Status Last Reviewed: 11/1/2024
| Num. | Date | Requested Description | Type | Code | Status |
|---|---|---|---|---|---|
| No current requests. This list has been stable since the last update. It will not be updated until there are new requests. |
Service Review Decision Reason Codes
886
These codes communicate the reason for the health care services review outcome.
Maintenance Request Status
The list below shows the status of change requests which are in process.
Each request will be in one of the following statuses:
- Received
The request has been submitted but is not yet under review. - Pending
Staff has looked at the request to ensure it's a legitimate request (not spam), that it is assigned to the correct CMG, and that all required information is present. - In Process
The CMG has initiated their decision process. - On Hold
The CMG has initiated their decision process but cannot complete it at this time. - CMG Approved
The CMG has considered and approved the request, this does not mean it was approved exactly as submitted, it means maintenance related to the request was approved. Requests in this status will be applied to the next version. - CMG Disapproved
The CMG has considered and disapproved the request, no maintenance action will occur. Requests in this status are complete/final.
8/1/2022
| 01 | Price Authorization Expired Start: 01/10/2001 |
| 02 | Price authorization no longer required Start: 01/10/2001 |
| 03 | Product not on the price authorization Start: 01/10/2001 |
| 04 | Authorized Quantity Exceeded Start: 01/10/2001 |
| 05 | Special Cost Incorrect Start: 01/10/2001 |
| 06 | No Credit Allowed Start: 01/10/2001 |
| 07 | Administrative Cancellation Start: 01/10/2001 |
| 08 | Unit resale higher than authorized Start: 01/10/2001 |
| 09 | Out of Network Start: 01/10/2001 |
| 0A | Testing not Included Start: 01/10/2001 |
| 0B | Request Forwarded To and Decision Response Forthcoming From an External Review Organization Start: 01/10/2001 |
| 0C | Authorization/Access Restrictions Start: 01/10/2001 |
| 0D | Requires PCP authorization Start: 01/10/2001 |
| 0E | Provider is Not Primary Care Physician Start: 01/10/2001 |
| 0F | Not Medically Necessary Start: 01/10/2001 |
| 0G | Level of Care Not Appropriate Start: 01/10/2001 |
| 0H | Certification Not Required for this Service Start: 01/10/2001 |
| 0J | Certification Responsibility of External Review Organization Start: 01/10/2001 |
| 0K | Primary Care Service Start: 01/10/2001 |
| 0L | Exceeds Plan Maximums Start: 01/10/2001 |
| 0M | Non-covered Service Start: 01/10/2001 |
| 0N | No Prior Approval Start: 01/10/2001 |
| 0P | Requested Information Not Received Start: 01/10/2001 |
| 0Q | Duplicate Request Start: 01/10/2001 |
| 0R | Service Inconsistent with Diagnosis Start: 01/10/2001 |
| 0S | Pre-existing Condition Start: 01/10/2001 |
| 0T | Experimental Service or Procedure Start: 01/10/2001 |
| 0U | Additional Patient Information required Start: 01/10/2001 |
| 0V | Requires Medical Review Start: 01/10/2001 |
| 0W | Disposition pending review Start: 01/10/2001 |
| 0X | Service Inconsistent with Provider Type Start: 01/10/2001 |
| 0Y | Service inconsistent with Patient's Age Start: 01/10/2001 |
| 0Z | Service inconsistent with Patient's Gender Start: 01/10/2001 |
| 10 | Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months) Start: 01/10/2001 |
| 11 | Pricing Start: 01/10/2001 |
| 12 | Patient is restricted to specific provider Start: 01/10/2001 |
| 13 | Service authorized for another provider Start: 01/10/2001 |
| 14 | Plan/contractual guidelines not followed Start: 01/10/2001 |
| 15 | Plan/contractual geographic restriction Start: 01/10/2001 |
| 16 | Inappropriate facility type Start: 01/10/2001 |
| 17 | Time limits not met Start: 02/01/2002 |
| 18 | Notification received Start: 06/01/2002 |
| 19 | Cosmetic Start: 06/01/2002 |
| 20 | Once in a lifetime restriction applies Start: 02/01/2004 |
| 21 | Transport Request Denied Start: 06/01/2004 |
| 22 | Ambulance Certification Segment information doesn't correspond to Transport Address Segment Start: 06/01/2004 |
| 23 | Mileage cannot be computed based on data submitted Start: 06/01/2004 |
| 24 | Computed mileage is inconsistent with transport information or service units submitted Start: 06/01/2004 |
| 25 | Services were not considered due to other errors in the request. Start: 06/06/2010 |
| 26 | Missing Provider Role Start: 06/05/2011 |
| 27 | Patient is currently in a Health Insurance Exchange premium payment grace period -- first month. Usage: Use only for Individual Market Qualified Health Plans. Start: 06/01/2014 | Last Modified: 07/01/2017 |
| 28 | Patient is currently in a Health Insurance Exchange premium payment grace period -- second month. Usage: Use only for Individual Market Qualified Health Plans. Start: 06/01/2014 | Last Modified: 07/01/2017 |
| 29 | Patient is currently in a Health Insurance Exchange premium payment grace period -- third month. Usage: Use only for Individual Market Qualified Health Plans. Start: 06/01/2014 | Last Modified: 07/01/2017 |
| 30 | Initial Utilization Review In Progress Start: 11/01/2017 |
| 31 | Escalated Utilization Review in Progress Start: 11/01/2017 |
| 32 | Excluded benefit, a service which is specifically excluded from the benefit plan. Start: 10/01/2020 |
| 33 | Appeal Denied Start: 03/01/2022 |
| 34 | Payer-initiated Void Start: 03/01/2022 |
| 35 | The documentation submitted is not legible. Start: 03/01/2022 |
| 36 | Signed documentation is required to support medical necessity. Start: 03/01/2022 |
| 37 | A signed Order or Intent-to-Order is required. Start: 03/01/2022 |
| 38 | A physician certification statement is required. Start: 03/01/2022 |
| 39 | An order that supports this service is required. Start: 03/01/2022 |
| 40 | The supporting documentation does not match the patient identified in the preauthorization request. Start: 03/01/2022 |
| 41 | The supporting documentation does not support the number of units requested. Start: 03/01/2022 |
| 42 | A nutritional status assessment is required. Start: 03/01/2022 |
| 43 | Initial and repeated wound measurements are required. Start: 03/01/2022 |
| 44 | Documentation of conservative treatment failure is required. Start: 03/01/2022 |
| 45 | Documentation of a diabetes diagnosis is required. Start: 03/01/2022 |
| 46 | Documentation that treatment is an adjunct to conventional therapy is required. Start: 03/01/2022 |
| 47 | Documentation of measurable signs of improvement is required. Start: 08/01/2022 |
| 48 | Documentation of a diabetic wound classification is required. Start: 08/01/2022 |
| 49 | Patient was not admitted within the authorized timeframe. Start: 08/01/2022 |