Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Transportation is only covered to the closest facility that can provide the necessary care. However, this amount may be billed to subsequent payer. The date of death precedes the date of service. Denial CO-252 | Medical Billing and Coding Forum - AAPC Reason Code 244: Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. : The procedure code is inconsistent with the provider type/specialty (taxonomy). 0. Reason Code 249: An attachment is required to adjudicate this claim/service. Reason Code 160: Attachment referenced on the claim was not received. Reason Code 53: Procedure/treatment has not been deemed 'proven to be effective' by the payer. Payment is denied when performed/billed by this type of provider. X12 welcomes the assembling of members with common interests as industry groups and caucuses. To be used for Property & Casualty only. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Reason Code 55: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). co 256 denial code descriptions - look.perfil.com At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). 05 The procedure code/bill type is inconsistent with the place of service. The procedure code is inconsistent with the provider type/specialty (taxonomy). This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Adjustment for postage cost. However, this amount may be billed to subsequent payer. Reason Code 4: The procedure/revenue code is inconsistent with the patient's gender. Rebill as a separate claim/service. Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes. B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. (Use only with Group Code CO). Reason Code 206: Per regulatory or other agreement. The prescribing/ordering provider is not eligible to prescribe/order the service billed. (Use Group Codes PR or CO depending upon liability). View the most common claim submission errors below. Applicable federal, state or local authority may cover the claim/service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. No maximum allowable defined by legislated fee arrangement. (Handled in QTY, QTY01=LA). Prior processing information appears incorrect. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Reason Code 131: Technical fees removed from charges. The diagnosis is inconsistent with the patient's gender. (Use only with Group Code OA). The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 56: Processed based on multiple or concurrent procedure rules. Bridge: Standardized Syntax Neutral X12 Metadata. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). CO Explanation of Benefits - Standard Codes - SAIF Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Denial was received because the provider did not respond to the development request; therefore, the services billed to Medicare could not be validated. This care may be covered by another payer per coordination of benefits. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim received by the dental plan, but benefits not available under this plan. Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). Previously paid. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. Just hold control key and press F. Jan 8, 2014. Payment is denied when performed/billed by this type of provider in this type of facility. Not authorized to provide work hardening services. The diagnosis is inconsistent with the procedure. Services not provided or authorized by designated (network/primary care) providers. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Adjusted for failure to obtain second surgical opinion. To be used for Property and Casualty Auto only. Reason Code 246: This claim has been identified as a resubmission. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. CO/31/ CO/31/ Medi-Cal specialty mental health billing. Payment denied for exacerbation when treatment exceeds time allowed. This is not patient specific. Chartered by the American National Standards Institute for more than 40 years, X12 develops and maintains EDI standards and XML schemas which drive business processes globally. Reason Code 28: Patient cannot be identified as our insured. CO 24 Charges are covered under a capitation agreement or managed care plan . The provider cannot collect this amount from the patient. WebCode Description 01 Deductible amount. The referring provider is not eligible to refer the service billed. Reason Code 144: Provider contracted/negotiated rate expired or not on file. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Claim/service not covered by this payer/contractor. Reason Code 21: Charges are covered under a capitation agreement/managed care plan. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The diagnosis is inconsistent with the provider type. Mutually exclusive procedures cannot be done in the same day/setting. Fee/Service not payable per patient Care Coordination arrangement. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Five Claim Denials and Resolutions Medical Necessity Reimbursement vs Contract rate updates. Claim received by the Medical Plan, but benefits not available under this plan. Reason Code 98: Predetermination: anticipated payment upon completion of services or claim adjudication. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Reason Code 9: The diagnosis is inconsistent with the provider type. Reason Code 151: Payer deems the information submitted does not support this day's supply. Reason Code 254: The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. These codes generally assign responsibility for the adjustment amounts. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. Procedure/product not approved by the Food and Drug Administration. An attachment is required to adjudicate this claim/service. If any patient is already covered under the Medicare advantage plan but in spite of that the claims are submitted to the insurance, then the claims which have been denied can be stated by the CO 24 denial code. Reason Code 125: New born's services are covered in the mother's Allowance. Claim lacks prior payer payment information. Webco 256 denial code descriptionshouses for rent by owner in calhoun, ga; co 256 denial code descriptionsjim jon prokes cause of death; co 256 denial code descriptionscafe patachou nutrition information co 256 denial code descriptions. Reason Code 97: Payment made to patient/insured/responsible party/employer. Reason Code 129: Prearranged demonstration project adjustment. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. X12 B2X Supply Chain Survey - What X12 EDI transactions do you support? Services denied by the prior payer(s) are not covered by this payer. Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Procedure/treatment is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim/service denied based on prior payer's coverage determination. From 1/01/22 - 9/13/22, that client had 1,119 claims that contained denial code CO 4. OA : Other adjustments. ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. denial codes Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Service/procedure was provided as a result of terrorism. Note: Use code 187. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). To be used for Property and Casualty only. (Use only with Group Code PR). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) This payment reflects the correct code. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Exceeds the contracted maximum number of hours/days/units by this provider for this period. Note: Refer to the 835 Healthcare Policy Refund to patient if collected. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: to be used for pharmaceuticals only. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. Join other member organizations in continuously adapting the expansive vocabulary and languageused by millions of organizationswhileleveraging more than 40 years of cross-industry standards development knowledge. Rebill as a separate claim/service. What steps can we take to avoid this reason code? If the reason code is valid, you can pass the same information to patient for their responsibility of payment in the statement. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. This page lists X12 Pilots that are currently in progress. (Use only with Group Code CO). Reason Code 242: Provider performance program withhold. ), Reason Code 15: Duplicate claim/service. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Reason Code 258: The procedure or service is inconsistent with the patient's history. Know what are challenges in Credentialing, Charge Entry, Payment Posting, Benefits/Eligibility Verification, Prior Authorization, Filing claims, AR Follow Ups, Old AR, Claim Denials, resubmitting rejections with Medical Billing Company Medical Billers and Coders. If any error on the claim that caused it to deny can be corrected, the corrected claim can be resubmitted to MassHealth. Services not provided by network/primary care providers. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Services not authorized by network/primary care providers. Use Group Code PR. To be used for Workers' Compensation only. Use only with Group Code CO. Payment adjusted based on Medical Provider Network (MPN). From 1/01/22 - 9/13/22, that client had 1,119 claims that contained denial code CO 4. Aid code invalid for DMH. However, this amount may be billed to subsequent payer. X12 welcomes feedback. Claim/service denied. The procedure code/bill type is inconsistent with the place of service. (Note: To be used for Property and Casualty only). This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. To be used for Property and Casualty only. To be used for Property and Casualty Auto only. Multi-tier licensing categories are based on how licensees benefit from X12's work,replacing traditional one-size-fits-all approaches. Submit a request for interpretation (RFI) related to the implementation and use of X12 work.