Healthcare policy identification denial list - Most common denial

How To Prevent The Most Common Prepayment Errors

We ask providers in all specialties and states to evaluate the information and resources below and verify you are taking the necessary steps to prevent future errors.

The errors fell into four categories:

1. We did not receive the requested documentation within the requested 45 days. We denied these claims.

Please evaluate the procedures in your office for responding to Medicare and/or the Comprehensive Error Rate Testing (CERT) contractor requests for documentation. When the physician office does not supply the needed documentation, there is no evidence the physician performed the service. The physician office is responsible for supplying documentation to support the services he/she billed to Medicare.

2.Services not documented in the medical records. This fell into two categories. We denied these claims.

Documentation received was for another service. When returning documentation based on a request from WPS Medicare and/or CERT, please verify that the name of the patient, date of service, and service match the request. It only takes a few moments and may prevent an error and a denial or a request for repayment.

The provider's signature was missing.


3. Documentation did not support the level of service billed. According to Medicare policy, the documentation contained in the medical record must not only support the medical necessity of the billed service, but must also support the level of service by documenting the work performed by the physician. Medicare considers it an error when the service is over or under-coded. We adjusted and reimbursed the service at the appropriate level based on the documentation received.


Health policy identification denial list

Medicare policy states that Claim Adjustment Reason Codes (CARCs) are required in the remittance advice and coordination of benefits transactions. Medicare policy further states that appropriate Remittance Advice Remark Codes (RARCs) that provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment are required in the remittance advice transaction.


The CARC and RARC changes that impact Medicare are usually requested by CMS staff in conjunction with a policy change. Contractors and Shared System Maintainers (SSMs) are notified about these changes in the corresponding instructions from the specific CMS component which implements the policy change, in addition to the regular code update notification. If a modification has been initiated by an entity other than CMS for a code currently used by Medicare, contractors shall use the modified code even though the modification was not initiated by Medicare


Loop ID 2110—Service Payment Information - 835 Healthcare policy identification


P.139 SVC  Service Payment Information 

SVC01-1 Product Service ID Qualifier
HC - HCPCS Codes ID - ICD-9-CM - Procedure
N4 - National Drug Code in 5-4-2 Format
NU - National Uniform Billing Committee (NUBC) UB92 Code
NU: 1st position of procedure code is Z or Y; or 1st position of procedure code is Z & type of service is R. (for National Accounts)
ID: 1st position of procedure code is S. (for National Accounts)


P.146 DTM Service Date
DTM02 Date (Service Date) Format CCYYMMDD
P.148 CAS Service Adjustment
CAS02,5,8,11,14,17 Clm Adj Reason Code (Adjustment Reason Code)
CAS03,6,9,12,15,18 Monetary Amount (Adjustment Amount)
CAS04,7,10,13,16,19 Quantity (Adjustment Quantity)


P.154 REF Service Identification

REF01 Reference ID Qualifier 6R 6R - Provider Control Number
REF02 Reference Identification (Provider Identifier) Line Item Control No. on 837 or Line Counter No. (for National Accounts)


P.158 AMT Service Supplemental amount

AMT01 Amount Qualifier Code B6 B6 - Allowed - Actual
AMT02 Monetary Amount (Service Supplemental Amt) Represents the Anthem Allowed Amount for the service


P.162 LQ Health Care Remark Codes
LQ01 Code List Qualifier Code HE     HE - Claim Payment Remark Codes
LQ02 Industry Code (Remark Code) Claim Payment Remark Code BC/BS: NCPDP Code referenced for Prescription Drug Program

P.164 PLB Provider Adjustment

PLB01 Reference Identification (Provider Identifier) Pay-to Provider Number National Accounts: Same value as Loop 1000B, REF02 (Claim Header Provider Number)

PLB03-1 Adjustment Reason Code
72 - Authorized Return
FB - Forwarding Balance
IR - Internal Revenue Service Withholding
L6 - Interest Owed (not applicable to National Accounts)
PI - Periodic Interim Payment (not applicable to National Accounts)



Healthcare policy identification denial list

4 The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present. 7/1/2010

5 The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

6 The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

7 The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  7/1/2010


8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


9 The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

10 The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

11 The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

12 The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  7/1/2010


51 These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

61 Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  7/1/2010


97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


107 Related or qualifying claim/service was not identified on the claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


108 Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
7/1/2010 152 Payer deems the information submitted does not support this length of service. 7/1/2010


167 This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


170 Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

171 Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present. 7/1/2010


172 Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

179 Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

183 The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


184 The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present. 7/1/2010

185 The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

B8 Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010

B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been  reived/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 7/1/2010

125 Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT.) 7/1/2010

148 Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT.) 7/1/2010

226 Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided ((may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT.)


227 Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT.) 7/1/2010


A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT.) 7/1/2010

40 Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7/1/2010


Deactivated Codes – CARC

Code Current Narrative Effective Date  per WPC posting

87 Transfer Amount. 1/1/2012 D23 This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility – Must also include Remittance Advice

Remark Code 1/1/2012


Q: We are receiving a denial with claim adjustment reason code (CARC) CO236. What steps can we take to avoid this denial code?

This procedure or procedure/modifier combination is not compatible with another procedure or procedure /modifier combination provided on the same day according to the National Correct Coding Initiative.

A: You are receiving this reason code when the service(s) has/have already been paid as part of another service billed for the same date of service.
The basic principles for the correct coding policy are:
• The service represents the standard of care in accomplishing the overall procedure;
• The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform the service may compromise the success of the procedure; and
• The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.


If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Be sure to submit only the corrected line. Resubmitting an entire claim will cause a duplicate claim denial


Q: We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below to avoid this denial.

M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.

• The service billed was already paid as part of another service/procedure for the same date of service. Payment for this service is always bundled into payment for other service(s) not specified. Separate payment is never made.

An example of a “bundled service” is a telephone call from a hospital nurse regarding a patient. Another example is procedure code A4550, surgical tray.

• Check the procedure code on the First Coast fee schedule lookup tool. Scroll down to policy indicators and review code status. If status is equal to “b,” the service/procedure is not paid separately, not even by appending a modifier.


M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.

• The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable.

• If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.

• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.

• Modifier 54: pre-and intra-operative services performed
• Modifier 55: post-operative management services only
• Modifier 56: pre-operative services only


N70 – Consolidated billing and payment applies.

• The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.

• Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.

• Always check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify beneficiary eligibility and get home health episode’s start and/or end date, if applicable.

http://medicare.fcso.com/faqs/answers/158472.asp

• You may also look up home health provider information, including servicing provider number, by clicking here zip.gif.

• The services billed are subject to consolidated billing requirements by the Home Health Agency (HHA), while the beneficiary is under a home health plan of care authorized by a physician. The HHA is responsible for providing these services, either directly or under arrangement


Q: We are receiving a denial with claim adjustment reason code (CARC) OA18. What steps can we take to avoid this denial code?

Exact duplicate claim/service

A: You will receive this reason code when more than one claim has been submitted for the same item or service(s) provided to the same beneficiary on the same date(s) of service.

• The Medicare claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims submitted by Physicians and Practitioners. Click here to review article on the claim system edits regarding duplicate claims and modifiers that may be used, as applicable to identify repeat or distinct procedures and services on a claim.

Exact duplicate claims

• Claims or claim lines that exactly match another claim or claim line with respect to the following elements: HIC number, provider number, from date of service, through date of service, type of service, procedure code, place of service and billed amount

• Claims or claim lines are denied

• Appeal rights

Suspect duplicate claims

• Claims or claim lines that contain closely aligned elements sufficient to suggest that duplication may be present and, as such, require that the suspect claim be reviewed

• Criteria for identifying vary according to the following: type of billing entity, type of item or service being billed, and other relevant criteria

• Appeal rights (unless an exact duplicate)

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Ensure necessary appropriate modifiers are appended to claim lines if applicable and resubmit the claim.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.



Q: We are receiving a denial with claim adjustment reason code (CARC) CO50/PR50. What steps can we take to avoid this denial code?

These are non-covered services because this is not deemed a “medical necessity” by the payer.
“Medical necessity” assures services are reasonable and necessary for the diagnosis or treatment of illness/injury

A: You are receiving this reason code when the procedure code is billed with an incompatible diagnosis, for payment purposes and the ICD-9 code(s) submitted is not covered under a Local or National Coverage determination (LCD/NCD).

• Medicare contractors develop LCDs when there is no NCD or when there is a need to further define an NCD.

• Provides a guide to assist providers in determining whether a particular item or service is covered and in submitting correct claims for payment.

• LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part.

• Refer to LCD lookup tool, to determine if a current and draft LCD exists for Medicare covered procedure codes.

• Before submitting a claim, you may access the LCD lookup tool and search by procedure and diagnosis to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).

• Refer to the "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes relating to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• Report only the diagnosis(es) for treatment date of service

• Do not resubmit an entire claim when a partial payment has been made; correct and resubmit denied lines only.

• Diagnosis-related denials can be appealed when your documentation supports that a diagnosis from the LCD would apply to your patient’s treatment condition.



Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, or when the procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.
• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of up to 60 days after receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification.
• Refer to the complete list of downloads of Categorization of Tests external link on the Centers for Medicare & Medicaid Services (CMS) website.
• Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.


Avoiding denial reason code PR B9 FAQ
Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?
Patient is enrolled in a hospice.

A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claims to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.

The following situations require a modifier be applied to the claim prior to submission.

• Modifier GV: Attending physician not employed by, or paid under agreement with, the patient’s hospice provider

• If the claim was submitted with a GV modifier, check the patient's file to verify that the attending physician is not employed by the hospice provider.

• Modifier GW: Services not related to the hospice patient’s terminal condition

• If the claim was submitted with a GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.

• If the claim was submitted without the appropriate modifier, apply the modifier and resubmit the claim.



Avoiding denial reason code PR 49 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?

Routine examinations and related services are not covered.

A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.

• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services, for routine or screening purposes, such as an annual physical.

• Before submitting a claim, you may access the LCD and procedure to diagnosis lookup tool and search by procedure and diagnosis codes to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).

• Refer to "Active/Future/Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.

• Medicare does cover certain preventive services.

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.


Q: We received a denial with claim adjustment reason code (CARC) PR 170. What steps can we take to avoid this denial?

This payment is denied when performed/billed by this type of provider.

A: This denial is received when services furnished or ordered by a chiropractor are not related to treatment by means of manual manipulation of the spine to correct a subluxation. Chiropractic services for treatment by means of manual manipulation of the spine to correct a subluxation are covered by Medicare. All other services furnished or ordered by a chiropractor are not.

• When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for acute or chronic subluxation, a modifier is required. If the claim is submitted without the applicable modifier, services are considered maintenance therapy, and the claim will deny.


Errors That Result In Denied Claims

This information is presented for you to review your internal procedures and identify areas where the number of denied claims could be reduced. Denied claims result in delay of payment. Please note HIPAA claim adjustment reason and remit remark codes as provided on the remittance advice.

Claim Errors (Remittance Advice Remarks)

• The rendering provider is not eligible to perform the service billed (185) or claim/service lacks information which is needed for adjudication. (16/MA30)
o Service code not covered to the provider type or specialty
Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:

• The request must submitted in writing
• The request must be supported with documentation

o documentation should include any claim examples or indicate why the code should be payable
• If there is no supporting documentation, the request will not be considered.
• Missing/incomplete/invalid HCPCS Code (A1/M20)
o Validate code keyed correctly
o Validate code is current for Date of Service (DOS)

• Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)
o For resolution to these denials, please refer to www.dhhr.wv.gov/bms
----Select Drug Code/NDC Drug Information.
o NDC, unit of measure and units should be submitted on Medicare primary claims (even though not required by Medicare) so the information will cross over to Medicaid, eliminating the need to submit Medicaid secondary -claims on paper.

• Incomplete/invalid plan information for other insurance (Invalid Medicare Action Code) (16/N245)
o Claims denied by Medicare and submitted electronically must include a Medicare Action Code (MAC)

• This service/equipment/drug is not covered under the patient’s current benefit plan (204)
o Non-covered WV Medicaid Service

• This case may be covered by another payer per coordination of benefits/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. (22/MA04)
o Payer information is not submitted on electronic claim
o Explanation of Benefit (EOB) is not submitted with paper claim

• Charges are covered under a capitation agreement/managed care plan (24)
o For members enrolled in Medicaid MCO - MCO is responsible for the service
o For Members who have a PAAS provider, PAAS approval is required
–View member’s Medicaid Card to verify MCO or PAAS information
–Utilize AVRS to verify MCO or PAAS information