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Payment Type Codes

Code List Scope Statement

These codes identify the type and purpose for a payment amount.

Code List Maintained By

CMS

Code List Updated Date

Mon, 03/01/2021 - 12:00

Code List Table

ADM	Administrative Fees used for a debt owed by the payee. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. The Administrative Fee is $15. Negative Amounts Only Start: 11/01/2015 \| Last Modified: 05/01/2017 Notes: CMS All Programs and Relevant Markets
APTC	Advance Payment of Premium Tax Credit. RMR04 will be positive. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
APTCADJ	Advance Payment of Premium Tax Credit Adjustment. RMR04 will be positive or negative. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
APTCMADJ	APTC Manual Adjustment. Used to show APTC manual adjustment when enrollment group level information is not applicable. RMR04 will be positive or negative and may be reversed in the future. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
BAL	When an AR invoice is split between multiple HIX 820 reports, this adjustment balances the reports. Negative Amounts & Positive Amounts Start: 10/01/2013 \| Last Modified: 05/01/2017 Notes: CMS All Programs and Relevant Markets
CSR	Advance Payment of Cost Sharing Reduction. RMR04 will be positive. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
CSRADJ	Advance Payment of Cost Sharing Reduction Adjustment. RMR04 will be positive or negative. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
CSRMADJ	CSR Manual Adjustment. Used to show CSR manual adjustment when enrollment group level information is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
CSRN	Cost Sharing Reduction Reconciliation. Negative Amounts & Positive Amounts Start: 01/01/2015 \| Last Modified: 05/01/2017 Notes: CMS Exchange Markets
CSRNADJ	Cost Sharing Reduction Reconciliation Adjustment. RMR04 will be positive or negative. Start: 01/01/2015 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
DDVC	Default Data Validation Charge or Allocation Payment. If DDVC is the Payment Type Code, a corresponding Report Type Code of DDVCRPT will also be included. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts Start: 02/01/2021 Notes: All Markets
DEBTADJ	Payee's debt amount covered by an affiliate's payment. RMR04 will be positive. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. When used to report that a prior debt was covered, RMR04 with the payment type code of BAL will also be used. Start: 10/01/2013 \| Last Modified: 11/01/2014 \| Stop: 05/01/2015 Notes: CMS
DEPENDENTPREM	Dependent responsible premium amount. RMR04 will be positive. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
DEPENDENTPREMADJCANCEL	Dependent premium amount adjustment due to cancellation. RMR04 will positive or negative Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
DEPENDENTPREMADJNSF	Dependent responsible premium amount due to non-sufficient funds. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
DEPENDENTPREMADJTERMINATE	Dependent responsible premium amount due to the termination of a policy. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYEEPREM	Employee responsible premium amount. RMR04 will be positive. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYEEPREMADJCANCEL	Employee responsible premium amount adjustment due to cancellation. RMR04 will be positive or negative Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYEEPREMADJNSF	Employee responsible premium amount adjustment due to non-sufficient funds. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYEEPREMADJTERMINATE	Employee responsible premium amount adjustment due to the termination of a policy. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYERPREM	Employer responsible premium amount. RMR04 will be positive. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYERPREMADJCANCEL	Employer responsible premium amount adjustment due to cancellation. RMR04 will be positive or negative Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYERPREMADJNSF	Employer responsible premium amount adjustment due to non-sufficient funds. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EMPLOYERPREMADJTERMINATE	Employer responsible premium amount adjustment due to the termination of a policy. RMR04 will be positive or negative. Start: 11/01/2014 \| Last Modified: 11/01/2015 Notes: CMS SHOP Market Only
EXTLOAN	Payment Offsets For Co-op Loan. Negative Amounts Only Start: 10/18/2016 Notes: CMS Co-ops Only
HCRPC	High Cost Risk Pool Contribution Amount. Negative Amounts & Positive Amounts Start: 08/01/2019 Notes: All Markets
HCRPP	High Cost Risk Pool Payment Amount. Negative Amounts & Positive Amounts Start: 08/01/2019 Notes: All Markets
HCRPPYREF	High Cost Risk Pool Refund For Prior Fiscal Years. Positive Amounts Only Start: 08/01/2019 Notes: All Markets
HCRPADMIN	High Cost Risk Pool Refund of Admin Charge. Positive Amounts Only Start: 08/01/2019 Notes: All Markets
HCRPINT	High Cost Risk Pool Refund of Interest Charge. Positive Amounts Only Start: 08/01/2019 Notes: All Markets
INT	Interest charges for a debt owed by the payee. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. The Secretary of Treasury certifies and updates an interest rate on a quarterly basis. Negative Amounts Only Start: 11/01/2015 \| Last Modified: 05/01/2017 Notes: CMS All Programs and Relevant Markets
INVOICE	Used to show a total amount that will be billed or otherwise collected. Only used when BPR02 would otherwise be negative. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Negative Amounts Only Start: 10/01/2013 \| Last Modified: 05/01/2017 Notes: CMS All Programs and Relevant Markets
PEN	Penalty charges for a debt owed by the payee. The Treasury will add additional administrative fees of up to 30 percent and accrue the required penalty charge of 6 percent per year on any amount outstanding. Interest will continue to accrue. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Negative Amounts Only Start: 11/01/2015 \| Last Modified: 05/01/2017 Notes: CMS All Programs and Relevant Markets
RA	Risk Adjustment Charge or Payment. If RA is the Payment Type Code, a corresponding Report Type Code of RARPT will also be included. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts Start: 01/01/2015 \| Last Modified: 03/01/2021 Notes: All Markets
RAADJ	Risk Adjustment Payment or Charge Adjustment. RMR04 will be positive or negative. Start: 01/01/2015 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
RAAR	Risk Adjustment Administration Fee Refund. A Risk Adjustment Admin Fee is only charged if an Issuer does not pay their RA Charges within 30 days. Positive Amounts Only Start: 10/01/2015 \| Last Modified: 05/01/2017 Notes: All Markets
RACR	Risk Adjustment Refund For Prior Fiscal Years. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAD	Risk Adjustment Default Charge or Allocation Payment. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts Start: 05/01/2015 \| Last Modified: 03/01/2021 Notes: All Markets
RADV	Risk Adjustment Data Validation Adjustment Charge or Payment. If RADV is the Payment Type Code, a corresponding Report Type Code of RADVRPT will also be included. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts Start: 02/01/2021 Notes: All Markets
RAIR	Risk Adjustment Interest Charge Refund. A Risk Adjustment Interest Charge is only assessed if an Issuer does not pay their RA Charges within 30 days. Negative Amounts & Positive Amounts Start: 10/01/2015 \| Last Modified: 05/01/2017 Notes: All Markets
RAREF	Risk Adjustment Refund For Current Fiscal Year. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAUF	Risk Adjustment User Fee. Negative Amounts Only Start: 01/01/2015 \| Last Modified: 05/01/2017 Notes: All Markets
RAUFADJ	Risk Adjustment User Fee Adjustment. RMR04 will be positive or negative. Start: 01/01/2015 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
RAUFAR	Risk Adjustment User Fee Refund of admin charge. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAUFIR	Risk Adjustment User Fee Refund of interest charge. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAUFR	Risk Adjustment User Fee Refund. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAUFR2PY	Risk Adjustment User Fee Refund. Positive Amounts Only Start: 10/18/2016 \| Last Modified: 08/01/2018 \| Stop: 09/30/2018 Notes: All Markets
RAUFREF	Risk Adjustment User Fee refund for current fiscal year. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RAUFRN	Risk Adjustment User Fee Refund. Positive Amounts Only Start: 05/01/2015 \| Last Modified: 08/01/2018 \| Stop: 09/30/2018 Notes: All Markets
RC	Risk Corridor Program payment or charge amount. Negative Amounts & Positive Amounts Start: 01/01/2015 \| Last Modified: 05/01/2017 Notes: CMS Exchange Markets
RC15	Risk Corridors Charges. Negative Amounts Only Start: 10/18/2016 Notes: CMS Exchange Markets
RCADJ	Risk Corridor Adjustment. RMR04 will be positive or negative. Start: 01/01/2015 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
RCAR	Risk Corridors Refund Of Admin Charge. Positive Amounts Only Start: 10/18/2016 Notes: CMS Exchange Markets
RCCR15	Risk Corridors Refund For Prior Fiscal Years. Positive Amounts Only Start: 10/18/2016 Notes: CMS Exchange Markets
RCCR16	Risk Corridors Refund For Current Fiscal Year. Positive Amounts Only Start: 10/18/2016 Notes: CMS Exchange Markets
RCIR	Risk Corridors Refund Of Interest Charge. Positive Amounts Only Start: 05/01/2015 Notes: CMS Exchange Markets
RCREF	Risk Corridors Refund For Current Fiscal Year. Positive Amounts Only Start: 05/01/2015 Notes: CMS Exchange Markets
REDUCED	Payment reduced to cover a debt owed by the payee. RMR04 will be negative. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Negative Amounts Only Start: 10/01/2013 \| Last Modified: 05/01/2017 Notes: CMS Exchange Markets
RIC	Reinsurance Contribution Amount. Negative Amounts & Positive Amounts Start: 06/01/2014 \| Last Modified: 05/01/2017 Notes: All Markets
RICADJ	Reinsurance Contribution Adjustment. RMR04 will be positive or negative. Start: 06/01/2014 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
RICAR	Reinsurance Contribution Refund Of Admin Charge. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RICIR	Reinsurance Contribution Refund Of Interest Charge. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RICR	Reinsurance Contribution Refund For Prior Fiscal Years. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RICREF	Reinsurance Contribution Refund For Current Fiscal Year. Positive Amounts Only Start: 05/01/2015 Notes: All Markets
RIP	Reinsurance Payment Amount. Negative Amounts & Positive Amounts Start: 06/01/2014 \| Last Modified: 05/01/2017 Notes: CMS Individual Market Only
RIPADJ	Reinsurance Payment Adjustment. RMR04 will be positive or negative. Start: 06/01/2014 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
SHOPUF	Federally-facilitated Marketplace User Fee for SHOP plans. (SHOP HIX 820 Trace Number may be provided in the Document Control Number in the payment reports). Negative Amounts & Positive Amounts Start: 10/01/2013 \| Last Modified: 05/01/2017 Notes: CMS SHOP Market
SHOPUFADJ	Federally-facilitated Marketplace User Fee Adjustment for SHOP plans. RMR04 will be positive or negative. This code will not be used. Start: 10/01/2013 \| Last Modified: 11/01/2015 \| Stop: 11/01/2015 Notes: CMS Individual Market Only
SHOPUFMADJ	Federally-facilitated Marketplace User Fee Manual Adjustment for SHOP Plans. Start: 10/01/2013 \| Last Modified: 11/01/2015 \| Stop: 11/01/2015 Notes: CMS Individual Market Only
UF	Federally-facilitated Marketplace User Fee. RMR04 will be negative. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
UFADJ	Federally-facilitated Marketplace User Fee Adjustment. RMR04 will be positive or negative. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
UFAR	FFM User Fee refund of admin charges. Positive Amounts Only Start: 05/01/2015 Notes: CMS Exchange Markets
UFIR	FFM User Fee Refund of interest charges. Positive Amounts Only Start: 05/01/2015 Notes: CMS Exchange Markets
UFMADJ	Federally-facilitated Marketplace User Fee Manual Adjustment. Used to show user fee manual adjustment when enrollment group level information is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Start: 10/01/2013 \| Last Modified: 11/01/2015 Notes: CMS Individual Market Only
UFR	Federally-facilitated Marketplace User Fee Adjustment related to providing contraceptive care coverage. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Positive Amounts Only Start: 11/01/2015 \| Last Modified: 05/01/2017 Notes: CMS Exchange Markets
UFR2PY	FFM User Fee Refund. Positive Amounts Only Start: 10/18/2016 \| Last Modified: 08/01/2018 \| Stop: 09/30/2018 Notes: CMS Exchange Markets
UFRP	FFM User Fee Refund. Positive Amounts Only Start: 05/01/2015 Notes: CMS Exchange Markets
UFRPN	FFM User Fee Refund. Positive Amounts Only Start: 05/01/2015 \| Last Modified: 08/01/2018 \| Stop: 09/30/2018 Notes: CMS Exchange Markets
COMM	Any commissions withheld by the Exchange. RMR04 will be negative. Start: 10/01/2013 Notes: SBM Only
COMMADJ	Any commissions adjustment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
DEDUCT	Deductible amount due to the Payer. RMR04 will be positive or negative. Start: 10/01/2015 Notes: SBM Only
INTPREM	Initial premium payment received by the Exchange from the customer. This amount will be the gross premium received from the customer. RMR04 will be positive. Start: 10/01/2013 Notes: SBM Only
MDCAID	State Medicaid Subsidy. RMR04 will be positive. Start: 10/01/2013 Notes: SBM Only
MDCAIDADJ	State Medicaid Subsidy Adjustment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
MISC	Used to indicate miscellaneous amounts (i.e. write-offs, etc.) RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
MRF	Marketplace-Related Fee. This is the amount that is being paid not attributable to an individual coverage but at a plan or carrier level. If negative, the fee was withheld from carrier payments. If positive, the fee was paid to the carrier. RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
MRFADJ	Adjustments to a previously sent MRF. The MRFADJ is not attributable to an individual coverage level but at a plan or carrier level. RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
NONPAYADJ	Code use to indicate an adjustment is being made due to a NSF or stop payment. Amount will always be negative. Start: 10/01/2013 Notes: SBM Only
OPMUF	OPM Multi-State Plan user fee. RMR04 will be negative. Start: 10/01/2013 Notes: SBM Only
OPMUFADJ	OPM Multi-State Plan user fee manual adjustment. Used to show user fee manual adjustment when enrollment group level information is not provided. RMR04 will be positive or negative and may be reversed in the future. Start: 10/01/2013 Notes: SBM Only
PREM	Premium payment amount received for the enrollment group for coverage (excluding APTC and Exchange-Related Fees). RMR04 will be positive. Start: 10/01/2013 Notes: SBM Only
PREMADJ	Adjustments to premium payment amount received for the enrollment group for coverage (excluding APTC and Marketplace-Related Fees). RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
PREMALL	Premium payment amount received for the enrollment group for coverage (including APTC and Marketplace-Related Fees). RMR04 will be positive. Start: 10/01/2013 Notes: SBM Only
PREMALLADJ	Adjustments to premium payment amount received for the enrollment group for coverage (including APTC and Marketplace-Related Fees). RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
REFUND	Total refunded amount sent back to the customer. RMR04 will be negative. Start: 10/01/2013 Notes: SBM Only
RETURN	Total returned payment (i.e. returned due to non-sufficient funds). RMR04 will be negative. Start: 10/01/2013 Notes: SBM Only
SBMUF	State Based Marketplace User Fee. RMR04 will be negative. Start: 05/01/2015 Notes: SBM Only
SBMUFADJ	State Based Marketplace User Fee Adjustment. RMR04 will be positive or negative. Start: 05/01/2015 Notes: SBM Only
SMAND	State Mandate Benefit Subsidy. RMR04 will be positive. Start: 10/01/2013 Notes: SBM Only
SMANDADJ	State Mandate Benefit Subsidy Adjustment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: SBM Only
TPP	Money paid by a third party payer as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013 Notes: SBM Only
TPPADJ	Adjustments to Money paid by a third party payer as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013 Notes: SBM Only
TRIBE	Money paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013 Notes: SBM Only
TRIBEADJ	Adjustments to Money paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013 Notes: SBM Only
WRITEOFF	Write off amount Start: 06/01/2014 Notes: SBM Only

Code List Notes

Exchange Payment Type codes are transmitted in 005010X306, loop 2300, RMR02. They identify the type and purpose for the payment amount transmitted in ASC X12 005010X306, loop 2300, RMR04.

Note:

Catastrophic is included in Individual Market and Merged is Individual and Small Group Markets combined.
All markets include both on and off exchange issuers.
Exchange markets include Individual/Small Group/Catastrophic/Merged.
Specific transaction detail may be provided in the Document Control Number in the payment reports effective July 2017.

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Industry Specific Remark Codes

Code List ID

973

Code List Scope Statement

These codes convey information about remittance processing or further explain an adjustment already described by a Claim Adjustment Reason Code (CARC) from ECL 139.

Code List Maintained By

CMG01

Code List Updated Date

Mon, 06/01/2020 - 12:00

Code List Table

01	The injured employee or other party has not signed the required attestation document therefore Florida Statute 440.105(7) requires that benefits and payments be suspended until such signature is obtained. Start: 06/01/2020
02	Coverage based on a property and casualty Excess Insurance policy which is governed by state statute or regulation. Start: 06/01/2020
03	Reimbursement based on the treating hospital's designation as a lien hospital with billing precedence. Start: 06/01/2020
04	Reimbursement based on state-specific Workers' Compensation requirements for timely submission of bills for services rendered. Start: 06/01/2020
05	Reimbursement based on a state-specific Workers' Compensation limitation that the procedure code be billed only once, regardless of the number of limbs tested. Start: 06/01/2020
06	The provider's preliminary notice of injury and treatment was not furnished by the close of the third business day following the first treatment in accordance with Florida Statute Section 440.13(4)(a), therefore this claim is not considered valid. Start: 06/01/2020

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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.

Status Last Reviewed: 6/19/2024

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.

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

*Explain the business scenario or use case when the requested new code would be used, the reason an existing code is no longer appropriate for the code list’s business purpose, or reason the current description needs to be revised.

Read more about Industry Specific Remark Codes

Insurance Descriptor Codes

Code List ID

979

Code List Scope Statement

These codes describe, identify, or clarify the insurance being reported in an eligibility and benefits response.

Code List Maintained By

CMG01

Code List Updated Date

Mon, 07/01/2024 - 12:00

Code List Table

01	Short Term Insurance Start: 11/01/2022
D	Disability Insurance Start: 05/17/2018
M	Medicare Advantage Point of Service (POS) Plan that excludes Part D coverage Start: 05/17/2018
12	Medicare is secondary, Working Aged Beneficiary or Spouse with employer group health plan is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
13	Medicare is secondary, End-Stage Renal Disease Beneficiary in the mandated coordination period with an employer's group health plan is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
14	Medicare is secondary, no-fault insurance, including auto, is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
15	Medicare is secondary, Worker's Compensation is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
16	Medicare is secondary, Public Health Service (PHS) or Other Federal Agency is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
17	Dental Insurance Start: 05/17/2018
18	Vision Insurance Start: 05/17/2018
19	Prescription Drug Insurance Start: 05/17/2018
41	Medicare is secondary, Black Lung is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
42	Medicare is secondary, Veteran's Administration is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
43	Medicare is secondary, Disabled Beneficiary Under Age 65 with a large group health plan (LGHP) is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
47	Medicare is secondary, other liability insurance is primary Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
48	Medicaid Start: 11/01/2023
49	Medicare and Medicaid Dual Eligible Start: 07/01/2024
AP	Automobile Insurance Start: 05/17/2018
C1	Commercial Insurance Start: 05/17/2018
CO	Beneficiary is under Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
EP	Exclusive Provider Organization (EPO) Plan Start: 05/17/2018
HB	Health Insurance Exchange (HIX) Bronze Start: 05/17/2018
HD	High Deductible Health Plan (HDHP) Start: 05/17/2018
HG	Health Insurance Exchange (HIX) Gold Start: 05/17/2018
HM	Health Maintenance Organization (HMO) Plan Start: 05/17/2018
HP	Health Insurance Exchange (HIX) Platinum Start: 05/17/2018
HS	Health Insurance Exchange (HIX) Silver An individual eligible for Medicare for whom Medicaid pays only Medicare premiums. Start: 05/17/2018
IN	Indemnity Plan Gives a subscriber the choice to select any provider. Payment is fixed percentage of the cost for covered care after satisfying an annual deductible. Start: 05/17/2018
LC	Long Term Care Insurance Coverage designed to help pay for some or all long term care costs, reducing the risk that a policy-holder would need to deplete all of his or her assets to pay for long term care. Start: 05/17/2018
LI	Life Insurance Start: 05/17/2018
LT	Impacted by litigation Start: 07/19/2018 Technical Note: Although this code does not conform to the intended use of this code list as defined in the list's description, it is being grandfathered in as part of the conversion from an internal code list to an external code list. In the future, requested codes must conform to the list's defined purpose to be approved.
MA	Medicare Part A Start: 05/17/2018
MB	Medicare Part B Start: 05/17/2018
MD	Medicare Part D Start: 05/17/2018
ME	Medicare Advantage Preferred Provider Organization (PPO) Plan that excludes Part D Coverage Start: 05/17/2018
MJ	Medicare Advantage Health Maintenance Organization (HMO) Plan that includes Part D Coverage Start: 05/17/2018
MK	Medicare Advantage Health Maintenance Organization (HMO) Risk Plan that includes Part D Coverage Start: 05/17/2018
ML	Medicare Advantage Indemnity Plan that includes Part D Coverage Start: 05/17/2018
MM	Medicare Advantage Preferred Provider Organization (PPO) Plan that includes Part D Coverage Start: 05/17/2018
MN	Medicare Advantage Indemnity Plan that excludes Part D coverage Start: 05/17/2018
MO	Medicare Advantage Point of Service (POS) Plan that includes Part D Coverage Start: 05/17/2018
MR	Medicare Advantage Health Maintenance Organization (HMO) Risk Plan that excludes Part D coverage Start: 05/17/2018
MT	Medicare Advantage Health Maintenance Organization (HMO) Plan that excludes Part D coverage Start: 05/17/2018
OA	Open Access Point of Service Plan (POS) Plan Start: 05/17/2018
PE	Property Insurance - Personal Start: 05/17/2018
PR	Preferred Provider Organization (PPO) Plan Start: 05/17/2018
PS	Point of Service (POS) Plan Start: 05/17/2018
RP	Property Insurance - Real Start: 05/17/2018
SA	Set Aside Arrangement Set aside funds arrangement that exists for patients that are identified for Insurance Type Code 14, 15 or 47. Start: 11/01/2023
SP	Supplemental Insurance An insurance policy intended to cover non-covered charges of another insurance policy. Start: 05/17/2018
WC	Workers Compensation Insurance Coverage provides medical treatment, rehabilitation, lost wages and related expenses arising from a job related injury or disease. Start: 05/17/2018
WU	Wrap-Up Insurance A Workers Compensation Policy written for a specific job site, which will include or cover more than one insured. Start: 05/17/2018

Code List Filters Block Reference

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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.

Status last Reviewed: 6/19/2024

Num.	Date	Requested Description	Type	Code	Status
83	8/30/2022	19: Prescription Drug Insurance. Refer to the NCPDP External Code List for specific prescription drug insurance values and descriptions associated to the Adjudicated Program Type (A28-ZR) field used within NCPDP transactions. Insurance Type Code 19 should only be used when the insurance can be mapped to one of the NCPDP values. New prescription drug insurance programs not yet defined within the NCPDP External Code list should be reported to NCPDP for review.	Revise	19	In Process
87	10/18/2023	In the 5010 version of the X12 270/271 Insurance Descriptor Codes, there is a code MC for Medicaid. In the Insurance Descriptor codes on X12 External Code list, MC is no longer an option in the list of codes available. This code should be added to this list to align with the 5010 270/271 standard guide.	New		CMG Disapproved
88	12/4/2023	This request is to add a new Insurance type code. The code would be to identify DoD (Department of Defense) and/or Tricare coverage.	New		On Hold
89	12/4/2023	This request is to add a new Insurance type code. The code would be to identify Dual coverage, specific to coverage that is a combination of Medicare and Medicaid in a single plan.	New		CMG Approved
90	5/29/2024	Accountable Care Organization	New		Pending

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Insurance Descriptor Codes

Insurance Business Process Application Error Codes

Code List ID

895

Code List Scope Statement

These codes report application warnings and errors for insurance business processes.

Code List Maintained By

CMG02

Code List Updated Date

Fri, 07/12/2024 - 12:00

Code List Table

E001	Missing/Invalid submitter identifier Start: 05/01/2004
W001	Missing/Invalid submitter identifier Start: 05/01/2004
E002	Missing/Invalid receiver identifier Start: 05/01/2004
W002	Missing/Invalid receiver identifier Start: 05/01/2004
E003	Missing/Invalid member identifier Start: 05/01/2004
W003	Missing/Invalid member identifier Start: 05/01/2004
E004	Missing/Invalid subscriber identifier Start: 05/01/2004
W004	Missing/Invalid subscriber identifier Start: 05/01/2004
E005	Missing/Invalid patient identifier Start: 05/01/2004
W005	Missing/Invalid patient identifier Start: 05/01/2004
E006	Missing/Invalid plan sponsor identifier Start: 05/01/2004
W006	Missing/Invalid plan sponsor identifier Start: 05/01/2004
E007	Missing/invalid payee identifier Start: 05/01/2004
W007	Missing/invalid payee identifier Start: 05/01/2004
E008	Missing/Invalid TPA/broker identifier Start: 05/01/2004
W008	Missing/Invalid TPA/broker identifier Start: 05/01/2004
E009	Missing/Invalid premium receiver identifier Start: 05/01/2004
W009	Missing/Invalid premium receiver identifier Start: 05/01/2004
E010	Missing/Invalid premium payer identifier Start: 05/01/2004
W010	Missing/Invalid premium payer identifier Start: 05/01/2004
E011	Missing/Invalid payer identifier Start: 05/01/2004
W011	Missing/Invalid payer identifier Start: 05/01/2004
E012	Missing/Invalid billing provider identifier Start: 05/01/2004
W012	Missing/Invalid billing provider identifier Start: 05/01/2004
E013	Missing/Invalid pay to provider identifier Start: 05/01/2004
W013	Missing/Invalid pay to provider identifier Start: 05/01/2004
E014	Missing/Invalid rendering provider identifier Start: 05/01/2004
W014	Missing/Invalid rendering provider identifier Start: 05/01/2004
E015	Missing/Invalid supervising provider identifier Start: 05/01/2004
W015	Missing/Invalid supervising provider identifier Start: 05/01/2004
E016	Missing/Invalid attending provider identifier Start: 05/01/2004
W016	Missing/Invalid attending provider identifier Start: 05/01/2004
E017	Missing/Invalid other provider identifier Start: 05/01/2004
W017	Missing/Invalid other provider identifier Start: 05/01/2004
E018	Missing/Invalid operating provider identifier Start: 05/01/2004
W018	Missing/Invalid operating provider identifier Start: 05/01/2004
E019	Missing/Invalid referring provider identifier Start: 05/01/2004
W019	Missing/Invalid referring provider identifier Start: 05/01/2004
E020	Missing/Invalid purchased service provider identifier Start: 05/01/2004
W020	Missing/Invalid purchased service provider identifier Start: 05/01/2004
E021	Missing/Invalid service facility identifier Start: 05/01/2004
W021	Missing/Invalid service facility identifier Start: 05/01/2004
E022	Missing/Invalid ordering provider identifier Start: 05/01/2004
W022	Missing/Invalid ordering provider identifier Start: 05/01/2004
E023	Missing/Invalid assistant surgeon identifier Start: 05/01/2004
W023	Missing/Invalid assistant surgeon identifier Start: 05/01/2004
E024	Amount/Quantity out of balance Start: 05/01/2004
W024	Amount/Quantity out of balance Start: 05/01/2004
E025	Duplicate Start: 05/01/2004
W025	Duplicate Start: 05/01/2004
E026	Billing date predates service date Start: 05/01/2004
W026	Billing date predates service date Start: 05/01/2004
E027	Business application currently not available Start: 05/01/2004
W027	Business application currently not available Start: 05/01/2004
E028	Sender not authorized for this transaction Start: 05/01/2004
W028	Sender not authorized for this transaction Start: 05/01/2004
E029	Number of errors exceeds permitted threshold Start: 05/01/2004
W029	Number of errors exceeds permitted threshold Start: 05/01/2004
E030	Required loop missing Start: 05/01/2004
W030	Required loop missing Start: 05/01/2004
E031	Required segment missing Start: 05/01/2004
W031	Required segment missing Start: 05/01/2004
E032	Required element missing Start: 05/01/2004
W032	Required element missing Start: 05/01/2004
E033	Situational required loop is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
W033	Situational required loop is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
E034	Situational required segment is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
W034	Situational required segment is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
E035	Situational required element is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
W035	Situational required element is missing Start: 05/01/2004 \| Last Modified: 11/20/2008
E036	Data too long Start: 05/01/2004
W036	Data too long Start: 05/01/2004
E037	Data too short Start: 05/01/2004
W037	Data too short Start: 05/01/2004
E038	Invalid external code value Start: 05/01/2004
W038	Invalid external code value Start: 05/01/2004
E039	Data value out of sequence Start: 05/01/2004
W039	Data value out of sequence Start: 05/01/2004
E040	"Not Used" data element present Start: 05/01/2004
W040	"Not Used" data element present Start: 05/01/2004
E041	Too many sub-elements in composite Start: 05/01/2004
W041	Too many sub-elements in composite Start: 05/01/2004
E042	Unexpected segment Start: 05/01/2004
W042	Unexpected segment Start: 05/01/2004
E043	Missing data Start: 05/01/2004
W043	Missing data Start: 05/01/2004
E044	Out of range Start: 05/01/2004
W044	Out of range Start: 05/01/2004
E045	Invalid date Start: 05/01/2004
W045	Invalid date Start: 05/01/2004
E046	Not matching Start: 05/01/2004
W046	Not matching Start: 05/01/2004
E047	Invalid combination Start: 05/01/2004
W047	Invalid combination Start: 05/01/2004
E048	Customer identification number does not exist Start: 05/01/2004
W048	Customer identification number does not exist Start: 05/01/2004
E049	Duplicate batch Start: 05/01/2004
W049	Duplicate batch Start: 05/01/2004
E050	Incorrect data Start: 05/01/2004
W050	Incorrect data Start: 05/01/2004
E051	Incorrect date Start: 05/01/2004
W051	Incorrect date Start: 05/01/2004
E052	Duplicate transmission Start: 05/01/2004
W052	Duplicate transmission Start: 05/01/2004
E053	Invalid claim amount Start: 05/01/2004
W053	Invalid claim amount Start: 05/01/2004
E054	Invalid identification code Start: 05/01/2004
W054	Invalid identification code Start: 05/01/2004
E055	Missing or invalid issuer identification Start: 05/01/2004
W055	Missing or invalid issuer identification Start: 05/01/2004
E056	Missing or invalid item quantity Start: 05/01/2004
W056	Missing or invalid item quantity Start: 05/01/2004
E057	Missing or invalid item identification Start: 05/01/2004
W057	Missing or invalid item identification Start: 05/01/2004
E058	Missing or unauthorized transaction type code Start: 05/01/2004
W058	Missing or unauthorized transaction type code Start: 05/01/2004
E059	Unknown claim number Start: 05/01/2004
W059	Unknown claim number Start: 05/01/2004
E060	Bin segment contentes not in MIME format Start: 05/01/2004
W060	Bin segment contents not in MIME format Start: 05/01/2004
E061	Missing/invalid MIME header Start: 05/01/2004
W061	Missing/Invalid MIME header Start: 05/01/2004
E062	Missing/Invalid MIME boundary Start: 05/01/2004
W062	Missing/Invalid MIME boundary Start: 05/01/2004
E063	Missing/Invalid MIME transfer encoding Start: 05/01/2004
W063	Missing/Invalid MIME transfer encoding Start: 05/01/2004
E064	Missing/Invalid MIME content type Start: 05/01/2004
W064	Missing/Invalid MIME content type Start: 05/01/2004
E065	Missing/Invalid MIME content disposition (filename) Start: 05/01/2004
W065	Missing/Invalid MIME content disposition (filename) Start: 05/01/2004
E066	Missing/Invalid file name extension Start: 05/01/2004
W066	Missing/Invalid file name extension Start: 05/01/2004
E067	Invalid MIME base64 encoding Start: 05/01/2004
W067	Invalid MIME base64 encoding Start: 05/01/2004
E068	Invalid MIME quoted-printable encoding Start: 05/01/2004
W068	Invalid MIME quoted-printable encoding Start: 05/01/2004
E069	Missing/Invalid MIME line terminator (should be CR+LF) Start: 05/01/2004
W069	Missing/Invalid MIME line terminator (should be CR+LF) Start: 05/01/2004
E070	Missing/Invalid "end of MIME" headers Start: 05/01/2004
W070	Missing/Invalid "end of MIME" headers Start: 05/01/2004
E071	Missing/Invalid CDA in first MIME body parts Start: 05/01/2004
W071	Missing/Invalid CDA in first MIME body parts Start: 05/01/2004
E072	Missing/Invalid XML tag Start: 05/01/2004
W072	Missing/Invalid XML tag Start: 05/01/2004
E073	Unrecoverable XML error Start: 05/01/2004
W073	Unrecoverable XML error Start: 05/01/2004
E074	Invalid Data format for HL7 data type Start: 05/01/2004
W074	Invalid Data format for HL7 data type Start: 05/01/2004
E075	Missing/Invalid required LOINC answer part(s) in the CDA Start: 05/01/2004
W075	Missing/Invalid required LOINC answer part(s) in the CDA Start: 05/01/2004
E076	Missing/Invalid Provider information in the CDA Start: 05/01/2004
W076	Missing/Invalid Provider information in the CDA Start: 05/01/2004
E077	Missing/Invalid Patient information in the CDA Start: 05/01/2004
W077	Missing/Invalid Patient information in the CDA Start: 05/01/2004
E078	Missing/Invalid Attachment Control information in the CDA Start: 05/01/2004
W078	Missing/Invalid Attachment Control information in the CDA Start: 05/01/2004
E079	Missing/Invalid LOINC Start: 05/01/2004
W079	Missing/Invalid LOINC Start: 05/01/2004
E080	Missing/Invalid LOINC Modifier Start: 05/01/2004
W080	Missing/Invalid LOINC Modifier Start: 05/01/2004
E081	Missing/Invalid LOINC code for this attachment type Start: 05/01/2004
W081	Missing/Invalid LOINC code for this attachment type Start: 05/01/2004
E082	Missing/Invalid LOINC Modifier for this attachment type Start: 05/01/2004
W082	Missing/Invalid LOINC Modifier for this attachment type Start: 05/01/2004
E083	Situational prohibited element is present Start: 05/01/2004 \| Last Modified: 11/20/2008
W083	Situational prohibited element is present Start: 05/01/2004 \| Last Modified: 11/20/2008
E084	Duplicate qualifier value in repeated segment within a single loop Start: 05/01/2009
W084	Duplicate qualifier value in repeated segment within a single loop Start: 05/01/2009
E085	Situational required composite element is missing Start: 05/01/2009
W085	Situational required composite element is missing Start: 05/01/2009
E086	Situational required repeating element is missing Start: 05/01/2009
W086	Situational required repeating element is missing Start: 05/01/2009
E087	Situational prohibited loop is present Start: 05/01/2009
W087	Situational prohibited loop is present Start: 05/01/2009
E088	Situational prohibited segment is present Start: 05/01/2009
W088	Situational prohibited segment is present Start: 05/01/2009
E089	Situational prohibited composite element is present Start: 05/01/2009
W089	Situational prohibited composite element is present Start: 05/01/2009
E090	Situational prohibited repeating element is present Start: 05/01/2009
W090	Situational prohibited repeating element is present Start: 05/01/2009
E091	Transaction successfully received but not processed as applicable business function not performed. Start: 01/30/2011
W091	Transaction successfully received but not processed as applicable business function not performed. Start: 01/30/2011
E092	Missing/Invalid required SNOMED CT answer part(s) in the CDA Start: 06/05/2011
W092	Missing/Invalid required SNOMED CT answer part(s) in the CDA Start: 06/05/2011
E093	Matching Policy Information/Document not found. Start: 06/01/2014
W093	Matching Policy Information/Document not found. Start: 06/01/2014
E094	Financial Assistance not permitted across multiple marketplaces - Double Dip Check Edit Identified. Start: 06/01/2014
W094	Financial Assistance not permitted across multiple marketplaces - Double Dip Check Edit Identified. Start: 06/01/2014
E095	Business Process transaction out of sequence. Start: 01/25/2015
W095	Business Process transaction out of sequence. Start: 01/25/2015
E096	Advanced Premium Tax Credit is more than Total Premium. Start: 01/25/2015
W096	Advanced Premium Tax Credit is more than Total Premium. Start: 01/25/2015
E097	Marketplace, Off Market Variant. Start: 01/25/2015
W097	Marketplace, Off Market Variant. Start: 01/25/2015
E098	Maintenance Type Code Start: 07/01/2015
W098	Maintenance Type Code Start: 07/01/2015
E099	Maintenance Reason Code Start: 07/01/2015
W099	Maintenance Reason Code Start: 07/01/2015
E100	Additional Maintenance Reason Code Start: 07/01/2015
W100	Additional Maintenance Reason Code Start: 07/01/2015
E101	Enrollment Group member(s) count on transaction does not match Enrollment Group member(s) count found on file of record Start: 07/01/2015
W101	Enrollment Group member(s) count on transaction does not match Enrollment Group member(s) count found on file of record Start: 07/01/2015
E102	Effective Start Date Start: 07/01/2015
W102	Effective Start Date Start: 07/01/2015
E103	Advanced Payment for Tax Credit (APTC) Start: 07/01/2015
W103	Advanced Payment for Tax Credit (APTC) Start: 07/01/2015
E104	Total Individual Responsibility Amount Start: 07/01/2015
W104	Total Individual Responsibility Amount Start: 07/01/2015
E105	Other Payment Amount 1 Start: 07/01/2015
W105	Other Payment Amount 1 Start: 07/01/2015
E106	Other Payment Amount 2 Start: 07/01/2015
W106	Other Payment Amount 2 Start: 07/01/2015
E107	Total Premium Amount Start: 07/01/2015
W107	Total Premium Amount Start: 07/01/2015
E108	Individual Premium Amount Start: 07/01/2015
W108	Individual Premium Amount Start: 07/01/2015
E109	Total Employer Responsibility Amount Start: 07/01/2015
W109	Total Employer Responsibility Amount Start: 07/01/2015
E110	Financial Date Precedes Premium Date Start: 07/01/2015
W110	Financial Date Precedes Premium Date Start: 07/01/2015
E111	Exceeds Unique Start Date(s) Start: 07/01/2015
W111	Exceeds Unique Start Date(s) Start: 07/01/2015
E112	Exceeds Allowable Changes Start: 07/01/2015
W112	Exceeds Allowable Changes Start: 07/01/2015
E113	Cost Sharing Reduction (CSR) Date precedes the Total Premium Amount Effective Start Date Start: 07/01/2015
W113	Cost Sharing Reduction (CSR) Date precedes the Total Premium Amount Effective Start Date Start: 07/01/2015
E114	Renewal Transaction cannot be processed as it is outside of allocated time period Start: 07/01/2015
W114	Renewal Transaction cannot be processed as it is outside of allocated time period Start: 07/01/2015
E115	Financial Amounts Unchanged by newly reported data Start: 07/01/2015
W115	Financial Amounts Unchanged by newly reported data Start: 07/01/2015
E116	Effective Start Date does not align with Previous Effective End Date Start: 07/01/2015
W116	Effective Start Date does not align with Previous Effective End Date Start: 07/01/2015
E117	Duplicate Payment of Advanced Premium Tax Credit Start: 08/24/2015
W117	Duplicate Payment of Advanced Premium Tax Credit Start: 08/24/2015
E118	Duplicate Payment of Cost Sharing Reduction Start: 08/24/2015
W118	Duplicate Payment of Cost Sharing Reduction Start: 08/24/2015
E119	Duplicate Payment of User Fee Start: 08/24/2015
W119	Duplicate Payment of User Fee Start: 08/24/2015
E120	Missing Payment of Advanced Premium Tax Credit Start: 08/24/2015
W120	Missing Payment of Advanced Premium Tax Credit Start: 08/24/2015
E121	Missing Payment of Cost Sharing Reduction Start: 08/24/2015
W121	Missing Payment of Cost Sharing Reduction Start: 08/24/2015
E122	Missing Payment of User Fee Start: 08/24/2015
W122	Missing Payment of User Fee Start: 08/24/2015
E123	Advanced Premium Tax Credit (APTC) Payment Mismatch - The Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) APTC amount and the Health Plan APTC amount are equal but do not match the APTC payment amount received Start: 08/24/2015
W123	Advanced Premium Tax Credit (APTC) Payment Mismatch - The Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) APTC amount and the Health Plan APTC amount are equal but do not match the APTC payment amount received Start: 08/24/2015
E124	Cost Shared Reduction (CSR) Payment Mismatch - The Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) CSR amount and the Health Plan CSR amount are equal but do not match the CSR payment amount received Start: 08/24/2015
W124	Cost Shared Reduction (CSR) Payment Mismatch - The Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) CSR amount and the Health Plan CSR amount are equal but do not match the CSR payment amount received Start: 08/24/2015
E125	User Fee Payment Mismatch - The calculated Federally Facilitated Marketplace (FFM) User Fee amount and the calculated Health Plan User Fee amount are equal but do not match the User Fee payment amount received Start: 08/24/2015
W125	User Fee Payment Mismatch - The calculated Federally Facilitated Marketplace (FFM) User Fee amount and the calculated Health Plan User Fee amount are equal but do not match the User Fee payment amount received Start: 08/24/2015
E126	Effectuation Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
W126	Effectuation Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
E127	Cancel Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
W127	Cancel Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
E128	Termination Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
W128	Termination Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
E129	Maintenance Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
W129	Maintenance Transaction cannot be processed as it is outside of allocated time period Start: 03/01/2016
E130	Policy level cancel/terminations shall not contain health coverage information Start: 03/01/2016
W130	Policy level cancel/terminations shall not contain health coverage information Start: 03/01/2016
E131	Dependent/Member not included in current coverage Start: 07/01/2016
W131	Dependent/Member not included in current coverage Start: 07/01/2016
E132	The data in the transaction does not match the exchange/marketplace type Start: 07/01/2017
W132	The data in the transaction does not match the exchange/marketplace type Start: 07/01/2017
E133	Policy Cancelled - cannot be processed Start: 07/01/2017
W133	Policy Cancelled - cannot be processed Start: 07/01/2017
E134	Policy Non-Effectuated - cannot be processed Start: 07/01/2017
W134	Policy Non-Effectuated - cannot be processed Start: 07/01/2017
E135	Policy ID Start: 07/01/2017
W135	Policy ID Start: 07/01/2017
E136	Subscriber ID Start: 07/01/2017
W136	Subscriber ID Start: 07/01/2017
E137	Member ID Start: 07/01/2017
W137	Member ID Start: 07/01/2017
E138	No Longer Eligible (NLE) Start: 07/01/2017
W138	No Longer Eligible (NLE) Start: 07/01/2017
E139	Exchange Assigned Start: 07/01/2017
W139	Exchange Assigned Start: 07/01/2017
E140	Issuer Assigned Start: 07/01/2017
W140	Issuer Assigned Start: 07/01/2017
E141	Issuer Prior Assigned Start: 07/01/2017
W141	Issuer Prior Assigned Start: 07/01/2017
E142	Action results already match current information on file Start: 07/01/2017
W142	Action results already match current information on file Start: 07/01/2017
E143	Action results do not match current information on file Start: 07/01/2017
W143	Action results do not match current information on file Start: 07/01/2017
E144	Cancellation Transaction Start: 07/01/2017
W144	Cancellation Transaction Start: 07/01/2017
E145	Initial Enrollment Transaction Start: 07/01/2017
W145	Initial Enrollment Transaction Start: 07/01/2017
E146	Maintenance Transaction Start: 07/01/2017
W146	Maintenance Transaction Start: 07/01/2017
E147	Reinstatement Transaction Start: 07/01/2017
W147	Reinstatement Transaction Start: 07/01/2017
E148	Termination Transaction Start: 07/01/2017
W148	Termination Transaction Start: 07/01/2017
E149	Email Address Start: 07/01/2017
W149	Email Address Start: 07/01/2017
E150	Mailing Address Start: 07/01/2017
W150	Mailing Address Start: 07/01/2017
E151	Telephone Number Start: 07/01/2017
W151	Telephone Number Start: 07/01/2017
E152	Consumer executed voluntary withdrawal of coverage Start: 11/01/2017
W152	Consumer executed voluntary withdrawal of coverage Start: 11/01/2017
E153	Unable to be processed causing a gap or overlap in coverage dates Start: 11/01/2017
W153	Unable to be processed causing a gap or overlap in coverage dates Start: 11/01/2017
E154	Invoke the Enrollment Resolution and Reconciliation (ER&R) manual process Start: 11/01/2017
W154	Invoke the Enrollment Resolution and Reconciliation (ER&R) manual process Start: 11/01/2017
E155	Marketplace Coverage in Effect Start: 11/01/2017
W155	Marketplace Coverage in Effect Start: 11/01/2017
E156	Reinstatement transaction cannot be processed as it is outside of the allocated time period Start: 11/01/2017
W156	Reinstatement transaction cannot be processed as it is outside of the allocated time period Start: 11/01/2017
E157	Coverage Start Date Start: 11/01/2017
W157	Coverage Start Date Start: 11/01/2017
E158	Coverage End Date Start: 11/01/2017
W158	Coverage End Date Start: 11/01/2017
E159	Dependent/Member shall not be included in Policy Level Start: 03/01/2018
W159	Dependent/Member shall not be included in Policy Level Start: 03/01/2018
E160	One day coverage Start: 07/01/2018
W160	One day coverage Start: 07/01/2018
E161	Invalid Start: 07/01/2018
W161	Invalid Start: 07/01/2018
E162	Eligibility Begin Date Start: 06/02/2019
W162	Eligibility Begin Date Start: 06/02/2019
E163	Associated submission not found Start: 12/01/2020
W163	Associated submission not found Start: 12/01/2020
E164	Exceeds Receiver Allowed Occurrences Start: 12/01/2020
W164	Exceeds Receiver Allowed Occurrences Start: 12/01/2020
E165	HL7 US Realm Header Legal Authenticator data is missing Start: 07/01/2021
W165	HL7 US Realm Header Legal Authenticator data is missing Start: 07/01/2021
E166	HL7 US Realm Header Author data is missing Start: 07/01/2021
W166	HL7 US Realm Header Author data is missing Start: 07/01/2021
E167	HL7 US Realm Header SetID data is missing Start: 07/01/2021
W167	HL7 US Realm Header SetID data is missing Start: 07/01/2021
E168	HL7 US Realm Header VersionNumber data is missing Start: 07/01/2021
W168	HL7 US Realm Header VersionNumber data is missing Start: 07/01/2021
E169	HL7 C-CDA Structured document sections name data is missing Start: 07/01/2021
W169	HL7 C-CDA Structured document sections name data is missing Start: 07/01/2021
E170	HL7 C-CDA Structured document sections title data is missing Start: 07/01/2021
W170	HL7 C-CDA Structured document sections title data is missing Start: 07/01/2021
E171	HL7 C-CDA Structured document narrative block (text) data is missing Start: 07/01/2021
W171	HL7 C-CDA Structured document narrative block (text) data is missing Start: 07/01/2021
E172	HL7 C-CDA Unstructured document LOINC Code is missing Start: 07/01/2021
W172	HL7 C-CDA Unstructured document LOINC Code is missing Start: 07/01/2021
E173	HL7 C-CDA Unstructured document contained a reference to a URL or URI Start: 07/01/2021
W173	HL7 C-CDA Unstructured document contained a reference to a URL or URI Start: 07/01/2021
E174	HL7 C-CDA Unstructured document @mediaType (MIME type) is missing Start: 07/01/2021
W174	HL7 C-CDA Unstructured document @mediaType (MIME type) is missing Start: 07/01/2021
E175	HL7 C-CDA Unstructured document included more than 1 @mediaType (MIME type) Start: 07/01/2021
W175	HL7 C-CDA Unstructured document included more than 1 @mediaType (MIME type) Start: 07/01/2021
E176	HL7 C-CDA Unstructured document Base64 encoding does not meet the RFC 4648 requirements Start: 07/01/2021
W176	HL7 C-CDA Unstructured document Base64 encoding does not meet the RFC 4648 requirements Start: 07/01/2021
E177	HL7 C-CDA Unstructured document compression does not meet the RFC 1951 requirements Start: 07/01/2021
W177	HL7 C-CDA Unstructured document compression does not meet the RFC 1951 requirements Start: 07/01/2021
E178	HL7 C-CDA LOINC code does not match the LOINC code in the request Start: 07/01/2021
W178	HL7 C-CDA LOINC code does not match the LOINC code in the request Start: 07/01/2021
E179	HL7 Attachment Control Number is missing Start: 07/01/2021
W179	HL7 Attachment Control Number is missing Start: 07/01/2021
E180	Missing Billing provider affiliation for the Rendering provider(s). Start: 11/01/2022
W180	Missing Billing provider affiliation for the Rendering provider(s). Start: 11/01/2022
E181	Invalid affiliation between Rendering and Billing providers. Start: 11/01/2022
W181	Invalid affiliation between Rendering and Billing providers. Start: 11/01/2022
E182	System Delay-No Additional Action Required Start: 11/01/2022
W182	System Delay-No Additional Action Required Start: 11/01/2022
E183	System Delay-Resubmission Required Start: 11/01/2022
W183	System Delay-Resubmission Required Start: 11/01/2022
E184	Fully Subsidized Policy - Policy's total premium is provided for by the Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) Start: 07/11/2024
W184	Fully Subsidized Policy - Policy's total premium is provided for by the Federally Facilitated Marketplace (FFM) or State Based Marketplace (SBM) Start: 07/11/2024

Code List Filters Block Reference

Filter by code:

Filter codes by status:

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.

Status last Reviewed: 7/12/2024

Num.	Date	Requested Description	Type	Code	Status
37	5/23/24	Invalid action	New Codes		CMG Approved

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Insurance Business Process Application Error Codes

Service Review Decision Reason Codes

Code List ID

886

Code List Scope Statement

These codes communicate the reason for the health care services review outcome.

Code List Maintained By

CMG01

Code List Updated Date

Mon, 08/01/2022 - 12:00

Code List Table

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

Code List Filters Block Reference

Filter by code:

Filter codes by status:

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.

Status Last Reviewed: 6/19/2024

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.

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Service Review Decision Reason Codes

Claim Status Codes

Code List ID

508

Code List Scope Statement

These codes convey the status of an entire claim or a specific service line.

Code List Maintained By

CMG03

Code List Updated Date

Mon, 07/01/2024 - 12:00

Code List Table

0	Cannot provide further status electronically. Start: 01/01/1995
1	For more detailed information, see remittance advice. Start: 01/01/1995
2	More detailed information in letter. Start: 01/01/1995
3	Claim has been adjudicated and is awaiting payment cycle. Start: 01/01/1995
4	This is a subsequent request for information from the original request. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
5	This is a final request for information. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
6	Balance due from the subscriber. Start: 01/01/1995
7	Claim may be reconsidered at a future date. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
8	No payment due to contract/plan provisions. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
9	No payment will be made for this claim. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
10	All originally submitted procedure codes have been combined. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
11	Some originally submitted procedure codes have been combined. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
12	One or more originally submitted procedure codes have been combined. Start: 01/01/1995 \| Last Modified: 06/30/2001
13	All originally submitted procedure codes have been modified. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
14	Some all originally submitted procedure codes have been modified. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
15	One or more originally submitted procedure code have been modified. Start: 01/01/1995 \| Last Modified: 06/30/2001
16	Claim/encounter has been forwarded to entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
17	Claim/encounter has been forwarded by third party entity to entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
18	Entity received claim/encounter, but returned invalid status. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
19	Entity acknowledges receipt of claim/encounter. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
20	Accepted for processing. Start: 01/01/1995 \| Last Modified: 06/30/2001
21	Missing or invalid information. Usage: At least one other status code is required to identify the missing or invalid information. Start: 01/01/1995 \| Last Modified: 07/01/2017
22	... before entering the adjudication system. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
23	Returned to Entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
24	Entity not approved as an electronic submitter. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
25	Entity not approved. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
26	Entity not found. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
27	Policy canceled. Start: 01/01/1995 \| Last Modified: 06/30/2001
28	Claim submitted to wrong payer. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
29	Subscriber and policy number/contract number mismatched. Start: 01/01/1995
30	Subscriber and subscriber id mismatched. Start: 01/01/1995
31	Subscriber and policyholder name mismatched. Start: 01/01/1995
32	Subscriber and policy number/contract number not found. Start: 01/01/1995
33	Subscriber and subscriber id not found. Start: 01/01/1995
34	Subscriber and policyholder name not found. Start: 01/01/1995
35	Claim/encounter not found. Start: 01/01/1995
37	Predetermination is on file, awaiting completion of services. Start: 01/01/1995
38	Awaiting next periodic adjudication cycle. Start: 01/01/1995
39	Charges for pregnancy deferred until delivery. Start: 01/01/1995
40	Waiting for final approval. Start: 01/01/1995
41	Special handling required at payer site. Start: 01/01/1995
42	Awaiting related charges. Start: 01/01/1995
44	Charges pending provider audit. Start: 01/01/1995
45	Awaiting benefit determination. Start: 01/01/1995
46	Internal review/audit. Start: 01/01/1995
47	Internal review/audit - partial payment made. Start: 01/01/1995
48	Referral/authorization. Start: 01/01/1995 \| Last Modified: 02/28/2001 \| Stop: 01/01/2012 Notes: Refer to codes 252 and 761.
49	Pending provider accreditation review. Start: 01/01/1995
50	Claim waiting for internal provider verification. Start: 01/01/1995
51	Investigating occupational illness/accident. Start: 01/01/1995
52	Investigating existence of other insurance coverage. Start: 01/01/1995
53	Claim being researched for Insured ID/Group Policy Number error. Start: 01/01/1995
54	Duplicate of a previously processed claim/line. Start: 01/01/1995
55	Claim assigned to an approver/analyst. Start: 01/01/1995
56	Awaiting eligibility determination. Start: 01/01/1995
57	Pending COBRA information requested. Start: 01/01/1995
59	Information was requested by a non-electronic method. Usage: At least one other status code is required to identify the requested information. Start: 01/01/1995 \| Last Modified: 07/01/2017
60	Information was requested by an electronic method. Usage: At least one other status code is required to identify the requested information. Start: 01/01/1995 \| Last Modified: 07/01/2017
61	Eligibility for extended benefits. Start: 01/01/1995
64	Re-pricing information. Start: 01/01/1995
65	Claim/line has been paid. Start: 01/01/1995
66	Payment reflects usual and customary charges. Start: 01/01/1995
67	Payment made in full. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
68	Partial payment made for this claim. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
69	Payment reflects plan provisions. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
70	Payment reflects contract provisions. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
71	Periodic installment released. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
72	Claim contains split payment. Start: 01/01/1995
73	Payment made to entity, assignment of benefits not on file. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
78	Duplicate of an existing claim/line, awaiting processing. Start: 01/01/1995
81	Contract/plan does not cover pre-existing conditions. Start: 01/01/1995
83	No coverage for newborns. Start: 01/01/1995
84	Service not authorized. Start: 01/01/1995
85	Entity not primary. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
86	Diagnosis and patient gender mismatch. Start: 01/01/1995 \| Last Modified: 02/28/2000
87	Denied: Entity not found. (Use code 26 with appropriate Claim Status category Code) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
88	Entity not eligible for benefits for submitted dates of service. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
89	Entity not eligible for dental benefits for submitted dates of service. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
90	Entity not eligible for medical benefits for submitted dates of service. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
91	Entity not eligible/not approved for dates of service. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
92	Entity does not meet dependent or student qualification. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
93	Entity is not selected primary care provider. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
94	Entity not referred by selected primary care provider. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
95	Requested additional information not received. Start: 01/01/1995 \| Last Modified: 07/09/2007 Notes: If known, the payer must report a second claim status code identifying the requested information.
96	No agreement with entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
97	Patient eligibility not found with entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
98	Charges applied to deductible. Start: 01/01/1995
99	Pre-treatment review. Start: 01/01/1995
100	Pre-certification penalty taken. Start: 01/01/1995
101	Claim was processed as adjustment to previous claim. Start: 01/01/1995
102	Newborn's charges processed on mother's claim. Start: 01/01/1995
103	Claim combined with other claim(s). Start: 01/01/1995
104	Processed according to plan provisions (Plan refers to provisions that exist between the Health Plan and the Consumer or Patient) Start: 01/01/1995 \| Last Modified: 06/01/2008
105	Claim/line is capitated. Start: 01/01/1995
106	This amount is not entity's responsibility. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
107	Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services) Start: 01/01/1995 \| Last Modified: 06/01/2008
108	Coverage has been canceled for this entity. (Use code 27) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
109	Entity not eligible. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
110	Claim requires pricing information. Start: 01/01/1995
111	At the policyholder's request these claims cannot be submitted electronically. Start: 01/01/1995
112	Policyholder processes their own claims. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
113	Cannot process individual insurance policy claims. Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
114	Claim/service should be processed by entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
115	Cannot process HMO claims Start: 01/01/1995 \| Last Modified: 01/27/2008 \| Stop: 07/01/2008
116	Claim submitted to incorrect payer. Start: 01/01/1995
117	Claim requires signature-on-file indicator. Start: 01/01/1995
118	TPO rejected claim/line because payer name is missing. (Use status code 21 and status code 125 with entity code IN) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
119	TPO rejected claim/line because certification information is missing. (Use status code 21 and status code 252) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
120	TPO rejected claim/line because claim does not contain enough information. (Use status code 21) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
121	Service line number greater than maximum allowable for payer. Start: 01/01/1995
122	Missing/invalid data prevents payer from processing claim. (Use CSC Code 21) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
123	Additional information requested from entity. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
124	Entity's name, address, phone and id number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
125	Entity's name. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
126	Entity's address. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
127	Entity's Communication Number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
128	Entity's tax id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
129	Entity's Blue Cross provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
130	Entity's Blue Shield provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
131	Entity's Medicare provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
132	Entity's Medicaid provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
133	Entity's UPIN. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
134	Entity's TRICARE provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 03/01/2022
135	Entity's commercial provider id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
136	Entity's health industry id number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
137	Entity's plan network id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
138	Entity's site id . Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
139	Entity's health maintenance provider id (HMO). Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
140	Entity's preferred provider organization id (PPO). Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
141	Entity's administrative services organization id (ASO). Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
142	Entity's license/certification number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
143	Entity's state license number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
144	Entity's specialty license number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
145	Entity's specialty/taxonomy code. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
146	Entity's anesthesia license number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
147	Entity's qualification degree/designation (e.g. RN,PhD,MD). Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
148	Entity's social security number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
149	Entity's employer id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
150	Entity's drug enforcement agency (DEA) number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
152	Pharmacy processor number. Start: 01/01/1995
153	Entity's id number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
154	Relationship of surgeon & assistant surgeon. Start: 01/01/1995
155	Entity's relationship to patient. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
156	Patient relationship to subscriber Start: 01/01/1995
157	Entity's Gender. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
158	Entity's date of birth. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
159	Entity's date of death. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
160	Entity's marital status. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
161	Entity's employment status. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
162	Entity's health insurance claim number (HICN). Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
163	Entity's policy/group number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
164	Entity's contract/member number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
165	Entity's employer name, address and phone. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
166	Entity's employer name. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
167	Entity's employer address. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
168	Entity's employer phone number. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
169	Entity's employer id. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
170	Entity's employee id. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
171	Other insurance coverage information (health, liability, auto, etc.). Start: 01/01/1995
172	Other employer name, address and telephone number. Start: 01/01/1995
173	Entity's name, address, phone, gender, DOB, marital status, employment status and relation to subscriber. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
174	Entity's student status. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
175	Entity's school name. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
176	Entity's school address. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
177	Transplant recipient's name, date of birth, gender, relationship to insured. Start: 01/01/1995 \| Last Modified: 02/28/2000
178	Submitted charges. Start: 01/01/1995
179	Outside lab charges. Start: 01/01/1995
180	Hospital s semi-private room rate. Start: 01/01/1995
181	Hospital s room rate. Start: 01/01/1995
182	Allowable/paid from other entities coverage Usage: This code requires the use of an entity code. Start: 01/01/1995 \| Last Modified: 07/01/2017
183	Amount entity has paid. Usage: This code requires use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
184	Purchase price for the rented durable medical equipment. Start: 01/01/1995
185	Rental price for durable medical equipment. Start: 01/01/1995
186	Purchase and rental price of durable medical equipment. Start: 01/01/1995
187	Date(s) of service. Start: 01/01/1995
188	Statement from-through dates. Start: 01/01/1995
189	Facility admission date Start: 01/01/1995 \| Last Modified: 10/31/2006
190	Facility discharge date Start: 01/01/1995 \| Last Modified: 10/31/2006
191	Date of Last Menstrual Period (LMP) Start: 02/28/1997
192	Date of first service for current series/symptom/illness. Start: 01/01/1995
193	First consultation/evaluation date. Start: 02/28/1997
194	Confinement dates. Start: 01/01/1995
195	Unable to work dates/Disability Dates. Start: 01/01/1995 \| Last Modified: 09/20/2009
196	Return to work dates. Start: 01/01/1995
197	Effective coverage date(s). Start: 01/01/1995
198	Medicare effective date. Start: 01/01/1995
199	Date of conception and expected date of delivery. Start: 01/01/1995
200	Date of equipment return. Start: 01/01/1995
201	Date of dental appliance prior placement. Start: 01/01/1995
202	Date of dental prior replacement/reason for replacement. Start: 01/01/1995
203	Date of dental appliance placed. Start: 01/01/1995
204	Date dental canal(s) opened and date service completed. Start: 01/01/1995
205	Date(s) dental root canal therapy previously performed. Start: 01/01/1995
206	Most recent date of curettage, root planing, or periodontal surgery. Start: 01/01/1995
207	Dental impression and seating date. Start: 01/01/1995
208	Most recent date pacemaker was implanted. Start: 01/01/1995
209	Most recent pacemaker battery change date. Start: 01/01/1995
210	Date of the last x-ray. Start: 01/01/1995
211	Date(s) of dialysis training provided to patient. Start: 01/01/1995
212	Date of last routine dialysis. Start: 01/01/1995
213	Date of first routine dialysis. Start: 01/01/1995
214	Original date of prescription/orders/referral. Start: 02/28/1997
215	Date of tooth extraction/evolution. Start: 01/01/1995
216	Drug information. Start: 01/01/1995
217	Drug name, strength and dosage form. Start: 01/01/1995
218	NDC number. Start: 01/01/1995
219	Prescription number. Start: 01/01/1995
220	Drug product id number. (Use code 218) Start: 01/01/1995 \| Last Modified: 10/17/2010 \| Stop: 07/01/2011
221	Drug days supply and dosage. Start: 01/01/1995 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
222	Drug dispensing units and average wholesale price (AWP). Start: 01/01/1995
223	Route of drug/myelogram administration. Start: 01/01/1995
224	Anatomical location for joint injection. Start: 01/01/1995
225	Anatomical location. Start: 01/01/1995
226	Joint injection site. Start: 01/01/1995
227	Hospital information. Start: 01/01/1995
228	Type of bill for UB claim Start: 01/01/1995 \| Last Modified: 10/31/2006
229	Hospital admission source. Start: 01/01/1995
230	Hospital admission hour. Start: 01/01/1995
231	Hospital admission type. Start: 01/01/1995
232	Admitting diagnosis. Start: 01/01/1995
233	Hospital discharge hour. Start: 01/01/1995
234	Patient discharge status. Start: 01/01/1995
235	Units of blood furnished. Start: 01/01/1995
236	Units of blood replaced. Start: 01/01/1995
237	Units of deductible blood. Start: 01/01/1995
238	Separate claim for mother/baby charges. Start: 01/01/1995
239	Dental information. Start: 01/01/1995
240	Tooth surface(s) involved. Start: 01/01/1995
241	List of all missing teeth (upper and lower). Start: 01/01/1995
242	Tooth numbers, surfaces, and/or quadrants involved. Start: 01/01/1995
243	Months of dental treatment remaining. Start: 01/01/1995
244	Tooth number or letter. Start: 01/01/1995
245	Dental quadrant/arch. Start: 01/01/1995
246	Total orthodontic service fee, initial appliance fee, monthly fee, length of service. Start: 01/01/1995
247	Line information. Start: 01/01/1995
248	Accident date, state, description and cause. Start: 01/01/1995 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
249	Place of service. Start: 01/01/1995
250	Type of service. Start: 01/01/1995
251	Total anesthesia minutes. Start: 01/01/1995
252	Entity's prior authorization/certification number. Usage: This code requires the use of an Entity Code. Start: 01/01/1995 \| Last Modified: 07/01/2017
253	Procedure/revenue code for service(s) rendered. Use codes 454 or 455. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
254	Principal diagnosis code. Start: 01/01/1995 \| Last Modified: 01/30/2011
255	Diagnosis code. Start: 01/01/1995
256	DRG code(s). Start: 01/01/1995
257	ADSM-III-R code for services rendered. Start: 01/01/1995
258	Days/units for procedure/revenue code. Start: 01/01/1995
259	Frequency of service. Start: 01/01/1995
260	Length of medical necessity, including begin date. Start: 02/28/1997
261	Obesity measurements. Start: 01/01/1995
262	Type of surgery/service for which anesthesia was administered. Start: 01/01/1995
263	Length of time for services rendered. Start: 01/01/1995
264	Number of liters/minute & total hours/day for respiratory support. Start: 01/01/1995
265	Number of lesions excised. Start: 01/01/1995
266	Facility point of origin and destination - ambulance. Start: 01/01/1995
267	Number of miles patient was transported. Start: 01/01/1995
268	Location of durable medical equipment use. Start: 01/01/1995
269	Length/size of laceration/tumor. Start: 01/01/1995
270	Subluxation location. Start: 01/01/1995
271	Number of spine segments. Start: 01/01/1995
272	Oxygen contents for oxygen system rental. Start: 01/01/1995
273	Weight. Start: 01/01/1995
274	Height. Start: 01/01/1995
275	Claim. Start: 01/01/1995
276	UB04/HCFA-1450/1500 claim form Start: 01/01/1995 \| Last Modified: 10/31/2006
277	Paper claim. Start: 01/01/1995
278	Signed claim form. Start: 01/01/1995 \| Stop: 11/01/2011
279	Claim/service must be itemized Start: 01/01/1995 \| Last Modified: 10/17/2010
280	Itemized claim by provider. Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 279
281	Related confinement claim. Start: 01/01/1995
282	Copy of prescription. Start: 01/01/1995
283	Medicare entitlement information is required to determine primary coverage Start: 01/01/1995 \| Last Modified: 01/27/2008
284	Copy of Medicare ID card. Start: 01/01/1995
285	Vouchers/explanation of benefits (EOB). Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 286
286	Other payer's Explanation of Benefits/payment information. Start: 01/01/1995
287	Medical necessity for service. Start: 01/01/1995
288	Hospital late charges Start: 01/01/1995 \| Last Modified: 10/17/2010
289	Reason for late discharge. Start: 01/01/1995 \| Stop: 11/01/2011
290	Pre-existing information. Start: 01/01/1995
291	Reason for termination of pregnancy. Start: 01/01/1995
292	Purpose of family conference/therapy. Start: 01/01/1995
293	Reason for physical therapy. Start: 01/01/1995
294	Supporting documentation. Usage: At least one other status code is required to identify the supporting documentation. Start: 01/01/1995 \| Last Modified: 07/01/2017
295	Attending physician report. Start: 01/01/1995
296	Nurse's notes. Start: 01/01/1995
297	Medical notes/report. Start: 02/28/1997
298	Operative report. Start: 01/01/1995
299	Emergency room notes/report. Start: 01/01/1995
300	Lab/test report/notes/results. Start: 02/28/1997
301	MRI report. Start: 01/01/1995
302	Refer to codes 300 for lab notes and 311 for pathology notes Start: 01/01/1995 \| Stop: 01/31/1997
303	Physical therapy notes. Use code 297:6O (6 'OH' - not zero) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
304	Reports for service. Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 297, 298, 299, 300
305	Radiology/x-ray reports and/or interpretation Start: 01/01/1995 \| Last Modified: 01/30/2011
306	Detailed description of service. Start: 01/01/1995
307	Narrative with pocket depth chart. Start: 01/01/1995
308	Discharge summary. Start: 01/01/1995
309	Code was duplicate of code 299 Start: 01/01/1995 \| Stop: 01/31/1997
310	Progress notes for the six months prior to statement date. Start: 01/01/1995
311	Pathology notes/report. Start: 01/01/1995
312	Dental charting. Start: 01/01/1995
313	Bridgework information. Start: 01/01/1995
314	Dental records for this service. Start: 01/01/1995
315	Past perio treatment history. Start: 01/01/1995
316	Complete medical history. Start: 01/01/1995
317	Patient's medical records. Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
318	X-rays/radiology films Start: 01/01/1995 \| Last Modified: 10/17/2010
319	Pre/post-operative x-rays/photographs. Start: 02/28/1997
320	Study models. Start: 01/01/1995
321	Radiographs or models. (Use codes 318 and/or 320) Start: 01/01/1995 \| Last Modified: 10/17/2010 \| Stop: 07/01/2011
322	Recent Full Mouth X-rays Start: 01/01/1995 \| Last Modified: 10/17/2010
323	Study models, x-rays, and/or narrative. Start: 01/01/1995
324	Recent x-ray of treatment area and/or narrative. Start: 01/01/1995
325	Recent fm x-rays and/or narrative. Start: 01/01/1995
326	Copy of transplant acquisition invoice. Start: 01/01/1995
327	Periodontal case type diagnosis and recent pocket depth chart with narrative. Start: 01/01/1995
328	Speech therapy notes. Use code 297:6R Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
329	Exercise notes. Start: 01/01/1995
330	Occupational notes. Start: 01/01/1995
331	History and physical. Start: 01/01/1995 \| Last Modified: 08/01/2007
332	Authorization/certification (include period covered). (Use code 252) Start: 02/28/1997 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
333	Patient release of information authorization. Start: 01/01/1995
334	Oxygen certification. Start: 01/01/1995
335	Durable medical equipment certification. Start: 01/01/1995
336	Chiropractic certification. Start: 01/01/1995
337	Ambulance certification/documentation. Start: 01/01/1995
338	Home health certification. Use code 332:4Y Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
339	Enteral/parenteral certification. Start: 01/01/1995
340	Pacemaker certification. Start: 01/01/1995
341	Private duty nursing certification. Start: 01/01/1995
342	Podiatric certification. Start: 01/01/1995
343	Documentation that facility is state licensed and Medicare approved as a surgical facility. Start: 01/01/1995
344	Documentation that provider of physical therapy is Medicare Part B approved. Start: 01/01/1995
345	Treatment plan for service/diagnosis Start: 01/01/1995
346	Proposed treatment plan for next 6 months. Start: 01/01/1995
347	Refer to code 345 for treatment plan and code 282 for prescription Start: 01/01/1995 \| Stop: 01/31/1997
348	Chiropractic treatment plan. (Use 345:QL) Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
349	Psychiatric treatment plan. Use codes 345:5I, 5J, 5K, 5L, 5M, 5N, 5O (5 'OH' - not zero), 5P Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
350	Speech pathology treatment plan. Use code 345:6R Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
351	Physical/occupational therapy treatment plan. Use codes 345:6O (6 'OH' - not zero), 6N Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 02/28/1997
352	Duration of treatment plan. Start: 01/01/1995
353	Orthodontics treatment plan. Start: 01/01/1995
354	Treatment plan for replacement of remaining missing teeth. Start: 01/01/1995
355	Has claim been paid? Start: 01/01/1995 \| Stop: 11/01/2011
356	Was blood furnished? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 235
357	Has or will blood be replaced? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 236
358	Does provider accept assignment of benefits? (Use code 589) Start: 01/01/1995 \| Last Modified: 10/17/2010 \| Stop: 07/01/2011
359	Is there a release of information signature on file? (Use code 333) Start: 01/01/1995 \| Last Modified: 10/17/2010 \| Stop: 07/01/2011
360	Benefits Assignment Certification Indicator Start: 01/01/1995 \| Last Modified: 10/17/2010
361	Is there other insurance? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 171 and 550
362	Is the dental patient covered by medical insurance? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 171
363	Possible Workers' Compensation Start: 01/01/1995 \| Last Modified: 10/17/2010
364	Is accident/illness/condition employment related? Start: 01/01/1995
365	Is service the result of an accident? Start: 01/01/1995
366	Is injury due to auto accident? Start: 01/01/1995
367	Is service performed for a recurring condition or new condition? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 397
368	Is medical doctor (MD) or doctor of osteopath (DO) on staff of this facility? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 676
369	Does patient condition preclude use of ordinary bed? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 287, 335
370	Can patient operate controls of bed? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 287, 335
371	Is patient confined to room? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 287, 335, 527
372	Is patient confined to bed? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 287, 335, 527
373	Is patient an insulin diabetic? Start: 01/01/1995 \| Stop: 11/01/2011
374	Is prescribed lenses a result of cataract surgery? Start: 01/01/1995
375	Was refraction performed? Start: 01/01/1995
376	Was charge for ambulance for a round-trip? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 453
377	Was durable medical equipment purchased new or used? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 184, 185, 186, 335
378	Is pacemaker temporary or permanent? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 340
379	Were services performed supervised by a physician? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to codes 453, 454, 666 & procedure code
380	CRNA supervision/medical direction. Start: 01/01/1995 \| Last Modified: 10/17/2010
381	Is drug generic? Start: 01/01/1995 \| Stop: 11/01/2011 Notes: Refer to code 216
382	Did provider authorize generic or brand name dispensing? Start: 01/01/1995
383	Nerve block use (surgery vs. pain management) Start: 01/01/1995 \| Last Modified: 10/17/2010
384	Is prosthesis/crown/inlay placement an initial placement or a replacement? Start: 01/01/1995
385	Is appliance upper or lower arch & is appliance fixed or removable? Start: 01/01/1995
386	Orthodontic Treatment/Purpose Indicator Start: 01/01/1995 \| Last Modified: 10/17/2010
387	Date patient last examined by entity. Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
388	Date post-operative care assumed Start: 02/28/1997
389	Date post-operative care relinquished Start: 02/28/1997
390	Date of most recent medical event necessitating service(s) Start: 02/28/1997
391	Date(s) dialysis conducted Start: 02/28/1997
392	Date(s) of blood transfusion(s) Start: 02/28/1997 \| Stop: 11/01/2011
393	Date of previous pacemaker check Start: 02/28/1997 \| Stop: 11/01/2011
394	Date(s) of most recent hospitalization related to service Start: 02/28/1997
395	Date entity signed certification/recertification Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
396	Date home dialysis began Start: 02/28/1997
397	Date of onset/exacerbation of illness/condition Start: 02/28/1997
398	Visual field test results Start: 02/28/1997
399	Report of prior testing related to this service, including dates Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 417
400	Claim is out of balance Start: 02/28/1997
401	Source of payment is not valid Start: 02/28/1997
402	Amount must be greater than zero. Usage: At least one other status code is required to identify which amount element is in error. Start: 02/28/1997 \| Last Modified: 07/01/2017
403	Entity referral notes/orders/prescription. Effective 05/01/2018: Entity referral notes/orders/prescription. Usage: this code requires use of an entity code. Start: 02/28/1997 \| Last Modified: 11/01/2017
404	Specific findings, complaints, or symptoms necessitating service Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to codes 287, 488
405	Summary of services Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 306
406	Brief medical history as related to service(s) Start: 02/28/1997
407	Complications/mitigating circumstances Start: 02/28/1997
408	Initial certification Start: 02/28/1997
409	Medication logs/records (including medication therapy) Start: 02/28/1997
410	Explain differences between treatment plan and patient's condition Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
411	Medical necessity for non-routine service(s) Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 287
412	Medical records to substantiate decision of non-coverage Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
413	Explain/justify differences between treatment plan and services rendered. Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
414	Necessity for concurrent care (more than one physician treating the patient) Start: 02/28/1997 \| Last Modified: 10/17/2010
415	Justify services outside composite rate Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 287
416	Verification of patient's ability to retain and use information Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
417	Prior testing, including result(s) and date(s) as related to service(s) Start: 02/28/1997
418	Indicating why medications cannot be taken orally Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
419	Individual test(s) comprising the panel and the charges for each test Start: 02/28/1997
420	Name, dosage and medical justification of contrast material used for radiology procedure Start: 02/28/1997
421	Medical review attachment/information for service(s) Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
422	Homebound status Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 575
423	Prognosis Start: 02/28/1997 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
424	Statement of non-coverage including itemized bill Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 279 & 286
425	Itemize non-covered services Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 279 & 286
426	All current diagnoses Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 255, 232 & 488
427	Emergency care provided during transport Start: 02/28/1997 \| Stop: 11/01/2011
428	Reason for transport by ambulance Start: 02/28/1997
429	Loaded miles and charges for transport to nearest facility with appropriate services Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to codes 267, 178, 430
430	Nearest appropriate facility Start: 02/28/1997
431	Patient's condition/functional status at time of service. Start: 02/28/1997 \| Last Modified: 10/17/2010
432	Date benefits exhausted Start: 02/28/1997
433	Copy of patient revocation of hospice benefits Start: 02/28/1997
434	Reasons for more than one transfer per entitlement period Start: 02/28/1997
435	Notice of Admission Start: 02/28/1997
436	Short term goals Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 345
437	Long term goals Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 345
438	Number of patients attending session Start: 02/28/1997 \| Stop: 11/01/2011
439	Size, depth, amount, and type of drainage wounds Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 297 or other specific report type codes
440	why non-skilled caregiver has not been taught procedure Start: 02/28/1997 \| Stop: 11/01/2011
441	Entity professional qualification for service(s) Start: 02/28/1997
442	Modalities of service Start: 02/28/1997
443	Initial evaluation report Start: 02/28/1997
444	Method used to obtain test sample Start: 02/28/1997 \| Stop: 11/01/2011
445	Explain why hearing loss not correctable by hearing aid Start: 02/28/1997 \| Stop: 11/01/2011 Notes: Refer to code 287
446	Documentation from prior claim(s) related to service(s) Start: 02/28/1997 \| Stop: 11/01/2011
447	Plan of teaching Start: 02/28/1997 \| Stop: 11/01/2011
448	Invalid billing combination. See STC12 for details. This code should only be used to indicate an inconsistency between two or more data elements on the claim. A detailed explanation is required in STC12 when this code is used. Start: 02/28/1997 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
449	Projected date to discontinue service(s) Start: 02/28/1997
450	Awaiting spend down determination Start: 02/28/1997
451	Preoperative and post-operative diagnosis Start: 02/28/1997
452	Total visits in total number of hours/day and total number of hours/week Start: 02/28/1997
453	Procedure Code Modifier(s) for Service(s) Rendered Start: 02/28/1997
454	Procedure code for services rendered. Start: 02/28/1997
455	Revenue code for services rendered. Start: 02/28/1997
456	Covered Day(s) Start: 02/28/1997
457	Non-Covered Day(s) Start: 02/28/1997
458	Coinsurance Day(s) Start: 02/28/1997
459	Lifetime Reserve Day(s) Start: 02/28/1997
460	NUBC Condition Code(s) Start: 02/28/1997
461	NUBC Occurrence Code(s) and Date(s) Start: 02/28/1997 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
462	NUBC Occurrence Span Code(s) and Date(s) Start: 02/28/1997 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
463	NUBC Value Code(s) and/or Amount(s) Start: 02/28/1997 \| Last Modified: 01/24/2010 \| Stop: 01/01/2012
464	Payer Assigned Claim Control Number Start: 02/28/1997 \| Last Modified: 10/31/2004
465	Principal Procedure Code for Service(s) Rendered Start: 02/28/1997
466	Entity's Original Signature. Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
467	Entity Signature Date. Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
468	Patient Signature Source Start: 02/28/1997
469	Purchase Service Charge Start: 02/28/1997
470	Was service purchased from another entity? Usage: This code requires use of an Entity Code. Start: 02/28/1997 \| Last Modified: 07/01/2017
471	Were services related to an emergency? Start: 02/28/1997
472	Ambulance Run Sheet Start: 02/28/1997
473	Missing or invalid lab indicator Start: 06/30/1998
474	Procedure code and patient gender mismatch Start: 06/30/1998 \| Last Modified: 02/29/2000
475	Procedure code not valid for patient age Start: 06/30/1998 \| Last Modified: 02/29/2000
476	Missing or invalid units of service Start: 06/30/1998
477	Diagnosis code pointer is missing or invalid Start: 06/30/1998
478	Claim submitter's identifier Start: 06/30/1998 \| Last Modified: 01/24/2010
479	Other Carrier payer ID is missing or invalid Start: 06/30/1998
480	Entity's claim filing indicator. Usage: This code requires use of an Entity Code. Start: 06/30/1998 \| Last Modified: 07/01/2017
481	Claim/submission format is invalid. Start: 10/31/1998
482	Date Error, Century Missing Start: 02/28/1999 \| Last Modified: 09/20/2009 \| Stop: 10/01/2010
483	Maximum coverage amount met or exceeded for benefit period. Start: 06/30/1999
484	Business Application Currently Not Available Start: 02/29/2000
485	More information available than can be returned in real time mode. Narrow your current search criteria. This change effective September 1, 2017: More information available than can be returned in real-time mode. Narrow your current search criteria. Start: 02/28/2001 \| Last Modified: 03/01/2017
486	Principal Procedure Date Start: 10/31/2001 \| Last Modified: 07/01/2009
487	Claim not found, claim should have been submitted to/through 'entity'. Usage: This code requires use of an Entity Code. Start: 02/28/2002 \| Last Modified: 07/01/2017
488	Diagnosis code(s) for the services rendered. Start: 06/30/2002
489	Attachment Control Number Start: 10/31/2002
490	Other Procedure Code for Service(s) Rendered Start: 02/28/2003
491	Entity not eligible for encounter submission. Usage: This code requires use of an Entity Code. Start: 02/28/2003 \| Last Modified: 07/01/2017
492	Other Procedure Date Start: 02/28/2003
493	Version/Release/Industry ID code not currently supported by information holder Start: 02/28/2003
494	Real-Time requests not supported by the information holder, resubmit as batch request This change effective September 1, 2017: Real-time requests not supported by the information holder, resubmit as batch request Start: 02/28/2003 \| Last Modified: 03/01/2017
495	Requests for re-adjudication must reference the newly assigned payer claim control number for this previously adjusted claim. Correct the payer claim control number and re-submit. Start: 10/31/2003
496	Submitter not approved for electronic claim submissions on behalf of this entity. Usage: This code requires use of an Entity Code. Start: 02/29/2004 \| Last Modified: 07/01/2017
497	Sales tax not paid Start: 06/30/2004
498	Maximum leave days exhausted Start: 06/30/2004
499	No rate on file with the payer for this service for this entity Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
500	Entity's Postal/Zip Code. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
501	Entity's State/Province. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
502	Entity's City. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
503	Entity's Street Address. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
504	Entity's Last Name. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
505	Entity's First Name. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
506	Entity is changing processor/clearinghouse. This claim must be submitted to the new processor/clearinghouse. Usage: This code requires use of an Entity Code. Start: 06/30/2004 \| Last Modified: 07/01/2017
507	HCPCS Start: 10/31/2004
508	ICD9 Usage: At least one other status code is required to identify the related procedure code or diagnosis code. Start: 10/31/2004 \| Last Modified: 07/01/2017
509	External Cause of Injury Code. Start: 10/31/2004 \| Last Modified: 03/01/2016
510	Future date. Usage: At least one other status code is required to identify the data element in error. Start: 10/31/2004 \| Last Modified: 07/01/2017
511	Invalid character. Usage: At least one other status code is required to identify the data element in error. Start: 10/31/2004 \| Last Modified: 07/01/2017
512	Length invalid for receiver's application system. Usage: At least one other status code is required to identify the data element in error. Start: 10/31/2004 \| Last Modified: 07/01/2017
513	HIPPS Rate Code for services Rendered Start: 10/31/2004
514	Entity's Middle Name Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
515	Managed Care review Start: 10/31/2004
516	Other Entity's Adjudication or Payment/Remittance Date. Usage: An Entity code is required to identify the Other Payer Entity, i.e. primary, secondary. Start: 10/31/2004 \| Last Modified: 07/01/2017
517	Adjusted Repriced Claim Reference Number Start: 10/31/2004
518	Adjusted Repriced Line item Reference Number Start: 10/31/2004
519	Adjustment Amount Start: 10/31/2004
520	Adjustment Quantity Start: 10/31/2004
521	Adjustment Reason Code Start: 10/31/2004
522	Anesthesia Modifying Units Start: 10/31/2004
523	Anesthesia Unit Count Start: 10/31/2004
524	Arterial Blood Gas Quantity Start: 10/31/2004
525	Begin Therapy Date Start: 10/31/2004
526	Bundled or Unbundled Line Number Start: 10/31/2004
527	Certification Condition Indicator Start: 10/31/2004
528	Certification Period Projected Visit Count Start: 10/31/2004
529	Certification Revision Date Start: 10/31/2004
530	Claim Adjustment Indicator Start: 10/31/2004
531	Claim Disproportinate Share Amount Start: 10/31/2004
532	Claim DRG Amount Start: 10/31/2004
533	Claim DRG Outlier Amount Start: 10/31/2004
534	Claim ESRD Payment Amount Start: 10/31/2004
535	Claim Frequency Code Start: 10/31/2004
536	Claim Indirect Teaching Amount Start: 10/31/2004
537	Claim MSP Pass-through Amount Start: 10/31/2004
538	Claim or Encounter Identifier Start: 10/31/2004
539	Claim PPS Capital Amount Start: 10/31/2004
540	Claim PPS Capital Outlier Amount Start: 10/31/2004
541	Claim Submission Reason Code Start: 10/31/2004
542	Claim Total Denied Charge Amount Start: 10/31/2004
543	Clearinghouse or Value Added Network Trace Start: 10/31/2004
544	Clinical Laboratory Improvement Amendment (CLIA) Number Start: 10/31/2004 \| Last Modified: 03/01/2018
545	Contract Amount Start: 10/31/2004
546	Contract Code Start: 10/31/2004
547	Contract Percentage Start: 10/31/2004
548	Contract Type Code Start: 10/31/2004
549	Contract Version Identifier Start: 10/31/2004
550	Coordination of Benefits Code Start: 10/31/2004
551	Coordination of Benefits Total Submitted Charge Start: 10/31/2004
552	Cost Report Day Count Start: 10/31/2004
553	Covered Amount Start: 10/31/2004
554	Date Claim Paid Start: 10/31/2004
555	Delay Reason Code Start: 10/31/2004
556	Demonstration Project Identifier Start: 10/31/2004
557	Diagnosis Date Start: 10/31/2004
558	Discount Amount Start: 10/31/2004
559	Document Control Identifier Start: 10/31/2004
560	Entity's Additional/Secondary Identifier. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
561	Entity's Contact Name. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
562	Entity's National Provider Identifier (NPI). Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
563	Entity's Tax Amount. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
564	EPSDT Indicator Start: 10/31/2004
565	Estimated Claim Due Amount Start: 10/31/2004
566	Exception Code Start: 10/31/2004
567	Facility Code Qualifier Start: 10/31/2004
568	Family Planning Indicator Start: 10/31/2004
569	Fixed Format Information Start: 10/31/2004
570	Free Form Message Text Start: 10/31/2004 \| Stop: 01/01/2013
571	Frequency Count Start: 10/31/2004
572	Frequency Period Start: 10/31/2004
573	Functional Limitation Code Start: 10/31/2004
574	HCPCS Payable Amount Home Health Start: 10/31/2004
575	Homebound Indicator Start: 10/31/2004
576	Immunization Batch Number Start: 10/31/2004
577	Industry Code Start: 10/31/2004
578	Insurance Type Code Start: 10/31/2004
579	Investigational Device Exemption Identifier Start: 10/31/2004
580	Last Certification Date Start: 10/31/2004
581	Last Worked Date Start: 10/31/2004
582	Lifetime Psychiatric Days Count Start: 10/31/2004
583	Line Item Charge Amount Start: 10/31/2004
584	Line Item Control Number Start: 10/31/2004
585	Denied Charge or Non-covered Charge Start: 10/31/2004 \| Last Modified: 07/09/2007
586	Line Note Text Start: 10/31/2004
587	Measurement Reference Identification Code Start: 10/31/2004
588	Medical Record Number Start: 10/31/2004
589	Provider Accept Assignment Code Start: 10/31/2004 \| Last Modified: 10/17/2010
590	Medicare Coverage Indicator Start: 10/31/2004
591	Medicare Paid at 100% Amount Start: 10/31/2004
592	Medicare Paid at 80% Amount Start: 10/31/2004
593	Medicare Section 4081 Indicator Start: 10/31/2004
594	Mental Status Code Start: 10/31/2004
595	Monthly Treatment Count Start: 10/31/2004
596	Non-covered Charge Amount Start: 10/31/2004
597	Non-payable Professional Component Amount Start: 10/31/2004
598	Non-payable Professional Component Billed Amount Start: 10/31/2004
599	Note Reference Code Start: 10/31/2004
600	Oxygen Saturation Qty Start: 10/31/2004
601	Oxygen Test Condition Code Start: 10/31/2004
602	Oxygen Test Date Start: 10/31/2004
603	Old Capital Amount Start: 10/31/2004
604	Originator Application Transaction Identifier Start: 10/31/2004
605	Orthodontic Treatment Months Count Start: 10/31/2004
606	Paid From Part A Medicare Trust Fund Amount Start: 10/31/2004
607	Paid From Part B Medicare Trust Fund Amount Start: 10/31/2004
608	Paid Service Unit Count Start: 10/31/2004
609	Participation Agreement Start: 10/31/2004
610	Patient Discharge Facility Type Code Start: 10/31/2004
611	Peer Review Authorization Number Start: 10/31/2004
612	Per Day Limit Amount Start: 10/31/2004
613	Physician Contact Date Start: 10/31/2004
614	Physician Order Date Start: 10/31/2004
615	Policy Compliance Code Start: 10/31/2004
616	Policy Name Start: 10/31/2004
617	Postage Claimed Amount Start: 10/31/2004
618	PPS-Capital DSH DRG Amount Start: 10/31/2004
619	PPS-Capital Exception Amount Start: 10/31/2004
620	PPS-Capital FSP DRG Amount Start: 10/31/2004
621	PPS-Capital HSP DRG Amount Start: 10/31/2004
622	PPS-Capital IME Amount Start: 10/31/2004
623	PPS-Operating Federal Specific DRG Amount Start: 10/31/2004
624	PPS-Operating Hospital Specific DRG Amount Start: 10/31/2004
625	Predetermination of Benefits Identifier Start: 10/31/2004
626	Pregnancy Indicator Start: 10/31/2004
627	Pre-Tax Claim Amount Start: 10/31/2004
628	Pricing Methodology Start: 10/31/2004
629	Property Casualty Claim Number Start: 10/31/2004
630	Referring CLIA Number Start: 10/31/2004
631	Reimbursement Rate Start: 10/31/2004
632	Reject Reason Code Start: 10/31/2004
633	Related Causes Code (Accident, auto accident, employment) Start: 10/31/2004 \| Last Modified: 10/17/2010
634	Remark Code Start: 10/31/2004
635	Repriced Ambulatory Patient Group Code Start: 10/31/2004
636	Repriced Line Item Reference Number Start: 10/31/2004
637	Repriced Saving Amount Start: 10/31/2004
638	Repricing Per Diem or Flat Rate Amount Start: 10/31/2004
639	Responsibility Amount Start: 10/31/2004
640	Sales Tax Amount Start: 10/31/2004
641	Service Adjudication or Payment Date. Note: Use code 516. Start: 10/31/2004 \| Last Modified: 09/20/2009 \| Stop: 10/01/2010
642	Service Authorization Exception Code Start: 10/31/2004
643	Service Line Paid Amount Start: 10/31/2004
644	Service Line Rate Start: 10/31/2004
645	Service Tax Amount Start: 10/31/2004
646	Ship, Delivery or Calendar Pattern Code Start: 10/31/2004
647	Shipped Date Start: 10/31/2004
648	Similar Illness or Symptom Date Start: 10/31/2004
649	Skilled Nursing Facility Indicator Start: 10/31/2004
650	Special Program Indicator Start: 10/31/2004
651	State Industrial Accident Provider Number Start: 10/31/2004
652	Terms Discount Percentage Start: 10/31/2004
653	Test Performed Date Start: 10/31/2004
654	Total Denied Charge Amount Start: 10/31/2004
655	Total Medicare Paid Amount Start: 10/31/2004
656	Total Visits Projected This Certification Count Start: 10/31/2004
657	Total Visits Rendered Count Start: 10/31/2004
658	Treatment Code Start: 10/31/2004
659	Unit or Basis for Measurement Code Start: 10/31/2004
660	Universal Product Number Start: 10/31/2004
661	Visits Prior to Recertification Date Count CR702 Start: 10/31/2004
662	X-ray Availability Indicator Start: 10/31/2004
663	Entity's Group Name. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
664	Orthodontic Banding Date Start: 10/31/2004
665	Surgery Date Start: 10/31/2004
666	Surgical Procedure Code Start: 10/31/2004
667	Real-Time requests not supported by the information holder, do not resubmit This change effective September 1, 2017: Real-time requests not supported by the information holder, do not resubmit Start: 02/28/2005 \| Last Modified: 03/01/2017
668	Missing Endodontics treatment history and prognosis Start: 06/30/2005
669	Dental service narrative needed. Start: 10/31/2005
670	Funds applied from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts Start: 06/30/2006 \| Last Modified: 02/28/2007
671	Funds may be available from a consumer spending account such as consumer directed/driven health plan (CDHP), Health savings account (H S A) and or other similar accounts Start: 06/30/2006 \| Last Modified: 02/28/2007
672	Other Payer's payment information is out of balance Start: 10/31/2006
673	Patient Reason for Visit Start: 10/31/2006
674	Authorization exceeded Start: 10/31/2006
675	Facility admission through discharge dates Start: 10/31/2006
676	Entity possibly compensated by facility. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
677	Entity not affiliated. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
678	Revenue code and patient gender mismatch Start: 10/31/2006
679	Submit newborn services on mother's claim Start: 10/31/2006
680	Entity's Country. Usage: This code requires use of an Entity Code. Start: 10/31/2004 \| Last Modified: 07/01/2017
681	Claim currency not supported Start: 10/31/2006
682	Cosmetic procedure Start: 02/28/2007
683	Awaiting Associated Hospital Claims Start: 02/28/2007
684	Rejected. Syntax error noted for this claim/service/inquiry. See Functional or Implementation Acknowledgement for details. (Usage: Only for use to reject claims or status requests in transactions that were 'accepted with errors' on a 997 or 999 Acknowledgement.) Start: 11/05/2007 \| Last Modified: 07/01/2017
685	Claim could not complete adjudication in real time. Claim will continue processing in a batch mode. Do not resubmit. This change effective September 1, 2017: Claim could not complete adjudication in real-time. Claim will continue processing in a batch mode. Do not resubmit. Start: 01/27/2008 \| Last Modified: 03/01/2017
686	The claim/ encounter has completed the adjudication cycle and the entire claim has been voided Start: 01/27/2008
687	Claim estimation can not be completed in real time. Do not resubmit. This change effective September 1, 2017: Claim predetermination/estimation could not be completed in real-time. Do not resubmit. Start: 01/27/2008 \| Last Modified: 03/01/2017
688	Present on Admission Indicator for reported diagnosis code(s). Start: 01/27/2008
689	Entity was unable to respond within the expected time frame. Usage: This code requires use of an Entity Code. Start: 06/01/2008 \| Last Modified: 07/01/2017
690	Multiple claims or estimate requests cannot be processed in real time. This change effective September 1, 2017: Multiple claims or estimate requests cannot be processed in real-time. Start: 06/01/2008 \| Last Modified: 03/01/2017
691	Multiple claim status requests cannot be processed in real time. This change effective September 1, 2017: Multiple claim status requests cannot be processed in real-time. Start: 06/01/2008 \| Last Modified: 03/01/2017
692	Contracted funding agreement-Subscriber is employed by the provider of services Start: 09/21/2008
693	Amount must be greater than or equal to zero. Usage: At least one other status code is required to identify which amount element is in error. Start: 01/25/2009 \| Last Modified: 07/01/2017
694	Amount must not be equal to zero. Usage: At least one other status code is required to identify which amount element is in error. Start: 01/25/2009 \| Last Modified: 07/01/2017
695	Entity's Country Subdivision Code. Usage: This code requires use of an Entity Code. Start: 01/25/2009 \| Last Modified: 07/01/2017
696	Claim Adjustment Group Code. Start: 01/25/2009
697	Invalid Decimal Precision. Usage: At least one other status code is required to identify the data element in error. Start: 07/01/2009 \| Last Modified: 07/01/2017
698	Form Type Identification Start: 07/01/2009
699	Question/Response from Supporting Documentation Form Start: 07/01/2009
700	ICD10. Usage: At least one other status code is required to identify the related procedure code or diagnosis code. Start: 07/01/2009 \| Last Modified: 07/01/2017
701	Initial Treatment Date Start: 07/01/2009
702	Repriced Claim Reference Number Start: 11/01/2009
703	Advanced Billing Concepts (ABC) code Start: 01/24/2010
704	Claim Note Text Start: 01/24/2010
705	Repriced Allowed Amount Start: 01/24/2010
706	Repriced Approved Amount Start: 01/24/2010
707	Repriced Approved Ambulatory Patient Group Amount Start: 01/24/2010
708	Repriced Approved Revenue Code Start: 01/24/2010
709	Repriced Approved Service Unit Count Start: 01/24/2010
710	Line Adjudication Information. Usage: At least one other status code is required to identify the data element in error. Start: 01/24/2010 \| Last Modified: 07/01/2017
711	Stretcher purpose Start: 01/24/2010
712	Obstetric Additional Units Start: 01/24/2010
713	Patient Condition Description Start: 01/24/2010
714	Care Plan Oversight Number Start: 01/24/2010
715	Acute Manifestation Date Start: 01/24/2010
716	Repriced Approved DRG Code Start: 01/24/2010
717	This claim has been split for processing. Start: 01/24/2010
718	Claim/service not submitted within the required timeframe (timely filing). Start: 01/24/2010
719	NUBC Occurrence Code(s) Start: 01/24/2010
720	NUBC Occurrence Code Date(s) Start: 01/24/2010
721	NUBC Occurrence Span Code(s) Start: 01/24/2010
722	NUBC Occurrence Span Code Date(s) Start: 01/24/2010
723	Drug days supply Start: 01/24/2010
724	Drug dosage. This change effective 5/01/2017: Drug Quantity Start: 01/24/2010 \| Last Modified: 11/01/2016
725	NUBC Value Code(s) Start: 01/24/2010
726	NUBC Value Code Amount(s) Start: 01/24/2010
727	Accident date Start: 01/24/2010
728	Accident state Start: 01/24/2010
729	Accident description Start: 01/24/2010
730	Accident cause Start: 01/24/2010
731	Measurement value/test result Start: 01/24/2010
732	Information submitted inconsistent with billing guidelines. Usage: At least one other status code is required to identify the inconsistent information. Start: 01/24/2010 \| Last Modified: 07/01/2017
733	Prefix for entity's contract/member number. Start: 01/24/2010
734	Verifying premium payment Start: 06/06/2010
735	This service/claim is included in the allowance for another service or claim. Start: 06/06/2010
736	A related or qualifying service/claim has not been received/adjudicated. Start: 06/06/2010
737	Current Dental Terminology (CDT) Code Start: 06/06/2010
738	Home Infusion EDI Coalition (HEIC) Product/Service Code Start: 06/06/2010
739	Jurisdiction Specific Procedure or Supply Code Start: 06/06/2010
740	Drop-Off Location Start: 06/06/2010
741	Entity must be a person. Usage: This code requires use of an Entity Code. Start: 06/06/2010 \| Last Modified: 07/01/2017
742	Payer Responsibility Sequence Number Code Start: 06/06/2010
743	Entity's credential/enrollment information. Usage: This code requires use of an Entity Code. Start: 10/17/2010 \| Last Modified: 07/01/2017
744	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Start: 10/17/2010
745	Identifier Qualifier Usage: At least one other status code is required to identify the specific identifier qualifier in error. Start: 10/17/2010 \| Last Modified: 07/01/2017
746	Duplicate Submission Usage: use only at the information receiver level in the Health Care Claim Acknowledgement transaction. Start: 10/17/2010 \| Last Modified: 07/01/2017
747	Hospice Employee Indicator Start: 10/17/2010
748	Corrected Data Usage: Requires a second status code to identify the corrected data. Start: 10/17/2010 \| Last Modified: 07/01/2017
749	Date of Injury/Illness Start: 10/17/2010
750	Auto Accident State or Province Code Start: 10/17/2010 \| Last Modified: 01/30/2011
751	Ambulance Pick-up State or Province Code Start: 10/17/2010 \| Last Modified: 01/30/2011
752	Ambulance Drop-off State or Province Code Start: 10/17/2010 \| Last Modified: 01/30/2011
753	Co-pay status code. Start: 01/30/2011
754	Entity Name Suffix. Usage: This code requires the use of an Entity Code. Start: 01/30/2011 \| Last Modified: 07/01/2017
755	Entity's primary identifier. Usage: This code requires the use of an Entity Code. Start: 01/30/2011 \| Last Modified: 07/01/2017
756	Entity's Received Date. Usage: This code requires the use of an Entity Code. Start: 01/30/2011 \| Last Modified: 07/01/2017
757	Last seen date. Start: 01/30/2011
758	Repriced approved HCPCS code. Start: 01/30/2011
759	Round trip purpose description. Start: 01/30/2011
760	Tooth status code. Start: 01/30/2011
761	Entity's referral number. Usage: This code requires the use of an Entity Code. Start: 01/30/2011 \| Last Modified: 07/01/2017
762	Locum Tenens Provider Identifier. Code must be used with Entity Code 82 - Rendering Provider Start: 01/20/2013
763	Ambulance Pickup ZipCode Start: 01/20/2013
764	Professional charges are non covered. Start: 06/02/2013
765	Institutional charges are non covered. Start: 06/02/2013
766	Services were performed during a Health Insurance Exchange (HIX) premium payment grace period. Start: 11/01/2013
767	Qualifications for emergent/urgent care Start: 01/26/2014
768	Service date outside the accidental injury coverage period. Start: 01/26/2014
769	DME Repair or Maintenance Start: 06/01/2014
770	Duplicate of a claim processed or in process as a crossover/coordination of benefits claim. Start: 09/28/2014
771	Claim submitted prematurely. Please resubmit after crossover/payer to payer COB allotted waiting period. Start: 09/28/2014
772	The greatest level of diagnosis code specificity is required. Start: 03/01/2016
773	One calendar year per claim. Start: 11/01/2016
774	Experimental/Investigational Start: 11/01/2016
775	Entity Type Qualifier (Person/Non-Person Entity). Usage: this code requires use of an entity code. Start: 07/01/2017
776	Pre/Post-operative care Start: 07/01/2017
777	Processed based on multiple or concurrent procedure rules. Start: 07/01/2017
778	Non-Compensable incident/event. Usage: To be used for Property and Casualty only. Start: 07/01/2017
779	Service submitted for the same/similar service within a set timeframe. Start: 11/01/2017
780	Lifetime benefit maximum Start: 11/01/2017
781	Claim has been identified as a readmission Start: 11/01/2017
782	Second surgical opinion Start: 03/01/2018
783	Federal sequestration adjustment Start: 11/01/2018
784	Electronic Visit Verification criteria do not match. Start: 03/01/2019
785	Missing/Invalid Sterilization/Abortion/Hospital Consent Form. Start: 07/01/2019
786	Submit claim to the third party property and casualty automobile insurer. Start: 07/01/2019
787	Resubmit a new claim, not a replacement claim. Start: 07/01/2019
788	Submit these services to the Pharmacy plan/processor for further consideration/adjudication. Start: 07/01/2019 \| Last Modified: 11/16/2022
789	Submit these services to the patient's Medical Plan for further consideration. Start: 07/01/2019
790	Submit these services to the patient's Dental Plan for further consideration. Start: 07/01/2019
791	Submit these services to the patient's Vision Plan for further consideration. Start: 07/01/2019
792	Submit these services to the patient's Behavioral Health Plan for further consideration. Start: 07/01/2019
793	Submit these services to the patient's Property and Casualty Plan for further consideration. Start: 07/01/2019
794	Claim could not complete adjudication in real time. Resubmit as a batch request. Start: 11/01/2020
795	Claim submitted prematurely. Please provide the prior payer's final adjudication. Start: 11/01/2020
796	Procedure code not valid for date of service. Start: 11/01/2021
797	Entity's TRICARE provider id. Usage: This code requires use of an Entity Code. Start: 11/01/2021 \| Last Modified: 03/01/2022 \| Stop: 03/01/2022
798	Claim predetermination/estimation could not be completed in real time. Claim requires manual review upon submission. Do not resubmit. Start: 08/01/2022
799	Resubmit a replacement claim, not a new claim. Start: 08/01/2022
800	Entity's required reporting has been forwarded to the jurisdiction. Usage: This code requires use of an Entity Code. To be used for Property and Casualty only. Start: 03/01/2023
801	Entity's required reporting was accepted by the jurisdiction. Usage: This code requires use of an Entity Code. To be used for Property and Casualty only. Start: 03/01/2023
802	Entity's required reporting was rejected by the jurisdiction. Usage: This code requires use of an Entity Code. To be used for Property and Casualty only. Start: 03/01/2023
803	Provider reporting has been rejected due to non-compliance with the jurisdiction's mandated registration. To be used for Property and Casualty only. Start: 03/01/2023
804	Exceeds inquiry limit for batch. Start: 07/01/2024
805	Mammography Certification Number Start: 07/01/2024
806	Residential county does not match the county of the service location. Start: 07/01/2024
807	Health Risk Assessment Start: 07/01/2024

Code List Filters Block Reference

Filter by code:

Filter codes by status:

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.

Status last Reviewed: 6/19/2024

Num.	Date	Requested Description	Type	Status
115	1/16/2024	Exceeds inquiry limit established in trading partner agreement.	New	CMG Approved
116	3/14/2024	Mammography Certification Number	New	CMG Approved
118	5/2/2024	Entity's County. Usage: This code requires use of an Entity Code	New	CMG Approved
119	5/7/2024	Health Risk Assessment	New	CMG Approved

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Claim Status Codes

Claim Status Category Codes

Code List ID

507

Code List Scope Statement

These codes organize the Claim Status Codes (ECL 508) into logical groupings.

Code List Maintained By

CMG03

Code List Updated Date

Tue, 03/03/2020 - 12:00

Code List Table

Supplemental
X0	Supplemental Messages Start: 01/01/1995 \| Stop: 10/16/2003
Acknowledgements
A0	Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity. Start: 01/01/1995
A1	Acknowledgement/Receipt-The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication. Start: 01/01/1995
A2	Acknowledgement/Acceptance into adjudication system-The claim/encounter has been accepted into the adjudication system. Start: 01/01/1995
A3	Acknowledgement/Returned as unprocessable claim-The claim/encounter has been rejected and has not been entered into the adjudication system. Start: 01/01/1995
A4	Acknowledgement/Not Found-The claim/encounter can not be found in the adjudication system. Start: 01/01/1995
A5	Acknowledgement/Split Claim-The claim/encounter has been split upon acceptance into the adjudication system. Start: 02/28/2002
A6	Acknowledgement/Rejected for Missing Information - The claim/encounter is missing the information specified in the Status details and has been rejected. Start: 10/31/2002
A7	Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected. Start: 10/31/2002
A8	Acknowledgement/Rejected for relational field in error. Start: 10/31/2004
Data Reporting Acknowledgments
DR01	Acknowledgement/Receipt - The claim/encounter has been received. This does not mean the claim has been accepted into the data reporting/processing system. Usage: Can only be used in the Data Reporting Acknowledgement Transaction. Start: 07/01/2018
DR02	Acknowledgement/Acceptance into the data reporting/processing system - The claim/encounter has been accepted into the data reporting/processing system. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR03	Acknowledgement/Returned as unprocessable claim - The claim/encounter has been rejected and has not been entered into the data reporting/processing system. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR04	Acknowledgement/Not Found - The claim/encounter can not be found in the data reporting/processing system. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR05	Acknowledgement/Rejected for Missing Information - The claim/encounter is missing the information specified in the Status details and has been rejected. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR06	Acknowledgment/Rejected for invalid information - The claim/encounter has invalid information as specified in the Status details and has been rejected. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR07	Acknowledgement/Rejected for relational field in error. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
DR08	Acknowledgement/Warning - The claim/encounter has been accepted into the data reporting/processing system but has received a warning as specified in the Status details. Usage: Can only be used in the Data Reporting Acknowledgment Transaction. Start: 07/01/2018
Pending
P0	Pending: Adjudication/Details-This is a generic message about a pended claim. A pended claim is one for which no remittance advice has been issued, or only part of the claim has been paid. Start: 01/01/1995
P1	Pending/In Process-The claim or encounter is in the adjudication system. Start: 01/01/1995
P2	Pending/Payer Review-The claim/encounter is suspended and is pending review (e.g. medical review, repricing, Third Party Administrator processing). Start: 01/01/1995 \| Last Modified: 01/27/2008
P3	Pending/Provider Requested Information - The claim or encounter is waiting for information that has already been requested from the provider. (Usage: A Claim Status Code identifying the type of information requested, must be reported) Start: 01/01/1995 \| Last Modified: 07/01/2017
P4	Pending/Patient Requested Information - The claim or encounter is waiting for information that has already been requested from the patient. (Usage: A status code identifying the type of information requested must be sent) Start: 01/01/1995 \| Last Modified: 07/01/2017
P5	Pending/Payer Administrative/System hold Start: 10/31/2006
Finalized
F0	Finalized-The claim/encounter has completed the adjudication cycle and no more action will be taken. Start: 01/01/1995
F1	Finalized/Payment-The claim/line has been paid. Start: 01/01/1995
F2	Finalized/Denial-The claim/line has been denied. Start: 01/01/1995
F3	Finalized/Revised - Adjudication information has been changed Start: 02/28/2001
F3F	Finalized/Forwarded-The claim/encounter processing has been completed. Any applicable payment has been made and the claim/encounter has been forwarded to a subsequent entity as identified on the original claim or in this payer's records. Start: 01/01/1995
F3N	Finalized/Not Forwarded-The claim/encounter processing has been completed. Any applicable payment has been made. The claim/encounter has NOT been forwarded to any subsequent entity identified on the original claim. Start: 01/01/1995
F4	Finalized/Adjudication Complete - No payment forthcoming-The claim/encounter has been adjudicated and no further payment is forthcoming. Start: 01/01/1995
F5	Finalized/Cannot Process Start: 01/01/1995 \| Stop: 10/16/2003
Requests for additional information
R0	Requests for additional Information/General Requests-Requests that don't fall into other R-type categories. Start: 01/01/1995
R1	Requests for additional Information/Entity Requests-Requests for information about specific entities (subscribers, patients, various providers). Start: 01/01/1995
R3	Requests for additional Information/Claim/Line-Requests for information that could normally be submitted on a claim. Start: 01/01/1995 \| Last Modified: 02/28/1998
R4	Requests for additional Information/Documentation-Requests for additional supporting documentation. Examples: certification, x-ray, notes. Start: 01/01/1995 \| Last Modified: 02/28/1998
R5	Request for additional information/more specific detail-Additional information as a follow up to a previous request is needed. The original information was received but is inadequate. More specific/detailed information is requested. Start: 01/01/1995 \| Last Modified: 06/30/1998
R6	Requests for additional information – Regulatory requirements Start: 02/28/2007
R7	Requests for additional information – Confirm care is consistent with Health Plan policy coverage Start: 02/28/2007
R8	Requests for additional information – Confirm care is consistent with health plan coverage exceptions Start: 02/28/2007
R9	Requests for additional information – Determination of medical necessity Start: 02/28/2007
R10	Requests for additional information – Support a filed grievance or appeal Start: 02/28/2007
R11	Requests for additional information – Pre-payment review of claims Start: 02/28/2007
R12	Requests for additional information – Clarification or justification of use for specified procedure code Start: 02/28/2007
R13	Requests for additional information – Original documents submitted are not readable. Used only for subsequent request(s). Start: 02/28/2007
R14	Requests for additional information – Original documents received are not what was requested. Used only for subsequent request(s). Start: 02/28/2007
R15	Requests for additional information – Workers Compensation coverage determination. Start: 02/28/2007
R16	Requests for additional information – Eligibility determination Start: 02/28/2007
R17	Replacement of a Prior Request. Used to indicate that the current attachment request replaces a prior attachment request. Start: 01/20/2013
General
RQ	General Questions (Yes/No Responses)-Questions that may be answered by a simple 'yes' or 'no'. Start: 01/01/1995 \| Last Modified: 07/09/2007 \| Stop: 01/01/2008
Error
E0	Response not possible - error on submitted request data Start: 01/01/1995 \| Last Modified: 02/28/2002
E1	Response not possible - System Status Start: 02/29/2000
E2	Information Holder is not responding; resubmit at a later time. Start: 06/30/2003
E3	Correction required - relational fields in error. Start: 01/24/2010
E4	Trading partner agreement specific requirement not met: Data correction required. (Usage: A status code identifying the type of information requested must be sent) Start: 01/30/2011 \| Last Modified: 07/01/2017
Searches
D0	Data Search Unsuccessful - The payer is unable to return status on the requested claim(s) based on the submitted search criteria. Start: 01/01/1995 \| Last Modified: 09/20/2009

Code List Filters Block Reference

Filter by code:

Filter codes by status:

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.

Status Last Reviewed: 6/19/2024

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.

Maintenance Request Form

Claim Status Category Codes

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Claim Status Category Codes

Error Reason Codes

Code List ID

977

Code List Scope Statement

These codes describe a processing error related to a particular EDI transmission.

Code List Maintained By

CMG02

Code List Updated Date

Thu, 07/01/2021 - 12:00

Code List Table

01	Inappropriate combination of service type code and service type code descriptor. Activation Date: 11/01/2017
02	Inappropriate service type code(s) Activation Date: 11/01/2017
03	The submitted procedure code(s) is not supported. Activation Date: 11/01/2017
04	Inquiries related to procedure codes are not supported. Activation Date: 11/01/2017
05	The submitted modifier code(s) is not supported. Activation Date: 11/01/2017
06	Inquiries related to modifier codes are not supported. Activation Date: 11/01/2017
07	The submitted diagnosis code(s) is not supported. Activation Date: 11/01/2017
08	Inquiries related to diagnosis codes are not supported. Activation Date: 11/01/2017
09	Duplicate ID Activation Date: 11/01/2017 \| Deactivation Date: 08/01/2019
10	Invalid subscriber or insured ID Activation Date: 11/01/2017
11	Missing subscriber or insured ID Activation Date: 11/01/2017
12	Missing subscriber or insured name Activation Date: 11/01/2017
13	Invalid date of death Activation Date: 11/01/2017
14	Missing date of death Activation Date: 11/01/2017
15	Missing provider name Activation Date: 11/01/2017
16	Invalid taxonomy Activation Date: 11/01/2017
17	Missing taxonomy Activation Date: 11/01/2017
18	Missing provider state Activation Date: 11/01/2017
19	Invalid referring provider ID Activation Date: 11/01/2017
20	Missing referring provider ID Activation Date: 11/01/2017
21	The request date(s) is not within the provider's plan enrollment period. Activation Date: 11/01/2017
22	The request date(s) precedes the date of birth. Activation Date: 11/01/2017
23	The date of death in our records precedes the request date(s). Activation Date: 11/01/2017
24	The request date(s) is not within the allowable inquiry period. Activation Date: 11/01/2017
25	The request date(s) is in the future. Activation Date: 11/01/2017
26	Invalid request date(s) Activation Date: 11/01/2017
27	Invalid patient ID Activation Date: 11/01/2017
28	Missing patient ID Activation Date: 11/01/2017
29	Missing patient name Activation Date: 11/01/2017
30	Invalid case number Activation Date: 11/01/2017
31	Missing case number Activation Date: 11/01/2017
32	Invalid provider address Activation Date: 11/01/2017
33	Missing provider address Activation Date: 11/01/2017
34	The referral number was not found. Activation Date: 11/01/2017
35	Invalid diagnosis code(s) Activation Date: 11/01/2017
36	Missing diagnosis code(s) Activation Date: 11/01/2017
37	Invalid procedure code(s) Activation Date: 11/01/2017
38	Missing procedure code(s) Activation Date: 11/01/2017
39	Invalid modifier code(s) Activation Date: 11/01/2017
40	Missing modifier code(s) Activation Date: 11/01/2017
41	Invalid authorization number Activation Date: 11/01/2017
42	Invalid referral number Activation Date: 11/01/2017
43	Missing referral number Activation Date: 11/01/2017
44	The authorized quantity of patient requests was exceeded. Activation Date: 11/01/2017
45	The provider is out of network for the member. Activation Date: 11/01/2017
46	The responding system is unable to complete the request at the current time. Activation Date: 11/01/2017
47	The provider ID does not match our records and we were not able to identify the provider. Activation Date: 11/01/2017
48	Inappropriate combination of qualifier and product or service code. Activation Date: 11/01/2017
49	Inappropriate combination of provider ID and taxonomy. Activation Date: 11/01/2017
50	Inappropriate combination of place of service and product or service code. Activation Date: 11/01/2017
51	Duplicate patient ID Activation Date: 11/01/2017 \| Deactivation Date: 08/01/2019
52	The service is inconsistent with the patient's age. Activation Date: 11/01/2017
53	The diagnosis is inconsistent with the patient's age. Activation Date: 11/01/2017
54	The patient's date of birth does not match our records. Activation Date: 11/01/2017
55	The subscriber or insured was not found. Activation Date: 11/01/2017
56	The subscriber ID or insured ID is not unique (returns multiple matches) in our records. Activation Date: 11/01/2017 \| Deactivation Date: 08/01/2019
57	Although the subscriber was found, the patient was not found. Activation Date: 11/01/2017
58	The submitted group or plan does not match our records. Activation Date: 11/01/2017
59	A response was not received from the information source's system. Activation Date: 11/01/2017
60	The submitted services are inconsistent with the submitted diagnosis code(s). Activation Date: 11/01/2017
61	Invalid provider ID Activation Date: 11/01/2017
62	Missing provider ID Activation Date: 11/01/2017
63	This service is not medically appropriate for this patient. Activation Date: 11/01/2017
64	The submitted authorization number does not match our records. Activation Date: 11/01/2017
65	Invalid date of birth Activation Date: 11/01/2017
66	Missing date of birth Activation Date: 11/01/2017
67	Missing gender code Activation Date: 11/01/2017
68	The provider ID does not match our records but we were able to identify the provider. Activation Date: 11/01/2017
69	Invalid member ID Activation Date: 11/01/2017
70	The responding system is unable to respond within the alloted time. Activation Date: 11/01/2017
71	Missing last name Activation Date: 11/01/2017
72	Missing first name Activation Date: 11/01/2017
73	Missing member ID Activation Date: 11/01/2017
74	The member ID does not match our records. Activation Date: 11/01/2017
75	The gender code does not match our records. Activation Date: 11/01/2017
76	The first name does not match our records. Activation Date: 11/01/2017
77	The last name does not match our records. Activation Date: 11/01/2017
78	The middle name does not match our records. Activation Date: 11/01/2017
79	Invalid name suffix Activation Date: 11/01/2017
80	Missing name suffix Activation Date: 11/01/2017
81	The name suffix does not match our records. Activation Date: 11/01/2017
82	There were duplicates within the minimum number of service types supported (ten), so there are fewer than ten responses. Activation Date: 11/01/2017
83	There were duplicate service type inquiries so the number of responses does not match the number of inquiries. Activation Date: 11/01/2017
84	The number of service type inquiries exceeds the number of responses we can return. Activation Date: 11/01/2017
85	We have responded with general benefit information, however the submitted procedure code requires separate medical review. Activation Date: 11/01/2017
86	We have responded, however the submitted procedure code requires separate medical review and prior authorization. Activation Date: 11/01/2017
87	We have responded with general benefit information, however the submitted service type code requires separate medical review. Activation Date: 11/01/2017
88	We have responded, however the submitted service type code requires separate medical review and prior authorization. Activation Date: 11/01/2017
89	Invalid group number Activation Date: 11/01/2017
90	Missing group number Activation Date: 11/01/2017
91	The responding system cannot process this real-time inquiry in real-time mode. Activation Date: 11/01/2017
92	Duplicate first name Activation Date: 08/24/2018
93	Duplicate last name Activation Date: 08/24/2018
94	Duplicate date of birth Activation Date: 08/24/2018
95	Duplicate policy(s) Activation Date: 08/24/2018
96	A date range greater than 12 months is not supported. Activation Date: 08/24/2018
97	The date range of the inquiry exceeds the period of time supported. Activation Date: 08/24/2018
98	The member ID is not unique (returns multiple matches) in our records. Activation Date: 08/01/2019
99	Inappropriate combination of service type codes Activation Date: 08/01/2019
100	Service type code(s) on this request is valid only for responses and is not valid on requests. Activation Date: 08/01/2019
101	The provider ID does match our records but has not met the eligibility requirements to send or receive this transaction. Activation Date: 08/01/2019
102	Benefit utilization information for this response, such as remaining or accumulator amounts, is restricted by the responding system. Activation Date: 10/01/2019
103	Information source is not responding; clearinghouse/intermediary has temporarily suspended request submissions. Activation Date: 07/01/2021
104	Information Source's system encountered errors preventing benefit related information from being returned. Activation Date: 07/01/2021
105	Information Source's system encountered errors preventing eligibility, coverage and/or policy related information from being returned. Activation Date: 07/01/2021

Code List Filters Block Reference

Filter by code:

Filter codes by status:

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.

Status Last Reviewed: 6/19/2024

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.

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name

Request Type

Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Error Reason Codes

Claim Adjustment Reason Codes

Code List ID

139

Code List Scope Statement

These codes describe why a claim or service line was paid differently than it was billed.

Code List Maintained By

CMG03

Code List Updated Date

Fri, 03/01/2024 - 12:00

Code List Table

1	Deductible Amount Start: 01/01/1995
2	Coinsurance Amount Start: 01/01/1995
3	Co-payment Amount Start: 01/01/1995
4	The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 03/01/2020
5	The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 03/01/2018
6	The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
7	The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
8	The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
9	The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
10	The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
11	The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
12	The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
13	The date of death precedes the date of service. Start: 01/01/1995
14	The date of birth follows the date of service. Start: 01/01/1995
15	The authorization number is missing, invalid, or does not apply to the billed services or provider. Start: 01/01/1995 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
16	Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. 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.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 03/01/2018
17	Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 07/01/2009
18	Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) Start: 01/01/1995 \| Last Modified: 06/02/2013
19	This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
20	This injury/illness is covered by the liability carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
21	This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
22	This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 \| Last Modified: 09/30/2007
23	The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) Start: 01/01/1995 \| Last Modified: 09/30/2012
24	Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 \| Last Modified: 09/30/2007
25	Payment denied. Your Stop loss deductible has not been met. Start: 01/01/1995 \| Stop: 04/01/2008
26	Expenses incurred prior to coverage. Start: 01/01/1995
27	Expenses incurred after coverage terminated. Start: 01/01/1995
28	Coverage not in effect at the time the service was provided. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Redundant to codes 26&27.
29	The time limit for filing has expired. Start: 01/01/1995
30	Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Start: 01/01/1995 \| Stop: 02/01/2006
31	Patient cannot be identified as our insured. Start: 01/01/1995 \| Last Modified: 09/30/2007
32	Our records indicate the patient is not an eligible dependent. Start: 01/01/1995 \| Last Modified: 03/01/2018
33	Insured has no dependent coverage. Start: 01/01/1995 \| Last Modified: 09/30/2007
34	Insured has no coverage for newborns. Start: 01/01/1995 \| Last Modified: 09/30/2007
35	Lifetime benefit maximum has been reached. Start: 01/01/1995 \| Last Modified: 10/31/2002
36	Balance does not exceed co-payment amount. Start: 01/01/1995 \| Stop: 10/16/2003
37	Balance does not exceed deductible. Start: 01/01/1995 \| Stop: 10/16/2003
38	Services not provided or authorized by designated (network/primary care) providers. Start: 01/01/1995 \| Last Modified: 06/02/2013 \| Stop: 01/01/2013 Notes: CARC codes 242 and 243 are replacements for this deactivated code
39	Services denied at the time authorization/pre-certification was requested. Start: 01/01/1995
40	Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
41	Discount agreed to in Preferred Provider contract. Start: 01/01/1995 \| Stop: 10/16/2003
42	Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45) Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 06/01/2007
43	Gramm-Rudman reduction. Start: 01/01/1995 \| Stop: 07/01/2006
44	Prompt-pay discount. Start: 01/01/1995
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) Start: 01/01/1995 \| Last Modified: 07/01/2017
46	This (these) service(s) is (are) not covered. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 96.
47	This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Start: 01/01/1995 \| Stop: 02/01/2006
48	This (these) procedure(s) is (are) not covered. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 96.
49	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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
50	These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
51	These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
52	The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Start: 01/01/1995 \| Stop: 02/01/2006
53	Services by an immediate relative or a member of the same household are not covered. Start: 01/01/1995
54	Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
55	Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
56	Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
57	Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Split into codes 150, 151, 152, 153 and 154.
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
60	Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Start: 01/01/1995 \| Last Modified: 06/01/2008
61	Adjusted for failure to obtain second surgical opinion Start: 01/01/1995 \| Last Modified: 03/01/2017 Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.
62	Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 04/01/2007
63	Correction to a prior claim. Start: 01/01/1995 \| Stop: 10/16/2003
64	Denial reversed per Medical Review. Start: 01/01/1995 \| Stop: 10/16/2003
65	Procedure code was incorrect. This payment reflects the correct code. Start: 01/01/1995 \| Stop: 10/16/2003
66	Blood Deductible. Start: 01/01/1995
67	Lifetime reserve days. (Handled in QTY, QTY01=LA) Start: 01/01/1995 \| Stop: 10/16/2003
68	DRG weight. (Handled in CLP12) Start: 01/01/1995 \| Stop: 10/16/2003
69	Day outlier amount. Start: 01/01/1995
70	Cost outlier - Adjustment to compensate for additional costs. Start: 01/01/1995 \| Last Modified: 06/30/2001
71	Primary Payer amount. Start: 01/01/1995 \| Stop: 06/30/2000 Notes: Use code 23.
72	Coinsurance day. (Handled in QTY, QTY01=CD) Start: 01/01/1995 \| Stop: 10/16/2003
73	Administrative days. Start: 01/01/1995 \| Stop: 10/16/2003
74	Indirect Medical Education Adjustment. Start: 01/01/1995
75	Direct Medical Education Adjustment. Start: 01/01/1995
76	Disproportionate Share Adjustment. Start: 01/01/1995
77	Covered days. (Handled in QTY, QTY01=CA) Start: 01/01/1995 \| Stop: 10/16/2003
78	Non-Covered days/Room charge adjustment. Start: 01/01/1995
79	Cost Report days. (Handled in MIA15) Start: 01/01/1995 \| Stop: 10/16/2003
80	Outlier days. (Handled in QTY, QTY01=OU) Start: 01/01/1995 \| Stop: 10/16/2003
81	Discharges. Start: 01/01/1995 \| Stop: 10/16/2003
82	PIP days. Start: 01/01/1995 \| Stop: 10/16/2003
83	Total visits. Start: 01/01/1995 \| Stop: 10/16/2003
84	Capital Adjustment. (Handled in MIA) Start: 01/01/1995 \| Stop: 10/16/2003
85	Patient Interest Adjustment (Use Only Group code PR) Start: 01/01/1995 \| Last Modified: 07/09/2007 Notes: Only use when the payment of interest is the responsibility of the patient.
86	Statutory Adjustment. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Duplicative of code 45.
87	Transfer amount. Start: 01/01/1995 \| Last Modified: 09/20/2009 \| Stop: 01/01/2012
88	Adjustment amount represents collection against receivable created in prior overpayment. Start: 01/01/1995 \| Stop: 06/30/2007
89	Professional fees removed from charges. Start: 01/01/1995
90	Ingredient cost adjustment. Usage: To be used for pharmaceuticals only. Start: 01/01/1995 \| Last Modified: 07/01/2017
91	Dispensing fee adjustment. Start: 01/01/1995
92	Claim Paid in full. Start: 01/01/1995 \| Stop: 10/16/2003
93	No Claim level Adjustments. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: As of 004010, CAS at the claim level is optional.
94	Processed in Excess of charges. Start: 01/01/1995
95	Plan procedures not followed. Start: 01/01/1995 \| Last Modified: 09/30/2007
96	Non-covered charge(s). 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.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
98	The hospital must file the Medicare claim for this inpatient non-physician service. Start: 01/01/1995 \| Stop: 10/16/2003
99	Medicare Secondary Payer Adjustment Amount. Start: 01/01/1995 \| Stop: 10/16/2003
100	Payment made to patient/insured/responsible party. Start: 01/01/1995 \| Last Modified: 05/01/2018
101	Predetermination: anticipated payment upon completion of services or claim adjudication. Start: 01/01/1995 \| Last Modified: 02/28/1999
102	Major Medical Adjustment. Start: 01/01/1995
103	Provider promotional discount (e.g., Senior citizen discount). Start: 01/01/1995 \| Last Modified: 06/30/2001
104	Managed care withholding. Start: 01/01/1995
105	Tax withholding. Start: 01/01/1995
106	Patient payment option/election not in effect. Start: 01/01/1995
107	The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
108	Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. Start: 01/01/1995 \| Last Modified: 01/29/2012
110	Billing date predates service date. Start: 01/01/1995
111	Not covered unless the provider accepts assignment. Start: 01/01/1995
112	Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 \| Last Modified: 09/30/2007
113	Payment denied because service/procedure was provided outside the United States or as a result of war. Start: 01/01/1995 \| Last Modified: 02/28/2001 \| Stop: 06/30/2007 Notes: Use Codes 157, 158 or 159.
114	Procedure/product not approved by the Food and Drug Administration. Start: 01/01/1995
115	Procedure postponed, canceled, or delayed. Start: 01/01/1995 \| Last Modified: 09/30/2007
116	The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 \| Last Modified: 09/30/2007
117	Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 \| Last Modified: 09/30/2007
118	ESRD network support adjustment. Start: 01/01/1995 \| Last Modified: 09/30/2007
119	Benefit maximum for this time period or occurrence has been reached. Start: 01/01/1995 \| Last Modified: 02/29/2004
120	Patient is covered by a managed care plan. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 24.
121	Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 \| Last Modified: 09/30/2007
122	Psychiatric reduction. Start: 01/01/1995
123	Payer refund due to overpayment. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals.
124	Payer refund amount - not our patient. Start: 01/01/1995 \| Last Modified: 06/30/1999 \| Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals.
125	Submission/billing error(s). 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.) Start: 01/01/1995 \| Last Modified: 09/20/2009 \| Stop: 11/01/2013
126	Deductible -- Major Medical Start: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code PR and code 1.
127	Coinsurance -- Major Medical Start: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code PR and code 2.
128	Newborn's services are covered in the mother's Allowance. Start: 02/28/1997
129	Prior processing information appears incorrect. 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.) Start: 02/28/1997 \| Last Modified: 01/30/2011
130	Claim submission fee. Start: 02/28/1997 \| Last Modified: 06/30/2001
131	Claim specific negotiated discount. Start: 02/28/1997
132	Prearranged demonstration project adjustment. Start: 02/28/1997
133	The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). Start: 07/01/2014 \| Last Modified: 07/01/2017
134	Technical fees removed from charges. Start: 10/31/1998
135	Interim bills cannot be processed. Start: 10/31/1998 \| Last Modified: 09/30/2007
136	Failure to follow prior payer's coverage rules. (Use only with Group Code OA) Start: 10/31/1998 \| Last Modified: 07/01/2013
137	Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 \| Last Modified: 09/30/2007
138	Appeal procedures not followed or time limits not met. Start: 06/30/1999 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
139	Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO. Start: 06/30/1999 \| Last Modified: 05/01/2018
140	Patient/Insured health identification number and name do not match. Start: 06/30/1999
141	Claim spans eligible and ineligible periods of coverage. Start: 06/30/1999 \| Last Modified: 09/30/2007 \| Stop: 07/01/2012
142	Monthly Medicaid patient liability amount. Start: 06/30/2000 \| Last Modified: 09/30/2007
143	Portion of payment deferred. Start: 02/28/2001
144	Incentive adjustment, e.g. preferred product/service. Start: 06/30/2001
145	Premium payment withholding Start: 06/30/2002 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code CO and code 45.
146	Diagnosis was invalid for the date(s) of service reported. Start: 06/30/2002 \| Last Modified: 09/30/2007
147	Provider contracted/negotiated rate expired or not on file. Start: 06/30/2002
148	Information from another provider was not provided or was insufficient/incomplete. 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.) Start: 06/30/2002 \| Last Modified: 09/20/2009
149	Lifetime benefit maximum has been reached for this service/benefit category. Start: 10/31/2002
150	Payer deems the information submitted does not support this level of service. Start: 10/31/2002 \| Last Modified: 09/30/2007
151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Start: 10/31/2002 \| Last Modified: 01/27/2008
152	Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 10/31/2002 \| Last Modified: 07/01/2017
153	Payer deems the information submitted does not support this dosage. Start: 10/31/2002 \| Last Modified: 09/30/2007
154	Payer deems the information submitted does not support this day's supply. Start: 10/31/2002 \| Last Modified: 09/30/2007
155	Patient refused the service/procedure. Start: 06/30/2003 \| Last Modified: 09/30/2007
156	Flexible spending account payments. Note: Use code 187. Start: 09/30/2003 \| Last Modified: 01/25/2009 \| Stop: 10/01/2009
157	Service/procedure was provided as a result of an act of war. Start: 09/30/2003 \| Last Modified: 09/30/2007
158	Service/procedure was provided outside of the United States. Start: 09/30/2003 \| Last Modified: 09/30/2007
159	Service/procedure was provided as a result of terrorism. Start: 09/30/2003 \| Last Modified: 09/30/2007
160	Injury/illness was the result of an activity that is a benefit exclusion. Start: 09/30/2003 \| Last Modified: 09/30/2007
161	Provider performance bonus Start: 02/29/2004
162	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Start: 02/29/2004 \| Stop: 07/01/2014 Notes: Use code P1
163	Attachment/other documentation referenced on the claim was not received. Start: 06/30/2004 \| Last Modified: 06/02/2013
164	Attachment/other documentation referenced on the claim was not received in a timely fashion. Start: 06/30/2004 \| Last Modified: 06/02/2013
165	Referral absent or exceeded. Start: 10/31/2004 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
166	These services were submitted after this payers responsibility for processing claims under this plan ended. Start: 02/28/2005
167	This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
168	Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. Start: 06/30/2005 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
169	Alternate benefit has been provided. Start: 06/30/2005 \| Last Modified: 09/30/2007
170	Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
171	Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
172	Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
173	Service/equipment was not prescribed by a physician. Start: 06/30/2005 \| Last Modified: 07/01/2013
174	Service was not prescribed prior to delivery. Start: 06/30/2005 \| Last Modified: 09/30/2007
175	Prescription is incomplete. Start: 06/30/2005 \| Last Modified: 09/30/2007
176	Prescription is not current. Start: 06/30/2005 \| Last Modified: 09/30/2007
177	Patient has not met the required eligibility requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
178	Patient has not met the required spend down requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
179	Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 03/01/2017
180	Patient has not met the required residency requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
181	Procedure code was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007
182	Procedure modifier was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007
183	The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
184	The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
185	The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 07/01/2017
186	Level of care change adjustment. Start: 06/30/2005 \| Last Modified: 09/30/2007
187	Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) Start: 06/30/2005 \| Last Modified: 01/25/2009
188	This product/procedure is only covered when used according to FDA recommendations. Start: 06/30/2005
189	'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service Start: 06/30/2005
190	Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Start: 10/31/2005
191	Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: 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. 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) Start: 10/31/2005 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014 Notes: Use code P2
192	Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. Start: 10/31/2005 \| Last Modified: 07/01/2017
193	Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. Start: 02/28/2006 \| Last Modified: 01/27/2008
194	Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Start: 02/28/2006 \| Last Modified: 09/30/2007
195	Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 \| Last Modified: 09/30/2007
196	Claim/service denied based on prior payer's coverage determination. Start: 06/30/2006 \| Stop: 02/01/2007 Notes: Use code 136.
197	Precertification/authorization/notification/pre-treatment absent. Start: 10/31/2006 \| Last Modified: 05/01/2018
198	Precertification/notification/authorization/pre-treatment exceeded. Start: 10/31/2006 \| Last Modified: 05/01/2018
199	Revenue code and Procedure code do not match. Start: 10/31/2006
200	Expenses incurred during lapse in coverage Start: 10/31/2006
201	Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (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.) Start: 10/31/2006 \| Last Modified: 09/28/2014 Notes: Not for use by Workers' Compensation payers; use code P3 instead.
202	Non-covered personal comfort or convenience services. Start: 02/28/2007 \| Last Modified: 09/30/2007
203	Discontinued or reduced service. Start: 02/28/2007 \| Last Modified: 09/30/2007
204	This service/equipment/drug is not covered under the patient's current benefit plan Start: 02/28/2007
205	Pharmacy discount card processing fee Start: 07/09/2007
206	National Provider Identifier - missing. Start: 07/09/2007 \| Last Modified: 09/30/2007
207	National Provider identifier - Invalid format Start: 07/09/2007 \| Last Modified: 06/01/2008
208	National Provider Identifier - Not matched. Start: 07/09/2007 \| Last Modified: 09/30/2007
209	Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA) Start: 07/09/2007 \| Last Modified: 07/01/2013
210	Payment adjusted because pre-certification/authorization not received in a timely fashion Start: 07/09/2007
211	National Drug Codes (NDC) not eligible for rebate, are not covered. Start: 07/09/2007
212	Administrative surcharges are not covered Start: 11/05/2007
213	Non-compliance with the physician self referral prohibition legislation or payer policy. Start: 01/27/2008
214	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: 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. 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). To be used for Workers' Compensation only Start: 01/27/2008 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014 Notes: Use code P4
215	Based on subrogation of a third party settlement Start: 01/27/2008
216	Based on the findings of a review organization Start: 01/27/2008
217	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only) Start: 01/27/2008 \| Last Modified: 09/30/2012 \| Stop: 07/01/2014 Notes: Use code P5
218	Based on entitlement to benefits. Note: 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. 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). To be used for Workers' Compensation only Start: 01/27/2008 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014 Notes: Use code P6
219	Based on extent of injury. 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. 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). Start: 01/27/2008 \| Last Modified: 07/01/2017
220	The applicable fee schedule/fee database does not contain the billed code. 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. (Note: To be used for Property and Casualty only) Start: 01/27/2008 \| Last Modified: 09/30/2012 \| Stop: 07/01/2014 Notes: Use code P7
221	Claim is under investigation. Note: 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. 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). (Note: To be used by Property & Casualty only) Start: 01/27/2008 \| Last Modified: 07/01/2013 \| Stop: 07/01/2014 Notes: Use code P8
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/01/2008 \| Last Modified: 07/01/2017
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Start: 06/01/2008
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Start: 06/01/2008
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) Start: 06/01/2008
226	Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. 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.) Start: 09/21/2008 \| Last Modified: 07/01/2013
227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 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.) Start: 09/21/2008 \| Last Modified: 09/20/2009
228	Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication Start: 09/21/2008
229	Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR) Start: 01/25/2009 \| Last Modified: 07/01/2017
230	No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty. Start: 01/25/2009 \| Stop: 07/01/2014 Notes: Use code P9
231	Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2009 \| Last Modified: 07/01/2017
232	Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Start: 11/01/2009 \| Last Modified: 07/01/2017
233	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Start: 01/24/2010
234	This procedure is not paid separately. 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.) Start: 01/24/2010
235	Sales Tax Start: 06/06/2010
236	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. Start: 01/30/2011 \| Last Modified: 07/01/2013
237	Legislated/Regulatory Penalty. 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.) Start: 06/05/2011
238	Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR) Start: 03/01/2012 \| Last Modified: 07/01/2013
239	Claim spans eligible and ineligible periods of coverage. Rebill separate claims. Start: 03/01/2012 \| Last Modified: 01/29/2012
240	The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/03/2012 \| Last Modified: 07/01/2017
241	Low Income Subsidy (LIS) Co-payment Amount Start: 06/03/2012
242	Services not provided by network/primary care providers. Start: 06/03/2012 \| Last Modified: 06/02/2013 Notes: This code replaces deactivated code 38
243	Services not authorized by network/primary care providers. Start: 06/03/2012 \| Last Modified: 06/02/2013 Notes: This code replaces deactivated code 38
244	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only. Start: 09/30/2012 \| Stop: 07/01/2014 Notes: Use code P10
245	Provider performance program withhold. Start: 09/30/2012
246	This non-payable code is for required reporting only. Start: 09/30/2012
247	Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
248	Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
249	This claim has been identified as a readmission. (Use only with Group Code CO) Start: 09/30/2012
250	The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. 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). Start: 09/30/2012 \| Last Modified: 06/01/2014
251	The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. 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). Start: 09/30/2012 \| Last Modified: 06/01/2014
252	An attachment/other documentation is required to adjudicate this claim/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). Start: 09/30/2012 \| Last Modified: 06/02/2013
253	Sequestration - reduction in federal payment Start: 06/02/2013 \| Last Modified: 11/01/2013
254	Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. Start: 06/02/2013 \| Last Modified: 11/01/2017 Notes: Use CARC 290 if the claim was forwarded.
255	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA) Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P11
256	Service not payable per managed care contract. Start: 06/02/2013
257	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) Start: 11/01/2013 \| Last Modified: 06/01/2014 Notes: To be used after the first month of the grace period.
258	Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. Start: 11/01/2013
259	Additional payment for Dental/Vision service utilization. Start: 01/26/2014
260	Processed under Medicaid ACA Enhanced Fee Schedule Start: 01/26/2014
261	The procedure or service is inconsistent with the patient's history. Start: 06/01/2014
262	Adjustment for delivery cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 \| Last Modified: 07/01/2017
263	Adjustment for shipping cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 \| Last Modified: 07/01/2017
264	Adjustment for postage cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 \| Last Modified: 07/01/2017
265	Adjustment for administrative cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 \| Last Modified: 07/01/2017
266	Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 \| Last Modified: 07/01/2017
267	Claim/service spans multiple months. 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.) Start: 11/01/2014 \| Last Modified: 04/01/2015
268	The Claim spans two calendar years. Please resubmit one claim per calendar year. Start: 11/01/2014
269	Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 03/01/2015 \| Last Modified: 07/01/2017
270	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration. Start: 07/01/2015 \| Last Modified: 11/01/2017 Notes: Use CARC 291 if the claim was forwarded.
271	Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA) Start: 11/01/2015 \| Last Modified: 03/01/2018
272	Coverage/program guidelines were not met. Start: 11/01/2015
273	Coverage/program guidelines were exceeded. Start: 11/01/2015
274	Fee/Service not payable per patient Care Coordination arrangement. Start: 11/01/2015
275	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR) Start: 11/01/2015
276	Services denied by the prior payer(s) are not covered by this payer. Start: 11/01/2015
277	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) Start: 11/01/2015 Notes: To be used during 31 day SHOP grace period.
278	Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2016 \| Last Modified: 07/01/2017
279	Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network. Start: 11/01/2016 \| Last Modified: 07/01/2017
280	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration. Start: 03/01/2017 \| Last Modified: 11/01/2017 Notes: Use CARC 292 if the claim was forwarded.
281	Deductible waived per contractual agreement. Use only with Group Code CO. Start: 07/01/2017
282	The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2017
283	Attending provider is not eligible to provide direction of care. Start: 11/01/2017
284	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. Start: 11/01/2017
285	Appeal procedures not followed Start: 11/01/2017
286	Appeal time limits not met Start: 11/01/2017
287	Referral exceeded Start: 11/01/2017
288	Referral absent Start: 11/01/2017
289	Services considered under the dental and medical plans, benefits not available. Start: 11/01/2017 Notes: Also see CARCs 254, 270 and 280.
290	Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration. Start: 11/01/2017 Notes: Use CARC 254 if the claim was not forwarded.
291	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration. Start: 11/01/2017 Notes: Use CARC 270 if the claim was not forwarded.
292	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration. Start: 11/01/2017 Notes: Use CARC 280 if the claim was not forwarded.
293	Payment made to employer. Start: 05/01/2018
294	Payment made to attorney. Start: 11/01/2017
295	Pharmacy Direct/Indirect Remuneration (DIR) Start: 03/01/2018
296	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. Start: 07/01/2018
297	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration. Start: 03/01/2019
298	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration. Start: 03/01/2019
299	The billing provider is not eligible to receive payment for the service billed. Start: 07/01/2019
300	Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration. Start: 07/01/2019
301	Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration. Start: 07/01/2019
302	Precertification/notification/authorization/pre-treatment time limit has expired. Start: 11/01/2020
303	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO) Start: 07/01/2021
304	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration. Start: 03/01/2022
305	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration. Start: 03/01/2022
306	Type of bill is inconsistent with the patient status. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 11/01/2023
A0	Patient refund amount. Start: 01/01/1995
A1	Claim/Service denied. 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.) Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available. Start: 01/01/1995 \| Last Modified: 11/16/2022
A2	Contractual adjustment. Start: 01/01/1995 \| Last Modified: 02/28/2007 \| Stop: 01/01/2008 Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3	Medicare Secondary Payer liability met. Start: 01/01/1995 \| Stop: 10/16/2003
A4	Medicare Claim PPS Capital Day Outlier Amount. Start: 01/01/1995 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008
A5	Medicare Claim PPS Capital Cost Outlier Amount. Start: 01/01/1995
A6	Prior hospitalization or 30 day transfer requirement not met. Start: 01/01/1995
A7	Presumptive Payment Adjustment Start: 01/01/1995 \| Stop: 07/01/2015
A8	Ungroupable DRG. Start: 01/01/1995 \| Last Modified: 09/30/2007
B1	Non-covered visits. Start: 01/01/1995
B2	Covered visits. Start: 01/01/1995 \| Stop: 10/16/2003
B3	Covered charges. Start: 01/01/1995 \| Stop: 10/16/2003
B4	Late filing penalty. Start: 01/01/1995
B5	Coverage/program guidelines were not met or were exceeded. Start: 01/01/1995 \| Last Modified: 11/01/2015 \| Stop: 05/01/2016 Notes: This code has been replaced by 272 and 273.
B6	This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Start: 01/01/1995 \| Stop: 02/01/2006
B7	This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
B8	Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
B9	Patient is enrolled in a Hospice. Start: 01/01/1995 \| Last Modified: 09/30/2007
B10	Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Start: 01/01/1995
B11	The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. Start: 01/01/1995
B12	Services not documented in patient's medical records. Start: 01/01/1995 \| Last Modified: 03/01/2018
B13	Previously paid. Payment for this claim/service may have been provided in a previous payment. Start: 01/01/1995
B14	Only one visit or consultation per physician per day is covered. Start: 01/01/1995 \| Last Modified: 09/30/2007
B15	This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 07/01/2017
B16	'New Patient' qualifications were not met. Start: 01/01/1995 \| Last Modified: 09/30/2007
B17	Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. Start: 01/01/1995 \| Stop: 02/01/2006
B18	This procedure code and modifier were invalid on the date of service. Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 03/01/2009
B19	Claim/service adjusted because of the finding of a Review Organization. Start: 01/01/1995 \| Stop: 10/16/2003
B20	Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 \| Last Modified: 09/30/2007
B21	The charges were reduced because the service/care was partially furnished by another physician. Start: 01/01/1995 \| Stop: 10/16/2003
B22	This payment is adjusted based on the diagnosis. Start: 01/01/1995 \| Last Modified: 02/28/2001
B23	Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 \| Last Modified: 09/30/2007
D1	Claim/service denied. Level of subluxation is missing or inadequate. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D2	Claim lacks the name, strength, or dosage of the drug furnished. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D3	Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D4	Claim/service does not indicate the period of time for which this will be needed. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D5	Claim/service denied. Claim lacks individual lab codes included in the test. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D6	Claim/service denied. Claim did not include patient's medical record for the service. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D7	Claim/service denied. Claim lacks date of patient's most recent physician visit. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D8	Claim/service denied. Claim lacks indicator that 'x-ray is available for review.' Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D9	Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D10	Claim/service denied. Completed physician financial relationship form not on file. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D11	Claim lacks completed pacemaker registration form. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D12	Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D13	Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D14	Claim lacks indication that plan of treatment is on file. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D15	Claim lacks indication that service was supervised or evaluated by a physician. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D16	Claim lacks prior payer payment information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code [N4].
D17	Claim/Service has invalid non-covered days. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D18	Claim/Service has missing diagnosis information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D19	Claim/Service lacks Physician/Operative or other supporting documentation Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D20	Claim/Service missing service/product information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D21	This (these) diagnosis(es) is (are) missing or are invalid Start: 01/01/1995 \| Stop: 06/30/2007
D22	Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code Start: 01/27/2008 \| Stop: 01/01/2009
D23	This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. 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.) Start: 11/01/2009 \| Stop: 01/01/2012
P1	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 162
P2	Not a work related injury/illness and thus not the liability of the workers' compensation carrier 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. 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). To be used for Workers' Compensation only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code 191
P3	Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR) Start: 11/01/2013 Notes: This code replaces deactivated code 201
P4	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. 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. 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). To be used for Workers' Compensation only Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code 214
P5	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 217
P6	Based on entitlement to benefits. 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. 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). To be used for Property and Casualty only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code 218
P7	The applicable fee schedule/fee database does not contain the billed code. 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. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 220
P8	Claim is under investigation. 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. 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). To be used for Property and Casualty only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code 221
P9	No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 230
P10	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 244
P11	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA) Start: 11/01/2013 Notes: This code replaces deactivated code 255
P12	Workers' compensation jurisdictional fee schedule adjustment. 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). 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. To be used for Workers' Compensation only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code W1
P13	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. 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. 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. To be used for Workers' Compensation only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code W2
P14	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code W3
P15	Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only. Start: 11/01/2013 Notes: This code replaces deactivated code W4
P16	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA) Start: 11/01/2013 Notes: This code replaces deactivated code W5
P17	Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W6
P18	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W7
P19	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W8
P20	Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W9
P21	Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. 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. 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. To be used for Property and Casualty Auto only. Start: 11/01/2013 \| Last Modified: 03/01/2018 Notes: This code replaces deactivated code Y1
P22	Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. 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. 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. To be used for Property and Casualty Auto only. Start: 11/01/2013 \| Last Modified: 03/01/2018 Notes: This code replaces deactivated code Y2
P23	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. 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). 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. To be used for Property and Casualty Auto only. Start: 11/01/2013 \| Last Modified: 07/01/2017 Notes: This code replaces deactivated code Y3
P24	Payment adjusted based on Preferred Provider Organization (PPO). 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). 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. To be used for Property and Casualty only. Use only with Group Code CO. Start: 11/01/2017
P25	Payment adjusted based on Medical Provider Network (MPN). 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). 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. To be used for Property and Casualty only. (Use only with Group Code CO). Start: 11/01/2017
P26	Payment adjusted based on Voluntary Provider network (VPN). 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). 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. To be used for Property and Casualty only. (Use only with Group Code CO). Start: 11/01/2017
P27	Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. 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. 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. To be used for Property and Casualty Auto only. Start: 11/01/2017
P28	Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. 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. 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. To be used for Property and Casualty Auto only. Start: 11/01/2017
P29	Liability Benefits jurisdictional fee schedule adjustment. 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). 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. To be used for Property and Casualty Auto only. Start: 11/01/2017
P30	Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only. Start: 11/01/2020
P31	Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only. Start: 11/01/2020
P32	Payment adjusted due to Apportionment. Start: 08/01/2022
W1	Workers' compensation jurisdictional fee schedule adjustment. Note: 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). 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. Start: 02/29/2000 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P12
W2	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: 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. 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. To be used for Workers' Compensation only. Start: 10/17/2010 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P13
W3	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only. Start: 09/30/2012 \| Stop: 07/01/2014 Notes: Use code P14
W4	Workers' Compensation Medical Treatment Guideline Adjustment. Start: 09/30/2012 \| Stop: 07/01/2014 Notes: Use code P15
W5	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA) Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P16
W6	Referral not authorized by attending physician per regulatory requirement. Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P17
W7	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P18
W8	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P19
W9	Service not paid under jurisdiction allowed outpatient facility fee schedule. Start: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P20
Y1	Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: 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. 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. To be used for P&C Auto only. Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P21
Y2	Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: 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. 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. To be used for P&C Auto only. Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P22
Y3	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: 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). 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. To be used for P&C Auto only. Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014 Notes: Use code P23

Code List Notes

Did you receive a code from a health plan, such as: PR32 or CO286? If so read About Claim Adjustment Group Codes below.

Code List Filters Block Reference

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Code List Accordions

About Claim Adjustment Group Codes

Did you receive a code from a health plan, such as: PR32 or CO286? The "PR" is a Claim Adjustment Group Code and the description for "32" is below. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and definitions are below:

CO	Contractual Obligation
CR	Corrections and Reversal Note: This value is not to be used with 005010 and up.
OA	Other Adjustment
PI	Payer Initiated Reductions
PR	Patient Responsibility

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.

Status Last Reviewed: 6/19/2024

Num.	Date	Requested Description	Type	Status
436	5/7/2024	Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the Transportation Vendor for further consideration.	New	On Hold
437	5/9/2024	Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the Transportation Vendor for further consideration.	New	On Hold
439	5/29/24	Claim Level Reason Code - 34002 Reject Code - 34002	New	Pending

Maintenance Request Form

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Current Code Value

*The description you are suggesting for a new code or to replace the description for a current code.

Read more about Claim Adjustment Reason Codes

Claim Adjustment Group Codes

Code List ID

974

Code List Scope Statement

These codes categorize a payment adjustment.

Code List Maintained By

CMG01

Code List Updated Date

Sun, 05/20/2018 - 12:00

Code List Table

CO	Contractual Obligation Start: 05/20/2018
OA	Other Adjustment Start: 05/20/2018
PI	Payor Initiated Reduction Start: 05/20/2018
PR	Patient Responsibility Start: 05/20/2018

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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.

Status Last Reviewed: 6/19/2024

Num.	Date	Requested Description	Type	Code	Status
317	12/6/2021	Legislative / Regulatory Issues	New		In Process

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