Medicare denial code - Full list - Description

Medicare denial code and Description


A group code is a code identifying the general category of payment adjustment. A group code must always be used in conjunction with a claim adjustment reason code to show liability for amounts not covered by Medicare for a claim or service. MACs do not have discretion to omit appropriate codes and messages. MACs must use appropriate group, claim adjustment reason, and remittance advice remark codes to communicate clearly why an amount is not covered by Medicare and who is financially responsible for that amount. Valid Group Codes for use on Medicare remittance advice:

• CO - Contractual Obligations. This group code shall be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write off for the provider and are not billed to the patient.


• OA - Other Adjustments. This group code shall be used when no other group code applies to the adjustment.

• PR - Patient Responsibility. This group code shall be used when the adjustment represent an amount that may be billed to the patient or insured. This group would typically be used for deductible and copay adjustments

1 Deductible Amount

2 Coinsurance Amount

3 Co-payment Amount

4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

5 The procedure code/bill type is inconsistent with the place of service.
6 The procedure/revenue code is inconsistent with the patient's age.
Note: Changed as of 6/02
7 The procedure/revenue code is inconsistent with the patient's gender.
Note: Changed as of 6/02
8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
Note: Changed as of 6/02
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender.
Note: Changed as of 2/00
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, or
does not apply to the billed services or provider.
Note: Changed as of 2/01
16 Claim/service lacks information which is needed for adjudication. Additional
information is supplied using remittance advice remarks codes whenever appropriate
Note: Changed as of 2/02
17 Payment adjusted because requested information was not provided or was
insufficient/incomplete. Additional information is supplied using the remittance advice
remarks codes whenever appropriate.
Note: Changed as of 2/02
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the
Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per
coordination of benefits.
Note: Changed as of 2/01
23 Payment adjusted due to the impact of prior payer(s) adjudication including payments
and/or adjustments
Note: Changed as of 2/01, and 6/05
24 Payment for charges adjusted. Charges are covered under a capitation
agreement/managed care plan.
Note: Changed as of 6/00
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility, spend
down, waiting, or residency requirements.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
Note: Changed as of 10/02
36 Balance does not exceed co-payment amount.
Note: Inactive for 003040
37 Balance does not exceed deductible.
Note: Inactive for 003040
38 Services not provided or authorized by designated (network/primary care) providers.
Note: Changed as of 6/03
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.
48 This (these) procedure(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
49 These are non-covered services because this is a routine exam or screening procedure
done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a `medical necessity' by
the payer.
51 These are non-covered services because this is a pre-existing condition
52 The referring/prescribing/rendering provider is not eligible to
refer/prescribe/order/perform the service billed.
Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.
53 Services by an immediate relative or a member of the same household are not
covered.
54 Multiple physicians/assistants are not covered in this case .
55 Claim/service denied because procedure/treatment is deemed
experimental/investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer.
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.
Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
58 Payment adjusted because treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service.
Note: Changed as of 2/01
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Note: Changed as of 6/00
60 Charges for outpatient services with this proximity to inpatient services are not
covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
Note: Changed as of 6/00
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Note: Changed as of 2/01
63 Correction to a prior claim.
Note: Inactive for 003040
64 Denial reversed per Medical Review.
Note: Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code.
Note: Inactive for 003040
66 Blood Deductible.
67 Lifetime reserve days. (Handled in QTY, QTY01=LA)
Note: Inactive for 003040
68 DRG weight. (Handled in CLP12)
Note: Inactive for 003040
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs.
Note: Changed as of 6/01
71 Primary Payer amount.
Note: Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD)
Note: Inactive for 003040
73 Administrative days.
Note: Inactive for 003050
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days. (Handled in QTY, QTY01=CA)
Note: Inactive for 003040
78 Non-Covered days/Room charge adjustment.
79 Cost Report days. (Handled in MIA15)
Note: Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU)
Note: Inactive for 003050
81 Discharges.
Note: Inactive for 003040
82 PIP days.
Note: Inactive for 003040
83 Total visits.
Note: Inactive for 003040
84 Capital Adjustment. (Handled in MIA)
Note: Inactive for 003050
85 Interest amount.
86 Statutory Adjustment.
Note: Inactive for 004010, since 6/98. Duplicative of code 45.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior
overpayment.
Note: Inactive for 004050.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim Paid in full.
Note: Inactive for 003040
93 No Claim level Adjustments.
Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
Note: Changed as of 6/00
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.
Note: Changed as of 2/99
98 The hospital must file the Medicare claim for this inpatient non-physician service.
Note: Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount.
Note: Inactive for 003040
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim
adjudication.
Note: Changed as of 2/99
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
Note: Changed as of 6/01
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not
previously paid or identified on this claim.
Note: Changed as of 6/03
108 Payment adjusted because rent/purchase guidelines were not met.
Note: Changed as of 6/02
109 Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
Note: Changed as of 2/01
113 Payment denied because service/procedure was provided outside the United States or
as a result of war.
Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.
Note: Changed as of 2/01
116 Payment denied. The advance indemnification notice signed by the patient did not
comply with requirements.
Note: Changed as of 2/01
117 Payment adjusted because transportation is only covered to the closest facility that
can provide the necessary care.
Note: Changed as of 2/01
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
Note: Changed as of 2/04
120 Patient is covered by a managed care plan.
Note: Inactive for 004030, since 6/99. Use code 24.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
124 Payer refund amount - not our patient.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
125 Payment adjusted due to a submission/billing error(s). Additional information is
supplied using the remittance advice remarks codes whenever appropriate.
Note: Changed as of 2/02
126 Deductible -- Major Medical
Note: New as of 2/97
127 Coinsurance -- Major Medical
Note: New as of 2/97
128 Newborn's services are covered in the mother's Allowance.
Note: New as of 2/97
129 Payment denied - Prior processing information appears incorrect.
Note: Changed as of 2/01
130 Claim submission fee.
Note: Changed as of 6/01
131 Claim specific negotiated discount.
Note: New as of 2/97
132 Prearranged demonstration project adjustment.
Note: New as of 2/97
133 The disposition of this claim/service is pending further review.
Note: Changed as of 10/99
134 Technical fees removed from charges.
Note: New as of 10/98
135 Claim denied. Interim bills cannot be processed.
Note: New as of 10/98
136 Claim Adjusted. Plan procedures of a prior payer were not followed.
Note: Changed as of 6/00
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health
Related Taxes.
Note: New as of 2/99
138 Claim/service denied. Appeal procedures not followed or time limits not met.
Note: New as of 6/99
139 Contracted funding agreement - Subscriber is employed by the provider of services.
Note: New as of 6/99
140 Patient/Insured health identification number and name do not match.
Note: New as of 6/99
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
Note: Changed as of 6/00
142 Claim adjusted by the monthly Medicaid patient liability amount.
Note: New as of 6/00
143 Portion of payment deferred.
Note: New as of 2/01
144 Incentive adjustment, e.g. preferred product/service.
Note: New as of 6/01
145 Premium payment withholding
Note: New as of 6/02
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
Note: New as of 6/02
147 Provider contracted/negotiated rate expired or not on file.
Note: New as of 6/02
148 Claim/service rejected at this time because information from another provider was not
provided or was insufficient/incomplete.
Note: New as of 6/02
149 Lifetime benefit maximum has been reached for this service/benefit category.
Note: New as of 10/02
150 Payment adjusted because the payer deems the information submitted does not
support this level of service.
Note: New as of 10/02
151 Payment adjusted because the payer deems the information submitted does not
support this many services.
Note: New as of 10/02
152 Payment adjusted because the payer deems the information submitted does not
support this length of service.
Note: New as of 10/02
153 Payment adjusted because the payer deems the information submitted does not
support this dosage.
Note: New as of 10/02
154 Payment adjusted because the payer deems the information submitted does not
support this day's supply.
Note: New as of 10/02
155 This claim is denied because the patient refused the service/procedure.
Note: New as of 6/03
156 Flexible spending account payments
Note: New as of 9/03
157 Payment denied/reduced because service/procedure was provided as a result of an act
of war.
Note: New as of 9/03
158 Payment denied/reduced because the service/procedure was provided outside of the
United States.
Note: New as of 9/03
159 Payment denied/reduced because the service/procedure was provided as a result of
terrorism.
Note: New as of 9/03
160 Payment denied/reduced because injury/illness was the result of an activity that is a
benefit exclusion.
Note: New as of 9/03
161 Provider performance bonus
Note: New as of 2/04
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks
Code for specific explanation.
Note: New as of 2/04
163 Claim/Service adjusted because the attachment referenced on the claim was not
received.
Note: New as of 6/04
164 Claim/Service adjusted because the attachment referenced on the claim was not
received in a timely fashion.
Note: New as of 6/04
165 Payment denied /reduced for absence of, or exceeded referral
Note: New as of 10/04
166 These services were submitted after this payers responsibility for processing claims
under this plan ended.
Note: New as of 2/05
167 This (these) diagnosis(es) is (are) not covered.
Note: New as of 6/05
168 Payment denied as Service(s) have been considered under the patient's medical plan.
Benefits are not available under this dental plan
Note: New as of 6/05
169 Payment adjusted because an alternate benefit has been provided
Note: New as of 6/05
170 Payment is denied when performed/billed by this type of provider.
Note: New as of 6/05
171 Payment is denied when performed/billed by this type of provider in this type of
facility.
Note: New as of 6/05
172 Payment is adjusted when performed/billed by a provider of this specialty
Note: New as of 6/05
173 Payment adjusted because this service was not prescribed by a physician
Note: New as of 6/05
174 Payment denied because this service was not prescribed prior to delivery
Note: New as of 6/05
175 Payment denied because the prescription is incomplete
Note: New as of 6/05
176 Payment denied because the prescription is not current
Note: New as of 6/05
177 Payment denied because the patient has not met the required eligibility requirements
Note: New as of 6/05
178 Payment adjusted because the patient has not met the required spend down
requirements.
Note: New as of 6/05
179 Payment adjusted because the patient has not met the required waiting requirements
Note: New as of 6/05
180 Payment adjusted because the patient has not met the required residency
requirements
Note: New as of 6/05
181 Payment adjusted because this procedure code was invalid on the date of service
Note: New as of 6/05
182 Payment adjusted because the procedure modifier was invalid on the date of service
Note: New as of 6/05. Modified on 8/8/2005
183 The referring provider is not eligible to refer the service billed.
Note: New as of 6/05
184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Note: New as of 6/05
185 The rendering provider is not eligible to perform the service billed.
Note: New as of 6/05
186 Payment adjusted since the level of care changed
Note: New as of 6/05
187 Health Savings account payments
Note: New as of 6/05
188 This product/procedure is only covered when used according to FDA recommendations.
Note: New as of 6/05
189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when
there is a specific procedure code for this procedure/service
Note: New as of 6/05
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual adjustment.
Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use another
appropriate specific adjustment code.
A3 Medicare Secondary Payer liability met.
Note: Inactive for 004010, since 6/98.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
Note:
A7 Presumptive Payment Adjustment
Note:
A8 Claim denied; ungroupable DRG
B1 Non-covered visits.
Note:
B2 Covered visits.
Note: Inactive for 003040
B3 Covered charges.
Note: Inactive for 003040
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were
exceeded.
Note: Changed as of 2/01
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.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B7 This provider was not certified/eligible to be paid for this procedure/service on this
date of service.
Note: Changed as of 10/98
B8 Claim/service not covered/reduced because alternative services were available, and
should have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
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.
Note:
B11 The claim/service has been transferred to the proper payer/processor for processing.
Claim/service not covered by this payer/processor.
Note:
B12 Services not documented in patients' medical records.
Note:
B13 Previously paid. Payment for this claim/service may have been provided in a previous
payment.
Note:
B14 Payment denied because only one visit or consultation per physician per day is
covered.
Note: Changed as of 2/01
B15 Payment adjusted because this procedure/service is not paid separately.
Note: Changed as of 2/01
B16 Payment adjusted because `New Patient' qualifications were not met.
Note: Changed as of 2/01
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.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B18 Payment adjusted because this procedure code and modifier were invalid on the date
of service
Note: Changed as of 2/01, 6/05
B19 Claim/service adjusted because of the finding of a Review Organization.
Note: Inactive for 003070
B20 Payment adjusted because procedure/service was partially or fully furnished by
another provider.
Note: Changed as of 2/01
B21 The charges were reduced because the service/care was partially furnished by another
physician.
Note: Inactive for 003040
B22 This payment is adjusted based on the diagnosis.
Note: Changed as of 2/01
B23 Payment denied because this provider has failed an aspect of a proficiency testing
program.
Note: Changed as of 2/01
D1 Claim/service denied. Level of subluxation is missing or inadequate.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D2 Claim lacks the name, strength, or dosage of the drug furnished.
Note: Inactive for 004010, since 2/99. 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.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D4 Claim/service does not indicate the period of time for which this will be needed.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D5 Claim/service denied. Claim lacks individual lab codes included in the test.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D6 Claim/service denied. Claim did not include patient's medical record for the service.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
Note: Inactive for 004010, since 2/99. 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.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D10 Claim/service denied. Completed physician financial relationship form not on file.
Note: Inactive for 003070, since 8/97. Use code 17.
D11 Claim lacks completed pacemaker registration form.
Note: Inactive for 003070, since 8/97. 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.
Note: Inactive for 003070, since 8/97. Use code 17.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring
physician has a financial interest.
Note: Inactive for 003070, since 8/97. Use code 17.
D14 Claim lacks indication that plan of treatment is on file.
Note: Inactive for 003070, since 8/97. Use code 17.
D15 Claim lacks indication that service was supervised or evaluated by a physician.
Note: Inactive for 003070, since 8/97. Use code 17.
D16 Claim lacks prior payer payment information.
Note: Inactive as of version 5010. Use code 16 with appropriate claim payment
remark code [N4].
D17 Claim/Service has invalid non-covered days.
Note: Inactive as of version 5010. Use code 16 with appropriate claim payment
remark code [M32, M33].
D18 Claim/Service has missing diagnosis information.
Note: Inactive as of version 5010. Use code 16 with appropriate claim payment
remark code [MA63, MA65].
D19 Claim/Service lacks Physician/Operative or other supporting documentation
Note: Inactive as of version 5010. Use code 16 with appropriate claim payment
remark code [M29, M30, M35, M66].
D20 Claim/Service missing service/product information.
Note: Inactive as of version 5010. Use code 16 with appropriate claim payment
remark code [M20, M67, M19, MA67].
D21 This (these) diagnosis(es) is (are) missing or are invalid
Note: New as of 6/05
W1 Workers Compensation State Fee Schedule Adjustment
Note: New as of 2/00
M1 X-ray not taken within the past 12 months or near enough to the start of treatment.
M2 Not paid separately when the patient is an inpatient.
M3 Equipment is the same or similar to equipment already being used.
M4 This is the last monthly installment payment for this durable medical equipment.
M5 Monthly rental payments can continue until the earlier of the 15th month from the first
rental month, or the month when the equipment is no longer needed.
M6 You must furnish and service this item for as long as the patient continues to need it.
We can pay for maintenance and/or servicing for every 6 month period after the end
of the 15th paid rental month or the end of the warranty period.
M7 No rental payments after the item is purchased, or after the total of issued rental
payments equals the purchase price.
M8 We do not accept blood gas tests results when the test was conducted by a medical
supplier or taken while the patient is on oxygen.
M9 This is the tenth rental month. You must offer the patient the choice of changing the
rental to a purchase agreement.
M10 Equipment purchases are limited to the first or the tenth month of medical necessity.
M11 DME, orthotics and prosthetics must be billed to the DME carrier who services the
patient's zip code.
M12 Diagnostic tests performed by a physician must indicate whether purchased services
are included on the claim.
M13 Only one initial visit is covered per specialty per medical group.
Note: (Modified 6/30/03)
M14 No separate payment for an injection administered during an office visit, and no
payment for a full office visit if the patient only received an injection.
M15 Separately billed services/tests have been bundled as they are considered components
of the same procedure. Separate payment is not allowed.
M16 Please see the letter or bulletin of (date) for further information.
Note: (Reactivated 4/1/04)
M17 Payment approved as you did not know, and could not reasonably have been expected
to know, that this would not normally have been covered for this patient. In the
future, you will be liable for charges for the same service(s) under the same or similar
conditions.
M18 Certain services may be approved for home use. Neither a hospital nor a Skilled
Nursing Facility (SNF) is considered to be a patient's home.
Note: (Modified 6/30/03)
M19 Missing oxygen certification/re-certification.
Note: (Modified 2/28/03) Related to N234
M20 Missing/incomplete/invalid HCPCS.
Note: (Modified 2/28/03)
M21 Missing/incomplete/invalid place of residence for this service/item provided in a home.
Note: (Modified 2/28/03)
M22 Missing/incomplete/invalid number of miles traveled.
Note: (Modified 2/28/03)
M23 Missing invoice.
Note: (Modified 8/1/05)
M24 Missing/incomplete/invalid number of doses per vial.
Note: (Modified 2/28/03)
M25 Payment has been adjusted because the information furnished does not substantiate
the need for this level of service. If you believe the service should have been fully
covered as billed, or if you did not know and could not reasonably have been expected
to know that we would not pay for this level of service, or if you notified the patient in
writing in advance that we would not pay for this level of service and he/she agreed in
writing to pay, ask us to review your claim within 120 days of the date of this notice. If
you do not request a appeal, we will, upon application from the patient, reimburse
him/her for the amount you have collected from him/her in excess of any deductible
and coinsurance amounts. We will recover the reimbursement from you as an
overpayment.
Note: (Modified 10/1/02, 6/30/03, 8/1/05)
M26 Payment has been adjusted because the information furnished does not substantiate
the need for this level of service. If you have collected any amount from the patient for
this level of service /any amount that exceeds the limiting charge for the less
extensive service, the law requires you to refund that amount to the patient within 30
days of receiving this notice.
The requirements for refund are in 1824(I) of the Social Security Act and
42CFR411.408. The section specifies that physicians who knowingly and willfully fail to
make appropriate refunds may be subject to civil monetary penalties and/or exclusion
from the program. If you have any questions about this notice, please contact this
office.
Note: (Modified 10/1/02, 6/30/03, 8/1/05. Also refer to N356)
M27 The patient has been relieved of liability of payment of these items and services under
the limitation of liability provision of the law. You, the provider, are ultimately liable for
the patient's waived charges, including any charges for coinsurance, since the items or
services were not reasonable and necessary or constituted custodial care, and you
knew or could reasonably have been expected to know, that they were not covered.
You may appeal this determination. You may ask for an appeal regarding both the
coverage determination and the issue of whether you exercised due care. The appeal
request must be filed within 120 days of the date you receive this notice. You must
make the request through this office.
Note: (Modified 10/1/02, 8/1/05)
M28 This does not qualify for payment under Part B when Part A coverage is exhausted or
not otherwise available.
M29 Missing operative report.
Note: (Modified 2/28/03) Related to N233
M30 Missing pathology report.
Note: (Modified 8/1/04, 2/28/03) Related to N236
M31 Missing radiology report.
Note: (Modified 8/1/04, 2/28/03) Related to N240
M32 This is a conditional payment made pending a decision on this service by the patient's
primary payer. This payment may be subject to refund upon your receipt of any
additional payment for this service from another payer. You must contact this office
immediately upon receipt of an additional payment for this service.
M33 Missing/incomplete/invalid UPIN for the ordering/referring/performing provider.
Note: (Deactivated eff. 8/1/04) Consider using M68
M34 Claim lacks the CLIA certification number.
Note: (Deactivated eff. 8/1/04) Consider using MA120
M35 Missing/incomplete/invalid pre-operative photos or visual field results.
Note: (Deactivated eff. 2/5/05) Consider using N178
M36 This is the 11th rental month. We cannot pay for this until you indicate that the patient
has been given the option of changing the rental to a purchase.
M37 Service not covered when the patient is under age 35.
M38 The patient is liable for the charges for this service as you informed the patient in
writing before the service was furnished that we would not pay for it, and the patient
agreed to pay.
M39 The patient is not liable for payment for this service as the advance notice of noncoverage
you provided the patient did not comply with program requirements.
Note: (Modified 2/1/04)
M40 Claim must be assigned and must be filed by the practitioner's employer.
M41 We do not pay for this as the patient has no legal obligation to pay for this.
M42 The medical necessity form must be personally signed by the attending physician.
M43 Payment for this service previously issued to you or another provider by another
carrier/intermediary.
Note: (Deactivated eff. 1/31/04) Consider using Reason Code 23
M44 Missing/incomplete/invalid condition code.
Note: (Modified 2/28/03)
M45 Missing/incomplete/invalid occurrence code(s).
Note: (Modified 12/2/04) Related to N299
M46 Missing/incomplete/invalid occurrence span code(s).
Note: (Modified 12/2/04) Related to N300
M47 Missing/incomplete/invalid internal or document control number.
Note: (Modified 2/28/03)
M48 Payment for services furnished to hospital inpatients (other than professional services
of physicians) can only be made to the hospital. You must request payment from the
hospital rather than the patient for this service.
Note: (Deactivated eff. 1/31/04) Consider using M97
M49 Missing/incomplete/invalid value code(s) or amount(s).
Note: (Modified 2/28/03)
M50 Missing/incomplete/invalid revenue code(s).
Note: (Modified 2/28/03)
M51 Missing/incomplete/invalid procedure code(s).
Note: (Modified 12/2/04) Related to N301
M52 Missing/incomplete/invalid “from” date(s) of service.
Note: (Modified 2/28/03)
M53 Missing/incomplete/invalid days or units of service.
Note: (Modified 2/28/03)
M54 Missing/incomplete/invalid total charges.
Note: (Modified 2/28/03)
M55 We do not pay for self-administered anti-emetic drugs that are not administered with a
covered oral anti-cancer drug.
M56 Missing/incomplete/invalid payer identifier.
Note: (Modified 2/28/03)
M57 Missing/incomplete/invalid provider identifier.
Note: (Deactivated eff. 6/2/05)
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
Note: (Deactivated eff. 2/5/05)
M59 Missing/incomplete/invalid “to” date(s) of service.
Note: (Modified 2/28/03)
M60 Missing Certificate of Medical Necessity.
Note: (Modified 8/1/04, 6/30/03) Related to N227
M61 We cannot pay for this as the approval period for the FDA clinical trial has expired.
M62 Missing/incomplete/invalid treatment authorization code.
Note: (Modified 2/28/03)
M63 We do not pay for more than one of these on the same day.
Note: (Deactivated eff. 1/31/04) Consider using M86
M64 Missing/incomplete/invalid other diagnosis.
Note: (Modified 2/28/03)
M65 One interpreting physician charge can be submitted per claim when a purchased
diagnostic test is indicated. Please submit a separate claim for each interpreting
physician.
M66 Our records indicate that you billed diagnostic tests subject to price limitations and the
procedure code submitted includes a professional component. Only the technical
component is subject to price limitations. Please submit the technical and professional
components of this service as separate line items.
M67 Missing/incomplete/invalid other procedure code(s).
Note: (Modified 12/2/04) Related to N302
M68 Missing/incomplete/invalid attending, ordering, rendering, supervising or referring
physician identification.
Note: (Deactivated eff. 6/2/05)
M69 Paid at the regular rate as you did not submit documentation to justify the modified
procedure code.
Note: (Modified 2/1/04)
M70 NDC code submitted for this service was translated to a HCPCS code for processing,
but please continue to submit the NDC on future claims for this item.
M71 Total payment reduced due to overlap of tests billed.
M72 Did not enter full 8-digit date (MM/DD/CCYY).
Note: (Deactivated eff. 10/16/03) Consider using MA52
M73 The HPSA/Physician Scarcity bonus can only be paid on the professional component of
this service. Rebill as separate professional and technical components.
Note: (Modified 8/1/04)
M74 This service does not qualify for a HPSA/Physician Scarcity bonus payment.
Note: (Modified 12/2/04)
M75 Allowed amount adjusted. Multiple automated multichannel tests performed on the
same day combined for payment.
M76 Missing/incomplete/invalid diagnosis or condition.
Note: (Modified 2/28/03)
M77 Missing/incomplete/invalid place of service.
Note: (Modified 2/28/03)
M78 Missing/incomplete/invalid HCPCS modifier.
Note: (Modified 2/28/03)
M79 Missing/incomplete/invalid charge.
Note: (Modified 2/28/03)
M80 Not covered when performed during the same session/date as a previously processed
service for the patient.
Note: (Modified 10/31/02)
M81 You are required to code to the highest level of specificity.
Note: (Modified 2/1/04)
M82 Service is not covered when patient is under age 50.
M83 Service is not covered unless the patient is classified as at high risk.
M84 Medical code sets used must be the codes in effect at the time of service
Note: (Modified 2/1/04)
M85 Subjected to review of physician evaluation and management services.
M86 Service denied because payment already made for same/similar procedure within set
time frame.
Note: (Modified 6/30/03)
M87 Claim/service(s) subjected to CFO-CAP prepayment review.
M88 We cannot pay for laboratory tests unless billed by the laboratory that did the work.
Note: (Deactivated eff. 8/1/04) Consider using Reason Code B20
M89 Not covered more than once under age 40.
M90 Not covered more than once in a 12 month period.
M91 Lab procedures with different CLIA certification numbers must be billed on separate
claims.
M92 Services subjected to review under the Home Health Medical Review Initiative.
Note: (Deactivated eff. 8/1/04.)
M93 Information supplied supports a break in therapy. A new capped rental period began
with delivery of this equipment.
M94 Information supplied does not support a break in therapy. A new capped rental period
will not begin.
M95 Services subjected to Home Health Initiative medical review/cost report audit.
M96 The technical component of a service furnished to an inpatient may only be billed by
that inpatient facility. You must contact the inpatient facility for technical component
reimbursement. If not already billed, you should bill us for the professional component
only.
M97 Not paid to practitioner when provided to patient in this place of service. Payment
included in the reimbursement issued the facility.
M98 Begin to report the Universal Product Number on claims for items of this type. We will
soon begin to deny payment for items of this type if billed without the correct UPN.
Note: (Deactivated eff. 1/31/2004) Consider using M99
M99 Missing/incomplete/invalid Universal Product Number/Serial Number.
Note: (Modified 2/28/03)
M100 We do not pay for an oral anti-emetic drug that is not administered for use
immediately before, at, or within 48 hours of administration of a covered
chemotherapy drug.
M101 Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny
payment for this service if billed without a G1-G5 modifier.
Note: (Deactivated eff. 1/31/2004) Consider using M78
M102 Service not performed on equipment approved by the FDA for this purpose.
M103 Information supplied supports a break in therapy. However, the medical information
we have for this patient does not support the need for this item as billed. We have
approved payment for this item at a reduced level, and a new capped rental period will
begin with the delivery of this equipment.
M104 Information supplied supports a break in therapy. A new capped rental period will
begin with delivery of the equipment. This is the maximum approved under the fee
schedule for this item or service.
M105 Information supplied does not support a break in therapy. The medical information we
have for this patient does not support the need for this item as billed. We have
approved payment for this item at a reduced level, and a new capped rental period will
not begin.
M106 Information supplied does not support a break in therapy. A new capped rental period
will not begin. This is the maximum approved under the fee schedule for this item or
service.
Note: (Deactivated eff. 1/31/2004) Consider using MA 31
M107 Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded
36.5%.
M108 Missing/incomplete/invalid provider identifier for the provider who interpreted the
diagnostic test.
Note: (Deactivated eff. 6/2/05)
M109 We have provided you with a bundled payment for a teleconsultation. You must send
25 percent of the teleconsultation payment to the referring practitioner.
M110 Missing/incomplete/invalid provider identifier for the provider from whom you
purchased interpretation services.
Note: (Deactivated eff. 6/2/05)
M111 We do not pay for chiropractic manipulative treatment when the patient refuses to
have an x-ray taken.
M112 The approved amount is based on the maximum allowance for this item under the
DMEPOS Competitive Bidding Demonstration.
M113 Our records indicate that this patient began using this service(s) prior to the current
round of the DMEPOS Competitive Bidding Demonstration. Therefore, the approved
amount is based on the allowance in effect prior to this round of bidding for this item.
M114 This service was processed in accordance with rules and guidelines under the
Competitive Bidding Demonstration Project. If you would like more information
regarding this project, you may phone 1-888-289-0710.
M115 This item is denied when provided to this patient by a non-demonstration supplier.
M116 Paid under the Competitive Bidding Demonstration project. Project is ending, and
future services may not be paid under this project.
Note: (Modified 2/1/04)
M117 Not covered unless submitted via electronic claim.
Note: (Modified 6/30/03)
M118 Letter to follow containing further information.
M119 Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
Note: (Modified 2/28/03, 4/1/04)
M120 Missing/incomplete/invalid provider identifier for the substituting physician who
furnished the service(s) under a reciprocal billing or locum tenens arrangement.
Note: (Deactivated eff. 6/2/05)
M121 We pay for this service only when performed with a covered cryosurgical ablation.
M122 Missing/incomplete/invalid level of subluxation.
Note: (Modified 2/28/03)
M123 Missing/incomplete/invalid name, strength, or dosage of the drug furnished.
Note: (Modified 2/28/03)
M124 Missing indication of whether the patient owns the equipment that requires the part or
supply.
Note: (Modified 2/28/03) Related to N230
M125 Missing/incomplete/invalid information on the period of time for which the
service/supply/equipment will be needed.
Note: (Modified 2/28/03)
M126 Missing/incomplete/invalid individual lab codes included in the test.
Note: (Modified 2/28/03)
M127 Missing patient medical record for this service.
Note: (Modified 2/28/03) Related to N237
M128 Missing/incomplete/invalid date of the patient’s last physician visit.
Note: (Deactivated eff. 6/2/05)
M129 Missing/incomplete/invalid indicator of x-ray availability for review.
Note: (Modified 2/28/03, 6/30/03)
M130 Missing invoice or statement certifying the actual cost of the lens, less discounts,
and/or the type of intraocular lens used.
Note: (Modified 2/28/03) Related to N231
M131 Missing physician financial relationship form.
Note: (Modified 2/28/03) Related to N239
M132 Missing pacemaker registration form.
Note: (Modified 2/28/03) Related to N235
M133 Claim did not identify who performed the purchased diagnostic test or the amount you
Medicaid Claim Denial Codes
15
were charged for the test.
M134 Performed by a facility/supplier in which the provider has a financial interest.
Note: (Modified 6/30/03)
M135 Missing/incomplete/invalid plan of treatment.
Note: (Modified 2/28/03)
M136 Missing/incomplete/invalid indication that the service was supervised or evaluated by a
physician.
Note: (Modified 2/28/03)
M137 Part B coinsurance under a demonstration project.
M138 Patient identified as a demonstration participant but the patient was not enrolled in the
demonstration at the time services were rendered. Coverage is limited to
demonstration participants.
M139 Denied services exceed the coverage limit for the demonstration.
M140 Service not covered until after the patient’s 50th birthday, i.e., no coverage prior to
the day after the 50th birthday
Note: (Deactivated eff. 1/30/2004) Consider using M82
M141 Missing physician certified plan of care.
Note: (Modified 2/28/03) Related to N238
M142 Missing American Diabetes Association Certificate of Recognition.
Note: (Modified 2/28/03) Related to N226
M143 We have no record that you are licensed to dispensed drugs in the State where
located.
M144 Pre-/post-operative care payment is included in the allowance for the
surgery/procedure.
MA01 If you do not agree with what we approved for these services, you may appeal our
decision. To make sure that we are fair to you, we require another individual that did
not process your initial claim to conduct the appeal. However, in order to be eligible for
an appeal, you must write to us within 120 days of the date you received this notice,
unless you have a good reason for being late.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)
MA02 If you do not agree with this determination, you have the right to appeal. You must file
a written request for an appeal within 120 days of the date you receive this notice.
Decisions made by a Quality Improvement Organization (QIO) must be appealed to
that QIO within 60 days.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)
MA03 If you do not agree with the approved amounts and $100 or more is in dispute (less
deductible and coinsurance), you may ask for a hearing within six months of the date
of this notice. To meet the $100, you may combine amounts on other claims that have
been denied, including reopened appeals if you received a revised decision. You must
appeal each claim on time. At the reconsideration, you must present any new evidence
which could affect our decision.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)
MA04 Secondary payment cannot be considered without the identity of or payment
information from the primary payer. The information was either not reported or was
illegible.
MA05 Incorrect admission date patient status or type of bill entry on claim.
Note: (Deactivated eff. 10/16/03) Consider using MA30, MA40 or MA43
MA06 Missing/incomplete/invalid beginning and/or ending date(s).
Note: (Deactivated eff. 8/1/04) Consider using MA31
MA07 The claim information has also been forwarded to Medicaid for review.
MA08 You should also submit this claim to the patient's other insurer for potential payment
of supplemental benefits. We did not forward the claim information as the
supplemental coverage is not with a Medigap plan, or you do not participate in
Medicare.
MA09 Claim submitted as unassigned but processed as assigned. You agreed to accept
assignment for all claims.
MA10 The patient's payment was in excess of the amount owed. You must refund the
overpayment to the patient.
MA11 Payment is being issued on a conditional basis. If no-fault insurance, liability
insurance, Workers' Compensation, Department of Veterans Affairs, or a group health
plan for employees and dependents also covers this claim, a refund may be due us.
Please contact us if the patient is covered by any of these sources.
Note: (Deactivated eff. 1/31/2004) Consider using M32
MA12 You have not established that you have the right under the law to bill for services
furnished by the person(s) that furnished this (these) service(s).
MA13 You may be subject to penalties if you bill the patient for amounts not reported with
the PR (patient responsibility) group code.
MA14 Patient is a member of an employer-sponsored prepaid health plan. Services from
outside that health plan are not covered. However, as you were not previously notified
of this, we are paying this time. In the future, we will not pay you for non-plan
services.
MA15 Your claim has been separated to expedite handling. You will receive a separate notice
for the other services reported.
MA16 The patient is covered by the Black Lung Program. Send this claim to the Department
of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.
MA17 We are the primary payer and have paid at the primary rate. You must contact the
patient's other insurer to refund any excess it may have paid due to its erroneous
primary payment.
MA18 The claim information is also being forwarded to the patient's supplemental insurer.
Send any questions regarding supplemental benefits to them.
MA19 Information was not sent to the Medigap insurer due to incorrect/invalid information
you submitted concerning that insurer. Please verify your information and submit your
secondary claim directly to that insurer.
MA20 Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the
use of an urethral catheter for convenience or the control of incontinence.
Note: (Modified 6/30/03)
MA21 SSA records indicate mismatch with name and sex.
MA22 Payment of less than $1.00 suppressed.
MA23 Demand bill approved as result of medical review.
MA24 Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit
period.
Note: (Modified 6/30/03)
MA25 A patient may not elect to change a hospice provider more than once in a benefit
period.
MA26 Our records indicate that you were previously informed of this rule.
MA27 Missing/incomplete/invalid entitlement number or name shown on the claim.
Note: (Modified 2/28/03)
MA28 Receipt of this notice by a physician or supplier who did not accept assignment is for
information only and does not make the physician or supplier a party to the
determination. No additional rights to appeal this decision, above those rights already
provided for by regulation/instruction, are conferred by receipt of this notice.
MA29 Missing/incomplete/invalid provider name, city, state, or zip code.
Note: (Deactivated eff. 6/2/05)
MA30 Missing/incomplete/invalid type of bill.
Note: (Modified 2/28/03)
MA31 Missing/incomplete/invalid beginning and ending dates of the period billed.
Note: (Modified 2/28/03)
MA32 Missing/incomplete/invalid number of covered days during the billing period.
Note: (Modified 2/28/03)
MA33 Missing/incomplete/invalid noncovered days during the billing period.
Note: (Modified 2/28/03)
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
Note: (Modified 2/28/03)
MA35 Missing/incomplete/invalid number of lifetime reserve days.
Note: (Modified 2/28/03)
MA36 Missing/incomplete/invalid patient name.
Note: (Modified 2/28/03)
Medicaid Claim Denial Codes
17
MA37 Missing/incomplete/invalid patient's address.
Note: (Modified 2/28/03)
MA38 Missing/incomplete/invalid birth date.
Note: (Deactivated eff. 6/2/05)
MA39 Missing/incomplete/invalid gender.
Note: (Modified 2/28/03)
MA40 Missing/incomplete/invalid admission date.
Note: (Modified 2/28/03)
MA41 Missing/incomplete/invalid admission type.
Note: (Modified 2/28/03)
MA42 Missing/incomplete/invalid admission source.
Note: (Modified 2/28/03)
MA43 Missing/incomplete/invalid patient status.
Note: (Modified 2/28/03)
MA44 No appeal rights. Adjudicative decision based on law.
MA45 As previously advised, a portion or all of your payment is being held in a special
account.
MA46 The new information was considered, however, additional payment cannot be issued.
Please review the information listed for the explanation.
MA47 Our records show you have opted out of Medicare, agreeing with the patient not to bill
Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The
patient is responsible for payment.
MA48 Missing/incomplete/invalid name or address of responsible party or primary payer.
Note: (Modified 2/28/03)
MA49 Missing/incomplete/invalid six-digit provider identifier for home health agency or
hospice for physician(s) performing care plan oversight services.
Note: (Deactivated eff.8/1/04) Consider using MA76
MA50 Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved
clinical trial services.
Note: (Modified 2/28/03)
MA51 Missing/incomplete/invalid CLIA certification number for laboratory services billed by
physician office laboratory.
Note: (Deactivated eff. 2/5/05) Consider using MA120
MA52 Missing/incomplete/invalid date.
Note: (Deactivated eff. 6/2/05)
MA53 Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
Note: (Modified 2/1/04)
MA54 Physician certification or election consent for hospice care not received timely.
MA55 Not covered as patient received medical health care services, automatically revoking
his/her election to receive religious non-medical health care services.
MA56 Our records show you have opted out of Medicare, agreeing with the patient not to bill
Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The
patient is responsible for payment, but under Federal law, you cannot charge the
patient more than the limiting charge amount.
MA57 Patient submitted written request to revoke his/her election for religious non-medical
health care services.
MA58 Missing/incomplete/invalid release of information indicator.
Note: (Modified 2/28/03)
MA59 The patient overpaid you for these services. You must issue the patient a refund within
30 days for the difference between his/her payment and the total amount shown as
patient responsibility on this notice.
MA60 Missing/incomplete/invalid patient relationship to insured.
Note: (Modified 2/28/03)
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
Note: (Modified 2/28/03)
MA62 Telephone review decision.
MA63 Missing/incomplete/invalid principal diagnosis.
Note: (Modified 2/28/03)
MA64 Our records indicate that we should be the third payer for this claim. We cannot
process this claim until we have received payment information from the primary and
secondary payers.
MA65 Missing/incomplete/invalid admitting diagnosis.
Note: (Modified 2/28/03)
MA66 Missing/incomplete/invalid principal procedure code.
Note: (Modified 12/2/04) Related to N303
MA67 Correction to a prior claim.
MA68 We did not crossover this claim because the secondary insurance information on the
claim was incomplete. Please supply complete information or use the PLANID of the
insurer to assure correct and timely routing of the claim.
MA69 Missing/incomplete/invalid remarks.
Note: (Modified 2/28/03)
MA70 Missing/incomplete/invalid provider representative signature.
Note: (Modified 2/28/03)
MA71 Missing/incomplete/invalid provider representative signature date.
Note: (Modified 2/28/03)
MA72 The patient overpaid you for these assigned services. You must issue the patient a
refund within 30 days for the difference between his/her payment to you and the total
of the amount shown as patient responsibility and as paid to the patient on this notice.
MA73 Informational remittance associated with a Medicare demonstration. No payment
issued under fee-for-service Medicare as patient has elected managed care.
MA74 This payment replaces an earlier payment for this claim that was either lost, damaged
or returned.
MA75 Missing/incomplete/invalid patient or authorized representative signature.
Note: (Modified 2/28/03)
MA76 Missing/incomplete/invalid provider identifier for home health agency or hospice when
physician is performing care plan oversight services.
Note: (Modified 2/28/03, 2/1/04)
MA77 The patient overpaid you. You must issue the patient a refund within 30 days for the
difference between the patient’s payment less the total of our and other payer
payments and the amount shown as patient responsibility on this notice.
MA78 The patient overpaid you. You must issue the patient a refund within 30 days for the
difference between our allowed amount total and the amount paid by the patient.
Note: (Deactivated eff. 1/31/2004) Consider using MA59
MA79 Billed in excess of interim rate.
MA80 Informational notice. No payment issued for this claim with this notice. Payment
issued to the hospital by its intermediary for all services for this encounter under a
demonstration project.
MA81 Missing/incomplete/invalid provider/supplier signature.
Note: (Modified 2/28/03)
MA82 Missing/incomplete/invalid provider/supplier billing number/identifier or billing name,
address, city, state, zip code, or phone number.
Note: (Deactivated eff. 6/2/05)
MA83 Did not indicate whether we are the primary or secondary payer.
Note: (Modified 8/1/05)
MA84 Patient identified as participating in the National Emphysema Treatment Trial but our
records indicate that this patient is either not a participant, or has not yet been
approved for this phase of the study. Contact Johns Hopkins University, the study
coordinator, to resolve if there was a discrepancy.
MA85 Our records indicate that a primary payer exists (other than ourselves); however, you
did not complete or enter accurately the insurance plan/group/program name or
identification number. Enter the PlanID when effective.
Note: (Deactivated eff. 8/1/04) Consider using MA92
MA86 Missing/incomplete/invalid group or policy number of the insured for the primary
coverage.
Note: (Deactivated eff. 8/1/04) Consider using MA92
MA87 Missing/incomplete/invalid insured's name for the primary payer.
Note: (Deactivated eff. 8/1/04) Consider using MA92
Medicaid Claim Denial Codes
19
MA88 Missing/incomplete/invalid insured's address and/or telephone number for the primary
payer.
Note: (Modified 2/28/03)
MA89 Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
Note: (Modified 2/28/03)
MA90 Missing/incomplete/invalid employment status code for the primary insured.
Note: (Modified 2/28/03).
MA91 This determination is the result of the appeal you filed.
MA92 Missing plan information for other insurance.
Note: (Modified 2/1/04) Related to N245
MA93 Non-PIP (Periodic Interim Payment) claim.
Note: (Modified 6/30/03)
MA94 Did not enter the statement “Attending physician not hospice employee” on the claim
form to certify that the rendering physician is not an employee of the hospice.
Note: (Reactivated 4/1/04, Modified 8/1/05)
MA95 De-activate and refer to M51.
Note: (Modified 2/28/03)
MA96 Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not
enrolled in a Medicare managed care plan.
MA97 Missing/incomplete/invalid Medicare Managed Care Demonstration contract number.
Note: (Modified 2/28/03)
MA98 Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration
contract number for this beneficiary.
Note: (Deactivated eff. 10/16/03) Consider using MA97
MA99 Missing/incomplete/invalid Medigap information.
Note: (Modified 2/28/03)
MA100 Missing/incomplete/invalid date of current illness or symptoms
Note: (Modified 2/28/03, 3/30/05)
MA101 A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who
furnish these services/supplies to residents.
Note: (Modified 6/30/03)
MA102 Missing/incomplete/invalid name or provider identifier for the rendering/referring/
ordering/ supervising provider.
Note: (Deactivated eff. 8/1/04) Consider using M68
MA103 Hemophilia Add On.
MA104 Missing/incomplete/invalid date the patient was last seen or the provider identifier of
the attending physician.
Note: (Deactivated eff. 1/31/2004) Consider using M128 or M57
MA105 Missing/incomplete/invalid provider number for this place of service.
Note: (Deactivated eff. 6/2/05)
MA106 PIP (Periodic Interim Payment) claim.
Note: (Modified 6/30/03)
MA107 Paper claim contains more than three separate data items in field 19.
MA108 Paper claim contains more than one data item in field 23.
MA109 Claim processed in accordance with ambulatory surgical guidelines.
MA110 Missing/incomplete/invalid information on whether the diagnostic test(s) were
performed by an outside entity or if no purchased tests are included on the claim.
Note: (Modified 2/28/03)
MA111 Missing/incomplete/invalid purchase price of the test(s) and/or the performing
laboratory's name and address.
Note: (Modified 2/28/03)
MA112 Missing/incomplete/invalid group practice information.
Note: (Modified 2/28/03)
MA113 Incomplete/invalid taxpayer identification number (TIN) submitted by you per the
Internal Revenue Service. Your claims cannot be processed without your correct TIN,
and you may not bill the patient pending correction of your TIN. There are no appeal
rights for unprocessable claims, but you may resubmit this claim after you have
notified this office of your correct TIN.
MA114 Missing/incomplete/invalid information on where the services were furnished.
Note: (Modified 2/28/03)
MA115 Missing/incomplete/invalid physical location (name and address, or PIN) where the
service(s) were rendered in a Health Professional Shortage Area (HPSA).
Note: (Modified 2/28/03)
MA116 Did not complete the statement "Homebound" on the claim to validate whether
laboratory services were performed at home or in an institution.
Note: (Reactivated 4/1/04)
MA117 This claim has been assessed a $1.00 user fee.
MA118 Coinsurance and/or deductible amounts apply to a claim for services or supplies
furnished to a Medicare-eligible veteran through a facility of the Department of
Veterans Affairs. No Medicare payment issued.
MA119 Provider level adjustment for late claim filing applies to this claim.
MA120 Missing/incomplete/invalid CLIA certification number.
Note: (Modified 2/28/03)
MA121 Missing/incomplete/invalid x-ray date.
Note: (Modified 12/2/04)
MA122 Missing/incomplete/invalid initial treatment date.
Note: (Modified 12/2/04)
MA123 Your center was not selected to participate in this study, therefore, we cannot pay for
these services.
MA124 Processed for IME only.
Note: (Deactivated eff. 1/31/2004) Consider using Reason Code 74
MA125 Per legislation governing this program, payment constitutes payment in full.
MA126 Pancreas transplant not covered unless kidney transplant performed.
Note: (New Code 10/12/01)
MA127 Reserved for future use.
Note: (Deactivated eff. 6/2/05)
MA128 Missing/incomplete/invalid FDA approval number.
Note: (Modified 2/28/03, 3/30/05)
MA129 This provider was not certified for this procedure on this date of service.
Note: (Deactivated eff. 1/31/2004) Consider using MA120 and Reason Code B7
MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are
afforded because the claim is unprocessable. Please submit a new claim with the
complete/correct information.
MA131 Physician already paid for services in conjunction with this demonstration claim. You
must have the physician withdraw that claim and refund the payment before we can
process your claim.
MA132 Adjustment to the pre-demonstration rate.
MA133 Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient
stay.
MA134 Missing/incomplete/invalid provider number of the facility where the patient resides.
N1 You may appeal this decision in writing within the required time limits following receipt
of this notice by following the instructions included in your contract or plan benefit
documents.
Note: (Modified 2/28/03)
N2 This allowance has been made in accordance with the most appropriate course of
treatment provision of the plan.
N3 Missing consent form.
Note: (Modified 2/28/03) Related to N228
N4 Missing/incomplete/invalid prior insurance carrier EOB.
Note: (Modified 2/28/03)
N5 EOB received from previous payer. Claim not on file.
N6 Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the
amount Medicare would have allowed if the patient were enrolled in Medicare Part A
and/or Medicare Part B.
Note: (Modified 2/28/03)
N7 Processing of this claim/service has included consideration under Major Medical
provisions.
N8 Crossover claim denied by previous payer and complete claim data not forwarded.
Resubmit this claim to this payer to provide adequate data for adjudication.
N9 Adjustment represents the estimated amount the primary payer may have paid.
N10 Claim/service adjusted based on the findings of a review organization/professional
consult/manual adjudication/medical or dental advisor.
Note: (Modified 10/31/02)
N11 Denial reversed because of medical review.
N12 Policy provides coverage supplemental to Medicare. As member does not appear to be
enrolled in Medicare Part B, the member is responsible for payment of the portion of
the charge that would have been covered by Medicare.
N13 Payment based on professional/technical component modifier(s).
N14 Payment based on a contractual amount or agreement, fee schedule, or maximum
allowable amount.
N15 Services for a newborn must be billed separately.
N16 Family/member Out-of-Pocket maximum has been met. Payment based on a higher
percentage.
N17 Per admission deductible.
Note: (Deactivated eff. 8/1/04) Consider using Reason Code 1
N18 Payment based on the Medicare allowed amount.
Note: (Deactivated eff. 1/31/2004) Consider using N14
N19 Procedure code incidental to primary procedure.
N20 Service not payable with other service rendered on the same date.
N21 Your line item has been separated into multiple lines to expedite handling.
Note: (Modified 8/1/05)
N22 This procedure code was added/changed because it more accurately describes the
services rendered.
Note: (Modified 10/31/02, 2/28/03)
N23 Patient liability may be affected due to coordination of benefits with other carriers
and/or maximum benefit provisions.
Note: (Modified 8/13/01)
N24 Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
Note: (Modified 2/28/03)
N25 This company has been contracted by your benefit plan to provide administrative
claims payment services only. This company does not assume financial risk or
obligation with respect to claims processed on behalf of your benefit plan.
N26 Missing itemized bill.
Note: (Modified 2/28/03) Related to N232
N27 Missing/incomplete/invalid treatment number.
Note: (Modified 2/28/03)
N28 Consent form requirements not fulfilled.
N29 Missing documentation/orders/notes/summary/report/chart.
Note: (Modified 2/28/03, 8/1/05) Related to N225
N30 Patient ineligible for this service.
Note: (Modified 6/30/03)
N31 Missing/incomplete/invalid prescribing provider identifier.
Note: (Modified 12/2/04)
N32 Claim must be submitted by the provider who rendered the service.
Note: (Modified 6/30/03)
N33 No record of health check prior to initiation of treatment.
N34 Incorrect claim form for this service.
N35 Program integrity/utilization review decision.
N36 Claim must meet primary payer’s processing requirements before we can consider
payment.
N37 Missing/incomplete/invalid tooth number/letter.
Note: (Modified 2/28/03)
N38 Missing/incomplete/invalid place of service.
Note: (Deactivated eff. 2/5/05) Consider using M77
N39 Procedure code is not compatible with tooth number/letter.
N40 Missing x-ray.
Note: (Modified 2/1/04) Related to N242
N41 Authorization request denied.
Note: (Deactivated eff. 10/16/03) Consider using Reason Code 39
N42 No record of mental health assessment.
N43 Bed hold or leave days exceeded.
N44 Payer’s share of regulatory surcharges, assessments, allowances or health care-related
taxes paid directly to the regulatory authority.
Note: (Deactivated eff. 10/16/03) Consider using Reason Code 137
N45 Payment based on authorized amount.
N46 Missing/incomplete/invalid admission hour.
N47 Claim conflicts with another inpatient stay.
N48 Claim information does not agree with information received from other insurance
carrier.
N49 Court ordered coverage information needs validation.
N50 Missing/incomplete/invalid discharge information.
Note: (Modified 2/28/03)
N51 Electronic interchange agreement not on file for provider/submitter.
N52 Patient not enrolled in the billing provider's managed care plan on the date of service.
N53 Missing/incomplete/invalid point of pick-up address.
Note: (Modified 2/28/03)
N54 Claim information is inconsistent with pre-certified/authorized services.
N55 Procedures for billing with group/referring/performing providers were not followed.
N56 Procedure code billed is not correct/valid for the services billed or the date of service
billed.
Note: (Modified 2/28/03)
N57 Missing/incomplete/invalid prescribing date.
Note: (Modified 12/2/04) Related to N304
N58 Missing/incomplete/invalid patient liability amount.
Note: (Modified 2/28/03)
N59 Please refer to your provider manual for additional program and provider information.
N60 A valid NDC is required for payment of drug claims effective October 02.
Note: (Deactivated eff. 1/31/2004) Consider using M119
N61 Rebill services on separate claims.
N62 Inpatient admission spans multiple rate periods. Resubmit separate claims.
N63 Rebill services on separate claim lines.
N64 The “from” and “to” dates must be different.
N65 Procedure code or procedure rate count cannot be determined, or was not on file, for
the date of service/provider.
Note: (Modified 2/28/03)
N66 Missing/incomplete/invalid documentation.
Note: (Deactivated eff. 2/5/05) Consider using N29 or N225.
N67 Professional provider services not paid separately. Included in facility payment under a
demonstration project. Apply to that facility for payment, or resubmit your claim if:
the facility notifies you the patient was excluded from this demonstration; or if you
furnished these services in another location on the date of the patient’s admission or
discharge from a demonstration hospital. If services were furnished in a facility not
involved in the demonstration on the same date the patient was discharged from or
admitted to a demonstration facility, you must report the provider ID number for the
non-demonstration facility on the new claim.
N68 Prior payment being cancelled as we were subsequently notified this patient was
covered by a demonstration project in this site of service. Professional services were
included in the payment made to the facility. You must contact the facility for your
payment. Prior payment made to you by the patient or another insurer for this claim
must be refunded to the payer within 30 days.
N69 PPS (Prospective Payment System) code changed by claims processing system.
Insufficient visits or therapies.
Note: (Modified 6/30/03)
N70 Home health consolidated billing and payment applies.
Note: (Modified 2/28/02)
N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or
ambulance service was processed as an assigned claim. You are required by law to
accept assignment for these types of claims.
Note: (Modified 2/21/02, 6/30/03)
N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported
by clinical records.
Note: (Modified 6/30/03)
N73 A Skilled Nursing Facility is responsible for payment of outside providers who furnish
these services/supplies under arrangement to its residents.
Note: (Deactivated eff. 1/31/04) Consider using MA101 or N200
N74 Resubmit with multiple claims, each claim covering services provided in only one
calendar month.
N75 Missing/incomplete/invalid tooth surface information.
Note: (Modified 2/28/03)
N76 Missing/incomplete/invalid number of riders.
Note: (Modified 2/28/03)
N77 Missing/incomplete/invalid designated provider number.
Note: (Modified 2/28/03)
N78 The necessary components of the child and teen checkup (EPSDT) were not
completed.
N79 Service billed is not compatible with patient location information.
N80 Missing/incomplete/invalid prenatal screening information.
Note: (Modified 2/28/03)
N81 Procedure billed is not compatible with tooth surface code.
N82 Provider must accept insurance payment as payment in full when a third party payer
contract specifies full reimbursement.
N83 No appeal rights. Adjudicative decision based on the provisions of a demonstration
project.
N84 Further installment payments forthcoming.
N85 Final installment payment.
N86 A failed trial of pelvic muscle exercise training is required in order for biofeedback
training for the treatment of urinary incontinence to be covered.
N87 Home use of biofeedback therapy is not covered.
N88 This payment is being made conditionally. An HHA episode of care notice has been
filed for this patient. When a patient is treated under a HHA episode of care,
consolidated billing requires that certain therapy services and supplies, such as this,
be included in the HHA's payment. This payment will need to be recouped from you if
we establish that the patient is concurrently receiving treatment under a HHA episode
of care.
N89 Payment information for this claim has been forwarded to more than one other payer,
but format limitations permit only one of the secondary payers to be identified in this
remittance advice.
N90 Covered only when performed by the attending physician.
N91 Services not included in the appeal review.
N92 This facility is not certified for digital mammography.
N93 A separate claim must be submitted for each place of service. Services furnished at
multiple sites may not be billed in the same claim.
N94 Claim/Service denied because a more specific taxonomy code is required for
adjudication.
N95 This provider type/provider specialty may not bill this service.
Note: (New code 7/31/01, Modified 2/28/03)
N96 Patient must be refractory to conventional therapy (documented behavioral,
pharmacologic and/or surgical corrective therapy) and be an appropriate surgical
candidate such that implantation with anesthesia can occur.
Note: (New code 8/24/01)
N97 Patients with stress incontinence, urinary obstruction, and specific neurologic diseases
(e.g., diabetes with peripheral nerve involvement) which are associated with
secondary manifestations of the above three indications are excluded.
Note: (New code 8/24/01)
N98 Patient must have had a successful test stimulation in order to support subsequent
implantation. Before a patient is eligible for permanent implantation, he/she must
demonstrate a 50 percent or greater improvement through test stimulation.
Improvement is measured through voiding diaries.
Note: (New code 8/24/01)
N99 Patient must be able to demonstrate adequate ability to record voiding diary data such
that clinical results of the implant procedure can be properly evaluated.
Note: (New code 8/24/01)
N100 PPS (Prospect Payment System) code corrected during adjudication.
Note: (New code 9/14/01. Modified 6/30/03)
N101 Additional information is needed in order to process this claim. Please resubmit the
claim with the identification number of the provider where this service took place. The
Medicare number of the site of service provider should be preceded with the letters
"HSP" and entered into item #32 on the claim form. You may bill only one site of
service provider number per claim.
Note: (Deactivated eff. 1/31/04) Consider uisng MA105
N102 This claim has been denied without reviewing the medical record because the
requested records were not received or were not received timely.
Note: (New code 10/31/01)
N103 Social Security records indicate that this patient was a prisoner when the service was
rendered. This payer does not cover items and services furnished to an individual while
they are in State or local custody under a penal authority, unless under State or local
law, the individual is personally liable for the cost of his or her health care while
incarcerated and the State or local government pursues such debt in the same way
and with the same vigor as any other debt.
Note: (Modified 6/30/03)
N104 This claim/service is not payable under our claims jurisdiction area. You can identify
the correct Medicare contractor to process this claim/service through the CMS website
at www.cms.hhs.gov.
Note: (New code 1/29/02, Modified 10/31/02)
N105 This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the
RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301
for RRB EDI information for electronic claims processing.
Note: (New code 1/29/02)
N106 Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for
excluded services) can only be made to the SNF. You must request payment from the
SNF rather than the patient for this service.
Note: (New code 1/31/02)
N107 Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the
inpatient claim. They cannot be billed separately as outpatient services.
Note: (New code 1/31/02)
N108 Missing/incomplete/invalid upgrade information.
Note: (Modified 2/28/03)
N109 This claim was chosen for complex review and was denied after reviewing the medical
records.
Note: (New Code 2/26/02)
N110 This facility is not certified for film mammography.
Note: (New Code 2/28/02)
N111 No appeal right except duplicate claim/service issue. This service was included in a
claim that has been previously billed and adjudicated.
Note: (New Code 2/28/02)
N112 This claim is excluded from your electronic remittance advice.
Note: (New Code 2/28/02)
N113 Only one initial visit is covered per physician, group practice or provider.
Note: (New Code 4/16/02. Modified 6/30/03)
N114 During the transition to the Ambulance Fee Schedule, payment is based on the lesser
of a blended amount calculated using a percentage of the reasonable charge/cost and
fee schedule amounts, or the submitted charge for the service. You will be notified
yearly what the percentages for the blended payment calculation will be.
Note: (New Code 5/30/02)
N115 This decision was based on a local medical review policy (LMRP) or Local Coverage
Determination (LCD).An LMRP/LCD provides a guide to assist in determining whether a
particular item or service is covered. A copy of this policy is available at
http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the
contractor to request a copy of the LMRP/LCD.
Note: (Modified 4/1/04)
N116 This payment is being made conditionally because the service was provided in the
home, and it is possible that the patient is under a home health episode of care. When
a patient is treated under a home health episode of care, consolidated billing requires
that certain therapy services and supplies, such as this, be included in the home
health agency’s (HHA’s) payment. This payment will need to be recouped from you if
we establish that the patient is concurrently receiving treatment under an HHA episode
of care.
Note: (New Code 6/30/02)
N117 This service is paid only once in a patient’s lifetime.
Note: (New Code 7/30/02. Modified 6/30/03)
N118 This service is not paid if billed more than once every 28 days.
Note: (New Code 7/30/02)
N119 This service is not paid if billed once every 28 days, and the patient has spent 5 or
more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those
28 days.
Note: (New Code 7/30/02. Modified 6/30/03)
N120 Payment is subject to home health prospective payment system partial episode
payment adjustment. Patient was transferred/discharged/readmitted during payment
episode.
Note: (New Code 8/9/02. Modified 6/30/03)
N121 Medicare Part B does not pay for items or services provided by this type of practitioner
for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.
Note: (New Code 9/9/02. Modified 8/1/04, 6/30/03)
N122 Add-on code cannot be billed by itself.
Note: (New Code 9/12/02, Modified 8/1/05)
N123 This is a split service and represents a portion of the units from the originally
submitted service.
Note: (New Code 9/24/02)
N124 Payment has been denied for the/made only for a less extensive service/item because
the information furnished does not substantiate the need for the (more extensive)
service/item. The patient is liable for the charges for this service/item as you informed
the patient in writing before the service/item was furnished that we would not pay for
it, and the patient agreed to pay.
Note: (New Code 9/26/02)
N125 Payment has been (denied for the/made only for a less extensive) service/item
because the information furnished does not substantiate the need for the (more
extensive) service/item. If you have collected any amount from the patient, you must
refund that amount to the patient within 30 days of receiving this notice.
The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in
§§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section
1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make
appropriate refunds may be subject to civil money penalties and/or exclusion from the
Medicare program. If you have any questions about this notice, please contact this
office.
Note: (New Code 9/26/02, Modified 8/1/05. Also refer to N356)
N126 Social Security Records indicate that this individual has been deported. This payer
does not cover items and services furnished to individuals who have been deported.
Note: (New Code 10/17/02)
N127 This is a misdirected claim/service for a United Mine Workers of America (UMWA)
beneficiary. Please submit claims to them.
Note: (New Code 10/31/02) Modified 8/1/04
N128 This amount represents the prior to coverage portion of the allowance.
Note: (New Code 10/31/02)
N129 This amount represents the dollar amount not eligible due to the patient's age.
Note: (New Code 10/31/02)
N130 Consult plan benefit documents for information about restrictions for this service.
Note: (New Code 10/31/02)
N131 Total payments under multiple contracts cannot exceed the allowance for this service.
Note: (New Code 10/31/02)
N132 Payments will cease for services rendered by this US Government debarred or
excluded provider after the 30 day grace period as previously notified.
Note: (New Code 10/31/02)
N133 Services for predetermination and services requesting payment are being processed
separately.
Note: (New Code 10/31/02)
N134 This represents your scheduled payment for this service. If treatment has been
discontinued, please contact Customer Service.
Note: (New Code 10/31/02)
N135 Record fees are the patient's responsibility and limited to the specified co-payment.
Note: (New Code 10/31/02)
N136 To obtain information on the process to file an appeal in Arizona, call the Department's
Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.
Note: (New Code 10/31/02)
N137 The provider acting on the Member's behalf, may file an appeal with the Payer. The
provider, acting on the Member's behalf, may file a complaint with the State Insurance
Regulatory Authority without first filing an appeal, if the coverage decision involves an
urgent condition for which care has not been rendered. The address may be obtained
from the State Insurance Regulatory Authority.
Note: (New Code 10/31/02) Modified 8/1/04, 2/28/03)
N138 In the event you disagree with the Dental Advisor's opinion and have additional
information relative to the case, you may submit radiographs to the Dental Advisor
Unit at the subscriber's dental insurance carrier for a second Independent Dental
Advisor Review.
Note: (New Code 10/31/02)
N139 Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating
provider is not an appropriate appealing party. Therefore, if you disagree with the
Dental Advisor's opinion, you may appeal the determination if appointed in writing, by
the beneficiary, to act as his/her representative. Should you be appointed as a
representative, submit a copy of this letter, a signed statement explaining the matter
in which you disagree, and any radiographs and relevant information to the
subscriber's Dental insurance carrier within 90 days from the date of this letter.
Note: (New Code 10/31/02)
N140 You have not been designated as an authorized OCONUS provider therefore are not
considered an appropriate appealing party. If the beneficiary has appointed you, in
writing, to act as his/her representative and you disagree with the Dental Advisor's
opinion, you may appeal by submitting a copy of this letter, a signed statement
explaining the matter in which you disagree, and any relevant information to the
subscriber's Dental insurance carrier within 90 days from the date of this letter.
Note: (New Code 10/31/02)
N141 The patient was not residing in a long-term care facility during all or part of the service
dates billed.
Note: (New Code 10/31/02)
N142 The original claim was denied. Resubmit a new claim, not a replacement claim.
Note: (New Code 10/31/02)
N143 The patient was not in a hospice program during all or part of the service dates billed.
Note: (New Code 10/31/02)
N144 The rate changed during the dates of service billed.
Note: (New Code 10/31/02)
Medicaid Claim Denial Codes
27
N145 Missing/incomplete/invalid provider identifier for this place of service.
Note: (Deactivated eff. 6/2/05)
N146 Missing screening document.
Note: (Modified 8/1/04) Related to N243
N147 Long term care case mix or per diem rate cannot be determined because the patient
ID number is missing, incomplete, or invalid on the assignment request.
Note: (New Code 10/31/02)
N148 Missing/incomplete/invalid date of last menstrual period.
Note: (New Code 10/31/02)
N149 Rebill all applicable services on a single claim.
Note: (New Code 10/31/02)
N150 Missing/incomplete/invalid model number.
Note: (New Code 10/31/02)
N151 Telephone contact services will not be paid until the face-to-face contact requirement
has been met.
Note: (New Code 10/31/02)
N152 Missing/incomplete/invalid replacement claim information.
Note: (New Code 10/31/02)
N153 Missing/incomplete/invalid room and board rate.
Note: (New Code 10/31/02)
N154 This payment was delayed for correction of provider's mailing address.
Note: (New Code 10/31/02)
N155 Our records do not indicate that other insurance is on file. Please submit other
insurance information for our records.
Note: (New Code 10/31/02)
N156 The patient is responsible for the difference between the approved treatment and the
elective treatment.
Note: (New Code 10/31/02)
N157 Transportation to/from this destination is not covered.
Note: (New Code 2/28/03, Modified 2/1/04)
N158 Transportation in a vehicle other than an ambulance is not covered.
Note: (New Code 2/28/03)
N159 Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Note: (New Code 2/28/03)
N160 The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Note: (New Code 2/28/03, Modified 2/1/04)
N161 This drug/service/supply is covered only when the associated service is covered.
Note: (New Code 2/28/03)
N162 This is an alert. Although your claim was paid, you have billed for a test/specialty not
included in your Laboratory Certification. Your failure to correct the laboratory
certification information will result in a denial of payment in the near future.
Note: (New Code 2/28/03)
N163 Medical record does not support code billed per the code definition.
Note: (New Code 2/28/03)
N164 Transportation to/from this destination is not covered.
Note: (Deactivated eff. 1/31/04) Consider using N157
N165 Transportation in a vehicle other than an ambulance is not covered.
Note: (Deactivated eff. 1/31/04) Consider using N158)
N166 Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Note: (Deactivated eff. 1/31/04) Consider using N159
N167 Charges exceed the post-transplant coverage limit.
Note: (New Code 2/28/03)
N168 The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Note: (Deactivated eff. 1/31/04) Consider using N160
N169 This drug/service/supply is covered only when the associated service is covered.
Note: (Deactivated eff. 1/31/04) Consider using N161
N170 A new/revised/renewed certificate of medical necessity is needed.
Note: (New Code 2/28/03)
N171 Payment for repair or replacement is not covered or has exceeded the purchase price.
Note: (New Code 2/28/03)
N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated
service/item.
Note: (New Code 2/28/03)
N173 No qualifying hospital stay dates were provided for this episode of care.
Note: (New Code 2/28/03)
N174 This is not a covered service/procedure/ equipment/bed, however patient liability is
limited to amounts shown in the adjustments under group "PR".
Note: (New Code 2/28/03)
N175 Missing Review Organization Approval.
Note: (Modified 8/1/04) Related to N241
N176 Services provided aboard a ship are covered only when the ship is of United States
registry and is in United States waters. In addition, a doctor licensed to practice in the
United States must provide the service.
Note: (New Code 2/28/03)
N177 We did not send this claim to patient’s other insurer. They have indicated no additional
payment can be made.
Note: (New Code 2/28/03. Modified 6/30/03)
N178 Missing pre-operative photos or visual field results.
Note: (Modified 8/1/04) Related to N244
N179 Additional information has been requested from the member. The charges will be
reconsidered upon receipt of that information.
Note: (New Code 2/28/03)
N180 This item or service does not meet the criteria for the category under which it was
billed.
Note: (New Code 2/28/03)
N181 Additional information has been requested from another provider involved in the care
of this member. The charges will be reconsidered upon receipt of that information.
Note: (New Code 2/28/03)
N182 This claim/service must be billed according to the schedule for this plan.
Note: (New Code 2/28/03)
N183 This is a predetermination advisory message, when this service is submitted for
payment additional documentation as specified in plan documents will be required to
process benefits.
Note: (New Code 2/28/03)
N184 Rebill technical and professional components separately.
Note: (New Code 2/28/03)
N185 Do not resubmit this claim/service.
Note: (New Code 2/28/03)
N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military
Treatment Facility (MTF) for assistance.
Note: (New Code 2/28/03)
N187 You may request a review in writing within the required time limits following receipt of
this notice by following the instructions included in your contract or plan benefit
documents.
Note: (New Code 2/28/03)
N188 The approved level of care does not match the procedure code submitted.
Note: (New Code 2/28/03)
N189 This service has been paid as a one-time exception to the plan's benefit restrictions.
Note: (New Code 2/28/03)
N190 Missing contract indicator.
Note: (Modified 8/1/04) Related to N229
N191 The provider must update insurance information directly with payer.
Note: (New Code 2/28/03)
Medicaid Claim Denial Codes
29
N192 Patient is a Medicaid/Qualified Medicare Beneficiary.
Note: (New Code 2/28/03)
N193 Specific federal/state/local program may cover this service through another payer.
Note: (New Code 2/28/03)
N194 Technical component not paid if provider does not own the equipment used.
Note: (New Code 2/28/03)
N195 The technical component must be billed separately.
Note: (New Code 2/28/03)
N196 Patient eligible to apply for other coverage which may be primary.
Note: (New Code 2/28/03)
N197 The subscriber must update insurance information directly with payer.
Note: (New Code 2/28/03)
N198 Rendering provider must be affiliated with the pay-to provider.
Note: (New Code 2/28/03)
N199 Additional payment approved based on payer-initiated review/audit.
Note: (New Code 2/28/03)
N200 The professional component must be billed separately.
Note: (New Code 2/28/03)
N201 A mental health facility is responsible for payment of outside providers who furnish
these services/supplies to residents.
Note: (New Code 2/28/03)
N202 Additional information/explanation will be sent separately
Note: (New Code 6/30/03)
N203 Missing/incomplete/invalid anesthesia time/units
Note: (New Code 6/30/03)
N204 Services under review for possible pre-existing condition. Send medical records for
prior 12 months
Note: (New Code 6/30/03)
N205 Information provided was illegible
Note: (New Code 6/30/03)
N206 The supporting documentation does not match the claim
Note: (New Code 6/30/03)
N207 Missing/incomplete/invalid birth weight
Note: (New Code 6/30/03)
N208 Missing/incomplete/invalid DRG code
Note: (New Code 6/30/03)
N209 Missing/invalid/incomplete taxpayer identification number (TIN)
Note: (New Code 6/30/03)
N210 You may appeal this decision
Note: (New Code 6/30/03)
N211 You may not appeal this decision
Note: (New Code 6/30/03)
N212 Charges processed under a Point of Service benefit
Note: (New Code 2/1/04)
N213 Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information
Note: (New Code 4/1/04)
N214 Missing/incomplete/invalid history of the related initial surgical procedure(s)
Note: (New Code 4/1/04)
N215 A payer providing supplemental or secondary coverage shall not require a claims
determination for this service from a primary payer as a condition of making its own
claims determination.
Note: (New Code 4/1/04)
N216 Patient is not enrolled in this portion of our benefit package
Note: (New Code 4/1/04)
N217 We pay only one site of service per provider per claim
Note: (New Code 8/1/04)
N218 You must furnish and service this item for as long as the patient continues to need it.
We can pay for maintenance and/or servicing for the time period specified in the
Medicaid Claim Denial Codes
30
contract or coverage manual.
Note: (New Code 8/1/04)
N219 Payment based on previous payer's allowed amount.
Note: (New Code 8/1/04)
N220 See the payer's web site or contact the payer's Customer Service department to obtain
forms and instructions for filing a provider dispute.
Note: (New Code 8/1/04)
N221 Missing Admitting History and Physical report.
Note: (New Code 8/1/04)
N222 Incomplete/invalid Admitting History and Physical report.
Note: (New Code 8/1/04)
N223 Missing documentation of benefit to the patient during initial treatment period.
Note: (New Code 8/1/04)
N224 Incomplete/invalid documentation of benefit to the patient during initial treatment
period.
Note: (New Code 8/1/04)
N225 Incomplete/invalid documentation/orders/notes/summary/report/chart.
Note: (New Code 8/1/04, Modified 8/1/05)
N226 Incomplete/invalid American Diabetes Association Certificate of Recognition.
Note: (New Code 8/1/04)
N227 Incomplete/invalid Certificate of Medical Necessity.
Note: (New Code 8/1/04)
N228 Incomplete/invalid consent form.
Note: (New Code 8/1/04)
N229 Incomplete/invalid contract indicator.
Note: (New Code 8/1/04)
N230 Incomplete/invalid indication of whether the patient owns the equipment that requires
the part or supply.
Note: (New Code 8/1/04)
N231 Incomplete/invalid invoice or statement certifying the actual cost of the lens, less
discounts, and/or the type of intraocular lens used.
Note: (New Code 8/1/04)
N232 Incomplete/invalid itemized bill.
Note: (New Code 8/1/04)
N233 Incomplete/invalid operative report.
Note: (New Code 8/1/04)
N234 Incomplete/invalid oxygen certification/re-certification.
Note: (New Code 8/1/04)
N235 Incomplete/invalid pacemaker registration form.
Note: (New Code 8/1/04)
N236 Incomplete/invalid pathology report.
Note: (New Code 8/1/04)
N237 Incomplete/invalid patient medical record for this service.
Note: (New Code 8/1/04)
N238 Incomplete/invalid physician certified plan of care
Note: (New Code 8/1/04)
N239 Incomplete/invalid physician financial relationship form.
Note: (New Code 8/1/04)
N240 Incomplete/invalid radiology report.
Note: (New Code 8/1/04)
N241 Incomplete/invalid Review Organization Approval.
Note: (New Code 8/1/04)
N242 Incomplete/invalid x-ray.
Note: (New Code 8/1/04)
N243 Incomplete/invalid/not approved screening document.
Note: (New Code 8/1/04)
N244 Incomplete/invalid pre-operative photos/visual field results.
Note: (New Code 8/1/04)
Medicaid Claim Denial Codes
31
N245 Incomplete/invalid plan information for other insurance
Note: (New Code 8/1/04)
N246 State regulated patient payment limitations apply to this service.
Note: (New Code 12/2/04)
N247 Missing/incomplete/invalid assistant surgeon taxonomy.
Note: (New Code 12/2/04)
N248 Missing/incomplete/invalid assistant surgeon name.
Note: (New Code 12/2/04)
N249 Missing/incomplete/invalid assistant surgeon primary identifier.
Note: (New Code 12/2/04)
N250 Missing/incomplete/invalid assistant surgeon secondary identifier.
Note: (New Code 12/2/04)
N251 Missing/incomplete/invalid attending provider taxonomy.
Note: (New Code 12/2/04)
N252 Missing/incomplete/invalid attending provider name.
Note: (New Code 12/2/04)
N253 Missing/incomplete/invalid attending provider primary identifier.
Note: (New Code 12/2/04)
N254 Missing/incomplete/invalid attending provider secondary identifier.
Note: (New Code 12/2/04)
N255 Missing/incomplete/invalid billing provider taxonomy.
Note: (New Code 12/2/04)
N256 Missing/incomplete/invalid billing provider/supplier name.
Note: (New Code 12/2/04)
N257 Missing/incomplete/invalid billing provider/supplier primary identifier.
Note: (New Code 12/2/04)
N258 Missing/incomplete/invalid billing provider/supplier address.
Note: (New Code 12/2/04)
N259 Missing/incomplete/invalid billing provider/supplier secondary identifier.
Note: (New Code 12/2/04)
N260 Missing/incomplete/invalid billing provider/supplier contact information.
Note: (New Code 12/2/04)
N261 Missing/incomplete/invalid operating provider name.
Note: (New Code 12/2/04)
N262 Missing/incomplete/invalid operating provider primary identifier.
Note: (New Code 12/2/04)
N263 Missing/incomplete/invalid operating provider secondary identifier.
Note: (New Code 12/2/04)
N264 Missing/incomplete/invalid ordering provider name.
Note: (New Code 12/2/04)
N265 Missing/incomplete/invalid ordering provider primary identifier.
Note: (New Code 12/2/04)
N266 Missing/incomplete/invalid ordering provider address.
Note: (New Code 12/2/04)
N267 Missing/incomplete/invalid ordering provider secondary identifier.
Note: (New Code 12/2/04)
N268 Missing/incomplete/invalid ordering provider contact information.
Note: (New Code 12/2/04)
N269 Missing/incomplete/invalid other provider name.
Note: (New Code 12/2/04)
N270 Missing/incomplete/invalid other provider primary identifier.
Note: (New Code 12/2/04)
N271 Missing/incomplete/invalid other provider secondary identifier.
Note: (New Code 12/2/04)
N272 Missing/incomplete/invalid other payer attending provider identifier.
Note: (New Code 12/2/04)
N273 Missing/incomplete/invalid other payer operating provider identifier.
Medicaid Claim Denial Codes
32
Note: (New Code 12/2/04)
N274 Missing/incomplete/invalid other payer other provider identifier.
Note: (New Code 12/2/04)
N275 Missing/incomplete/invalid other payer purchased service provider identifier.
Note: (New Code 12/2/04)
N276 Missing/incomplete/invalid other payer referring provider identifier.
Note: (New Code 12/2/04)
N277 Missing/incomplete/invalid other payer rendering provider identifier.
Note: (New Code 12/2/04)
N278 Missing/incomplete/invalid other payer service facility provider identifier.
Note: (New Code 12/2/04)
N279 Missing/incomplete/invalid pay-to provider name.
Note: (New Code 12/2/04)
N280 Missing/incomplete/invalid pay-to provider primary identifier.
Note: (New Code 12/2/04)
N281 Missing/incomplete/invalid pay-to provider address.
Note: (New Code 12/2/04)
N282 Missing/incomplete/invalid pay-to provider secondary identifier.
Note: (New Code 12/2/04)
N283 Missing/incomplete/invalid purchased service provider identifier.
Note: (New Code 12/2/04)
N284 Missing/incomplete/invalid referring provider taxonomy.
Note: (New Code 12/2/04)
N285 Missing/incomplete/invalid referring provider name.
Note: (New Code 12/2/04)
N286 Missing/incomplete/invalid referring provider primary identifier.
Note: (New Code 12/2/04)
N287 Missing/incomplete/invalid referring provider secondary identifier.
Note: (New Code 12/2/04)
N288 Missing/incomplete/invalid rendering provider taxonomy.
Note: (New Code 12/2/04)
N289 Missing/incomplete/invalid rendering provider name.
Note: (New Code 12/2/04)
N290 Missing/incomplete/invalid rendering provider primary identifier.
Note: (New Code 12/2/04)
N291 Missing/incomplete/invalid rending provider secondary identifier.
Note: (New Code 12/2/04)
N292 Missing/incomplete/invalid service facility name.
Note: (New Code 12/2/04)
N293 Missing/incomplete/invalid service facility primary identifier.
Note: (New Code 12/2/04)
N294 Missing/incomplete/invalid service facility primary address.
Note: (New Code 12/2/04)
N295 Missing/incomplete/invalid service facility secondary identifier.
Note: (New Code 12/2/04)
N296 Missing/incomplete/invalid supervising provider name.
Note: (New Code 12/2/04)
N297 Missing/incomplete/invalid supervising provider primary identifier.
Note: (New Code 12/2/04)
N298 Missing/incomplete/invalid supervising provider secondary identifier.
Note: (New Code 12/2/04)
N299 Missing/incomplete/invalid occurrence date(s).
Note: (New Code 12/2/04)
N300 Missing/incomplete/invalid occurrence span date(s).
Note: (New Code 12/2/04)
N301 Missing/incomplete/invalid procedure date(s).
Note: (New Code 12/2/04)
Medicaid Claim Denial Codes
33
N302 Missing/incomplete/invalid other procedure date(s).
Note: (New Code 12/2/04)
N303 Missing/incomplete/invalid principal procedure date.
Note: (New Code 12/2/04)
N304 Missing/incomplete/invalid dispensed date.
Note: (New Code 12/2/04)
N305 Missing/incomplete/invalid accident date.
Note: (New Code 12/2/04)
N306 Missing/incomplete/invalid acute manifestation date.
Note: (New Code 12/2/04)
N307 Missing/incomplete/invalid adjudication or payment date.
Note: (New Code 12/2/04)
N308 Missing/incomplete/invalid appliance placement date.
Note: (New Code 12/2/04)
N309 Missing/incomplete/invalid assessment date.
Note: (New Code 12/2/04)
N310 Missing/incomplete/invalid assumed or relinquished care date.
Note: (New Code 12/2/04)
N311 Missing/incomplete/invalid authorized to return to work date.
Note: (New Code 12/2/04)
N312 Missing/incomplete/invalid begin therapy date.
Note: (New Code 12/2/04)
N313 Missing/incomplete/invalid certification revision date.
Note: (New Code 12/2/04)
N314 Missing/incomplete/invalid diagnosis date.
Note: (New Code 12/2/04)
N315 Missing/incomplete/invalid disability from date.
Note: (New Code 12/2/04)
N316 Missing/incomplete/invalid disability to date.
Note: (New Code 12/2/04)
N317 Missing/incomplete/invalid discharge hour.
Note: (New Code 12/2/04)
N318 Missing/incomplete/invalid discharge or end of care date.
Note: (New Code 12/2/04)
N319 Missing/incomplete/invalid hearing or vision prescription date.
Note: (New Code 12/2/04)
N320 Missing/incomplete/invalid Home Health Certification Period.
Note: (New Code 12/2/04)
N321 Missing/incomplete/invalid last admission period.
Note: (New Code 12/2/04)
N322 Missing/incomplete/invalid last certification date.
Note: (New Code 12/2/04)
N323 Missing/incomplete/invalid last contact date.
Note: (New Code 12/2/04)
N324 Missing/incomplete/invalid last seen/visit date.
Note: (New Code 12/2/04)
N325 Missing/incomplete/invalid last worked date.
Note: (New Code 12/2/04)
N326 Missing/incomplete/invalide last x-ray date.
Note: (New Code 12/2/04)
N327 Missing/incomplete/invalid other insured birth date.
Note: (New Code 12/2/04)
N328 Missing/incomplete/invalid Oxygen Saturation Test date.
Note: (New Code 12/2/04)
N329 Missing/incomplete/invalid patient birth date.
Note: (New Code 12/2/04)
N330 Missing/incomplete/invalid patient death date.
Medicaid Claim Denial Codes
34
Note: (New Code 12/2/04)
N331 Missing/incomplete/invalid physician order date.
Note: (New Code 12/2/04)
N332 Missing/incomplete/invalid prior hospital discharge date.
Note: (New Code 12/2/04)
N333 Missing/incomplete/invalid prior placement date.
Note: (New Code 12/2/04)
N334 Missing/incomplete/invalid re-evaluation date
Note: (New Code 12/2/04)
N335 Missing/incomplete/invalid referral date.
Note: (New Code 12/2/04)
N336 Missing/incomplete/invalid replacement date.
Note: (New Code 12/2/04)
N337 Missing/incomplete/invalid secondary diagnosis date.
Note: (New Code 12/2/04)
N338 Missing/incomplete/invalid shipped date.
Note: (New Code 12/2/04)
N339 Missing/incomplete/invalid similar illness or symptom date.
Note: (New Code 12/2/04)
N340 Missing/incomplete/invalid subscriber birth date.
Note: (New Code 12/2/04)
N341 Missing/incomplete/invalid surgery date.
Note: (New Code 12/2/04)
N342 Missing/incomplete/invalid test performed date.
Note: (New Code 12/2/04)
N343 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial
start date.
Note: (New Code 12/2/04)
N344 Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end
date.
Note: (New Code 12/2/04)
N345 Date range not valid with units submitted.
Note: (New Code 3/30/05)
N346 Missing/incomplete/invalid oral cavity designation code.
Note: (New Code 3/30/05)
N347 Your claim for a referred or purchased service cannot be paid because payment has
already been made for this same service to another provider by a payment contractor
representing the payer.
Note: (New Code 3/30/05)
N348 You chose that this service/supply/drug would be rendered/supplied and billed by a
different practitioner/supplier.
Note: (New Code 8/1/05)
N349 The administration method and drug must be reported to adjudicate this service.
Note: (New Code 8/1/05)
N350 Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC)
code or an Unlisted procedure.
Note: (New Code 8/1/05)
N351 Service date outside of the approved treatment plan service dates.
Note: (New Code 8/1/05)
N352 There are no scheduled payments for this service. Submit a claim for each patient
visit.
Note: (New Code 8/1/05)
N353 Benefits have been estimated, when the actual services have been rendered,
additional payment will be considered based on the submitted claim.
Note: (New Code 8/1/05)
N354 Incomplete/invalid invoice
Note: (New Code 8/1/05)
N355 The law permits exceptions to the refund requirement in two cases: - If you did not
Medicaid Claim Denial Codes
35
know, and could not have reasonably been expected to know, that we would not pay
for this service; or - If you notified the patient in writing before providing the service
that you believed that we were likely to deny the service, and the patient signed a
statement agreeing to pay for the service.
If you come within either exception, or if you believe the carrier was wrong in its
determination that we do not pay for this service, you should request review of this
determination within 30 days of the date of this notice. Your request for review should
include any additional information necessary to support your position.
If you request an appeal within 30 days of receiving this notice, you may delay
refunding the amount to the patient until you receive the results of the review. If the
review decision is favorable to you, you do not need to make any refund. If, however,
the review is unfavorable, the law specifies that you must make the refund within 15
days of receiving the unfavorable review decision.
The law also permits you to request an appeal at any time within 120 days of the date
you receive this notice. However, an appeal request that is received more than 30
days after the date of this notice, does not permit you to delay making the refund.
Regardless of when a review is requested, the patient will be notified that you have
requested one, and will receive a copy of the determination.
The patient has received a separate notice of this denial decision. The notice advises
that he/she may be entitled to a refund of any amounts paid, if you should have
known that we would not pay and did not tell him/her. It also instructs the patient to
contact our office if he/she does not hear anything about a refund within 30 days.
Note: (New Code 8/1/05)
N356 This service is not covered when performed with, or subsequent to, a non-covered
service.
Note: (New Code 8/1/05)


WHAT ARE MEDICARE DENIAL CODES?

A group code is defined as a code used to identify a general category of the payment adjustment. Thus, it must be always used along with a claim adjustment reason code for showing liability for the amounts that are not covered under Medicare for a service or claim. Medicare denial codes are standard messages used to provide or describe information to a medical patient or provider by insurances about why a claim was denied. This is the standard format followed by all insurances for relieving the burden on the medical provider.



Importance of finding correct Medicare Denial Codes and Reason

Medical denial codes and solutions are extremely important for claim adjustments. There are many valid group codes that are used for advice on Medicare remittance. CO or contractual obligations is the group code that is used whenever the contractual agreement existing between the payee and payer or the regulatory requirement has resulted in a proper adjustment. Generally, the adjustments are considered as a write off for the person who is the provider and is not billed to the concerned patient.


OA or other adjustments is the group code which is supposed to be used when there is no other existing group code that is applicable to the adjustment. PR or patient responsibility is the group code that is supposed to be utilized when the particular adjustment represents an amount that can be insured or billed to the individual patient involved. This group code is typically used for co-pay and deductible adjustments.