thera
n one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.

nished at multiple sites may not be billed in the same claim.

or adjudication.

al, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can
ogic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three ind
bsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improve
ary data such that clinical results of the implant procedure can be properly evaluated.
e, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or sh
n identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.
aims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claim
except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this servic
d on the inpatient claim. They cannot be billed separately as outpatient services.

ded in a claim that has been previously billed and adjudicated.

n the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted
provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/
rovided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home he
ent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.
isode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.
practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.

originally submitted service.

em
itembecause
becausethe
theinformation
informationfurnished
furnisheddoes
doesnot
notsubstantiate
substantiatethe
theneed
needfor
forthe
the(more
(moreextensive)
extensive)service/item.
service/item.The patient
If you haveiscollected
liable forany
theam
c
t (and in §§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and
s payer does not cover items and services furnished to individuals who have been deported.
UMWA) beneficiary. Please submit claims to them.

ons for this service.

this service.
ebarred or excluded provider after the 30 day grace period as previously notified.
being processed separately.
t has been discontinued, please contact Customer Service.

l the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.

the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first
e additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance c
iate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writin
herefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representativ
f the service dates billed.

ates billed.

he patient ID number is missing, incomplete, or invalid on the assignment request.

equirement has been met.

bmit other insurance information for our records.

reatment and the elective treatment.

t is not in the ambulance.

procedure/ equipment/ supply/ service.

t included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment
chase price.
y updated service/item.

liability is limited to amounts shown in the adjustments under group 'PR'.

d States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.
cated no additional payment can be made.

s will be reconsidered upon receipt of that information.

h it was billed.

bmitted for payment additional documentation as specified in plan documents will be required to process benefits.

rest Military Treatment Facility (MTF) for assistance.

ollowing receipt of this notice by following the instructions included in your contract or plan benefit documents.

efit restrictions.

another payer.

ords for prior 12 months

nformation.

uire a claims determination for this service from a primary payer as a condition of making its own claims determination.
led in this portion of our benefit package.

to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.
partment to obtain forms and instructions for filing a provider dispute.

reatment period.

that requires the part or supply.

ns, less discounts, and/or the type of intraocular lens used.
ENS) trial start date.
ENS) trial end date.

ment has already been made for this same service to another provider by a payment contractor representing the payer.
billed by a different practitioner/supplier.

sified (NOC) code or for an Unlisted/By Report procedure.

each patient visit.

endered, additional payment will be considered based on the submitted claim.
of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not
ce advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell h

lated service/procedure/supply have not been met.

bed in the contract or plan benefit documents is submitted.

enefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.

at would affect this determination.

coinsurance amounts.
ormation previously requested is submitted within one year after the date of this denial notice.
Account processor for review; for example, flexible spending account or health savings account.

tate legislation/regulation.

hen they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.
ttance Advice is required.
ine dependent eligibility.
verage may be TRICARE.

nformation related to these charges.

n a previous procedure.

NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms
t of supplemental benefits. We did not forward the claim information.

erage for the service.

coverage for the service.

vided within a specific time frame from the date of the accident.
retroactive rate change.
Coordination of Benefits or Third Party Liability Recovery.
review organization decision.
payer's contract incentive program.
non standard program.

support documentation.
sement has been made.

the Division of Workers' Compensation.

not provided.
legislated fee arrangement.
are Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

ondary Payer).
edicare Secondary Payer).

ber requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.

time. No estimate will be provided for the services that could not be estimated in real-time.
n available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is p

esponsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contac
contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will de
does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Acco
to cover the member liability on this claim/service is not available at this time.
al-time without change to the adjudication.
al-time with a change to the adjudication.

equipment.

nformation stored in our system.

riod has been met. The outlier payment otherwise applicable to this claim has not been paid.

f another service.

ry demand.

d tribal Group Health Plan.

based on the submitted procedure code and place of service.

ity, which you may collect, as this service is not covered by us.

e services/supplies/drugs to its patients/residents.

uest has been denied.

n stored in our system.

ovider that does not match our system record. Unless corrected this will not be paid in the future.
lectronic Prescribing (eRx) Incentive Program.
ng (eRx) Incentive Program.

plier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future.
Reporting Program.

e filed to the Payer/Plan in whose service area the specimen was collected.
e filed to the Payer/Plan in whose service area the equipment was received.
e filed to the Payer/Plan in whose service area the Ordering Physician is located.
Notice of Admission. A claim was not received.
ated readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.
number on the processed Notice of Admission (NOA) for this bundled payment.
ce of non-coverage. The patient is not liable for payment for this service.
r pilot program.
ontaining this non-payable reporting code must include an appropriate modifier for the claim to be processed.
ntaining this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.

undled Payment Model IV initiative.

des and associated modifiers are submitted.

und will be requested separately by another payer/contractor.
that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referrin
he ordering/referring provider name stored in our records.

n eligible injured person.

y conditions.

r vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.
d and medical necessity of services rendered.
n Review (UR).
allowed for the initial prescription.
Exam (IME).
fits for this loss.
fits for this loss.
for this loss.
ween related injuries and other unrelated medical/dental conditions/injuries.

to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Sta
service was rendered.
r Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.

r Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.
as calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appe
s Related Groups (APR-DRG), pursuant to Regulation 68.
Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

ee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.
ccording to Act 6.
 workers in this jurisdiction.
at needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate an
tification Segment (loop 2110 Service Payment Information).
is in the grace period of three consecutive months for non-payment of premium. Under 45 CFR 156.270, a Qualified Health Plan issuer mu
grace period.
redit grace period.
r premiums.

al/excessive/inappropriate.

t or treatment is disallowed.

comparable service.

ame provider.

acilities fee schedule.

applicable state fee schedule.

t the time of the loss.

e the statutory requirement.

ly necessary.
 during the course of care.

ct to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

n outpatient factor and/or fee schedule amount.

etermination.

mation on the initial adjudication.

ity Recovery retroactive adjustment.
m adjustment.
ms (Health Insurance Exchange or other) by the end of the premium payment grace period, resulting in loss of coverage.
) Incentive Program.

process for the same/similar type of services.

with corrected information if warranted.

d for the difference between the patient's payment and the amount shown as patient responsibility on this notice.

or the medical service or item.

rvice or item.
rvices (ORM) for this diagnosis.

ervices (ORM) for this diagnosis.

ty for medical services (ORM) for this diagnosis.

or perform normal activities due to an illness or injury.

nds to cover the member's liability for this claim/service.

ere the patient resides.

n the 1500 Claim Form.

tion (NEMA) Standard XR-29-2013.

t a demonstration code.

caid state program prior to any claim benefits being processed.

our original claim has been adjusted based on the information received.

on on fees associated with this payment type.

finalized. Please resubmit once payment or denial is received.

ecords for any wrongfully collected deductible. This amount may be billed to a subsequent payer.
ecords for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.
ecords for any wrongfully collected copayment. This amount may be billed to a subsequent payer.

P) patient/beneficiary requires a minimum of 20 hours of PHP services per week, as evidenced in the plan of care. PHP services must be fu
e required information.

insured tribal Group Health Plan, in accordance with Federal Regulation 42 CFR 136.
e filed to the Payer/Plan in whose service area the Rendering Physician is located.
e Contracted Medical Group or Hospital.
 r competitive bidding rates. For more information, contact your local contractor.
n processed at the in-network level of benefit. At the conclusion or expiration of the disaster declaration, network payment rules will be re

yor data and report that data to CMS between January 1, 2020 - March 31, 2020.

eral/ State, Balance Billing/ No Surprise Billing regulations. As such, any amount identified with OA, CO, or PI cannot be collected from the
nrollment information.

arge is the patient's responsibility.

te/disaster declaration. Any amounts applied to deductible or member liability will be applied to the prior plan year from which the proce
eds the compensable condition(s).

e Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act.
cy Medical Care Act.

denied services, you must exhaust all appeal levels with your primary OHI before we can consider your claim for reimbursement.

.S.C. SEC 1001.

o the member.
Care Act were applied to the processing of this claim. Payment amounts are eligible for dispute following the state's documented appeal/
this claim. Payment amounts are eligible for dispute pursuant to any Federal documented appeal/ grievance/ dispute resolution process(e
was used to calculate the member cost share(s).
the amount on record for this recipient.
s calculated using the lesser of the QPA or billed charge.
is the final out-of-network rate and was calculated based on an All Payer Model Agreement, in accordance with the NSA.
emergency services.
nonemergency services furnished by nonparticipating providers during a patient visit to a participating facility.
services furnished by nonparticipating providers of air ambulance services.
ance with the No Surprises Act.
, in accordance with the No Surprises Act.
t, in accordance with the No Surprises Act.
he billed amount because the billed amount was lower than the qualifying payment amount.
accordance with the No Surprises Act.
accordance with the No Surprises Act.
ement, in accordance with the No Surprises Act.
ordance with the No Surprises Act.
k rate by a Federal Independent Dispute Resolution Entity, in accordance with the No Surprises Act.
ial of payment provided in accordance with the No Surprises Act. The provider or facility may initiate open negotiation if they desire to ne
Act. The provider or facility may initiate open negotiation if they desire to negotiate a higher out-of-network rate.
nt to balance bill obtained, but notice and consent was not provided and obtained in a manner consistent with applicable Federal law. Thu
work cost sharing, that was obtained from the patient with regard to the billed services, is not permitted for these services. Thus, cost sha
will be processed under a new claim number.
vices (HCBS)
on the plan's allowance because the provider or facility obtained the patient's consent to waive the balance billing protections under the N

or instructions on how to submit information regarding whether or not the item or service was furnished during a patient visit to a particip
ct cost-sharing or out-of-network payment requirements. The payer disagrees with your determination that those requirements apply. You
as appeal
to been sent.
if the plan has partially or fully denied payment or if the provider believes the plan has not paid the services at the expected Me
appeal within 60 calendar days.

me 835 response.

he primary insurance. No further payment due.

ayor to recoup or otherwise recover all or part of these payments based on any of the following: outcome of pending or future litigation/

ent not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is not responsible for paymen
iling price lower than the maximum fair price.
mum fair price.
the Standard Default Refund Amount calculation ((Wholesale Acquisition Cost minus Maximum Fair Price) times Quantity).
acturer directly regarding your eligibility.
submits corrected prescription drug event data to CMS for maximum fair price validation.
you will be liable for charges for the same service(s) under the same or similar conditions.

not
thereasonably havefor
limiting charge been
theexpected to know
less extensive that we
service, thewould not payyou
law requires forto
this level that
refund of service,
amount or to
if you
the notified the patient
patient within in writing
30 days in adva
of receiving th
nds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please con
ent's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted

payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this ser

esponsible for the charges.

Document Control Number (DCN).

 s subject to price limitations. Please submit the technical and professional components of this service as separate line items.

ment. If not already billed, you should bill us for the professional component only.

ment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.
s item or service.
ment for this item at a reduced level, and a new capped rental period will not begin.
e projects, contact your local contractor.

cess your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the da

f this, we are paying this time. In the future, we will not pay you for non-plan services.

condary claim directly to that insurer.

 No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of

t is responsible for payment.

t is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.

ent responsibility on this notice.

r to assure correct and timely routing of the claim.

amount shown as patient responsibility and as paid to the patient on this notice.

nd the amount shown as patient responsibility on this notice.

s phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.

ot bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim aft

e and/or deductible are applicable.

t information.

ents or jurisdiction statutes. Refer to the URL provided in the ERA for the payer website to access the appeals process guidelines.
portion of the charge that would have been covered by Medicare.

t to claims processed on behalf of your benefit plan.

notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the pa
payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insure

nment for these types of claims.

ling requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be reco
mittance advice.

plantation with anesthesia can occur.

stations of the above three indications are excluded.
50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.

to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liab

formation for electronic claims processing.

than the patient for this service.

ule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculatio
y is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.
ent is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be
. The
m. patient
If you haveiscollected
liable forany
theamount
charges from
for this
theservice/item
patient, youas yourefund
must informed
thatthe patienttointhe
amount writing before
patient the30service/item
within was furnished
days of receiving tha
this notice.
suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from th

ulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered.
ubscriber's dental insurance carrier for a second Independent Dental Advisor Review.
mination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit
to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a s

ll result in a denial of payment in the near future.

s must provide the service.

ermination.

erage manual.
 g the payer.

e date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notifie
would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund w
policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of th
or the billed charge.

etermined when the claim is processed. This is not a pre-authorization or a guarantee of payment.

ronically or in the mail. Contact the insurer if there are any questions.
umer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.
the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment pro
hold in the near future.
claim to be processed.

contact the ordering/referring provider.

e of a drug.

well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and c

System applicable to Hawaii.

to Regulation 83 and / or Appendix 17-C of 11 NYCRR.

ection 4 of ORS 742.524.

tted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected

Qualified Health Plan issuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period
care. PHP services must be furnished in accordance with the plan of care.
twork payment rules will be reinstated.

cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer. Any amount the prov

lan year from which the procedure was cancelled.

for reimbursement.

e state's documented appeal/ grievance/ arbitration process.

 / dispute resolution process(es).

with the NSA.

egotiation if they desire to negotiate a higher out-of-network rate than the amount paid by the patient in cost sharing.

ith applicable Federal law. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Su
these services. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Surprises Act

billing protections under the No Surprises Act.

ring a patient visit to a participating facility.

those requirements apply. You may contact the payer to find out why it disagrees. You may appeal this adverse determination on behalf o
e services at the expected Medicare reimbursable rate or type of level/service. Providers may file their appeal in writing within 60 calenda

of pending or future litigation/ new or updated state, federal or regulatory guidance/ any other actions that may affect the Payor's obligati

t is not responsible for payment.

times Quantity).
 the patient
within in writing
30 days in advance
of receiving that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your
this notice.
s about this notice, please contact this office.
and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered

dditional payment for this service.

arate line items.
o us within 120 days of the date you received this notice, unless you have a good reason for being late.
on, are conferred by receipt of this notice.

arge amount.
ou may resubmit this claim after you have notified this office of your correct TIN.

ls process guidelines.
location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not invo
the patient or another insurer for this claim must be refunded to the payer within 30 days.

payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of c

he individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collec

e blended payment calculation will be.

uest a copy of the LCD.
s and supplies, such as this, be included in the home health agency's (HHA's) payment. This payment will need to be recouped from you if
0service/item was furnished
days of receiving that we would not pay for it, and the patient agreed to pay.
this notice.
lties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office.

h care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority.

d as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs an
mitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscribe
ted, the patient will be notified that you have requested one, and will receive a copy of the determination.
ear anything about a refund within 30 days
tractor to request a copy of the NCD.
time of payment processing.
ces at the time of payment processing.
insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and var
ment record. Unless corrected, a claim with this ordering provider will not be paid in the future.

first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace per
nt payer. Any amount the provider collected over the identified PR amount must be refunded to the patient within applicable Federal/Stat
ost sharing.

requirements under the No Surprises Act, and balance billing is prohibited.

nts under the No Surprises Act, and balance billing is prohibited.

erse determination on behalf of the patient through the payer’s internal appeals and external review processes.
al in writing within 60 calendar days after the date of the remittance advice. For the plan to review the appeal, the plan will need a compl

may affect the Payor's obligation to make these payments.

g to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application f

w, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination
 furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstratio

ent under a HHA episode of care.

government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider

ed to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.
ct this office.

agree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this lette
t information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
vels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other info
third months of the grace period.
within applicable Federal/State timeframes. Payment amounts are eligible for dispute pursuant to any Federal/State documented appeal/
eal, the plan will need a completed signed Waiver of Liability Statement. To obtain a Waiver of Liability form, please contact your Medicare
eal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deduc

h the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the d
or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.

f its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.

A episode of care.
days from the date of this letter.
ance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service
ral/State documented appeal/grievance process(es).
please contact your Medicare Advantage Plan.
im/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.

filed within 120 days of the date you receive this notice. You must make the request through this office.
facility on the new claim.
The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the ser
as an overpayment.
for the locale in which the services were rendered.