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First+Plus Provider Manual 2014
INTRODUCTION
CONTACT INFORMATION
FIRST+PLUS PROVIDERS RECRUITMENT MAP
ENROLLMENT AND ELIGIBILITY
FIRST+PLUS PRODUCT DESCRIPTION
BENEFIT CHARTS
EMERGENCY AND URGENT CARE
ADDITIONAL BENEFITS
PROVIDER ROLES AND RESPONSIBILITIES
PAGE 3
PAGE 5
PAGE 6
PAGE 8
PAGE 11
PAGE 21
PAGE 23
PAGE 24
COMPLIANCE WITH THE CONTRACT, REGULATIONS AND THIS MANUAL
GENERAL MEDICARE AND FEDERAL REGULATIONS
CONTRACT REQUIREMENTS
CODE OF CONDUCT
CONFLICT OF INTEREST POLICY
PROVIDER AND MEMBER COMMUNICATIONS
MEDICAL RECORDS
RESPONSABILITIES OF ALL PROVIDERS
THE ROLE OF THE PRIMARY CARE PRACTITITIONER (PCP)
ROLE AND RESPONSABILITIES OF THE SPECIALISTS
PANEL CLOSURE
REOPENING OF PANEL
SANCTIONS UNDER FEDERAL HEALTH PROGRAMS AND STATE LAW
APPOINTMENT STANDARDS
CONTRACTING PROVIDER GRIEVANCES PROCESS
CREDENTIALING
PAGE 32
PAGE 35
NETWORK ADEQUACY
PRIMARY SOURCE VERIFICATION REQUIREMENTS
PROVIDER ORIENTATION
RE-CREDENTIALING
TERMINATION
DUTY TO REPORT CERTAIN TERMINATION
MEMBER NOTIFICATION
PAGE 39
GRIEVANCES AND APPEALS
GRIEVANCE PROCESS
MEMBER RIGHTS
APPEALS PROCESS
APPEAL RECORDS
PAGE 41
MEDICAL AFFAIRS
UTILIZATION MANAGEMENT
AUTHORIZATION PROCESS
PRIOR AUTHORIZATIONS
AUTHORIZATION REQUIREMENTS
ADMISSION REVIEW
QUALITY IMPROVEMENT
SPECIAL NEEDS PLAN
QUALITY IMPROVEMENT PROGRAM
Provider Manual 2014
PAGE 55
1
ANNUAL MEDICAL ASSESMENT FORM (AMAF)
PAGE 79
BILLING AND CLAIMS
PAGE 87
DEFINITION
CMS 1500 FORM AND REQUIERED FILE
UB-04 FORM AND REQUIERED FILE
ADA FORM AND REQUIERED FILE
TIMELY CLAIMS SUBMISION
LIST EOB CODE DESCRIPTION
ELECTRONIC BILLING
FRAUD, WASTE & ABUSE
ADDITIONAL INFORMATION
Provider Manual 2014
PAGE 315
PAGE 319
PAGE 327
2
INTRODUCTION
Welcome to First Plus, First Medicals’ Medicare Advantage plan. As a member of the First+Plus
Provider Network you are an important member of our service delivery team, and we thank you
for joining us as we pursue our commitment to improve the health and wellbeing of our
Members.
The purpose of the Provider Manual is to serve as a resource and reference guide for our
providers. You may use it as a guide to answer questions concerning: eligibility verification,
identification cards, re-credentialing process, medical management and quality improvement
programs; as well as billing and claim procedures. This manual may be shared with your office
manager and office personnel. This manual is not intended to replace your written provider
agreement currently in place with First+Plus. You will receive updates periodically from the
First+Plus Provider Services Department.
If you should have any questions regarding any of the material contained in this provider manual,
please do not hesitate to contact the First+Plus Provider Services Department at 1-866-505-5885.
The provider manual is available on line at www.firstpluspr.com
First+Plus Overview
First+Plus Medicare Advantage offers the comprehensive coverage and healthcare choices
Medicare beneficiaries deserve.
One important benefit of a PPO (Preferred Provider Organization) plan is that Medicare
beneficiaries can receive services from out-of-network providers for an additional out-of –pocket
cost. Of course, the members maximize their First+Plus benefits by using in-network plan
providers.
•
Network Provider – “Provider” is the general term we use for doctors, other health care
professionals, hospitals, and other health care facilities that are licensed or certified by
Medicare and by the State to provide health care services. We call them “network
providers” when they have an agreement with our plan to accept our payment as
payment in full, and in some cases to coordinate as well as provide covered services to
members of our plan. Our plan pays network providers based on the agreements it has
with the providers or if the providers agree to provide you with plan-covered services.
Network providers may also be referred to as “plan providers.”
•
Preferred Provider is the provider a member selected when he/she enrolled in
First+Plus. In most cases a Preferred Provider is a general practitioner, internal medicine
or family doctor. However, because preferred provider organization (PPO),
o A member may select a physician in another specialty, i.e. Cardiology, Oncology,
Oby -Gyn. This provider should be knowledgeable about the members Medical
Provider Manual 2014
3
History, and should available to assist the member in coordinating the health
services the member needs.
•
Covered services is the general term we use to mean all of the health care services and
supplies that are covered by First+Plus.
•
Non-plan providers are providers with which we have not arranged to coordinate or
provide covered services to members of our plan. Out-of-network providers are providers
that are not employed, owned, or operated by our plan or are not under contract to deliver
covered services. A member with PPO coverage may Use non-plan providers to get
covered services. However, out-of-pocket costs may be higher than if the member used
plan providers.
•
Specialist is a doctor who provides health care services for a specific disease or part of
the body. Examples include oncologists (who care for patients with cancer), or
cardiologists (who care for patients with heart conditions). A member may get care from
specialists without a referral from another doctor. If the member uses our plan specialists,
the costs for covered services will be lower than if they used non-plan providers.
•
Primary Care Physician (PCP) (First Care Plus, First+Plus Complete and
First+Plus Platino) Primary Care Physician is virtually any physician in the First+Plus
network, including specialists, who meets state requirements and is trained to give basic
medical care. A PCP will manage member’s health care and provide prevention care and
treatment to common medical conditions. They will help monitor, arrange and coordinate
health care covered services.
Our Plan Objectives are to:
•
•
•
•
•
Improve the healthcare of our Members
Increase quality and continuity of care to our Members
Decrease inappropriate usage of health care resources, e.g. emergency room visits for
non-emergency situations
Achieve and maintain cost-effectiveness and efficiency
Promote Provider and Member satisfaction
Provider Manual 2014
4
CONTACT INFORMATION
If you have any questions or concerns, please call or write to First+Plus Provider Services
Department. We will be happy to help you. Our business hours are Monday thru Friday from
8:00am to 5:00pm.
Provider Services
Provider and Credential Services Phone Number: 1-866-505-5885
Fax Provider Department: (787) 300-3908
Fax Credentialing: (787) 300-3907
Providers Services Address: PO BOX 195080 San Juan, PR 00919
Medical Affairs
Pre-authorization Fax Number: (787) 705-9347 / (787) 622-0729
Patient Admissions (Uticorp): (787) 765-3303
Customer Services
Member Services Phone Number 1-888-767-7717
For Pre-authorization status and Case Management Notifications please
contact Customer Service Department
TTY 1-877-672-4242 *
Fax Number: (787) 300-3906
*This number requires special telephone equipment. Calls to this number are free.
Claims Department
Claims Department Address: PO Box 19559 San Juan, PR 00919-5559
Main Office Location
Extension Villa Caparra #530 Marginal Buchanan, Guaynabo, PR 00966
Provider Manual 2014
5
FIRST+PLUS PROVIDER RECRUITMENT MAP
Provider Manual 2014
6
You may contact the First+Plus Provider Services department for questions regarding:
•
•
•
•
•
•
•
Changes in provider information, including group or clinic name, address, telephone
number, Medicare number or Federal Tax ID number.
Your effective date and date anticipated for accepting new members.
Contract administration issues.
Credentialing and re-credentialing issues.
Reimbursement issues, fee schedules, coding questions.
Specific information concerning First+Plus policies and procedures.
Training for billing and claim submission.
The Provider Services staff at First+Plus is responsible for:
•
•
•
•
•
•
•
•
Developing and maintaining a comprehensive provider network.
Monitoring provider adherence to the availability and accessibility standards.
Assisting providers with any problems or concerns that they may have in providing
Members with services.
Providing clarification of Insurance Commission office of Puerto Rico, and Centers for
Medicaid and Medicare Services policies, regulations, and procedures.
Assisting providers with the complaint/grievances and appeals processes.
Conducting provider orientation sessions, in-service and specialized training.
Distributing provider satisfaction surveys and reporting the results to the appropriate
committees.
Generating and distributing the Provider Newsletter and/or other provider
communications.
Provider Manual 2014
7
ENROLLMENT AND ELIGIBILITY
For a Medicare Eligible beneficiary to enroll in the First+Plus plan, the prospective
Member must:
•
•
•
•
Be enrolled in both Medicare Parts A and B
Reside within the service area
Not have end stage renal disease
Additional requirements apply to Platino and Gobierno First+Plus Product. For more
information, please contact the Customer Service Department at 1-888-767-7717 Monday
through Friday from 8:00 AM to 8:00 PM
Verifying Eligibility Procedure:
If you need to verify eligibility for a First+Plus Member, you may do so by contacting Member
Services or by visiting our website at www.firstpluspr.com. Customer Services Representatives
are available Monday through Friday from 8:00 AM to 8:00 PM at 1-888-767-7717. You may
call the Member Services Department for provider questions including, but not limited to:
• Member Eligibility
• Benefits and coverage questions
• Claim denial
• New member contract status
The Centers for Medicare and Medicaid (CMS)
The Centers for Medicare and Medicaid Services (CMS) is the federal agency that administers
the Medicare program. The CMS contracts with, and regulates, Medicare Health Plans (including
First Medical) and Medicare Private Fee-for-Service organizations. Here are three ways to get
information directly from Medicare:
• Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.
• Visit the Medicare website (http://www.medicare.gov).
• Read Medicare & You 2013 Handbook. Every year in the fall, this booklet is mailed to
people with Medicare. It has a summary of Medicare benefits, rights and protections, and
answers to the most frequently asked questions about Medicare. You can get it at the
Medicare website (http://www.medicare.gov) or by calling 1-800-MEDICARE (1-800633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Provider Manual 2014
8
Sample ID Card:
Enrollees must use their First+Plus ID card to be eligible for benefits through the First+Plus
Health Plan network. Each First+Plus Member is issued a Member identification card to present
to all health care providers when seeking health care services. The member will also receive a
letter that will have the Member’s name, Member identification number or “ID number”, the
Preferred Provider name and telephone number. This card identifies the Member as a First+Plus
Member. Members should not show you their red, white and blue card for Original Medicare. If
a member uses his/her red, white and blue Medicare card instead of his/her First+Plus ID, even
though he/she is a member of First+Plus, the Medicare program will not pay for these services
and neither will First+Plus. The member will have to pay the full cost for services.
Please Note:
• The I.D. card does not guarantee eligibility. It is for identification purposes only.
• Eligibility must be verified prior to each visit at www.firstpluspr.com. Failure to verify
eligibility may result in non-payment of claims.
• If the Member does not have an identification card, you must call Customer Service to
determine eligibility.
• Members may have a copy of their certification form of enrollment as interim proof of
Membership until a card is issued and mailed.
The Description of the Subscriber card (shown on page 26) will identify the member as being
part of First+ Plus and will contain important information.
Provider Manual 2014
9
DESCRIPTION OF THE FIRST+PLUS 2014
MEMBER’S CARDS
Provider Manual 2014
10
FIRST+PLUS PRODUCT DESCRIPTION
Benefit Charts
First+Plus Advantage
Service Area: Entire Island
Delivery System
Service Área
Out-pf Pocket Maximum
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OP MH/SA
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
X-rays / Radiology
Radiology- (Diag. & Ther.)
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam
Hearing Aids
Medicare Covered Chiropractic
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage (1)
PPO
Entire Island
$6,700/$10,000
$10
In- Network Coverage
$0 / $50 per admit
$0 / $50 per admit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
$4 co pay
$12 co pay
$12 co pay
$0/$30 co pay
$15 co pay
$60 co pay
CIF
$20 co pay
Out of Network coverage
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
20% cost share
20% cost share
Same as in-network
Same as in-network with 20% cost share
10% / 20% cost share
10% / 20% cost share
0% / 20% cost share
10% cost share
10% cost share
CIF
15% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In- Network Coverage
CIF
CIF
CIF
Out of Network coverage
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
CIF
CIF
CIF
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In-Network Coverage
CIF
$100.00 (per years)
CIF (once annually)
$300 (every three years)
CIF
$12 co pay (two per year)
$12 co pay (two per year)
CIF
Out of Network Coverage
Same as in-network with 20% cost share
Same as in-network with 20% visual
examination cost and 50% visual
equipment cost
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Not Covered
Not Covered
Legend:
CIF-Covered in Full
First Plus Advantage 2014
Provider Manual 2014
Out of Network Coverage
11
First+Plus Advantage Plus
Service Área: Entire Island
Delivery System
Service Área
Out-of-Pocket Maximum
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OP MH/SA
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology- (Diag. & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam (1 per year)
Hearing Aids (every three years)
Medicare Covered Chiropractic
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
PPO
Entire Island
$6,700/$10,000
$0
In- Network Coverage
$0 / $50 per admit
$0 / $50 per admit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
$4 co pay
$12 co pay
$12 co pay
$0/$30 co pay
$15 co pay
$60 co pay
CIF
$25 co pay
Out of Network coverage
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
20% cost share
20% cost share
Same as in-network
Same as in-network with 20% cost share
10% / 20% cost share
10% / 20% cost share
CIF
$10 co pay
15% cost share
CIF
15% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In- Network Coverage
CIF
CIF
CIF
Out of Network coverage
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
CIF
CIF
CIF
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In-Network Coverage
CIF
$100.00 (per years)
Out of Network Coverage
Same as in-network with 20% cost share
Same as in-network with 20% visual
examination cost and 50% visual
equipment cost
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
$300
CIF
$12 co pay (two per year)
$12 co pay (two per year)
CIF
Not covered
In-Network Coverage
Enhanced
$6/$12/$35/$55/25%
$6/$12 Generic Only
Legend:
CIF-Covered in Full
First Plus Advantage Plus 2014
Provider Manual 2014
Out of Network Coverage
12
Not covered
Out of Network Coverage
Same as in-network
First+Plus Gobierno Plus
Service Area: Entire Island
Delivery System
Service Área
Proposed Monthly Premium
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
OP MH/SA
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology-(Diag, & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam (1 per year)
Hearing Aids (every three years)
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Copayments Above Catastrophic Limit
Plan Type
PPO
Entire Island
$0
$0
In- Network Coverage
$0/$50 unlimited
CIF, 190 days lifetime limit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
$4 co pay
$12 co pay
$0/$30 co pay
$15 co pay
$45 co pay
CIF
$25 co pay
Out of Network coverage
20% cost share
Same as in-network with 20% cost share
20% cost share
20% cost share
Same as in-network
Same as in-network with 20% cost share
$12 co pay
10%/20% cost share
10%/20% cost share
0%/20% cost share
15% co pay
$10 co pay
CIF
15% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In- Network Coverage
CIF
CIF
CIF
Out of Network coverage
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
CIF
CIF
CIF
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In-Network Coverage
CIF
$100.00 (per years)
Out of Network Coverage
Same as in-network with 20% cost share
Same as in-network with 20% visual
examination cost and 50% visual
equipment cost
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
$300
$12 co pay (two per year)
$12 co pay (two per year)
CIF
Not Covered
In-Network Coverage
Enhanced
$4/$8/$30/$60/25%
$4/$8 Generic Only
Max of $2.55/$6.35 or 5%
Enhanced
Legend:
CIF-Covered in Full First
First Plus Gobierno Plus 2014
Provider Manual 2014
Out of Network Coverage
13
Not Covered
Out of Network Coverage
Same as in-network
Same as in-network
First+Plus Gobierno Premium
Service Area: Entire Island
Delivery System
Service Área
Proposed Monthly Premium
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
OP MH/SA
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology-(Diag & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam (1 per year)
Hearing Aids (every three years)
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Copayments Above Catastrophic Limit
Plan Type
PPO
Entire Island
$100
$25
In- Network Coverage
CIF, unlimited
CIF, 190 days lifetime limit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
$0
$5
CIF
CIF
$50 co pay
CIF
$10 co pay
Out of Network coverage
20% cost share
Same as in-network with 20% cost share
20% cost share
20% cost share
Same as in-network
Same as in-network with 20% cost share
$5 co pay
10%/20% cost share
10%/20% cost share
0%/20% cost share
10%
CIF
CIF
10% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In- Network Coverage
CIF
CIF
CIF
Out of Network coverage
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
CIF
CIF
CIF
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In-Network Coverage
CIF
$100.00 (per years)
Out of Network Coverage
Same as in-network with 20% cost share
Same as in-network with 20% visual
examination cost and 50% visual
equipment cost
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
$400
CIF (4 per year)
CIF (4 per year)
CIF
$1,000..00 (every years)
In-Network Coverage
Enhanced
$3/$6/$20/$30/25%
$3 /$6 Generic Only
Max of $2.55/$6.35 or 5%
Enhanced
Legend:
CIF-Covered in Full
First Plus Gobierno Premium 2014
Provider Manual 2014
Out of Network Coverage
14
Same as in-network with 20% cost share
Out of Network Coverage
Same as in-network
Same as in-network
First+Plus Gobierno Premium II
Service Area: Entire Island
Delivery System
Service Área
Proposed Monthly Premium
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
OP MH/SA
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology-(Diag, & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam (1 per year)
Hearing Aids (every three years)
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Copayments Above Catastrophic Limit
Plan Type
PPO
Entire Island
$100
$0
In- Network Coverage
CIF, unlimited
CIF, 190 days lifetime limit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
CIF
$5 co pay
CIF
CIF
$45 co pay
CIF
$5 co pay
Out of Network coverage
20% cost share
Same as in-network with 20% cost share
20% cost share
20% cost share
Same as in-network
Same as in-network with 20% cost share
$5 co pay
10%/20% cost share
10%/20% cost share
0%/20% cost share
10% cost share
CIF
CIF
5% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In- Network Coverage
CIF
CIF
CIF
Out of Network coverage
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
CIF
CIF
CIF
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
In-Network Coverage
CIF
$100.00 (per years)
Out of Network Coverage
Same as in-network with 20% cost share
Same as in-network with 20% visual
examination cost and 50% visual
equipment cost
20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
Same as in-network with 20% cost share
CIF
$400
CIF (4 per year)
CIF (6 per year)
CIF
$1,000.00 (every years)
In-Network Coverage
Enhanced
$0/$3/$15/$25/25%
$0/$3 Generic Only
$2.55/$2.55/$6.35 or 5%
Enhanced
Legend:
CIF-Covered in Full
Gobierno Premium II 2014
Provider Manual 2014
Out of Network Coverage
15
Same as in-network with 20% cost share
Out of Network Coverage
Same as in-network
Same as in-network
First+Plus First Care+Plus (HMO)
Service Área: Entire Island
Delivery System
Service Área
Out-of-Pocket Maximun
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OP MH/SA
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
OP MH/SA
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology (Diag. & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam (1 per year)
Hearing Aids (every three years)
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
OTC Drugs/Diabetic Supplies
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Plan Type
Legend:
CIF-Covered in Full
First Plus First Care+Plus 201
Provider Manual 2014
16
HMO
Entire Island
$6,700
$0
In- Network Coverage
$0 / $50 per admit
$0 / $50 per admit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
CIF
$6 co pay
$6 co pay
$0 / $30 co pay
CIF
$50 co pay
CIF
$15 co pay
CIF
10% / 20% cost share
10% / 20% cost share
0% / 20% cost share
15% cost share
CIF
CIF
10% cost share
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In-Network Coverage
CIF
$100.00 (per years)
CIF
$300
$6 co pay (4 per year)
$6 co pay (4 per year)
CIF
$20.00 (per quarter)
$450.00 (per year)
In-Network Coverage
Enhanced
$5/$10/$25/$50/25%
$5 / $10 Generic Only
Enhanced
First+Plus Complete (SNP) HMO
Service Area: Entire Island
Delivery System
Service Área
Outh-of-Pocket Maximum
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OP MH/SA
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology-(Diag. & Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam
Hearing Aids
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
OTC Drugs/Diabetic Supplies
Nutritionist
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Plan Type
HMO
Entire Island
$6,700
$0
In- Network Coverage
$0/$50 per admit
CIF, 190 days lifetime limit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
CIF
$10 co pay
$10 co pay
$0/$30
$40 co pay
$55 co pay
CIF
$20 co pay
10%/20% cost share
10%/20% cost share
0%/20% cost share
15% cost share
$15 co pay
CIF
15% cost share
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In-Network Coverage
CIF
$100.00 (per years)
CIF (once annually)
$300 (every three years)
$10 co pay (1 per year)
CIF (8 per year)
CIF
$300.00 (every years)
$15.00 (per quarter)
CIF (4 per years)
In-Network Coverage
Enhanced
$6/$12/$30/$50/25%
$6/$12 Generic Only
Enhanced
Leyend:
CIF-Covered in Full
First Plus First Complete (SNP) 2014
Provider Manual 2014
17
First+Plus Platino (HMO)
Service Área: Entire Island
Delivery System
Service Área
Proposed Monthly Premium
Monthly Part B Premium reimbursement
Inpatient Services
Inpatient Hospital Care
Inpatient Psych/Alcohol and Drug Abuse
Skill Nursing
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance (Ground $ Air Transportation)
Emergency Room (worldwide)
Urgent Care (worldwide)
OP MH/SA
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology CT/MRI/PET
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam
Hearing Aids
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
OTC Drugs/Diabetic Supplies
Nutritionist
Part D
Plan Type
Deductible
Cost Sharing up to ICL
HMO
Entire Island
$6,700
$10
In- Network Coverage
CIF
CIF, 190 days lifetime limit
CIF, 100 days lifetime limit
CIF
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In-Network Coverage
CIF
$100.00 (per years)
CIF (once annually)
$300 (every three years)
CIF (2 per year)
CIF
$400.00 (per year)
$400.00 (per year)
$20.00 (2 per quarter)
CIF (2 per year)
Enhanced
$0/$3
$0/$3 Generic Only
Enhanced
Legend:
CIF-Covered in Full
First Plus Platino 2014
Provider Manual 2014
18
First+Plus Smart Value (HMO)
Service Area: Entire Island
Delivery System
Service Área
Out-of-Pocket Maximum
Monthly Part B Premium buydown
Inpatient Services
Inpatient Hospital Care (unlimited)
Inpatient Psych/Alcohol and Drug Abuse
(190 days lifetime limit)
Skill Nursing (100 days per benefit
period)
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance
Emergency Room (worldwide)
Urgent Care (worldwide)
OP MH/SA
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology (Diag. &Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam
Hearing Aids
Routine Chiropractic
Routine Podiatry
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Plan Type
Legend:
CIF-Covered in Full
Smart Value 2014
Provider Manual 2014
19
HMO
Entire Island
$6,700
$70
In- Network Coverage
$250/$475 per admit
$250/$475 per admit
$40/days 21-100
CIF
In- Network Coverage
20% cost share
20% cost share
25% cost share
20% cost share
$65 co pay
20% cost share
20% cost share
25% cost share
20% cost share
20% cost share
20% cost share
20% cost share
20% cost share
20% cost share
20% cost share
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In-Network Coverage
CIF
$100.00 (per years)
CIF (once annually)
$300 (every three years)
20% (1 per year)
20% (1 per year)
Not Covered
Not Covered
In-Network Coverage
Enhanced
$7/$15/$40/$65/25%
$7/$15 Generic only
Enhanced
First+Plus Smart Premium (HMO)
Service Área: Entire Island
Delivery System
Service Área
Proposed Monthly Premium
Monthly Part B Premium reimbursement
Inpatient Services
Inpatient Hospital Care (unlimited)
Inpatient Psych/Alcohol and Drug Abuse
(190 days lifetime limit)
Skill Nursing (100 days per benefit
period)
Home Health
Outpatient Services
PCP Visit
Specialist Visits
OPD Surgery
Ambulance
Emergency Room (worldwide)
Urgent Care (worldwide)
OP MH/SA
Outpatient Rehabilitation Services:
Physical, Occupational and Speech
Therapy
DME
Prosthetic / Orthotics
Diabetes Monitoring
Radiology (Diag &Ther.)
X-rays / Radiology
Laboratory
Part B Drugs covered under Original
Medicare
Preventive/Screening Services
Bone Mass Measurement
Colorectal Screening
Immunizations: Pneumonia Vaccine, Flu,
Shot, Hepatitis B, Anti-Rabies Vaccine
Mammography Screen
Pap Test
Pelvic Exam
Prostate Cancer Screening Exams (for
men over age 50)
Additional
Physical Exams (1 per year)
Routine Vision Exams Lens / Contacts
Routine Hearing Exam
Hearing Aids
Routine Chiropractic (one per year)
Routine Podiatry (one per year)
Routine Dental (Exam & Cleaning 2 per
year and X-ray 1 per year)
Comprehensive Dental Coverage (1)
Part D
Plan Type
Cost Sharing up to ICL
Gap Coverage
Legend:
CIF-Covered in Full
Smart Premium 2014
Provider Manual 2014
20
HMO
Entire Island
$6,700
$30
In- Network Coverage
$50/$150 per admit
$50/$150 per admit
CIF
CIF
In- Network Coverage
$5 co pay
$20 co pay
$30/$80 co pay
$50 co pay
$65 co pay
CIF
$20 co pay
$30 co pay
10%/20% cost share
10%/20% cost share
0%/20% cost share
20% cost share
$10 co pay
CIF
20% cost share
In- Network Coverage
CIF
CIF
CIF
CIF
CIF
CIF
CIF
In-Network Coverage
CIF
$100.00 (per years)
CIF (once annually)
$300 (every three years)
20% (1 per year)
20% (1 per year)
CIF
Not Covered
Enhanced
$5/$10/$35/$55/25%
$7/$15 Generic only
EMERGENCY AND URGENT CARE
First+Plus does not require pre-authorization for emergency or urgent care. Claims billed for an
emergency or urgent visit will be paid. Although the claims system is designed to suspend claims
for certain services that usually require pre-authorization, should a claim for emergency or urgent
services be suspended, the claims examiner has the ability to override the authorization
requirement and pay the claim.
Medical Emergency:
A “medical emergency” is when a member has medical symptoms that require immediate
medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical
symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting
worse.
If a member has a medical emergency:
• The member should get medical help as quickly as possible. Call 911 for help or
go to the nearest emergency room. The member does not need to get an approval or a referral
from the PCP. • Make sure that First+Plus knows about the member’s emergency, because we
will need to be involved in following up on the emergency care.
• First+Plus will help manage and follow up on emergency care.
First+Plus will talk with the doctors who are giving emergency care to help manage and follow
up on the member’s care. When the doctors who are giving the emergency care indicate the
member’s condition is stable and the medical emergency is over, what happens next is called
“post-stabilization care.” Follow-up care (post-stabilization care) will be covered according to
Medicare guidelines. In general, we will try to arrange for plan providers to take over the care as
soon as the member’s medical condition and the circumstances.
Emergency covered services:
• Members can get covered emergency medical care whenever they need it.
• Ambulance services are covered in situations where other means of transportation in Puerto
Rico would endanger the member’s health.
Urgently needed care (this is different from a medical emergency)
“Urgently needed care” is when a member needs medical attention right away for an
unforeseen illness or injury, and it is not reasonable given the situation for the member to get
Provider Manual 2014
21
medical care from other plan providers. In these cases, the member’s health is not in serious
danger. How a member gets “urgently needed care” depends on whether the member needs it
when he/she is in the plan’s service area, or outside the plan’s service area.
What is the difference between a “medical emergency” and “urgently needed care”?
The main difference between an urgent need for care and a medical emergency is in the danger
to the member’s health. “Urgently needed care” is if the member needs medical help
immediately, but his/her health is not in serious danger. A “medical emergency” is if the member
believes that his/her health is in serious danger.
Getting urgently needed care in the plan’s service area:
If a member has a sudden illness or injury that is not a medical emergency, and he/she is in the
plan’s service area, the member should call his/her doctor or First+Plus. The member can get
urgently needed care from a non-plan provider. However, using our plan providers will result in
lower costs.
Getting urgently needed care OUTSIDE the plan’s service area:
First+Plus covers urgently needed care that a member gets from non-plan providers when the
member is outside the plan’s service area. If the member needs urgent care while outside the
plan’s service area, we prefer that the member contacts their preferred provider first, whenever
possible. If treated for an urgent care condition while out of the service area, we prefer that the
member return to the service area to get follow-up care from plan providers. However, we will
cover follow-up care that a member gets from non-plan providers outside the plan’s service area
as long as the care still meets the definition of “urgently needed care.”
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ADDITIONAL BENEFITS
Renal Dialysis and Post-stabilization Care
First+Plus will have procedures to authorize payment for out-of-network services. However,
particular services will be monitored for timely processing of payment. These services include
out-of-plan Emergency and Urgent Care services, Renal Dialysis and Post-stabilization services.
First+Plus prefers to coordinate member care as it relates to Renal Dialysis and PostStabilization care in order to ensure that the member receives the most appropriate care for his or
her individual circumstances. Obtaining pre-authorization is recommended to ensure a
comprehensive treatment plan is developed, which may include coordinating care at an out-ofnetwork facility to accommodate the patient’s needs. If a claim for these services should be
suspended, the examiner would pay in accordance with an authorization if one is on file. If no
authorization is on file, and it is evident that the services were an emergency, the authorization
requirement would be overridden and the claim would be paid. If there is any question as to the
medical necessity, the claim is referred to the Medical Affairs department for review. Once a
determination is made, the claim is referred back to the Claims department, and the claim is paid
accordingly.
Women’s Care:
Consistent with First+Plus access philosophy, women have direct access to a women’s health
care specialist within the network for women’s routine and preventative health care services.
Women may also have access to services outside of the First+Plus network, under the PPO
coverage. Members are not required to obtain a referral or authorization to visit an OB/GYN.
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PROVIDER ROLES AND RESPONSIBILITIES
Compliance with the Contract, Regulations and this Manual:
First+Plus is subject to certain requirements as set forth by the Centers for Medicare and
Medicaid Services for this health plan. The First+Plus provider contract requires compliance
with our plan contract and with federal regulations governing Medicare Advantage Health Plans
and the plan’s policies and procedures. Those requirements are set forth in the First+Plus
provider contract, this manual and from time to time in provider newsletters and other
communications and notices sent by First+Plus.
General Medicare and Federal Regulations:
A First+Plus provider is required to not contract with, subcontract or employ individuals or
persons with ownership with a 5 percent or more controlling interest, who have been convicted
of criminal offenses related to their involvement in Medicaid, Medicare or social services under
Title XX of Social Security Act and thus has been excluded from participation in any Federal
Health Care Program under Sec. 1128 or 1128A of the Act A. First+Plus providers must verify
all CMS Exclusions Lists such as Office of Inspector General (OIG / http://www.oig.hhs.gov/)
and Exclude Parties List System (EPLS /http://www.epls.gov ) every time a First+Plus Provider
hires new personnel and then monthly, to ensure that none of its employees are listed on either
lists. These revisions must be documented and archived by providers for evidence to be
presented to First+Plus and/or CMS upon request. First+Plus Provider shall immediately notify
First+Plus in writing of any action to restrict, revoke, or suspend the licenses or certificates that
are necessary for the provider to operate; any changes in its business address (es), any
debarment, suspension or exclusion of you, your employees, contractors, subcontractors,
directors, officers or owner with a 5 percent or more controlling interest; and any other serious
situation that could interfere with provider responsibilities.
• If a First+Plus provider files an affidavit with CMS stating that they will furnish Medicarecovered services to Medicare beneficiaries only through private (direct) contracts with the
beneficiaries under Section 1802(b) of the Social Security Act (i.e. they will not accept payment
from Medicare), then their contract with First+Plus will terminate concurrently. A First+Plus
provider must provide notice to First+Plus within five (5) days of providing any notice with
CMS.
• First+Plus providers must provide Covered Services to all Members, including those with
ethnic backgrounds, physical or mental disabilities, and limited English proficiency, in a
culturally competent manner.
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• Plus First+Plus providers must provide disabled covered members with the necessary
assistance to effectively communicate with the participating provider and their staffs, as required
by the Americans with Disabilities Act.
• Providers shall comply with all applicable Medicare laws and regulations.
• All providers are to understand and comply with the First+Plus policies on the confidential
treatment of member information in all settings and must abide by all the federal and state laws
regarding confidentiality and disclosure of medical records or other health and enrollment
information.
• All providers are to treat members protected health information (PHI), including medical
records, confidentially and in compliance with all federal and state laws and regulations.
• First+Plus members have the right to appeal any Plan decision that involves issues of
information, confidentiality and privacy.
First+Plus Contract Requirements:
The Agreement with First+Plus contains numerous important provisions, which are synopsized
below. In some situations, a First+Plus contracted provider may subcontract with another
provider to provide services to a First+Plus Member. In all cases, any such subcontracts must
include the following provisions:
• Providers understand that First+Plus is responsible for overall administration of the health plan
including all final coverage determinations and monitoring of its contracted provider’s
compliance with federal regulations.
• First+Plus is responsible for all marketing of the health plan and providers are not authorized to
act as agents of First+Plus in marketing. Only First+Plus (and CMS) approved marketing
materials may be provided to beneficiaries to explain the First+Plus program.
• Providers will comply with First+Plus Utilization/Medical Management Policies and
procedures.
• Providers will comply with First+Plus Quality Management Programs.
• No Balance Billing of Members with the exception of applicable co-payments or coinsurances.
• A First+Plus contracted provider agrees not to impose any charges on any First+Plus Member
for Covered Benefits shown in the Evidence of Coverage. Further, contracted providers agree to
accept the First+Plus payment as payment in full and agree not to seek compensation from a
First+Plus Member for services provided to that Member, even in the event of non-payment by
First+Plus.
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• Services shall be provided in a culturally competent manner constituent with professionally
recognized standards of care. Providers shall not discriminate based upon health status factors.
Providers shall ensure that their office hours do not discriminate against Medicare enrollees.
• First+Plus Providers must not discriminate against Members based on their health status.
Further, Providers must ensure that Members are not unlawfully discriminated against on the
basis of race, color, creed, national origin, ancestry, religion, sex, marital status, age, physical or
mental handicap, or in any other manner prohibited by state or federal law.
• First+Plus requires that all providers participate in periodic audits and/or site surveys for
evaluating compliance with First+Plus Quality Management standards and regulatory
requirements.
• Provider agrees to audits and inspections by CMS the U.S. department of Health and Human
Services and/or its designees, and to cooperate, assists and provided information as requested.
• First+Plus Providers must provide all covered benefits in a manner consistent with
professionally recognized standards of health care.
• First+Plus Providers must cooperate with the plan’s grievance and appeals procedures that
protect beneficiary and member rights.
• First+Plus Providers have specific continuity of care obligations in the event that the First+Plus
Agreement terminates for any reason, including a provider’s de-participation or if First+Plus
becomes insolvent. In the event of insolvency, First+Plus Providers must continue to provide
care to Members through the period in which their CMS payments have been made to First+Plus.
Additionally, if the Member is hospitalized, services must be provided until termination of
CMS’s agreement with First+Plus or, in the event of First+Plus insolvency, through the date of
the Member’s discharge.
Review the First+Plus contract for any additional sections or provisions not discussed in this
section. In addition, the description of the contract provisions listed in this section does not
constitute the complete disclosure of all requirements placed on providers contracted with
First+Plus. Contracted providers should refer to their First+Plus contract for further information.
Provider And Member Communications:
Participating Providers are responsible to maintain the provider-member relationship with each
Member. Nothing contained in the First+Plus us Agreement or this Manual is intended to
interfere with such provider-member relationship. First+Plus shall not prohibit or restrict any
provider for disclosing to any enrollee, patient, or designated representative any information that
the provider deems appropriate regarding a condition or a course of treatment with an enrollee
including the availability of other therapies, test, etc. First+Plus shall not prohibit or restrict a
health care professional acting within the lawful scope of practice, from advocating on the behalf
of an individual who is a patient and enrolled under First+Plus. Providers shall not be prohibited
Provider Manual 2014
26
from discussing the risks, benefits and consequences of treatment or non- treatment with the
enrollee, patient or designated representative. Patients shall have the opportunity to refuse
treatment and to express preferences about future treatment decisions. The participating
physician shall have the sole responsibility for the medical care and treatment of Members.
In the event that a First+Plus Provider terminates their participation or relationship with the Plan,
First+Plus has the exclusive right and responsibility to communicate with its Members regarding
those changes; participating providers should not send independent notices to First+Plus
Members.
Medical Records:
Provider agrees to safeguard beneficiary privacy and confidentiality and assure accuracy of
beneficiary health records
• All providers must maintain documents for at least (10) ten years or (10) years from the age of
majority.
• Encounter must be record and the data must be certified on record, for completeness and
truthfulness.
• Copies of consent forms, when applicable, should be maintained in the record.
• Files must be kept private in accordance with HIPPA.
• Provider agrees to maintain enrollee health records in accordance with standards established by
First+Plus PPO, which shall take into account professional standards.
Enrollee Health records shall:
1. Identify the enrollee.
2. Identify all providers who participate in the enrollee’s care and information on services
furnishes by these providers.
3. A problem list; including significant illnesses and medical and psychological conditions for
the enrollee.
4. Presenting complaints, diagnoses, and treatment plans for the enrollee.
5. Prescribed medication, including dosages and dates of initial or refill prescriptions for the
enrollee.
6. Information on allergies and adverse reactions (or a notation that the patient has no known
allergies or history of adverse reaction).
7. Information on advanced directives.
8. Past medical history, physical examination, necessary treatments, and possible risk factors
for the enrollee relevant to the particular treatment.
9. Must be legible.
10. Noted medication allergies and adverse reactions.
Provider Manual 2014
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11. There must be a completed immunizations record in all records.
12. All entries in the record must be signed or initialed and dated.
• Pursuant to the Federal Patient Self Determination Act, Hospitals, Skilled Nursing Facilities,
Home Health Agencies, Providers of Home Health care must maintain written policies and
procedures concerning advanced directives with respect to all adult individuals receiving medical
care by or through the provider. Providers must document in an individual’s medical records
whether or not the individual has executed an advanced directive. Providers must provide written
information to individual concerning:
1. An individual’s rights under state law to make decisions regarding medical care.
2. The providers (or facilities) written policy with regard to implementing such rights.
• Providers will only provide copies of medical records to other providers and insurance
companies if the member has signed a release form allowing them to do so.
• Provider must transfer these records in a timely manner.
• Provider agrees to reviews by First+Plus to monitor and assess enrollee records with respect to
improving content, legibility, organization, and completeness of the records.
Responsibilities of all Providers:
The Provider must provide service in a manner consistent with professionally recognized
standards of care and in culturally component manner.
The Role of the Primary Care Practitioner (PCP):
Not all the Firs+Plus members are required to select a Primary Care Practitioner (PCP). The PCP
serves as the member’s initial and most important contact for receiving medically necessary
covered services. The PCP provides or coordinates care each member. This includes:
• Maintaining a current medical record for each member, including documentation of all medical
services (PCP and specialty) provided to the member
• Coordinate a member’s care needed from specialty physicians or other healthcare providers by
referring to providers in the First+Plus network of providers. Except in emergency situations, if
services are not available within the First+Plus network of providers, then the Preferred Provider
must contact First+Plus Medical Management team to obtain prior authorization to refer a
Member to a non-participating provider prior to the care being rendered.
• If a Member is referred to an emergency room, the Preferred Provider is responsible for
contacting First+Plus to provide notice of his or her authorization of the emergency visit.
• Provide direction and follow-up care for those Members who have received emergency
services.
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• Providing periodic physical examinations as outlined in the Preventive Health Guidelines.
• Providing routine injections and immunizations.
• Providing health education and information.
Roles of Specialists:
The role of a First+Plus participating specialist is to provide consulting expertise, as well as
specialty diagnostic, surgical and other medical care for First+Plus Members. First+Plus expects
a participating specialist to support the role of a Preferred Provider in coordinating and managing
a Member's health care by providing only those specific services for which the member has been
referred, and promptly returning the Member to the Preferred Provider as soon as medically
appropriate. Open, prompt communication with the Preferred Provider concerning follow-up
instructions, circumstances of further visit requirements, medications, lab work, x-rays, etc. are
essential to the coordination of care.
The First+Plus Specialist’s responsibilities include:
• The specialist must provide a report to the Members Preferred Provider within five (5) working
days of rendering care or as soon as possible in the event that legitimate delays result from lab
tests, x-rays, pathology reports, etc.
• If further care is required beyond the scope of the original referral, the specialist must contact
the Member's Preferred Provider to determine if an additional referral or authorization it
necessary before providing additional treatment.
• If a specialist is consulted during an emergency room visit, a referral is not required for
providing that care; however, authorization may be required for any follow-up care provided
after the emergency room visit.
• If a specialist is called in for a consultation during an observation or hospital stay, no referral is
required for providing that care in the hospital. However, for any follow-up care provided after
that hospitalization, an authorization may be required.
• Specialists should order all laboratory testing, radiology studies or other diagnostic testing
through a contracted, in-plan facility unless an emergency situation clearly indicates emergency
lab or radiology services are required. First+Plus has specific, contracted laboratory and
radiology service providers in all regions. There are specific First+Plus policies within each
region that outline which of these services may be rendered in an office setting. If you have any
questions, please contact our Provider Department.
Panel Closure:
Occasionally Preferred Providers will request closure of their panel to new First+Plus Members.
First+Plus requires a 90-day written notice to the Provider Services department prior to the
proposed effective date of such closure. This panel closure must be in writing. During the 90-day
period between notification of closure and revision of the provider directories to reflect such
closure, Preferred Provider must continue to accept Members who select them. First+Plus will
continue to list closed Preferred Providers in First+Plus provider directories with a notation
designating them as “not accepting new members”.
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Reopening of Panel:
When a Preferred Provider requests to re-open their panel to new members, the preferred
provider will send a written notice to the Provider Services Department requesting re-opening of
their panel and the effective date of the re-opening.
Sanctions Under Federal Health Programs and State Law:
Participating providers must ensure that no management’s staff or other persons who have been
convicted of criminal offenses related to their involvement in Medicaid, Medicare or other
Federal Health Care Programs are employed or subcontracted by the participating provider.
As some fully stated, providers must disclose to First+Plus whether the provider or any staff
member or subcontractor has any prior violation, fine, suspension, termination or other
administrative action taken under Medicare laws or the federal government. Participating
providers must notify to First+Plus immediately if any such sanction is imposed on the provider,
a staff member or subcontractor.
Appointment Availability Standards:
First+Plus has adopted the following standards for access:
Prompt access to providers is vital for care to Members. The First+Plus policy on Provider/Plan
Access Standards was developed with this core value in mind. The standards listed in this policy
support the value of service as it seeks to anticipate, understand and respond to individuals,
organizations, nursing facility and community needs as Members access healthcare services.
First+Plus is committed to assuring the care the Member is entitled to, be delivered in the correct
setting, correct timeframe and correct manner. Below is an outline of the standards developed by
First+Plus:
A. Access to Medical Care:
1. First+Plus requires health care providers to provide access to health care services without
excessive scheduling delays. Providers will have policies and procedures in place to properly
identify emergency conditions and appropriately triage such cases. Triage involves identifying
which cases can be managed in the office/nursing facility or making alternative arrangements,
e.g. immediate care service or emergency room for cases which cannot be safely managed in the
office/or nursing facility setting.
2. Medical Appointments: The maximum time period between a request for an appointment/or
visit to the nursing facility and the date offered will be:
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a. Life Threatening, Emergent problem: Immediate access.
b. Urgent Care: Same Day
Defined as services provided for the relief of acute pain, initial treatment of
acute infection, or a medical condition that requires medical attention, but a
brief time lapse before care is obtained does not endanger life or permanent
health. Urgent conditions include, but are not limited to, minor sprains,
fractures, pain, heat exhaustion and breathing difficulties, other than those of
sudden onset and persistent severity.
c. Preventive Care: 30 days
Defined as a preventive health evaluation without medical symptoms for
existing members. I.e. routine exam, annual physical.
d. Routine Care: 7-14 days or earlier based on the population.
Defined as non-urgent symptomatic condition that is medically stable. Special
attention will need to be given based on the geriatric population and how
symptoms are presented.
e. Pregnant woman in their first trimester are to be provided preventive care visit
within 14 days of request.
f. Pregnant woman in their second trimester are to be provided preventive care visit
within 7 days of request.
g. Pregnant woman in their third trimester are to be provided preventive care visit
within 3 days of request.
Note:
If a provider’s schedule cannot accommodate the Member requesting an Urgent Care or Routine
Care appointment within these time intervals, an appointment will be offered with an alternative
provider, nurse provider, physician assistant or certified nurse midwife at the same location, or if
none are available, at another location. The Member may choose to decline alternatives and
accept a delayed appointment with the provider.
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CONTRACTED PROVIDER GRIEVANCES PROCESS
First+Plus has established an internal process to meet all grievances arising from contracted
providers. Participating provider must exhaust the following administrative procedures before
initiating the grievance process:
Administrative Procedures
1. Verify if the claim was denied in full o partially due to billing errors, and or lack of
required documentation to process the claim accordingly
2. If after reviewing the explanation of payment reason codes you are still in disagreement
with the action taken by First+Plus, you should submit a request for re-evaluation of the
claim through the regular adjustment process.
3. You should complete and submit the form “Auditoria de Facturas”, a copy of the claim
with the corresponding corrections if applicable, and any supporting documentation
needed for the evaluation of the claim. Please remember that submitting a claim for reevaluation does not guarantee that the claim will be adjusted for payment.
4. The provider of services has twenty (20) days after the receipt of initial denial
notification forwarded by First+Plus, to submit the request for the adjustment to the
following address:
First+Plus
Claims Department
P.O. Box 195559
San Juan, Puerto Rico 00919-5559
Or hand delivered the claims to our office address located at:
First+Plus
Ext. Villa Caparra #530 Marginal
Buchanan, Guaynabo, P.R. 00966
5. You will be notified through the Explanation of Payment (Voucher) of the result of the
evaluation, and in some instances you might receive a letter with the decision taken on
your adjustment request.
6. If you received an adverse determination and still do not agree with that determination,
then you can proceed to submit a Grievance following the process detailed below.
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Grievance Process (You must have exhausted the Administrative Procedures described
above before submitting a request for a Grievance)
1. The provider must complete the Grievance Form (Page 44) in its entirety and send by
mail or deliver it personally to the offices of First Plus.
2. This grievance must include a copy of the claim, and the relevant information necessary
to evaluate the case. This includes but is not limited to copy of the Payment Voucher,
evidence of claim submission, among others.
3. If submitted by mail please send the documents to:
First+Plus
Provider’s Department
P.O. Box 195080
San Juan, Puerto Rico 00919
4. You will be notified in writing of the results of your grievance.
5. Failure to comply with the above process, the grievances will be dismissed. The provider
will receive a letter notifying the reason for the dismissal. The claims will be channeled
through regular adjustment process.
If you have any questions or require additional information, please contact us at 1-866-505-5885
or (787) 620-1649. Monday to Friday 8:00 am to 5:00 pm.
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Provider Manual 2014
34
CREDENTIALING
First+Plus has developed a systematic method for assessing provider applicants against the Plans
credentialing and re-credentialing standards for providers. Upon receipt of a completed
application, primary source verification is conducted by a credentials verification organization
within 180 days of application date. Following the verification of credentials, First+Plus
Credentialing Committee review each application, makes recommendations for participation or
continued participation and makes the final approval.
Providers who choose to opt out of the Medicare program will not be allowed to participate with
the Plan due to them opt out status with the Medicare program.
First+Plus requires all providers applying for participation must meet all credentialing standards
in accordance with the procedure outlined below. Any physician failing to meet the minimum
standards will not be recommended for acceptance into the network.
• First+Plus does not discriminate in terms of participation, reimbursement, or indemnification,
against any health care professional acting within the scope of his/her license.
• First+Plus does not discriminate against professionals who serve high-risk populations or who
specializes in the treatment of costly conditions.
• First+Plus does not discriminate against any health care professionals in terms of participation
reimbursement or indemnification.
• First+Plus does not discriminate against any professional who serves high-risk population or
who specialize in the treatment of costly conditions.
Providers are considered without regard to race, creed, color, gender, age, sexual orientation,
national origin or handicap, unless the latter affects the ability of the practitioner to provide
quality healthcare.
First Medical First+Plus will provide written notice with explanation to a provider that is denied
participation in the program.
Each practitioner is required to complete a provider application in which the provider has
certified that the information contained in the application for membership is true and correct in
all aspects and does not fail to state a material fact that would make it otherwise misleading. The
First+Plus application contains questions regarding physical and mental health status, illegal
drug use, history of loss of license, felony convictions, and history of loss of privileges or
disciplinary action. This application must be signed and dated by the practitioner.
Network Adequacy:
First+Plus will identify all providers necessary to ensure the adequacy of the network in
compliance with all CMS regulations. First+Plus will evaluate the network, taking into
consideration a Member’s ability to access commonly used services within the regular mandated
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travel time, or as reasonable patterns of care would allow (Metro Area: General Physician,
Internal Medicine, General Practice and Family Practice (15) and Specialty (30) Minutes. Rural
area: All Providers (30) minutes.
Primary Source:
All health care providers including physicians, dentists, chiropractors, podiatrists and any other
allied health professionals who request admittance into the First+Plus network must have their
credentials verified through state, federal, governmental agencies, licensing bodies, hospitals or
schools that have supervised the appropriation of such licenses, qualifications and appointments.
This is done through primary source verification of credentials through the respective primary
sources:
• Current, valid, unrestricted state license to practice
• Verification of appropriate education and training
• Board certified, if applicable, by a recognized certification program
• Malpractice history
• Medicare/Medicaid sanctions
• Medicare Opt-Out
First+Plus ensures compliance with Federal requirements prohibiting employment or contracts
excluded from participation under either Medicare or Medicaid.
New Providers:
First+Plus verifies the primary source of all new providers against the Medicare sanctions list
prior to entry into the First+Plus network. In addition First+Plus will review providers against
the Medicare opt out list, provided by the local carrier, to ensure that new providers have not
opted out of Medicare. Any provider found to have existing sanctions or to have opted out of
Medicare will be excluded from participation in the First+Plus network.
If currently participating:
First+Plus reviews the list of sanctioned Medicare providers and the Medicare opt out list on a
quarterly basis for existing members.
Upon confirmation of provider sanction information or that the provider has elected to opt out of
the Medicare program, the panel will be closed and the name suppressed from printing in a
future directory.
Simultaneously, the Credentialing Department may request information from the provider and
reporting agency to determine if there are further details of the sanction. If the information is
consistent and the provider has been barred from participation from Medicare and/or his or her
license has been the subject of a disciplinary action (including but not limited to: censure,
reprimand, loss of license, suspension etc.), termination procedures will follow immediately.
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Provider Orientation:
First+Plus will provide an orientation to providers approved in the credentialing process to
ensure that the providers fully understand the plan and compliance regulations.
Re-Credentialing;
First+Plus requires all plan providers to be re-credentialed every three years. The Provider must
submit updated credentials in order to be re-credentialed. In addition, the provider will be
reviewed utilizing internal information obtained from the necessary departments.
Termination:
First+Plus reserves the right to terminate a provider’s contract immediately, with written notice,
under the following circumstances:
•
•
•
•
•
•
•
•
•
•
•
Conviction for any criminal offense related to the practice.
Failure to comply with First Plus credentialing standards and procedure.
Final disciplinary action is taken by a governmental regulatory agency that impairs the
provider’s ability to practice;
There is a determination of fraud.
There is an imminent harm to patient care.
Failure to comply with quality assurance, peer review and utilization procedures.
Unprofessional conduct as defined by the Medical Examiner’s Board Professional Ethics
Code.
Revocation, reduction, or suspension of privileges at any Participating Hospital or any
hospital where PHYSICIAN conducts his principal practice.
failure by PHYSICIAN to meet the Conditions of Participation' specified hereinafter;
Discrimination against First + Plus Members.
Repeated failure of Provider’s to comply with the terms of the agreement.
A letter of notification will be sent to the provider. Within 60 days of receipt of the termination
letter, the provider can submit a written request to First+Plus for a hearing to consider the
proposed action. The hearing must be scheduled within the 30-day period following First+Plus
receipt of the provider’s written request. The Hearing Panel will be appointed by First+Plus and
must have at least three members, the majority of which must be a clinical peer. A “clinical peer”
is defined as a provider having the same or substantially similar specialty as the provider under
review. If the panel assembled has more than three members, the majority of the panel’s
members must be clinical peers. The hearing panel will render its decision as promptly as
possible, and will notify the provider of its decision in writing. The panel may decide to
reinstate, conditionally reinstate, or terminate the provider.
Termination will become final at the later of these dates: 60 days after the notice of intent to
terminate or 30 days after the panel’s determination letter has been sent to the provider. Under no
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circumstances will First+Plus initiate termination actions against a provider solely because
he/she:
1. Advocated on behalf of a member;
2. Filed a complaint against First+Plus with state or federal regulatory bodies;
3. Appealed a decision made by First+Plus; or
4. Provided information, filed a report, or requested a hearing or review.
The Department of Health requires First+Plus to report the termination of a provider’s contract
for any of the following reasons:
Duty to Report Certain Terminations:
The Department of Health requires First+Plus to report the termination of a provider’s contract
for any of the following reasons:
• Alleged mental or physical impairment, misconduct, or impairment of patient safety or welfare;
• Voluntary or involuntary termination of contract or employment to avoid disciplinary action;
• A determination of fraud or of imminent harm to patient’s health.
If a provider is terminated or suspended for deficiency in the quality of his or her care, written
notice of the action must be given to the licensing or disciplinary bodies or other appropriate
authorities.
Member Notification:
Members will be notified of a provider’s termination from the First+Plus network within
15vdays of receipt of the notice of termination. Members will be informed of other providers in
the First+Plus network that are in their geographic area and can provide the same services as the
provider who has been terminated.
FAX NUMBER TO SUBMIT DOCUMENTS: (787) 300-3907.
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GRIEVANCES AND APPEAL
A Grievance is any complaint or dispute other than organization determination, expressing dissatisfaction with the manner in which First Plus or a delegated entity provides health care services, regardless of whether any remedial action can be taken. A beneficiary can file a complaint
either in writing or verbally expressing dissatisfaction with any aspect of the operations, activities, or behavior of a plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a plan sponsor refused to expedite a coverage determination, a re-determination, an organization determination or reconsideration, or invoked an extension to an Organization determination or reconsideration time frame.
A beneficiary can file a grievance verbally or in writing via fax, email or regular mail. This complaint must be submitted within 60 calendar days from the day the event or incident occurred.
For standard grievances, First+Plus will have to respond to the complaint in writing within 30
calendar days from the date received. We have 24 hours from the date received, to respond to an
expedited grievance.
First+Plus may extend the time frame by up to 14 calendar days if you ask for the extension, or if
we justify a need for additional information and the delay is in the beneficiary best interest.
If First+Plus make a coverage determination or an organizational determination and the beneficiary are not satisfied with this decision, he/she can file an appeal. An appeal is a formal way of
asking us to review and change a coverage determination or an organizational determination we
have made.
All appeal requests must be submitted within 60 calendar days from which the initial determination was made. A beneficiary can file a Part D appeal verbally or in writing. For expedited requests First Plus, have 72 hours from the date received, to respond to a request in writing and 7
calendar days for a standard Part D appeal.
To request a Part C Appeal, with the exception of an expedited request, the beneficiary must
send a signed written request via fax, email or regular mail. For Part C service appeals,
First+Plus have 30 calendar days to respond in writing and 72 hours for expedited requests. First
Plus may extend this time frame by up to 14 calendar days if you ask for the extension, or if we
justify a need for additional information and the delay is in your best interest For Part C appeals
related to claims or reimbursements First Plus have 60 calendar days from the date received in
writing to respond. Those appeals cannot be requested expedited, in addition the time frame extension does not apply.
First Plus must keep track of all grievances and appeals in order to report data to CMS and to our
members, upon request. To obtain more information, please contact our Provider Call Center at
1-866-505-5885. Our service hours are Monday to Friday 8:00 am to 5:00 pm.
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Submitting a Grievance or an Appeal
To submit a grievance, an expedited grievance, a redetermination, or an expedited redetermination, the beneficiary can send us a signed written request or contact our Customer Service Department at 1-888-767-7717 or TTY /TDD users should call 1-877-672-4242. Our service hours
are Monday to Friday 8:00 am to 8:00 pm.
To request a Part C appeal the beneficiary or their representative must submit a signed written
request to the Grievance and Appeals Department by fax at 787-300-3918 or by mail to the following address:
First+Plus
P.O. Box 195080
San Juan, PR 00919-5080
Through email:
[email protected]
If First Plus denies the beneficiary’s request in whole or in part, the beneficiary will receive a
written decision explaining the denial reasons, and information on any dispute resolution options
you may have.
Remember, all types of Grievances and Appeals related to your Prescription Drug Coverage can
be filed verbally by calling our Customer Services Department at 1-888-767-7717. If a beneficiary has an appeal related to Part C he/she must submit a signed written request.
For more information on appeals and grievances, please call our Provider Call Center at 1-866505-5885 Monday to Friday from 8:00 am to 5:00pm
Appointing a Representative
A beneficiary or someone who he/she appoint as an authorized representative may file a grievance or appeal. A beneficiary can appoint a relative, friend, lawyer, advocate, doctor, or anyone
else to act for him/her. Or, a beneficiary may already have someone authorized under Commonwealth law to act for you. If a beneficiary want someone to act for him/her who is not already
authorized by the Court or under State law, then he/she and that person must sign and date a
statement that gives the person legal permission to be your representative.
The form is available on the following link, which will redirect you to the CMS website.
http://www.cms.gov/cmsforms/downloads/cms1696.pdf
Or in the First Plus web link under the grievance and Appeal section, the link is:
http://www.firstpluspr.com/es/
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MEDICAL AFFAIRS
Utilization Management:
First+Plus maintains a Utilization Management Program to ensure that First+Plus Members have
timely access to appropriate, medically necessary, and cost-effective health care services. The
Utilization Management Program addresses such issues as: preventive care, in-patient services,
and ambulatory care.
Responsibility for ensuring the implementation of all aspects of the Utilization Management
Program has been delegated to the Plan’s Medical Director by the Board of Directors. The main
goals of the Utilization Management Program are to ensure quality, relevant care while
promoting appropriate utilization of medical services and Plan resources.
The objectives of the Utilization Management Program are to: Provide a structured process to
continually monitor and evaluate the delivery of health care and services to our enrollees by:
•
•
•
•
•
•
•
Establishing system-wide health management processes across the continuum of care.
Establishing a process for provider feedback regarding utilization.
Monitoring indicators to detect possible under- and over-utilization.
Auditing utilization management decision timeliness on a monthly basis.
Determining enrollee and provider satisfaction with medical management.
Assessment of member benefits utilization on an annual basis to identify any changes and
needs for member add-on benefits.
Assure appropriate member access to services through analysis of Out of Network (OON)
utilization patterns
Improve Clinical Outcomes by:
•
•
•
•
Collaboration, system-wide, to identify, develop, and implement clinical practice
guidelines that address key health care needs of the enrollees.
Implementation of clear, consistent UM Program.
Implementing actions, when appropriate to improve under- and over-utilization.
Collaboration with the Quality Department to assess and implement actions to improve
continuity and coordination of care.
Improve provider and enrollee satisfaction by:
•
•
Assessing and improving UM satisfaction data from provider and enrollee surveys.
Promoting appropriate utilization of Plan resources through efficiency of service.
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Meet or exceed established quality standards by:
•
•
•
•
Measuring program performance
HEDIS
HOS
CAHPS
Utilization review staff is responsible for obtaining all pertinent clinical indications and medical
record information necessary to perform assessments of service authorizations.
The UM staff is responsible for application of utilization review criteria/guidelines (Milliman
Care Guidelines®) to each individual case and for referral to the Medical Director when criteria
are not met. The UM Department staff is responsible for identification of all potential or actual
quality of care issues, and cases of over and under-utilization of health care services for
First+Plus members during all components of review and authorization.
Evidence Based Clinical Practice Guidelines
First+Plus conducts its medical review and evaluation of health care services utilizing nationally
recognized policies, standards of care, and evidence based clinical guidelines. Examples of such
health care services include inpatient and outpatient care, durable medical equipment,
medications, and other services required for coordinating care for our members.
First+Plus staff uses such policies, standards, and guidelines from the Centers for Medicare and
Medicaid Services (CMS) and its carriers, Milliman Care Guidelines ®, InterQual Guidelines®
for Inpatient UM, national professional organizations (i.e. American Diabetes Association,
American Heart Association) and other federal government organizations such as the Food and
Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and the
Agency for Health Care Research and Quality (AHRQ).
A list of the above mentioned organizations most commonly used and their websites are included
below:
1. Center for Medicare and Medicaid Services (for contractors, providers, and other
healthcare industry professionals) http://www.cms.gov/home/medicare.asp
2. Center for Medicare and Medicaid ( Special Needs Plans)
https://www.cms.gov/SpecialNeedsPlans/
3. First Coast Service Option , Medicare carrier for Puerto Rico http://www.fcso.com/
4. Milliman Care Guidelines http://www.milliman.com/expertise/healthcare/products-
tools/milliman-care-guidelines/
5. American Diabetes Association
http://professional.diabetes.org/?utm_source=Homepage&utm_medium=HeaderPro
mo2&utm_content=ForProfessionals&utm_campaign=DP
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6. American Heart Association
http://www.heart.org/HEARTORG/HealthcareResearch/HealthcareResearch_UCM_001093_SubHomePage.jsp
7. Agency for Health Care Research and Quality http://www.ahrq.gov/
8. Food and Drug Administration
http://www.fda.gov/ForHealthProfessionals/default.htm
The comprehensive methods of review and authorization include the following processes:
UM Committee Charter:
Provide direction to the First+Plus Utilization Management Program and act as an advisory and
oversight committee. Evaluate current and proposed utilization management programs for effectiveness and performance against goals. Analyze utilization, both under and over, and recommend direction or program changes, as needed. Recommend corrective actions based on clinical
trends or changes in the standards of care. Review and approve guidelines for the delivery of
health services to First+Plus members. Oversee and monitor all delegated UM activities.
Authorization Process:
First+Plus requires prior authorization for some procedures and services to ensure that the most
appropriate care is provided for First+Plus members. This Prior Authorization Manual outlines
the process for submitting prior authorization requests to First+Plus Medical Affairs Department
for services included in the categories below.
Prior Authorizations:
Prior authorization is designed to promote the medical necessity of service, to prevent
unanticipated denials of coverage and ensure that participating providers are utilized and that all
services are provided at the appropriate level of care for the member’s needs. First+Plus precertification program reviews a specific list of medical services for medical necessity.
First+Plus does not require prior authorization for the following services:
• Emergency Services
• Emergency Ambulance Services dispatched through 911 or its local equivalent, where
other means of transportation would endanger the member’s health
• Urgently needed services
• Yearly routine physicals by in-plan providers: Colorectal and prostate screening exams.
• Yearly Routine Eye Care
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• Influenza vaccine (yearly), Pneumococcal vaccines and Hepatitis B vaccines by in-plan
providers
• Renal Dialysis Services for those temporarily out of the service area
• Basic Lab tests (i.e. CBC, BMP, UA)
• Skeletal X-rays / chest X-rays
• Clinical trials: Original Medicare covers routine costs of qualifying clinical trials. A
member does not need to obtain a referral to join a clinical trial. However, it is
recommended that the member inform First+Plus before they start a clinical trial so
First+Plus can keep track of the member’s health care services.
Authorization Requirements
Submission of a referral form (Medical Certification Form & Authorization Request Form)
and clinical information is required. The physician must provide medical justification including
medical history, laboratories results, and previous studies for better decision making (i.e.
progress notes, imaging reports, operative reports etc.). Prior Authorization is required for the
services included in the categories below:
Durable Medical Equipment:
Scooters
Wheelchairs and accessories (All types & Bariatric)
Beds and accessories (All types & Bariatric)
Lifter
Orthotics
Prosthetics
CPAP, BPAP
Oxygen
Continuous Passive Motion (CPM)
Diabetes supplies
Power nebulizers
Infusion Pumps (All types)
Mechanical Ventilator ( Home )
Negative Pressure Wound Therapy
Bone Grow Stimulator
Wearable Cardioverter Defibrillator
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Miscellaneous:
Medical Surgical Trays
Cardiac and Orthopedic Implants
Polysomnography (Sleep Studies)
Special EEG Test (24hrs)
Oncotype Dx Test
Specialized Services:
Home Care Services
Home Infusion Services
Skilled Nursing Facility and Extended Care Facility
Comprehensive Outpatient and Inpatient Rehabilitation Facility & Services (CORF)
Specialized Therapies:
Pain Management
Medical Nutrition Services
Physical Therapy/ST/OT
Wound Care
Hyperbaric Oxygen therapy (HBO)
Pulmonary Rehabilitation
Cardiac Rehabilitation
SRS- Stereotactic Radiosurgery
SBRT –Stereotactic Body Radiation Therapy
IMRT -Intensity Modulated Radiation Therapy
Medications:
Part B Drugs ( J codes)
Chemotherapy and administration
Respiratory Drugs
Surgeries:
Bariatric surgeries
Minimally Invasive Robotic Surgery (Da Vinci)
Reconstructive and other potential cosmetic surgeries: Rhynoplasty, Abdominoplasty,
Septoplasty, Blepharoplasty, Augmentation or Reduction of Breast, Face lift, Ptosis
repair.
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Urology:
Lithotripsy
Cardiology Procedures:
Permanent Cardiac Pacemaker trays and Pacing Cardioverter – Defibrillator Insertion
and the Implantable Cardioverter Defibrillator (ICD)
Enhanced External Counter pulsation (EECP/Vasotherapy)
Nuclear Medicine Studies:
PET CT Scans/PET Scans
SPECT(Brain , Myocardial Perfusion )
SPECT + Pharmacology Agents
Radiology:
MRI w / without contrast
MR Neurography (MRN)
MR Venography (MRV)
MRA
CT Scans w / without contrast
Cardiac CT Scan - Coronary CT Angiography
CT Colonoscopy (Virtual Colonoscopy)
Arthrography (CT and MR)
ERCP/MRCP
Others:
Air Ambulance (Out of Puerto Rico)
Ambulance Service Non –emergency
Organ Transplant (all types
Important Information:
Expedited (Urgent) Pre-Service Referral:
The organization makes decisions within 24-72 hours from receipt of the request.
Standard (Routine) Pre-Service Referral:
24 hours up to 14 calendar days.
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The Physician must provide medical justification including medical history, laboratories results
and previous studies for better decision making.
Medical Necessity: Request to extend a course of treatment beyond the period of time or number of treatments previously approved. The organization makes decisions according to Expedited
or Standard criteria.
Emergency Referrals:
NO AUTHORIZATION REQUIRED
The Utilization Reviewers obtains medical record within twenty-four (24) hours of notification
of admission (or next business day) by site visit to ensure the admission to the acute care hospital
is appropriate/medically indicated in accordance with the illness or condition or to confirm
information obtained during prior authorization of elective admissions.
Inpatient Concurrent/Extended length of Stay Review:
Concurrent review is the evaluation of a patient’s continued need for treatment and the
appropriateness of current and proposed treatment, as well as the setting in which the treatment is
being rendered or proposed. Concurrent review applies to all levels of inpatient care and partial
hospitalization. If an admission or an extended stay does not meet the required criteria, a request
for further review will be sent to the Medical Director.
Medical necessity and appropriateness of setting and treatment review is performed by
Utilization Reviewers that will actively track and manage the inpatient stays to ensure
coordination of care with the member’s physicians. The First+Plus Case Management staff will
give follow up to patients in extended length of stay (more than 10 days). Our Concurrent
Management program is designed to ensure that all inpatient stays are medically indicated and
that care is provided in the most appropriate setting using Inter Quall Guidelines®. Service
highlights include:
•
•
•
•
Notification from the Hospital’s Utilization Management Department for the initial
review only to determine the medical necessity of the admission, and follow up.
On site discussion of cases with Hospitals’ Case Management Department for periodical
evaluation during a member’s course of hospitalization to assess the medical necessity
and appropriateness of continued stay confinement at the requested level of care.
Coordination of early proactive interventions and discharge planning in conjunction with
the hospital’s Case Management Department to facilitate transition of care back to the
member’s nursing facility and physicians.
Identification of patients for enrollment in focused Case Management.
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Discharge Planning Review and Responsibilities:
Discharge Planning begins as early as possible during an inpatient admission in collaboration
with the hospital’s Case Management Department and the attending physician. Such planning is
designed to facilitate transition of care back to the member’s nursing facility and physicians and
identify any post-hospital care needs for the member.
In addition, all First+Plus members admitted to a Medicare approved facility must receive
notification of their discharge and appeal rights. If a First+Plus member disagrees with the
pending discharge, the hospital must issue the Notice of Discharge and Medicare Appeals Rights
as a part of the discharge appeal process. A copy of the letter must be filed in the member’s
hospital record and faxed to the First+Plus UM Department at (787) 705-9347 / (787) 622-0729
to be filed in the member’s record.
Retrospective Review:
Retrospective Review is a review process performed by Utilization Reviewers after services have
been rendered, to determine:
•
•
•
•
If unauthorized services were medically necessary/appropriate.
If services were rendered at the appropriate level of care and in a timely manner.
If a quality of care issues exist.
If Provider claims appeals are in order
The institution is responsible of notifying the cases which hasn’t been review to First+Plus and
to provide the appropriate information for case evaluation on a timely manner based on
applicable regulations and contractual agreements.
The attending physician and/or hospital/facility are notified in writing of the claim payment
determinations via the EOB. The determination of services medical necessity is based on the
analysis of the information provided and the application of nationally recognized clinical criteria.
Benefits will be paid; adjustments can be made according to the review made.
Ancillary Services (Home Health, Durable Medical Equipment, Hospice):
Referrals for any ancillary services including Home Health and Durable Medical Equipment
require authorization from the Utilization Management (UM) Department. Hospice referrals to a
Medicare certified agency are initiated for tracking and trending purposes only. When a member
enrolls in Medicare certified Hospice, the Hospice is reimbursed directly by Medicare Fee-ForService for all the Hospice services the member receives. While the member is enrolled in
Hospice, their First+Plus coverage is limited to Non-Hospice Part D, and any Supplemental
Benefits offered to our members.
Skilled Nursing Facility (SNF) Review:
When a member is transferred or admitted to Skilled Nursing Facility (SNF) Care, First+Plus
uses Medicare SNF criteria and Inter Qual Guidelines® to determine appropriate level of care.
All admissions to SNF require authorization by the First+Plus UM Department.
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Inpatient Rehabilitation Facility (IRF) Review:
Intensive rehabilitation services are provided after an injury, illness or surgery. This service includes physical, occupational and speech therapy in a coordinated multidisciplinary setting. All
admission to IRF requires authorization by the First+Plus UM Department.
Case Management Program
First+Plus uses a comprehensive, integrated approach for the treatment of chronic medical conditions and complex medical conditions that facilitates the physician-patient relationship, emphasize prevention and continually evaluate health outcomes.
First+Plus conducts a health risk assessment on newly enrolled members and classified them as
very high, high, moderate or low health risk.
All First+Plus members s in a Special Need Plan are enrolled in the Case Management Program
unless they opt-out from it. After the initial or annual Health Risk Assessment (HRA) members
from the SNP products are stratified as specified above and different levels of interventions are
applied by risk level. Members from other products who are identified as “high risk” or “disease
specific” will be referred to a Case Manager in order for intervention to take place as soon as
possible. Case Managers will contact those members and assess their medical and social situation
and identify any problems that may adversely impact their health. Case Managers will also assist
high-risk, frail elderly members with coordinating necessary medical service in accordance to
risk stratification Level
Primary care physicians and members receive copies of the Individualized Care Plans (ICP) developed based of the answers provided by the First+Plus members to the health risk assessments
performed. The providers are encouraged to discuss and evaluate the recommendations included
in the ICP with the member. The goals of the case manager is to provide comprehensive coordination of care and benefits for the SNP member, health promotion and prevention services. Specific functions of the case manager include but are not limited to:
a) Perform the activities of assessment, planning, coaching, education and advocacy for
members throughout the continuum of care, consistent with evidence based clinical
guidelines.
b) Collaborate and communicate with the member/family, the physician and other health
care providers in the development and implementation of a care plan that is driven by
the member’s goals for health improvement.
c) Support in the accomplishment of the goals specified the individual member’s care
plan.
d) Provide members and their families with information and education that promotes
self-care management.
e) Involve the member and his/her family in the coordination of services.
f) Assist members in their transition across health care settings by providing information, support and serving as a link between the member, family/caregiver and providers.
g) Support members in optimizing the utilization of available benefits.
h) Improve member and provider satisfaction.
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i) Ensure timely interventions that increase effectiveness and efficiency in care delivery.
j) Promote the health, independence, and optimal functioning of members.
First+Plus Case Managers communicate with members/caregivers on an ongoing basis, as needed, and document all follow-up in Case Management application. At a minimum, the case managers re-evaluate the Individualized Care Plan on an annual basis (365 days and /or before initial
HRA) for any necessary revisions. The re-assessment takes in consideration the member’s progress towards identified goals, results of the annual HRA, findings from the ER frequent Report,
and input from the member/caregiver in member with high risk level.
Members who have chosen to opt out of the HRA and/or Case Management processes are
flagged for re-contact in 12 months or if they are identified by Medical Affairs as high utilizes of
key incidents of care such as Re admission
Providers are encouraged to refer members that may benefit from the Case Management Program. Using the following form “Referral Form” (see form)
For more information or any questions related to the Case management Program or Referral
Form, please contact our customer service number at 1-888-767-7717. We are available Monday
through Friday from 8:00am to 8:00pm. TTY users should call 1-877-672-4242 or fax request to
(787) 705-9347 or (787) 622 -0729
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Benefit during Disaster and Catastrophic Events
First Plus has adopted this policy to comply with Section 160 of Chapter 4: Benefits and
Beneficiary Protections of the Medicare Managed Care Manual and to provide guidance in
case of a disaster or catastrophic event.
Definitions
Emergency: An emergency is a major disaster declared by the President of the
United States; an emergency or disaster declared by a state Governor, including
the Governor of Puerto Rico; or a public health emergency declared by the Secretary of the Department of Health and Human Services or by the Secretary of the
Puerto Rico Health Department.
Provider: Any Medicare provider or supplier (for example, hospital, skilled nursing facility, durable medical equipment, home health agency, outpatient physical
therapy, comprehensive outpatient rehabilitation facility, renal dialysis facility,
hospice, physician, non-physician
Procedure
1. During an Emergency declaration, First Plus will take the following actions:
a. Allow Part A/B and supplemental Part C plan benefits to be furnished at specified
non-contracted facilities (note that Part A/B benefits must, per 42 CFR §
422.204(b)(3), be furnished at Medicare certified facilities);
b. Waive in full, requirements for gatekeeper referrals where applicable;
c. Temporarily reduce plan-approved out-of-network cost sharing to in-network
cost-sharing amounts, where applicable; and
d. Waive the 30-day notification requirement to enrollees as long as all the changes
(such as reduction of cost-sharing and waiving authorization) benefit the enrollee.
e. Activate a waiver to the pre-authorizations requirements.
2. Prior to the Emergency Event - Medical Affairs Pre-Authorization staff will identify
providers with high volume of cases, cases with risk services and cases that requires transition in order to ensure their contingency plan is active.
a. Medical Affairs Pre-Authorization staff performs outbound calls to the identified
providers to validate the process they are taking to ensure continuity of care and
services.
b. For providers that are unable to perform contingency plan, the Transition Policy is
activated.
c. Medical Affairs Manager and/or Director contact First Plus Triage Nursing Line
to inform them of the pre-authorizations waiver and to notify them to activate the
Contingency Plan. Additionally, the Medical Affairs Manager and/or Director
share the First+Plus Medical Affairs Management Contact List of the staff available to support the Contingency Plan.
3. Post- Emergency Event - Medical Affairs Management Team identifies the staff available and necessary to re-start the department operations as soon as possible.
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a. Medical Affairs staff performs a validation process with the identified providers
delivering the care/services to monitor the continuity of care/services was performed.
b. For providers that are unable to perform Contingency Plan, the Transition Policy
is activated immediately.
c. For members with potential life threatening services, Medical Affairs PreAuthorization staff performs an outbound call to validate the member has the necessary care/services.
d. A report will be generated by Medical Affairs Management with the documentation of the actions performed prior and post the emergency event.
4. First Plus will continue to apply the abovementioned actions accordingly until the termination of the emergency. First Plus shall consider the following when deciding whether
an emergency has been terminated or not:
o In the case of a public health emergency, it terminates when it no longer exists or upon the expiration of the 30-day period beginning from the initial declaration, whichever occurs first.
o For major disasters or emergencies, First Plus should pay particular attention to the
termination of disaster or emergency incident periods listed on FEMA’s web site
(http://www.fema.gov/news/disasters.fema).
5. First Plus will monitor CMS releases and ensure if further guidance to extend the emergency period or to shorten it has been issued.
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QUALITY IMPROVEMENT PROGRAM AND ITS SCOPE
Medicare Advantage Organizations (MAOs) must implement and maintain a Quality Improvement Program (QI) as require under 42 CFR §422.152. As part of First+Plus commitment to
comply with regulations and First Medical corporate commitment in provide excellent health
services, First+Plus Quality Improvement Program has been developed to identify criteria to
conduct quality projects based on clinical and non-clinical factors to address and identify areas
for improvement.
The mission of the Quality Improvement Program is to promote and continuously improve the
highest quality of clinical care (medical and behavioral health) and quality of services provided
to First Plus enrollees by providers and the health plan. The scope of the First+ Plus Quality
Improvement Program includes the following:
-
Quality Projects and Programs
o HEDIS Quality Project
First+Plus HEDIS Quality Project is focused in the widely used set of performance measures in the health industry with the purpose of comply with quality
metrics related to Care Effectiveness, Access/Availability of Care, Care Experience (Satisfaction Survey), Utilization and Health Plan Information, with the implementation of different strategies.
.
o Quality Improvement Project (QIP)
First+Plus QIP has the goal to reduce hospital re-admissions of First+Plus members through the implementation of its Transition Care Management Program.
o Chronic Care Improvement Program (CCIP)
First+Plus CCIP is directed to its diabetic members with hypertension with the
goal to improve their health status controlling their blood pressure.
o Special Needs Plan Model of Care (MOC)
First+Plus MOC has the objectives of: improve the services’ access for physical
and mental health and for care transitions, ensure the appropriate utilization of
health services, encourage the communication between providers, members and
their care givers, and measure the results of this Model through health outcomes.
o Satisfaction Surveys (CAHPS and HOS)
The different Satisfaction Projects established by First+Plus are focused in to improve the satisfaction of its members with the provided services, the perception
related to accessibility, physician-member relationship, the communication with
the provider and their physical and mental health.
o STARS Project
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First+Plus STARS Quality Project has the purpose of facilitate and evaluate
health care services received by First+Plus members in order to be appropriate,
cost-effective and to improve their health status. These objectives will be
accomplished with the compliance of the quality standards required by CMS.
o SNP Structure and Process Project
First+Plus SNP Structure and Process Project is directed to comply with CMS and
NCQA requirements to ensure the provision of quality services to First+Plus most
vulnerable population.
Monitoring Tools – First+Plus Quality Team has developed some quality indicators that are
monitored regularly to ensure the compliance with the MOC requirements, HEDIS and STARS
metrics and operational indicators that evaluate the quality of services provided by First+Plus
departments.
One of the most important components of the First+Plus Quality Improvement Program is its
Quality Committee. This Committee is responsible for the development, implementation and
oversight of the overall Quality Program for First+Plus. The Committee evaluates the results of
quality improvement activities, utilization results, outcomes and recommends actions with the
purpose of improve and maintain the health status of First+Plus members.
The First+Plus Quality Improvement Program is approved by First Medical Board of Directors
and is evaluated annually to identify barriers (if any) to comply with the quality goals proposed
every year. Every First+Plus contracted provider is crucial to comply with the goals established
in the Quality Program: supporting First+Plus Quality Projects and Programs and complying
with the provider roles and responsibilities defined in every First+Plus Quality Project and Program. With the compliance of these roles and responsibilities, the provider will continue
facilitate services with quality and excellence to First+Plus members.
HEDIS Quality Project (Data and Information Group Health Effective)
HEDIS is a Quality Project required by CMS to all Medicare Advantage organizations. It is a
dynamic project that considers medical guidelines for establishing quality indicators that
measure the performance in different areas of health care and services. It has 75 indicators and is
divided into eight (8) domains of care:
1.
2.
3.
4.
5.
6.
7.
8.
Effectiveness of care
Access and availability of care
Satisfaction in the care experience received
Health Plan Stability
Use of Service
Cost of care
Health Care Team Report
Health Plan Information
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Some of the actions performed by First+Plus to support the efforts of its providers to impact
HEDIS metrics are:
• Frequent notifications with reference material related to the quality indicators, their
measurement criteria, recommendations and results;
• Individual notifications that includes the profile of the population under your care. These
communications may include specific identification of those members in compliance and noncompliance with certain HEDIS metrics;
• Development and implementation of quality initiatives that promote preventive health services
and treatment;
• Provide guidance on best coding practices and documentation of treatment offered.
Also, First + Plus makes target actions to its members to impact HEDIS metrics such as:
• Promote the doctor-patient relationship by facilitating the accessibility of preventive and
treatment services necessary to improve and maintain good health in the population of First+
Plus members;
• Motivate and educate members about the importance of meeting their health goals, treatment
plan and preventive services through various educational strategies;
• Facilitate coordination of annual preventive evaluation and/or treatment;
• Development and implementation of quality initiatives that provide preventive services in order
to improve or maintain their health status.
First + Plus is committed to report HEDIS indicators according to the criteria and guidelines
established by CMS. The results of these indicators are used to identify areas of improvement in
the performance of the health plan and its contracted providers. Following are some of the
HEDIS indicators that impact Stars Program as established by CMS. These indicators are
reviewed and updated annually. (May apply additional details for the indicators following
described and/or exclusions).
Breast Cancer Screening (BCS)
The percentage of women 40–69 years of age who had a mammogram to screen breast cancer.
Colorectal Cancer Screening (COL)
The percentage of members 50–75 years of age who had appropriate screening for colorectal
cancer.
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Cholesterol Management for Patients With Cardiovascular Conditions (CMC)- Cholesterol
Screening
The percentage of members 18–75 years of age who were discharged alive for AMI, coronary
artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1–
November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year,
who had each of the following during the measurement year:
•
LDL-C screening
Comprehensive Diabetes Care- Cholesterol Screening
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each
of the following.
•
LDL-C screening
Glaucoma Screening in Older Adults (GSO)
The percentage of Medicare members 65 years and older who received a glaucoma eye exam by
an eye care professional for early identification of glaucoma related conditions.
Adult BMI Assessment (ABA)
The percentage of members 18–74 years of age who had an outpatient visit and whose body
mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
Care for Older Adults (COA) - Medication Review
The percentage of adults 66 years and older who had each of the following during the
measurement year:
• Medication Review
Care for Older Adults (COA) -Functional Status Assessment
The percentage of adults 66 years and older who had each of the following during the measurement year:
•
Functional Status Assessment
Care for Older Adults (COA) – Pain Management
The percentage of adults 66 years and older who had each of the following during the
measurement year:
•
Pain Management
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Osteoporosis Management in Women Who Had a Fracture (OMW)
The percentage of women 67 years of age and older who suffered a fracture and who had either a
bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the
six months after the fracture.
Comprehensive Diabetes Care- Eye Exam
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each
of the following: An eye screening for diabetic retinal disease.
Comprehensive Diabetes Care-Nephropathy
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each
of the following.
•
Medical attention for nephropathy
Comprehensive Diabetes Care- HbA1c Control
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each
of the following.
•
HbA1c poor control (>9.0%).
•
HbA1c control (<8.0%).
Comprehensive Diabetes Care- LDL-C Control
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each
of the following.
•
LDL-C control (<100 mg/dL).
Controlling High Blood Pressure (CBP)
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and
whose BP was adequately controlled (<140/90) during the measurement year.
Disease-Modifying Anti-Rheumatic Drug Therapy
The percentage of members who were diagnosed with rheumatoid arthritis and who were
dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug
(DMARD).
Plan All-Cause Readmissions (PCR)
For members 18 years of age and older, the number of acute inpatient stays during the
measurement year that were followed by an acute readmission for any diagnosis within 30 days
and the predicted probability of an acute readmission.
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Listed below are other indicators specific to HEDIS (not related to Stars) that are
evaluated as part of the Project:
1.
Persistence of Beta-Blocker Treatment after a Heart Attack (PBH)
The percentage of members 18 years of age and older during the measurement year who were
hospitalized and discharged alive from July 1 of the year prior to the measurement year to June
30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker
treatment for six months after discharge.
2.
Antidepressant Medication Management (AMM)
The percentage of members 18 years of age and older with a diagnosis of major depression and
were newly treated with antidepressant medication, and who remained on an antidepressant
medication treatment. Acute Phase antidepressant medications for 12 weeks, Effective
Continuation Phase antidepressant medication treatment for at least 180 days (6 months).
3.
Follow-Up after Hospitalization for Mental Illness (FUH)
The percentage of discharges who were hospitalized for treatment of selected mental health
disorders and who had an outpatient visit, an intensive outpatient encounter or partial
hospitalization with a mental health practitioner. Two rates are reported: the percentage of discharges for which the member received follow-up within 7 and 30 days of discharge.
4.
Frequency of Selected Procedures (FSP)
This measure summarizes the utilization of frequently performed procedures that often show
wide regional variation and have generated concern regarding potentially inappropriate
utilization.
Medical Record Review Project
The Medical Record Review Project is conducted as part of HEDIS Quality Project. The participation of First+Plus providers is important for the recollection of medical information that is crucial to this Project.
The process established by First+Plus is the following:
1.
Coordination of Appointments
•
First+Plus sends an introductory letter of HEDIS Project and then contact the
provider to coordinate the appointment for the recollection of the necessary medical information. Once coordinated the appointment, the representative of
First+Plus visits the facility according to the date and time established. A list per
indicator is send with the names of patient’s clinical record needed. All revisions
and recollection of health information for HEDIS Project is performed in compliance with HIPAA requirements.
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2.
Medical Records Abstraction
First + Plus representative visits the facility or medical office at the coordinated time and date,
proceed with the digitization of medical records according to the necessary medical information.
3.
Information by Fax
Providers may choose the option to send the requested information via fax by completing the established format for this purpose.
The Medical Record Review process identifies the compliance of members of First+Plus with
the quality indicators under evaluation. The provider participation of First+Plus in this process is
crucial to achieve the expected results in HEDIS project.
The Role of the Provider to impact the First+Plus HEDIS metrics:
1.
All progress notes must be legible and complete with date and time of the encounter.
2.
Document the results of diagnostic tests ordered and make annotation of
recommendations in the member progress notes such as: changes in the list of medications, education about advance directives, medication adherence, among others.
3.
Reconcile members’ medications with medications ordered at discharge after hospitalization, documenting changes such as elimination of drugs, increased dosage, and route change,
among others.
4.
Motivating patients to meet their annual checkups.
5.
Make follow-up calls to members who do not comply with their treatment.
Following is the information that must be found in the progress notes of the clinical record of the
members for compliance with HEDIS quality measures:
MEASURE
Adult BMI Assessment
(ABA)
INFORMATION FROM THE MEDICAL
RECORD FOR POSITIVE EVENT (HIT)
Measurement Year and Prior Year Progress Notes, Flow
Sheets, Growth Chart from Pediatric Provider, Consult
Reports from Nutritionists or other Specialists
Colorectal Cancer
(COL)
Report of Colonoscopy since 2002,
Report of flexible Sigmoidoscopy since 2007
Hem occult, Guaiac, gFOBT, iFOBT note or lab result
negative/positive in measurement year
Note or medical history showing procedure (above)
Controlling High Blood Problem List
Pressure (CBP)
Notes from event that got member into the measure or
an earlier visit as long as it shows HTN or High Blood
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EXCLUSION
Pregnancy during MY
Note showing history of colon
or rectal cancer
Note showing history of total
colectomy
Full chart copy to rebut
assumption member has HBP
(minimum MY, ideally 2nd half
Cholesterol
Management (CMC)
Comprehensive
Diabetes Care (CDC)
Eyes (DRE)
Care for Older Adults
(COA)
Pressure
Notes from last visit in measurement year with a BP
reading
Vitals Flow sheet
Lab Results showing all Lipid tests in measurement year
Measurement Year Lab Reports showing:
Last HbA1c
Last LDL-C or LDL-D
OR
Last Lipid panel showing (Total Chol, HDL, Triglycerides)
All labs in measurement year showing urine specimen
results
Any Measurement year consult reports from
Nephrologist
Medication List
Problem List showing renal or kidney disease
Any note showing Dx of renal insufficiency or failure
Any notes/ scripts for ACE Inhibitor/ ARB therapy
Last Blood Pressure Listing from measurement year
from Progress notes or flow sheets
Any consults or hospital documents in measurement
year
All measurement year and prior reports from Eye Care
professional
Any mention of eye care or retinopathy in chart
Any referral for eye exam
Measurement Year Progress Notes:
• Any Advanced Directives, Living Wills or signed
documentation noting patient has reviewed
Advanced Care Materials
• Any medication list during measurement year with
evidence of review by prescriber or clinical
pharmacist
• Any measurement year Functional Status
Worksheets, Checklists or Evaluation Scales or
notation of performance or inability to perform –
Activities of Daily Living (ADL’s)/ Instrumental
Activities of Daily Living (IADL’s); any evaluation
of thinking, gait/ambulation, hearing/vision, and living situation/independence.
• Pain Assessment Worksheets, Numeric Rating
Scale, Visual Assessment Scale, any notation of
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PY+MY)
Medication list
Notation of Pregnancy
Full chart to rebut assumption
member had AMI, CABG or
PTCA or evidence IVD in PY /
MY
OPTIONAL EXCLUSIONS:
Notes showing member has
gestational, steroid-induced
diabetes
Notes showing polycystic ovary
disease (females only)
Med List, labs and any notes that
rebut DX of Diabetes
none
none
comprehensive pain management, pain treatment
plan, or notation of absence of pain
Medication
Reconciliation PostDischarge (MRP)
All measurement year discharge summaries (from the
outpatient record), Progress Notes, or dated medication
records within 30 days of discharge that display
evidence that discharge medications were reviewed
none
Supplemental Data
First Plus uses additional data sources other than claims to collect data on health services offered
to its members. This additional information is used to identify additional health services which are
provided to First Plus members and to confirm the health information provided thru claims
submitted by physicians.
The supplemental data can be used when the information can be found in the medical record
through forms with medical or demographic information, information in medical history forms,
diagnoses, laboratories results, test measurements, among others, or when the provider documents
in the medical record all the discussed information provided verbally to the member at the time
of the medical evaluation. This information is collected by medical records audit, request of the
medical information by fax, postal office or by quality initiatives activities performed.
Some additional sources of information are:
• Information questionnaires, such as Health Initial Assessments
• Medical Referrals
• Vaccination Record
• Laboratory Results
• Demographic Records
• Estimated Functional Assessments
Other sources such as CPT codes II are used to capture diagnostic test results for quality purpose
and are also used as supplemental data:
1. These codes can be reported in the claim, after discussing the results of laboratory, and or diagnostic tests with the member;
2. The regular CPT must be included along with these CPT codes II in the claims;
3. The use of these codes can reduce the need for Medical Record Review in the physicians’
offices.
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Use the following reference list with CPT II codes that can be used to impact HEDIS measures:
Description
CPT
CPT II
The most recent Hba1c test
during the year
83036, 83037
3044F=most recent Hba1c
level less than 7.0%
3045F=most recent Hba1c
level between 7.0-9.0%
3046F=most recent Hba1c
level greater than 9.0%
The most recent LDL-C test
during the year
80061,83700,83701,83704,83721 3048F=most recent LDL-C
less that 100mg/dl
3049F=most recent LDL-C
100-129mg/dl
3050F=most recent LDL
greater than or equal to
130mg/dl
Eye Exam=a retinal or
dilated eye exam by an eye
care professional (optometrist or ophthalmologist) is
completed every year or a
negative retinal exam (no
evidence of retinopathy) by
an eye care professional in
the prior year.
67028, 67030, 67031, 67036,
67039-67043, 67101, 67105,
67107, 67108, 67110, 67112,
67113, 67121, 67141, 67145,
67208, 67210, 67218, 67220,
67221, 67227, 67228, 92002,
92004, 92012, 92014, 92018,
92019, 92134, 92225-92228,
92230, 92235, 92240, 92250,
92260, 99203-99205, 9921399215, 99242-99245
3072F-low risk if retinopathy
in the previous year (no
evidence of retinopathy in
the previous year)
2022F=Dilated retinal eye
exam with interpretation by
the ophthalmologist or
optometrist documented and
review
2024F=7 standard field
stereoscopic photos with
interpretation by an
ophthalmologist or
optometrist documented and
reviewed
2026F=Eye imaging
validated to match diagnosis
from 7 standard field
sterestopic photos results
documented and reviewed
COA(Care of Older Adults)
1157F=Advance Care Plan
or similar legal document
present in the medical record
Evidence of Advance Care
Planning during the year
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1158F=Advance Care
planning discussion
documented in the medical
record
COA
1159F=Medication list
documented in the medical
record
Medication Review
90862, 99605, 99606
COA
1160F=Review of all
medications by a prescribing
practitioner or clinical pharmacist documented in the
medical record
1170F=Functional Status
Assessed
Functional Status
Assessment
COA
0521F=Plan of Care to
address pain documented
Pain Screening
1125F=Pain Severity
Quantified: pain present
1126F=no pain present
Comprehensive Diabetes
Care(CDC)
Nephropathy Screening Test
is performed at least once a
year. A member in
ACE\ARB or has
nephropathy is compliant for
this submeasure
Urine Macroalbumin
Evidence of Nephropathy
Treatment
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82042,82043,82044,84156
81000-81003, 81005
36147, 36800, 36810, 36815,
36818, 36819-36821, 3683136833, 50300, 50320, 50340,
50360, 50365, 50370, 50380,
90935, 90937, 90940, 90945,
90947, 90957-90962, 90965,
90966, 90969, 90970, 90989,
90993, 90997, 90999, 99512
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3060F=Positive
Microalbuminaria Test result
documented and reviewed
3061F=Negative
microalbuminaria test result
documented and reviewed
3062F=Positive
Macroalbumina test result
documented and reviewed
3066F=Documentation of
treatment of nephropathy
4010F=Angiotensin
Converting Enzyme (ACE)
Inhibitor or Angiotensin
Receptor Blocker (ARB)
therapy prescribed or
currently being taken
ACE inhibitor/ARB therapy
Diabetic Blood Pressure
Control
3074F=Systolic blood
pressure less than 130
mm/Hg
The most recent BP reading
during the year.
3078F=Diastolic blood
pressure less than 80 mm/Hg
Control 139/89
3075F=Systolic blood
pressure 130-139 mm/hg
3079F=Diastolic blood
pressure 80-89 mm/hg
3077F=Systolic blood
pressure greater than or equal
to 140 mm/hg
3080F=Diastolic blood
pressure greater than or equal
to 90 mm/hg
Medication Reconciliation
conducted by a prescribing
practitioner, clinical
pharmacist or registered
nurse on or within 30 days
of discharge
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1111F=Discharge
medications reconciled with
the current medication list in
outpatient medical record
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Quality Improvement Project (QIP)
CMS requires annually implementing a Quality Improvement Project. This year, CMS required
to Medicare Advantage organizations to implement a Quality Improvement Project focused on
reducing hospital re-admissions.
First Plus has developed a Transition Care Management Program to comply with the goal to reduce the hospital re-admissions of its members. There are several interventions being implemented to achieve this goal, such as: alert the Primary Physicians of the admission and discharge
of First+Plus members under their care to promote the post-discharge care visit, initiatives of
case management, among other interventions.
The Role of the Provider in the Quality Improvement Project to reduce hospital readmissions of First+Plus members:
1-Promote the post-discharge visit of the members under your care when First+Plus notified a
recent admission/discharge.
2- Educate the member who has had a recent admission to comply with their drugs therapy and
self-care strategies to avoid a readmission.
3- Collaborate in Case Management initiatives and First+Plus Post-Discharge Program.
4- Reconcile the medications of First+Plus members after hospital admission.
Chronic Care Improvement Program of First+Plus (CCIP)
As required by CMS, each Medicare Advantage organization must have established a program to
improve chronic care with a defined criteria to identify the members that are going to participate
in the Program. This year, CMS required developing a program focused to population with
cardiovascular problems.
First+Plus has identified an area of opportunity for its members diabetics with hypertension and
its CCIP Program is directed to improve the health status of these members with the goal of controlling their blood pressure. To achieve this goal, First+Plus are implementing various strategies
such as: sending educational material to all the members under the Program, educational sessions
and group activities, individual case management, among others.
The Role of the Provider in Chronic Care Improvement Program of First+Plus:
1- Educate your patient who is participating in the Program on strategies for controlling his/her
blood pressure and manage their diabetes.
2- Use clinical guidelines of Hypertension and Diabetes published by First+Plus that can be
accessed through http://www.firstpluspr.com/es/ in the Section of Provider’s Communication.
3- Promote your patient participation in the CCIP Program, to complete their records of blood
pressure, cholesterol, triglycerides and glycosylated hemoglobin.
4- Encourage females participating in the CCIP Program to access the Million Hearts Heart
Truth Program by accessing the following e-mail address:
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http://www.nhlbi.nih.gov/educational/hearttruth/espanol/index.htm
5- Support the Case Management Program activities for First+Plus members under your care.
6- Identify barriers that prevent members under the Program to comply with the goal of
controlling their blood pressure and establish strategies to eliminate them.
Special Needs Plans, Model of Care and Compliance Tool for Providers
First+Plus Special Needs Plans
Special Needs Plans (SNPs) are Medicare Advantage plans specialized for individuals with
special needs. In the Medicare Modernization Act of 2003, United State Congress identified
special needs individuals as: institutionalized beneficiaries or eligible for nursing home care,
dual eligible (Medicare and Medicaid) and/or individuals with severe or disabling chronic
conditions.
First+Plus currently offers the following Special Needs Plans:
•
•
First+Plus Complete- A Special Needs Plan available to people with Diabetes and
Medicare.
First+Plus Platino- A Special Needs Plan available to anyone who has both medical
assistance: Medicare and Medicaid.
Special Needs Plan Model of Care
Centers for Medicare and Medicaid Services (CMS) require that Special Needs Plans provide a
Model of Care through which they deliver healthcare services and manage care for members in a
Medicare Advantage organization. The Model of Care consists of eleven (11) elements:
1. Description of Special Needs Plan specific Target Population- Special Needs Plans must
provide a description of the population being served.
2. Measurable goals- Special Needs Plans must describe the specific care management
goal(s) in measurable terms (e.g., benchmarks, timeframes), how they expected to
achieve the goals and the criteria to determine whether goals are achieved.
3. Staff structure and care management roles- Special Needs Plans must provide a
description that identifies all staff, both employed and contracted, who performs
administrative, clinical and oversight functions for the Model of Care.
4. Interdisciplinary Care Team (ICT) - All Special Needs Plans must have an
Interdisciplinary Care Team (ICT) to coordinate the delivery of services and benefits for
members.
5. Provider network having special expertise and use of clinical practice guidelines and
protocols- Special Needs Plans should describe the specialized expertise in the
organization’s provider network to treat the special needs members and how is
determined that its providers are actively licensed and competent.
6. Model of Care Training (personnel and provider network)- Special Needs Plans must
describe how they conduct the initial and annual MOC training including: content and
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strategies to assure completion, actions to be taken for those who do not complete the
training and the personnel responsible for oversight these activities.
7. Health Risk Assessment (HRA)-The Health Risk Assessment includes a medical,
psychosocial, cognitive, and functional assessment that guides care management and
accounts for health status changes in the member. All Medicare Advantage organization
(MAO) must conduct HRAs when the member enrolls in the plan and within 12 months
of the last risk assessment, or as often as the health of the enrollee requires.
8. Individualized Care Plan (ICP)- The Interdisciplinary Care Team must consult with the
member to develop a comprehensive Individualized Care Plan that addresses the
member’s particular needs.
9. Communication Network- Special Needs Plan must coordinate the delivery of services
and benefits through integrated systems of communication among plan personnel, providers, and beneficiaries.
10. Care Management for the most vulnerable subpopulation- Special Needs Plans must
describe how most vulnerable members are identify and describe the delivery of add-on
services and benefits.
11. Performance and health outcome measurements- Special Needs Plan must describe how
and who collect, analyze, report and evaluate the Model of Care and how and to whom it
reports the results of the evaluation.
Model of Care Goals
First+Plus has adopted the following care management goals in which the First+Plus Provider
support is essential:
•
•
•
•
•
•
•
Improve member access to medical, mental health, and social services
Improve member access to affordable care
Improve coordination of care through an identified point of contact
Improve seamless transitions of care across healthcare settings, providers, and health
services
Improve member access to preventive health services
Assure appropriate utilization of services
Improve member health outcomes
Case Management Program- Please refers to the corresponding Section under Medical Affairs.
Compliance Tool for Providers
The provider role in the First+Plus Quality Projects is crucial because of his/her direct contact
with the member as the “health gatekeeper”. First+Plus Quality staff provides the following
Checklist as a Compliance Tool with the Elements of the Special Needs Plan Model of Care.
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First+Plus Special Needs Plan Model of Care Compliance Tool
Element: Interdisciplinary Care Team (ICT)
Call and ask to participate directly in the ICT, forum to discuss the case of your patient
with the purpose to identify alternatives available to meet the special needs of the
members and improves their health outcomes
Element: Provider network having special expertise and use of clinical practice guidelines
and protocols
Complete the First+Plus
credentialing and re-credentialing
process
Keep updated credentials
Notify credential changes and status
to First+Plus
Comply with the Clinical Practice
Guidelines and Protocols shared by
First+Plus. Electronic copy can be
access on www.firstpluspr.com
Element: Model of Care Training
Complete the First+Plus MOC
training
Complete the MOC Training
Acknowledgement Receipt Form
Keep the MOC training as reference
source. Electronic copy can be access on www.firstpluspr.com, under
Provider Section/Providers
Communication
Element: Health Risk Assessment (HRA)
Complete the Annual Medical
Assessment Form (AMAF) for each
First+Plus patient
Submit the completed AMAFs to
First+Plus
Continue and encourage the care
plan established in the AMAF
Re-assessed the member to identify
health status changes
Element: Individualized Care Plan
Review and discuss the
Individualized Care Plan sent by
First+Plus with the member
Encourage the member to continue
the treatment established in the care
plan
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Update the individualized care plan
as member health status change
Discuss the updated Individualized
Care Plan in response to changes in
the health status with the member
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Element: Network Communication
Communicate your availability to
participate in meetings and
conference call with the ICT by calling 787-620-1290
Access on regular basis the
First+Plus website to obtain
communications and recent events
Submit to First+Plus the
corresponding Acknowledgment of
Receipts
Check on regular basis your mail and
e-mail to validate if you have
received important communication
from First+Plus
Keep continue communication with
personnel of First+Plus Case
Management Program
Element: Care Management for the most vulnerable subpopulation
Maintain related with the benefits that the First+Plus Special Needs Plans provide
Refer to the marketing materials available through the First+Plus website
www.firstpluspr.com
Check in the Individualized Care Plan the risk stratification that First+Plus has
adjudicated to your patients to establish health strategies according to their risks
Refer the member to the several First+Plus Clinical Programs that meet the eligible
criteria using the Referral Form
Element: Performance and health outcome measurements
Analyze the several health reports of
your patients communicated by
First+Plus
Keep the proper communication in
the member record to support the
data recollection process, as HEDIS
Participate and support First+Plus
quality initiatives
Participate in First+Plus satisfaction
surveys
Timely respond to request of
information from First+Plus.
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First+Plus Special Needs Plan Structure and Process Project
The Centers for Medicare and Medicaid have contracted the National Committee for Quality Assurance (NCQA) to develop a strategy to evaluate the quality of care that Special Needs Plans provide. The strategy is divided in phases lasting several years starting with the definition and evaluation of the desirable structural characteristics, followed by the evaluation of the processes and ultimately, results. The assessment approach includes two types of assessment: HEDIS measures and
measures that assess the structure and process requirements by submitting documentation from the
health plan to NCQA.
During the evaluation process, First + Plus submits documentation to support the services offered
to its members, its Case Management Program, the Transition Care Program, Post-Discharge Management Program, among other documentation. The First+Plus Provider represents an important
role as a gatekeeper of the more vulnerable members and as a liaison between the member and the
case manager. First+Plus invites all its Providers to encourage First+Plus patients to benefit from
Case Management Program and from the First+ Plus Quality Projects and Programs.
CAHPS & HOS Satisfaction Surveys
A. Medicare Health Outcomes Survey
The Health Outcomes Survey by Medicare (HOS) provides a general indication of how well a
Medicare Advantage organization manages the Physical and Mental health of its members. Each
year, a sample of members of First + Plus are selected to answer the satisfaction questionnaire. The
first year of participation is called the Base Questionnaire and two years later, to the same group of
members, are repeated the same questionnaire and is called the Follow Up Questionnaire.
Here are some of the main components of the questionnaire of this Satisfaction Survey:
1. Physical Health Component
·
2.
Mental Health Component
·
3.
If the member has received education related to Urinary Incontinence
Physical activity in older adults
·
5.
Questions related to mood, problems with concentration, etc.
Management of urinary incontinence in older adults or urine leakage problems
·
4.
Questions related to activities of daily living
Limitation in physical activities or the execution of some physical activity such as
walking
Fall Prevention Management
·
If the member has received a falls prevention education
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6.
Osteoporosis Testing in Older Women
7.
Role of Physicians
·
Explanation of medical conditions (s) and laboratory results by the physician
·
Waiting time for treatment at medical office
The Role of First + Plus Providers in HOS Satisfaction Survey:
1. Communicate and educate your patients on how to improve their physical and mental
condition.
2.
Explain the treatment plan, so the member can understand his/her laboratory results, plan and
changes in his/her treatment and complications of the health condition(s).
3.
Encourage your patient to perform physical activity according to their medical condition.
4.
Provide written information on how to improve physical and mental health.
5.
Encourage your patient to contact their health plan to know about quality initiatives.
6.
Provide verbal and written education for the HOS components such as: prevention of falls,
urinary incontinence, influenza vaccine, among others.
7.
Monitor and provide tracking to the progress of physical and mental health of your patients
and their families at each visit.
B. Consumer Assessment of Healthcare Providers and System (CAHPS)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an annual satisfaction survey administered by CMS. The regulatory agency choose a sample of unaffiliated and affiliated members to get their opinion and experience in relation to clinical and administrative services
offered by both the health plan and its contracted providers.
CAHPS includes the following domains that are composed of a set of questions that are made to
members:
1.
Your health care in the last 6 months
2.
Your personal doctor
3.
Receiving health services from a specialist
4.
Your health plan
5.
Your Medicare rights
6.
Your drug plan and you
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Of these domains, specific indicators impact the Stars metrics such as:
1. Receiving needed health services
·
2.
·
In the past six months, how easy it was to get an appointment with a specialist?
Receiving timely care and appointments
In the past six months, when needed services as soon as possible, how fast you received
these services?
3.
Customer Service
4.
Overall rating of the quality of health care
·
Using the numbers from 0 (terrible) to 10 (being the best) what would be the score of
health care in the last 6 months?
5.
Overall health plan
6.
Coordination of Care
·
Did you receive follow up from the medical office for the diagnostic tests ordered?
7.
Drug Plan Information
8.
Drug Plan Rating
9.
Receiving necessary prescribed medications
The Role of First + Plus Provider in CAHPS Satisfaction Survey:
1. Educate your staff to receive First+Plus members with courtesy and respect.
2. Provide appointments to members in a timely manner according to the medical necessity presented.
3. Promote accessibility of health services needed by the member including referral to specialists.
4. If the member is referred to a specialist, makes sure the member understands the steps to take
and what to expect with that referral.
5. Maintain direct communication with consulting specialists to clarify any doubts or questions
about the member.
6. Conduct follow-up calls to members with outstanding diagnostic tests performed.
7. Keep all documentation in the medical record and accessible to the member, if requested.
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First+Plus Star Rating Project – Star Rating Methodology for Classification
The Center of Medicare and Medicaid Services (CMS) has developed a methodology for organizations with a Medicare Advantage contract aligned with the following three main objectives: provide better care, maintain healthier people and communities, and reduce health system costs
through continuous improvements. This classification is built on the granting of stars based on the
performance of the Medicare Advantage organizations related to quality standards identified annually by CMS. Also, this Star rating serves as a tool to inform and support the Medicare beneficiaries to make decisions concerning of their health plan through the comparison of their performance
based on the classification obtained. The classification is given from one (1) to five (5) stars:
Stars
1
2
3
4
5
Classification
Poor
Under Average
Average
Above Average
Excellent
The Classification is awarded based on the health plan’s performance of the 36 measures managing Medicare Part C and 15 measures for Medicare Part D. These quality measures are included
under the following categories:
• Outcomes: provision of services to enhance improvements in the members health status
through the services provided;
• Intermediate outcomes: specificity in the results of health services rendered;
• Experience: members perception about his/her experience during the received services;
• Access: issues or barriers to receive the necessary health care services;
• Process: processes and actions completed in the delivery of health care services.
The results of the quality measures using for the Stars Rating Classification are obtained from the
following data sources:
Data Source
HEDIS
CAHPS
HOS
PDE
(Prescription Drug Event Data)
Administrative Information
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Type
Health Effective Data Information System
based on the utilization of health care services
Satisfaction survey focused in the clinical care,
experience and results of the health care
services rendered and care coordination
Satisfaction survey focus in the experience and
health outcomes
Data of the pharmacy benefits utilization
Administrative data reported to CMS, audits
results, data concerning complaints and
appeals, health plan operational information
75
The Providers Role in First+Plus’ Stars Program:
CMS updates annually the quality measures under Stars Rating Classification. First+Plus
communicates these changes through the Provider Manual and/or related written communications
to support in the coordination of the appropriate health care services to First+Plus’ members and
comply with the requirements.
First+Plus providers take an active and leading role in the provision of essential and appropriate
health care services for the First+Plus members in order that they can maintain and improve their
health status. Some of the measures that are taken into consideration under Star Rating Classification that require specific interventions from First+Plus providers are:
Measure
Breast Cancer Screening
Colorectal Cancer Screening
Cardiovascular Care - Cholesterol Screening
Diabetes Care - Cholesterol Screening
Glaucoma Testing
Annual Flu Vaccine
Improving or Maintaining Physical Health
Improving or Maintaining Mental Health
Monitoring Physical Activity
Adult BMI Assessment
Care for Older Adults - Medication Review
Care of Older Adults - Functional Status Assessment
Care for Older Adults - Pain Screening
Osteoporosis Management in Women who
had a Fracture
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease Monitoring
Diabetes Care - Blood Sugar Controlled
Diabetes Care - Cholesterol Controlled
Controlling Blood Pressure
Rheumatoid Arthritis Management
Improving Bladder Control
Reducing the Risk of Falling
Plan All-Cause Readmissions
Getting Needed Care
Getting Appointments and Care Quickly
Care Coordination
Getting Needed Prescription Drugs
High Risk MedicationUtilization
Diabetes Treatment who also have high blood
pressure
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Data Source
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
CAHPS
HOS
HOS
HOS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HOS
HOS
HEDIS
CAHPS
CAHPS
CAHPS
CAHPS
PDE
PDE
76
Medication Adherence for Oral Diabetes
Medications
Medication Adherence for Hypertension
(ACEI or ARB)
Medication Adherence for Cholesterol
(Statins)
PDE
PDE
PDE
Through a continuous monitoring processes of the performance of these quality standards,
First+Plus ensures the provision of an excellent health care services to its members. These
monitoring procedures are carried out through population trends and individualized analysis for
providers. These analyses help First+Plus to create a provider network profile based on their
performance and quality of health services rendered. Based on these results, First+Plus develops
and implements various quality initiatives to improve the performance and achievement of
national, regional and/or organizational standards. These initiatives are supported by First+Plus
members and Providers’ network.
First+Plus encourages its contracted providers to review all the information included related to
quality initiatives, projects, programs and indicators, and complete the relevant interventions
aligned to them. Together, we can improve and maintain a good health status of First+Plus
members.
For more information or questions related to First+Plus’ Quality Programs and Projects, you may
contact the Provider Call Center at 1-866-505-5885 or (787) 620-1649. Monday to Friday 8:00am
to 5:00pm or send an email to the Quality Department at the following address:
[email protected]. We appreciate your constantly support and your active participation in
the Quality Projects and Programs to improve our member’s health. We are Quality!
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ANNUAL MEDICAL ASSESMENT FORM (AMAF)
As required by the Centers for Medicare and Medicaid Services (CMS), First+Plus is responsible
of ensuring all new beneficiaries receive a comprehensive evaluation within 90 days from the date
of enrollment and once a year for already established beneficiaries. The AMAF is the tool designed for physicians to document the annual face to face encounter.
The AMAF also facilitates with compliance and medical purposes such as:
•
Obtaining current clinical profiles of our population in order to design better medical management programs for our beneficiaries, in accordance with our Primary Care Physicians.
• Promoting activities focused on preventive measures and other quality initiatives compliance.
• Obtaining beneficiaries’ diagnoses updated in a timely manner in order to reflect the most
current health status of our population, as required by CMS.
For additional information or questions related to coding or Annual Medical Assessment Forms
(AMAF), please contact our Coding Department at (787) 622-0726 extension 302/294 or send us
an e-mail at [email protected]
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BILLING AND CLAIMS
Provider agrees to safeguard beneficiary privacy and confidentiality and assure accuracy of
beneficiary health records and encounter data. Submission of electronic claims/encounter data
must be done through the standard HIPAA formats 837P and 837I with the new 5010 HIPAA
compliance layout.
Those providers that submit paper claims must use the standard format CMS-1500 for professional
services, UB-04 for Institutional claims and J-400 ADA for dental services.
The providers must comply with prompt payment law requirements for timely claims submissions.
All required supporting documentation must also be submitted with a claim.
Each form type has its own require fields, depending on provider type. The required fields must be
completed on all form types in order for First Plus to evaluate and process your claim. Below
please find billing instructions for each form type (CMS-1450-UB-04/CMS-1500/ADA).
In order to process a claim adequately and promptly the provider must submit a clean claim to First
Plus. Our contract with Medicare requires that First Medical comply with all, Medicare laws,
regulations and CMS instructions applicable to the Medicare Advantage Program. Therefore, our
Claim Adjudication System applies all regulatory payment rules, according to the provider type,
and corresponding contract.
The Centers for Medicare and Medicaid Services (CMS) implemented several initiatives to prevent
improper payment before a claim is processed, and to identify and recoup improper payments after
the claim has been processed. These initiatives have been on place for many years and commonly
used and reported to providers by the Medicare contractors, and Medicare Advantage
Organizations such as First Medical. These initiatives have the purpose of reducing payment error
by identifying and addressing billing errors related to coverage and coding made by providers.
The National Correct Coding Initiatives (NCCI) Edits and the MUEs (Medicare Unlikely Edits)
are programs that apply the coding policies as defined by the American Medical Association
(AMA) Current Procedural Terminology (CPT) Manual, HealthCare Common Procedure Coding
System (HCPCS) Manual, National and local Medicare Policies and edits, coding guidelines
developed by national societies, standard medical and surgical practices and current coding
practice. The NCCI edits are updated quarterly. These edits are used to process physician services
under the Medicare Physician Fee Schedule.
It is important to understand, however, that the NCCI does not include all possible combinations of
correct coding edits or types of unbundling that exist. Providers are obligated to code correctly
even if edits do not exist to prevent use of an inappropriate code combination. Should providers
determine that claims have been coded incorrectly, they are responsible to contact First Medical to
submit a correct bill for the corresponding adjustment.
There are other payment rules which may be applicable to the different methodologies according
to the provider type and contract that the provider might have with First Medical. The OCE edits
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(Outpatient Code Editor) payment rules applies to hospital outpatient services that are contracted
under an APC payment methodology.
In the variety of provider contracts there might be other type of providers that are contracted under
DRG, APC, ASC, DME Fee Schedule, Anesthesia payment rules, Part B Drugs, Home Health
Services, etc. Different payment rules may apply for all of these payment methodologies.
It is important that the provider takes into consideration the importance of submitting a clean claim
with the correct coding information in all the required and correspondent fields. You can obtain
more information visiting the following Web Pages:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf
We are enclosing the billing instructions for submission of paper claims. Remember that it is
important to submit a timely and complete claim to expedite the processing of your claim.
TIMELY SUBMISSION OF CLAIMS
All claims from contracted providers must be submitted according to the Prompt Payment Law
Regulations of Puerto Rico, as amended from time to time. As of July 28th, 2011 the Prompt
Payment Law established the following time frame for claims submission:
Original ClaimOriginal Claim- inpatient services
Coordination of Benefits
Non-Processable Claims
Denials/partial payments (Adjustments)
90 days from service day
90 days from discharge date
90 days from the EOP date of the other payer
20 days from non processable letter
20 days from EOP DATE
For Non-Participating Providers, servicing First+Plus members, the CMS -Medicare regulations
related to timely submission of claims will be applied.
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BILLING INSTRUCCIONS FOR STANDARD PAPER CLAIM FORMS
We are enclosing the billing instructions for submission of paper claims. Remember that it is
important to submit a timely and complete claim to expedite the processing of your claim.
CMS- 1500
The following definitions apply to the provider terms used on the 1500 Claim Form.
Referring Provider
The Referring Provider is the individual who directed the patient for care to the provider rendering
the services being reported.
Examples include, but are not limited to, primary care provider referring to a specialist;
orthodontist referring to an oral and maxillofacial surgeon; physician referring to a physical
therapist; provider referring to a home health agency.
Enter the referring physician NPI number on field 17b of the CMS 1500 when applicable.
Ordering Provider
The Ordering Provider is the individual who requested the services or items being reported on A
service line.
Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment
or supplies.
Rendering Provider
The Rendering Provider is the individual who provided the care. In the case where a substitute
provider (locum tenens) was used, that individual is considered the Rendering Provider.
The Rendering Provider does not include individuals performing services in support roles, such as
lab technicians or radiology technicians.
Supervising Provider
The Supervising Provider is the individual who provided oversight of the Rendering Provider and
the care being reported.
An example includes, but is not limited to, supervision of a resident physician.
Purchased Service Provider
A Purchased Service Provider is an individual or entity that performs a service on a contractual or
reassignment basis for a separate provider who is billing for the service.
Examples of services include, but are not limited to: (a) processing a laboratory specimen; (b)
grinding eyeglass lenses to the specifications of the Rendering Provider; or (c) performing
diagnostic testing services (excluding clinical laboratory testing) subject to Medicare’s antimarkup rule. In the case where a substitute provider (a locum tenens physician) is used, that
individual is not considered a Purchased Service Provider.
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The following fields are required 1500 Health Insurance Claim Form:
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FIELD SPECIFIC INSTRUCTIONS –FIRST+PLUS
CARRIER BLOCK
The carrier block is located in the upper right margin of the form.
Instructions: Enter in the white, open carrier area the name and address of the payer to whom this
claim is being sent. Enter the name and address information in the following format:
1st Line – Name
2nd Line – First line of address
3rd Line – Second line of address
4th Line – City State (2 characters) and ZIP Code
Line Descriptor Type Bytes Columns
4 Payer Name A/N 41 38-78
5 Payer Address 1 A/N 41 38-78
6 Payer Address 2 A/N 41 38-78
7 Payer City State and ZIP A/N 41 38-78
For an address with three lines, enter it in the following format:
1st Line – Name
2nd Line – Line of address
3rd Line – Leave blank
4th Line – City State (2 characters) and ZIP Code
ITEMS 1–13: PATIENT AND INSURED INFORMATION
Item Number 1
Title: Medicare, Medicaid, TRICARE CHAMPUS, CHAMPVA, Group Health Plan, FECA,
Black Lung, Other
Instructions: Indicate the type of health insurance coverage applicable to this claim by placing an
X in the appropriate box. Only one box can be marked.
Description: “Medicare, Medicaid, TRICARE CHAMPUS, CHAMPVA, Group Health Plan,
FECA, Black Lung, or Other” means the insurance type to whom the claim is being submitted.
Other indicates health insurance including HMOs, commercial insurance, automobile accident,
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liability, or workers’ compensation. This information directs the claim to the correct program and
may establish primary liability.
Field Specifications: This field allows for entry of 1 character in any box within the field.
Situational Field
Item Number 1a
Title: Insured’s ID Number
Instructions: Enter “Insured’s ID Number” as shown on First+Plus insured’s ID card of the
member.
Description: The “Insured’s ID Number” is the identification number of the insured. This
information identifies the insured to the payer.
Field Specification: This field allows for entry of 29 characters.
REQUIRED FIELD
Note: Claims with invalid, missing or incorrect member id number will be rejected as nonprocessable claims. Providers must correct and return the corrected claim form along with
the non- processable letter within the time frame establish by the Prompt Payment Law of
Puerto Rico.
Item Number 2
Title: Patient’s Name
Instructions: Enter the patient’s full last name, first name, and middle initial. If the patient uses a
last name suffix (e.g., Jr, Sr) enter it after the last name, and before the first name. Titles (e.g.,
Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the
name. Use commas to separate the last name, first name, and middle initial. A hyphen can be used
for hyphenated names. Do not use periods within the name.
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Description: The “Patient’s Name” is the name of the person who received the treatment or
supplies.
Field Specification: This field allows for the entry of 28 characters.
REQUIRED FIELD
Note: Provider must ensure that the Patient ID and the name matches the member ID card
from First+Plus.
Item Number 3
Title: Patient’s Birth Date, Sex
Instructions: Enter the patient’s 8-digit birth date (MM | DD | CCYY). Enter an X in the correct
box to indicate sex of the patient. Only one box can be marked. If gender is unknown, leave blank.
Description: The “Patient’s Birth Date, Sex” (gender) is information that will identify the patient
and it distinguishes persons with similar names.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2
characters under DD, 4 characters under YY, and 1 character in either box.
REQUIRED FIELD
Item Number 4
Title: Insured’s Name
Instructions: Enter the insured’s full last name, first name, and middle initial. If the insured uses a
last name suffix (e.g., Jr, Sr) enter it after the last name, and before the first name. Titles (e.g.,
Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the
name. Use commas to separate the last name, first name, and middle initial. A hyphen can be used
for hyphenated names. Do not use periods within the name.
Description: The “Insured’s Name” identifies the person who holds the policy, which would be
the employee for employer-provided health insurance.
Field Specification: This field allows for the entry of 29 characters.
SITUATIONAL FIELD
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Item Number 5
Title: Patient’s Address (multiple fields)
Instructions: Enter the patient’s mailing address and telephone number. The first line is for the
street address; the second line, the city and state; the third line, the ZIP code and phone number.
Do not use punctuation (i.e., commas, periods) or other symbols in the address. When entering a 9digit ZIP code, include the hyphen. If reporting a foreign address, contact payer for specific
reporting instructions. If the patient’s address is the same as the insured’s address, then it is not
necessary to report the patient’s address. “Patient’s Telephone” does not exist in 4010A1 or
5010A1. The NUCC recommends that the phone number not be reported.
For Workers’ Compensation and Other Property and Casualty Claims: If required by a payer
to report a telephone number, do not use a hyphen or space as a separator within the telephone
number.
Description: The “Patient’s Address” refers to the patient’s permanent residence. A temporary
address should not be used.
Field Specification: This field allows for the entry of the following: 28 characters for street
address, 24 characters for city, 3 characters for state, 12 characters for ZIP code, 3 characters for
area code, and 10 characters for phone number.
REQUIRED FIELD
Item Number 6
Title: Patient Relationship to Insured
Instructions: Enter an X in the correct box to indicate the patient’s relationship to insured when
Item Number 4 is completed. Only one box can be marked.
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Description: The “Patient Relationship to Insured” refers to how the patient is related to the
insured. “Self” would indicate that the insured is the patient. “Spouse” would indicate that the
patient is the husband or wife
or qualified partner as defined by the insured’s plan. “Child” would indicate that the patient is the
minor dependent as defined by the insured’s plan. “Other” would indicate that the patient is other
than the self, spouse, or child, which may include employee, ward, or dependent as defined by the
insured’s plan.
Field Specification: This field allows for entry of 1 character in any box within the field.
REQUIRED FIELD
Item Number 7
Title: Insured’s Address (multiple fields)
Instructions: Enter the insured’s address and telephone number. If Item Number 4 is completed
then this field should be completed. The first line is for the street address; the second line, the city
and state; the third line, the ZIP code and phone number.
Do not use punctuation (i.e., commas, periods) or other symbols, in the address. When entering a
9-digit ZIP code, include the hyphen. If reporting a foreign address, contact payer for specific
reporting instructions. “Insured’s Telephone” does not exist in 4010A1 or 5010A1. The NUCC
recommends that the phone number not be reported.
For Workers Compensation Claims: Enter the address of the employer.
For Other Property & Casualty Claims: Enter the address of the insured noted in Item Number
4.
For Workers’ Compensation and Other Property and Casualty Claims: If required by a payer
to report a telephone number, do not use a hyphen or space as a separator within the telephone
number.
Description: The “Insured’s Address” refers to the insured’s permanent residence, which may be
different from the patient’s address in Item Number 5.
Field Specification: This field allows for the entry of the following: 29 characters for street
address, 23 characters for city, 4 characters for state, 12 characters for ZIP code, 3 characters for
area code, and 10 characters for phone number.
SITUATIONAL FIELD
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Item Number 8
Title: Patient Status
Instructions: “Patient Status” does not exist in 4010A1 or 5010A1. The NUCC recommends that
this field not be used. If required by a payer to report, enter an X in the box for the patient’s marital
status, and for the patient’s employment or student status. Only one box on each line can be
marked.
Description: The “Patient Status” indicates the patient’s marital and employment status.
“Employed” would indicate that the patient has a job.
Field Specification: This field allows for entry of 1 character in any box within the field.
SITUATIONAL FIELD
Item Number 9
Title: Other Insured’s Name
Instructions: If Item Number 11d is marked, complete fields 9 and 9a-d, otherwise leave blank.
When additional group health coverage exists, enter other insured’s full last name, first name, and
middle initial of the enrollee in another health plan if it is different from that shown in Item
Number 2. If the insured uses a last name suffix (e.g., Jr, Sr) enter it after the last name, and before
the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should
not be included with the name.
Use commas to separate the last name, first name, and middle initial. A hyphen can be used for
hyphenated names. Do not use periods within the name.
Description: The “Other Insured’s Name” indicates that there is a holder of another policy that
may cover the patient.
Field Specification: This field allows for the entry of 28 characters.
SITUATIONAL FIELD
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Item Number 9a
Title: Other Insured’s Policy or Group Number
Instructions: Enter the policy or group number of the other insured. Do not use a hyphen or space
as a separator within the policy or group number.
Description: The “Other Insured’s Policy or Group Number” identifies the policy or group
number for coverage of the insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
SITUATIONAL FIELD
Item Number 9b
Title: Other Insured’s Date of Birth, Sex
Instructions: “Other Insured’s Date of Birth, Sex” does not exist in 4010A1 or 5010A1. The
NUCC recommends that this field not be used.
If required by payer to report, enter the 8-digit date of birth (MM│DD│CCYY) of the other
insured and an X to indicate the sex of the other insured. Only one box can be marked. If gender is
unknown, leave blank.
Description: The “Other Insured’s Date of Birth, Sex” (gender) identifies the birth date and
gender of the insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2
characters under DD, 4 characters under YY, and 1 character in either box.
SITUATIONAL FIELD
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Item Number 9c
Title: Employer’s Name or School Name
Instructions: “Employer’s Name or School Name” does not exist in 4010A1 or 5010A1. The
NUCC recommends that this field not be used. If required by a payer to report, enter the name of
the other insured’s employer or school.
Description: The “Employer’s Name or School Name” identifies the name of the employer or
school attended by the other insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
SITUATIONAL FIELD.
Item Number 9d
Title: Insurance Plan Name or Program Name
Instructions: Enter the other insured’s insurance plan or program name.
Description: The “Insurance Plan Name or Program Name” identifies the name of the plan or
program of the other insured as indicated in Item Number 9.
Field Specification: This field allows for the entry of 28 characters.
SITUATIONAL FIELD.
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Item Numbers 10a–10c
Title: Is Patient’s Condition Related To:
Instructions: When appropriate, enter an X in the correct box to indicate whether one or more of
the services described in Item Number 24 are for a condition or injury that occurred on the job or
as a result of an automobile or other accident. Only one box on each line can be marked.
The state postal code where the accident occurred must be reported, if “YES” is marked in 10b for
“Auto Accident.” Any item marked “YES” indicates there may be other applicable insurance
coverage that would be primary, such as automobile liability insurance. Primary insurance
information must then be shown in Item Number 11.
Description: This information indicates whether the patient’s illness or injury is related to
employment, auto accident, or other accident. “Employment” (current or previous) would indicate
that the condition is related to the patient’s job or workplace. “Auto Accident” would indicate that
the condition is the result of an automobile accident. “Other Accident” would indicate that the
condition is the result of any other type of accident.
Field Specification: This field allows for the entry of the following: 1 character in either box per
each line and 2 characters in the Place/State field
SITUATIONAL FIELD.
Item Number 10d
Title: Reserved for Local Use
Instructions: Please refer to the most current instructions from the applicable public or private
payer regarding the use of this field. When required by payers to provide a sub-set of Condition
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Codes approved by the NUCC, enter the Condition Code in this field. The Condition Codes
approved for use on the 1500 Claim Form are available at www.nucc.org under Code Sets.
For Workers Compensation Claims: Condition Codes are required when submitting a bill that is
a duplicate or an appeal. (Original Reference Number must be entered in Box 22 for these
conditions). Note: Do not use Condition Codes when submitting a revised or corrected bill.
Field Specification: This field allows for the entry of 19 characters.
SITUATIONAL FIELD.
Item Number 11
Title: Insured’s Policy, Group, or FECA Number
Instructions: Enter the insured’s policy or group number as it appears on the insured’s health care
identification card. If Item Number 4 is completed, then this field should be completed.
Do not use a hyphen or space as a separator within the policy or group number.
For Workers Compensation and Other Property & Casualty Claims: Required if known.
Enter Workers’ Compensation or Property & Casualty Claim Number assigned by the payer.
Description: The “Insured’s Policy, Group, or FECA Number” refers to the alphanumeric
identifier for the health, auto, or other insurance plan coverage. For worker’s compensation claims
the workers compensation carrier’s alphanumeric identifier would be used. The FECA number is
the 9-digit alphanumeric identifier assigned to a patient claiming work-related condition(s) under
the Federal Employees Compensation Act 5 USC 8101.
Field Specification: This field allows for the entry of 29 characters.
SITUATIONAL FIELD.
Item Number 11a
Title: Insured’s Date of Birth, Sex
Instructions: Enter the 8-digit date of birth (MM | DD | CCYY) of the insured and an X to
indicate the sex of the insured. Only one box can be marked. If gender is unknown, leave blank.
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Description: The “Insured’s Date of Birth, Sex” (gender) refers to the birth date and gender of the
insured as indicated in Item Number 1a.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2
characters under DD, 4 characters under YY, and 1 character in either box.
REQUIRED FIELD.
Item Number 11b
Title: Employer’s Name or School Name
Instructions: “Employer’s Name or School Name” does not exist in 4010A1 or 5010A1. The
NUCC recommends that this field not be used. If required by payer to report, enter the name of
the insured’s employer or school.
Description: The insured’s “Employer’s Name or School Name” refers to the name of the
employer or school attended by the insured as indicated in Item Number 1a.
Field Specification: This field allows for the entry of 29 characters.
SITUATIONAL FIELD
Item Number 11c
Title: Insurance Plan Name or Program Name
Instructions: Enter the “Insurance Plan or Program Name” of the insured. Some payers require an
identification number of the primary insurer rather than the name in this field.
Description: The “Insurance Plan Name or Program Name” refers to the name of the plan or
program of the insured as indicated in Item Number 1a.
Field Specification: This field allows for the entry of 29 characters.
SITUATIONAL FIELD
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Item Number 11d
Title: Is there another Health Benefit Plan?
Instructions: When appropriate, enter an X in the correct box. If marked "YES", complete 9 and
9a–d. Only one box can be marked.
Description: "Is there another health benefit plan" indicates that the patient has insurance
coverage other than the plan indicated in Item Number 1.
Field Specification: This field allows for the entry of 1 character in either box.
SITUATIONAL FIELD
Item Number 12
Title: Patient’s or Authorized Person’s Signature
Instructions: Enter “Signature on File,” “SOF,” or legal signature. When legal signature, enter
date signed in 6-digit format (MMDDYY) or 8-digit format (MMDDCCYY
Description: The “Patient’s or Authorized Person’s Signature” indicates there is an authorization
on file for the release of any medical or other information necessary to process and/or adjudicate
the claim.
Field Specification: Use the space available to enter signature/information and date.
REQUIRED FIELD
NOTE: Claims with missing information on this field will be returned to the provider as non
processable claim. The provider must submit the corrected claim along with the nonprocessable letter within the time frame establishes by the Prompt Payment Law of Puerto
Rico.
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Item Number 13
Title: Insured’s or Authorized Person’s Signature
Instructions: Enter “Signature on File,” “SOF,” or legal signature.
Description: The “Insured’s or Authorized Person’s Signature” indicates that there is a signature
on file authorizing payment of medical benefits.
Field Specification: Use the space available to enter signature/information.
REQUIRED FIELD
NOTE: Claims with missing information on this field will be returned to the provider as non
processable claim. The provider must submit the corrected claim along with the nonprocessable letter within the time frame establishes by the Prompt Payment Law of Puerto
Rico.
ITEMS 14–33: PROVIDER OR SUPPLIER INFORMATION
Item Number 14
Title: Date of Current Illness, Injury, Pregnancy
Instructions: Enter the 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) date of the first
date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual
period (LMP) as the first date.
Description: The “Date of Current Illness, Injury and Pregnancy” refers to the first date of onset
of illness, the actual date of injury, or the LMP for pregnancy.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2
characters under DD, and 4 characters under YY.
SITUATIONAL FIELD
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Item Number 15
Title: If Patient Has Had Same or Similar Illness
Instructions: Enter the first date the patient had the same or a similar illness. Enter the date in the
6-digit format (MM | DD | YY) or 8-digit format (MM | DD | CCYY). Previous pregnancies are
not a similar illness.
If required by payer to report, enter the first date the patient had the same or a similar illness.
Enter the date in the 6-digit format (MM | DD | YY) or 8-digit format (MM | DD | CCYY).
Previous pregnancies are not a similar illness.
Description: A patient having had same or similar illness would indicate that the patient had a
previously related condition. If a post stabilization service the provider should indicate the date of
the previous emergency services provided to the patient.
Field Specification: This field allows for the entry of the following: 2 characters under MM, 2
characters under DD, and 4 characters under YY.
SITUATIONAL FIELD
Item Number 16
Title: Dates Patient Unable to Work in Current Occupation
Instructions: If the patient is employed and is unable to work in current occupation, a 6-digit
(MM | DD | YY) or 8-digit (MM | DD | CCYY) date must be shown for the "from–to" dates that
the patient is unable to work.
An entry in this field may indicate employment-related insurance coverage.
Description: “Dates Patient Unable to Work in Current Occupation” refers to the time span the
patient is or was unable to work.
Field Specification: This field allows for the entry of the following in each of the date fields: 2
characters under MM, 2 characters under DD, and 4 characters under YY.
SITUATIONAL FIELD
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Item Number 17
Title: Name of Referring Provider or Other Source
Instructions: Enter the name (First Name, Middle Initial, and Last Name) and credentials of the
professional who referred, ordered, or supervised the service(s) or supply (ies) on the claim.
If multiple providers are involved, enter one provider using the following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider
Do not use periods or commas within the name. A hyphen can be used for hyphenated names.
Description: The name is the referring provider, ordering provider, or supervising provider who
referred, ordered, or supervised the service(s) or supply (ies) on the claim.
Field Specification: This field allows for the entry of 26 characters.
SITUATIONAL FIELD
Item Number 17a and 17b (split field)
Title 17a: Other ID#
Instructions 17a: The Other ID number of the referring, ordering, or supervising provider is
reported in 17a in the shaded area. The qualifier indicating what the number represents is reported
in the qualifier field to the immediate right of 17a.
Description: The non-NPI ID number of the referring, ordering, or supervising provider refers to
the unique identifier of the professional or to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 2 characters in the qualifier field and 17
characters in the Other ID# field.
SITUATIONAL FIELD
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Title 17b: NPI #
Instructions 17b: Enter the NPI number of the referring, ordering, or supervising provider in Item
Number 17b.
Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of a 10-digit NPI number
SITUATIONAL FIELD.
NOTE: If field # 17 is completed, then field #17b must be completed also.
Item Number 18
Title: Hospitalization Dates Related to Current Services
Instructions: Enter the inpatient 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) hospital
admission date followed by the discharge date (if discharge has occurred). If not discharged, leave
discharge date blank. This date is when a medical service is furnished as a result of, or subsequent
to, a related hospitalization.
Description: The “Hospitalization Dates Related to Current Services” refers to an inpatient stay
and indicates the admission and discharge dates associated with the service(s) on the claim.
Field Specification: This field allows for the entry of the following in each of the date fields: 2
characters under MM, 2 characters under DD, and 4 characters under YY.
SITUATIONAL FIELD
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Item Number 19
Title: Reserved for local use
Instructions: Please refer to the most current instructions from the applicable public or private
payer regarding the use of this field. Some payers ask for certain identifiers in this field. If
identifiers are reported in this field, enter the appropriate qualifiers describing the identifier. Do
not enter a space, hyphen, or other separator between the qualifier code and the number.
This field is used to supply any additional supporting information related to the Claim.
First+Plus will advise provider for the use of this field when deem necessary.
Item Number 20
Title: Outside Lab? $Charges
Instructions: Complete this field when billing for purchased services by entering an X in
“YES.” A “YES” mark indicates that the reported service was provided by an entity other than the
billing provider (for example, services subject to Medicare’s anti-markup rule). A “NO” mark or
blank indicates that no purchased services are included on the claim.
If “Yes” is annotated, enter the purchase price under “$Charges” and complete Item Number 32.
Each purchased service must be reported on a separate claim form as only one charge can be
entered. When entering the charge amount, enter the amount in the field to the left of the vertical
line. Enter number right justified to the left of the vertical line. Enter 00 for cents if the amount is a
whole number. Do not use dollar signs, commas, or a decimal point when reporting amounts.
Negative dollar amounts are not allowed. Leave the right-hand field blank.
Description: “Outside lab? $Charges” reports the costs related to services rendered by an
independent provider as indicated in Item Number 32.
Field Specification: This field allows for the entry of the following: 1 character in either box in
the Outside Lab area and 8 characters to the left of the vertical line in the $Charges area.
SITUATIONAL FIELD
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Item Number 21
Title: Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line)
Instructions: Enter the patient’s diagnosis/condition. Relate lines 1, 2, 3, 4 to the lines of service
in 24E by line number (Diagnosis Pointer). Use the highest level of specificity. Do not provide
narrative description in this field.
Description: The “Diagnosis or Nature of Illness or Injury” refers to the sign, symptom,
complaint, or condition of the patient relating to the service(s) on the claim.
Field Specification: This field allows for the entry of 3 characters prior to the period, 1 character
above the period, and 4 characters after the period in each of the four line areas.
REQUIRED FIELD. At least a principal diagnosis must be reported on field #1.
NOTE: Claims with missing, invalid or incomplete information on this field will be returned
to the provider as non processable claim. The provider must submit the corrected claim
along with the non-processable letter within the time frame establishes by the Prompt
Payment Law of Puerto Rico.
Note 1: We encourage the reporting of any additional diagnosis beyond the four spaces allow on
the CMS 1500 Claim form. In order to comply with this, please specify the diagnosis order
number such as 5, 6, 7, 8, etc., and enter the appropriate additional diagnosis code.
Please be aware that you must code the diagnosis to the highest level of specificity. The ICD-9CM coding book has the information related to diagnosis that requires a four or fifth digit, as well
as the identification of diagnosis that cannot be used as principal diagnosis. Please refer to the
symbols and description use on the ICD-9-CM coding books.
Note 2: The Centers for Medicare and Medicaid Services along with the Uniform Billing
Committee has approved a new CMS 1500 Claim Form that will be release in a near future. The
new CMS 1500 claim form will allow the reporting of more than four diagnoses on field #21. This
field has been expanded to accommodate the ICD-10 diagnoses codes which are in schedule for
implementation on October 1st, 2014. Providers must start getting ready for this major change on
coding of diagnosis.
Note 3: When the new CMS 1500 become available, FIRST+PLUS will inform the providers of
the changes on billing requirements according with the new parameters determine by CMS and the
UNIFORM BILLING COMMITTEE.
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Item Number 22
Title: Medicaid Resubmission and/or Original Reference Number
Instructions: List the original reference number for resubmitted claims. Please refer to the
most current instructions from the applicable public or private payer regarding the use of this field
(e.g., code).
Description: Medicaid resubmission means the code and original reference number assigned by
the destination payer or receiver to indicate a previously submitted claim or encounter.
Field Specification: This field allows for the entry of 11 characters in the Code area and 18
characters in the Original Ref. No. area.
SITUATIONAL FIELD.
Note: If the provider is submitting an adjustment request/appeal the field ORIGINAL REF
NO must be filled with the unique Claim Number assigned by the Plan for each specific
claim, which can be found on the Explanation of Payment.
Item Number 23
Title: Prior Authorization Number
Instructions: Enter any of the following: prior authorization number or referral number,
mammography pre-certification number, or Clinical Laboratory Improvement Amendments
(CLIA) number, as assigned by the payer for the current service.
Do not enter hyphens or spaces within the number.
For Workers Compensation and Other Property & Casualty Claims: Required when prior
authorization, referral, concurrent review, or voluntary certification was received.
Description: The “Prior Authorization Number” refers to the payer assigned number
authorizing the service(s).
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Field Specification: This field allows for the entry of 29 characters.
Note 1: The pre-authorization of a service does not guarantee the payment. The payment is
subject to the member’s eligibility, and his/her benefit package at the time the service is rendered.
Remember that the authorized services are subject to the application of payment rules, coding
guidelines according to CMS, AMA regulations as well as any rules established by FIRST+PLUS.
Note 2: If service requires an authorization the number must be included with the claim.
SITUATIONAL FIELD.
SECTION 24
Shaded area
Title: Shaded section for supplemental information
Instructions: Supplemental information can only be entered with a corresponding, completed
service line.
The six service lines in section 24 have been divided horizontally to accommodate submission of
both the NPI and another/proprietary identifier and to accommodate the submission of
supplemental information to support the billed service.
The top area of the six service lines is shaded and is the location for reporting supplemental
information. It is not intended to allow the billing of 12 lines of service.
The supplemental information is to be placed in the shaded section of 24A through 24G as
defined in each Item Number. Providers must verify requirements for this supplemental
information with the payer.
Field Specifications: The shaded area of lines 1 through 6 allow for the entry of 61 characters
from the beginning of 24A to the end of 24G.
Situational Field
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Item Number 24A
Title: Date(s) of Service [lines 1–6]
Instructions: Enter date(s) of service, both the
“From” and “To” dates. If there is only one date of
service, enter that date under “From” and also on the
“To” field.
Note: The provider must enter both “from” and
“through “dates, regardless if both are the same date.
Claims with missing “through” service dates will be
returned to the providers as non-processable claims.
The number of days must correspond to the number of
units in 24G.
Description: “Date(s) of Service” indicate the actual
month, day, and year the service(s) was provided.
Field Specification: This field allows for the entry of
the following in each of the unshaved date fields: 2
characters under MM, 2 characters under DD, and 2
characters under YY.
REQUIRED FIELD
Item Number 24B
Title: Place of Service [lines 1–6]
Instructions: In 24B, enter the appropriate two-digit
code from the Place of Service Code list for
each item used or service performed. The Place of
Service Codes are available at:
www.cms.gov/physicianfeesched/downloads/Websit
e_POS_database.pdf
Description: The “Place of Service” Code identifies
the location where the service was rendered.
Field Specification: This field allows for the entry of
2 characters in the unshaved area.
Note:
Only one Place of Service code is allowed on
the CMS 1500. If you have rendered services for the
same patient on different places of services, you must
bill the services on separate CMS 1500 by the place of
services code. (e.i you rendered services to a patient on
both POS 11 (OFFICE) and 21 (inpatient), please send
separate bills by place of service code for the same
patient.
REQUIRED FIELD
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Item Number 24C
Title: EMG [lines 1–6]
Instructions: Check with payer to determine if this
element (emergency indicator) is necessary. If
required, enter Y for "YES" or leave blank if "NO" in
the bottom, unshaved area of the field.
The definition of emergency would be either defined
by federal or state regulations or programs, payer
contracts.
Field Specification: This field allows for the entry of
2 characters in the unshaved area.
REQUIRED FIELD
Item Number 24D
Title: Procedures, Services, or Supplies [lines 1–6]
Instructions: Enter the CPT or HCPCS code(s) and
modifier(s) (if applicable) from the appropriate code
set on effect for the date of service submitted on the
claim. This field accommodates the entry of procedure
code(s) must be shown without a narrative description.
Invalid, deleted code for the service date,
incomplete, missing or illegible codes will be denied
to the provider. Provider must made the
corrections and submit the same to First+Plus
Claims Department within the time frame establish
by Prompt Payment Law of Puerto Rico.
Description: The “Procedures, Services or Supplies”
refer to a listing of identifying codes for reporting
medical services and procedures.
Field Specification: This field allows for the entry of
the following: 6 characters in the un-shaded area of the
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CPT/HCPCS field and four sets of 2 characters in the
Modifier area.
Note : CPT Category II Codes
CPT Category II or CPT Codes that are developed
through the CPT Editorial Panel for use in
performance measurement serve to encode the quality
action(s) described in a measure’s numerator. CPT II
codes consist of five alphanumeric characters in a
string, ending with the letter “F”. We encourage the
reporting of these quality measure CPT codes.
REQUIRED FIELD
Item Number 24E
Title: Diagnosis Pointer [lines 1–6]
Instructions: In 24E, enter the diagnosis code
reference number (pointer) as shown in Item Number
21 to relate the date of service and the procedures
performed to the correspondent diagnosis. When
multiple diagnoses are related to one service, the
reference number for the primary diagnosis should be
listed first, other applicable diagnosis reference
numbers should follow. The reference number(s)
should be a 1, or a 2, or a 3, or a 4; or multiple
numbers as explained. (ICD-9-CM diagnosis codes
must be entered in Item Number 21 only. Do not
enter them in 24E.)
Enter numbers left justified in the field. Do not use
commas between the numbers.
Description: The “Diagnosis Pointer” refers to the
line number from Item Number 21 that relates to the
reason the service(s) was performed. There are
services that are related to specific conditions in order
to be reimbursable. Therefore, the provider must be
aware that any related diagnosis indicated on field
number 21 to a service code on field number 24d must
contain the pointer associated to the service.
Field Specification: This field allows for the entry of
4 characters in the unshaded area.
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REQUIRED FIELD
NOTES: Common errors usually observed are the
following:
-Providers indicates a pointer number that
Should be associated to a diagnosis code on field
21, but
there is not diagnosis code on that
Position number of field 21 (e.i- provider
Indicates a pointer 4 when there is not a
Diagnosis code on position 4 of field #21)
-Provider enters the ICD-9-cm code on this field
Instead of the pointer
-Providers leave the field blank
Failure to complete this field will result on a nonProcessable claim which will be returned to the
provider for correction.
Item Number 24F
Title: $ Charges [lines 1–6]
Instructions: Enter the charge for each listed service.
Enter number right justified in the dollar area of the
field. Do not use commas when reporting dollar
amounts. Negative dollar amounts are not allowed.
Dollar signs should not be entered. Enter 00 in the
cents area if the amount is a whole number.
Description: “$Charges” refers to the total billed
amount for each service line.
Field Specification: This field allows for the entry of
6 characters to the left of the vertical line and 2
characters to the right of the vertical line in the
unshaved area.
REQUIRED FIELD
Item Number 24G
Title: Days or Units [lines 1–6]
Instructions: Enter the number of days or units. This
field is most commonly used for multiple visits, units
of supplies, anesthesia minutes, or oxygen volume. If
only one service is performed, the numeral 1 must be
entered. Enter numbers right justified in the field. No
leading zeros are required. If reporting a fraction of a
unit, use the decimal point.
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Anesthesia services must be reported as minutes.
Description: “Days or Units” refers to the number of
days corresponding to the dates entered in 24A or units
as defined in CPT or HCPCS coding manual(s).
Field Specification: This field allows for the entry of
3 characters in the un-shaded area.
REQUIRED FIELD
Item Number 24H
Title: EPSDT/Family Plan [lines 1–6]
Instructions: For Early & Periodic Screening,
Diagnosis, and Treatment related services, enters the
response in the shaded portion of the field as follows:
If there is no requirement (e.g., state requirement) to
report a reason code for EPDST, enter Y for “YES” or
N for “NO” only.
Description: The “EPSDT/Family Plan” identifies
certain services that may be covered under some state
plans.
Field Specification: This field allows for the entry of
1 character in the un-shaded area and 2 characters in
the shaded area.
SITUATIONAL FIELD
Item Number 24I
Title: ID Qualifier [lines 1–6]
Instructions: Enter in the shaded area of 24I the
qualifier identifying if the number is a non-NPI. The
shaded area. Other ID# of the rendering provider is
reported in 24J
Description: Enter the non NPI number on this field
Field Specification: This field allows for the entry of
a 2 character qualifier in the shaded area.
SITUATIONAL FIELD
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Item Number 24J
Title: Rendering Provider ID # [lines 1–6]
Instructions: The individual rendering the service is
reported in 24J. Enter the NPI number in the
unshaved area of the field.
The Rendering Provider is the person or company who
rendered or supervised the care. Report the
Identification Number in 24J ONLY when it is
different from data recorded in items 33a. Enter
numbers left justified in the field.
Remember you only report this field when the
rendering and billing providers NPI are different.
Otherwise do not report when the rendering and billing
NPI are the same.
Description: The NPI ID number of the rendering
provider refers to the unique identifier of the provider.
Field Specification: This field allows for the entry of
a 10 digit NPI number of the unshaved area.
REQUIRED FIELD
NOTES: COMMON BILLING ERRORS
-
-
Provider Manual 2013
Scenario #1 Combination of rendering provider
and billing provider does not match the contracting
arrangement on file. This usually occurs when the
billing provider is a group/corporation and there
are either one or others providers under that group.
Under this specific set-up the rendering provider
must be specify on field 24J. That rendering provider should be included under the group contract.
If a claim is returned as non processable or deny
for this issue you should contact Providers Department Credentialing Unit to verify the contracting arrangement on file
Scenario #2 Providers has a contract arrangement
as a group/corporation and bills as individual provider. You should contact providers Department
Credentialing Unit to verify your contracting arrangements.
116
Item Number 25
Title: Federal Tax ID Number
Instructions: Enter the “Federal Tax ID Number” (employer identification number or Social
Security number) of the Billing Provider identified in Item Number 33/33a. This is the tax ID
number intended to be used for 1099 reporting purposes. Enter an X in appropriate box to indicate
which number is being reported. Only one box can be marked.
Description: The “Federal Tax ID Number” refers to the unique identifier assigned by a federal or
state agency.
Field Specification: This field allows for the entry of 15 characters for the “Federal Tax ID
Number” and 1 character in either box.
REQUIRED FIELD
Item Number 26
Title: Patient’s Account No.
Instructions: Enter the patient’s account number assigned by the provider of service’s or
supplier’s accounting system.
Description: The “Patient’s Account No.” refers to the identifier assigned by the provider.
Field Specification: This field allows for the entry of 14 characters. If you report this number on
your claim form the same will be reported on the EOP (Explanation of payment) for the
identification purposes of your account.
REQUIRED FIELD
Item Number 27
Title: Accept Assignment?
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Instructions: Enter an X in the correct box. Only one box can be marked.
Description: The accept assignment indicates that the provider agrees to accept assignment under
the terms of the payer’s program.
Field Specification: This field allows for the entry of 1 character in either box.
REQUIRED FIELD
Item Number 28
Title: Total Charge
Instructions: Enter total charges for the services (i.e., total of all charges in 24F).
Enter number right justified in the dollar area of the field. Do not use commas when reporting
dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter
00 in the cents area if the amount is a whole number.
Description: The “Total Charge” indicates the total billed amount for all services entered in 24F
(lines 1–6).
Field Specification: This field allows for the entry of 7 characters to the left of the vertical line
and 2 characters to the right of the vertical line.
REQUIRED FIELD
Item Number 29
Title: Amount Paid
Instructions: Enter total amount the patient and/or other payers paid on the covered services only.
Enter number right justified in the dollar area of the field. Do not use commas when reporting
dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter
00 in the cents area if the amount is a whole number.
Description: The “Amount Paid” refers to the payment received from the patient or other payers.
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Field Specification: This field allows for the entry of 6 characters to the left of the vertical line
and 2 characters to the right of the vertical line.
REQUIRED FIELD
Item Number 30
Title: Balance Due
Instructions: If required by a payer to report, enter total amount due. Enter number right justified
in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar
amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the
amount is a whole number.
Field Specification: This field allows for the entry of 6 characters to the left of the vertical line
and 2 characters to the right of the vertical line.
SITUATIONAL FIELD
Item Number 31
Title: Signature of Physician or Supplier Including Degrees or Credentials
Instructions: Enter the legal signature of the practitioner or supplier, signature of the practitioner
or supplier representative, “Signature on File,” or “SOF.” Enter either the 6-digit date (MM | DD |
YY), 8-digit date (MM | DD |CCYY), or alphanumeric date (e.g., January 1, 2003) the form was
signed.
Description: The “Signature of the Physician or Supplier Including Degrees or Credentials” refers
to the authorized or accountable person and the degree, credentials, or title.
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Field Specification: Use the space available to enter signature and date.
REQUIRED FIELD
NOTE: Claims with incomplete, no legible or blank field will be returned as non-processable.
You must return the corrected claim along with the non-processable letter within the time
frame establish by the Prompt Payment Law of Puerto Rico.
Item Number 32, 32a, and 32b
Title 32: Service Facility Location Information
Instructions: Enter the name, address, city, state, and zip code of the location where the services
were rendered. Providers of service (namely physicians) must identify the supplier’s name,
address, zip code, and NPI number when billing for purchased diagnostic tests. When more than
one supplier is used, a separate 1500 Claim Form should be used to bill for each supplier.
Enter the name and address information in the following format:
1st Line – Name
2nd Line – Address
3rd Line – City State and ZIP Code
Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main
Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code;
do not include a comma. When entering a 9-digit ZIP code, include the hyphen.
Field Specification: This field allows for the entry of three lines of 26 characters each in the
Service Facility Location Information area.
REQUIRED FIELD
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Item Number 32a
Title 32a: NPI#
Instructions: Enter the NPI number of the service facility location in 32a.
Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of 10 characters.
REQUIRED FIELD
Item Number 32b
Title 32b: Other ID#
Instructions: Enter the two digit qualifier identifying the non-NPI number followed by the ID
number. Do not enter a space, hyphen, or other separator between the qualifier and number.
Description: The non-NPI number of the service facility refers to the unique identifier of the
professional or
to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 14 characters in 32b.
SITUATIONAL FIELD
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Item Number 33
Title 33: Billing Provider Info & Ph. #
Instructions: Enter the provider’s or supplier’s billing name, address, zip code, and phone
number. The phone number is to be entered in the area to the right of the field title. Enter the name
and address information in the following format:
1st Line – Name
2nd Line – Address
3rd Line – City State and ZIP Code
Item 33 identifies the provider that is requesting to be paid for the services rendered and
should always be completed.
Description: The billing provider’s or supplier’s billing name, address, zip code, and phone
number refers to the billing office location and telephone number of the provider or supplier.
Field Specification: This field allows for the entry of the following: 3 characters for area code, 9
characters for phone number, and three lines of 29 characters each in the Billing Provider Info
area.
REQUIRED FIELD
Item Number 33a
Title 33a: NPI#
Instructions: Enter the NPI number of the BILLING PROVIDER in 33a. This field must be
always entered.
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Description: The NPI number refers to the HIPAA National Provider Identifier number.
Field Specification: This field allows for the entry of 10 characters.
REQUIRED FIELD
NOTES:
Common errors:
-Providers submit other identifiers such as Tax ID/SSI instead of the Billing Provider NPI
-Providers submit incorrect combination of billing and rendering providers
Claims with errors on this field will be rejected as non-processable claim. Provider must
submit a corrected claim along with the non- processable letter within the timeframe
establish by The Prompt Payment Law of Puerto Rico. If questions arise due to nonprocessable or denied claims contact Providers Department Services at the telephone
number specified on this manual.
Item Number 33b
Title 33b: Other ID#
Instructions: Enter the two digit qualifier identifying the non-NPI number followed by the ID
number. Do not enter a space, hyphen, or other separator between the qualifier and number.
Description: The non-NPI number of the billing provider refers to the unique identifier of the
provider or to the provider designated taxonomy code.
Field Specification: This field allows for the entry of 17 characters in 33b.
SITUATIONAL FIELD
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UB-04 (CMS-1450)
The CMS-1450- (UB-04) is used for the submission of institutional services such as:
Hospital Inpatient Services
Hospital Outpatient Services
Home Health Services
Skilled Nursing Services
Ambulatory Surgical Centers among others
The National Uniform Billing Committee (nubc.org) was appointed by HIPAA as Designated Standards Maintenance Organization (DSMO) for the Uniform Bill
The NUBC is responsible for the maintenance of the Official UB-04 Data Specifications
Manual.
UB-04 was developed and approved for use beginning in 2007
With the implementation of UB-04 on 2007 some of the fields and codes were changed.
The Uniform Billing was developed with the purpose of assist the providers on produce a
clean, accurate, and complete claim.
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The following fields are required UB-04 Health Insurance Claim Form:
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125
UB-04 FIELDS DESCRIPTION
FL 1- Billing Provider Name, address and Telephone Number
The minimum entry is the provider name, city, State, and Zip Code. The post office
box number or street name, and number may be included. The State may be
abbreviated using standard post office abbreviations. Five or nine digits Zip Codes are
acceptable.
1
REQUIRED
FL-2
Billing Provider’s Designated Pay-to-Name, Address, and Secondary
Identification Fields
It should be completed if the provider designated to receive the payment is different
that the provider specified on Field Locator 1.
2
SITUATIONAL
FL-3ªPatient Control Number
The patient’s unique alpha-numeric number assigned by the provider to
facilitate retrieval of individual financial records and posting payments.
Will be posted on the EOP/Remittance Advice, ANSI 835 if providers submit the same on
the claim.
3a.Pt
control
number
REQUIRED.
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FL-3bMedical/Health Record Number
The number assigned to the patient’s medical/health record by the provider.
3b Medical/Health
Record Number
REQUIRED
FL-4
Type of Bill
This is a four-digit alphanumeric code which include three specific pieces of information.
Indicates the facility where the service were rendered
This is a four digit number which must be submitted by the provider accord-
ing to the type of service performed.
Code Structure:
First Digit
Second Digit
Third Digit
Fourth Digit
-
Leading Zero
Type of facility
Bill Classification
Bill Frequency
Codes are available from the NUBC (National Uniform Billing Committee) at www.nubc.org via
the NUBC’s Official UB-04 Data Specifications Manual.
4 TYPE
REQUIRED
OF BILL
Examples:
First Digit:
The first digit will always be zero. (0).
Second Digit (Type of Facility)
1. Hospital
2. Skilled Nursing Facility
3. Home Health Facility
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4. Religious Nonmedical Health Care Institutions (RNHCI)-Hospital Inpatient
5. Reserved for Assignment by the NUBC
6. Intermediate Care
7. Clinic (requires special reporting information for the third digit)
8. Special Facility or ASC surgery (requires special reporting for the third digit)
9. Reserved for Assignment by the NUBC
Third Digit (Bill Classification - (except Clinics and Special Facilities)
1. Inpatient Including Medicare Part A
2. Inpatient Medicare Part B Only (Includes HHA Visits Under A Part B Plan Of
Treatment)
3. Outpatient – (Includes HHA Visits Under A Part A Plan Of Treatment Includ-
ing DME Under Part A)
4. Laboratory Services Provided To Non-Patients, Or Home Health Not Under A
Plan Of Treatment
5. Intermediate Care Level I
6. Intermediate Care Level II
7. Reserved For Assignment By The NUBC
8. Swing Beds
9. Reserved For Assignment By The NUBC
Third Digit – Clinics Only
071X- Rural health Clinic (RHC)
072X- Clinic -Hospital Based or Independent Renal Dialysis Center
073X- Free-standing
074X-ORF –Outpatient Rehabilitation Facility
075 X-CORF-Comprehensive Outpatient Rehabilitation Facilities
076X-CMHC-Comprehensive mental Health Centers (partial hospitalizations
program Service)
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077X- Federally Qualified Health Center (FQHC)
078X- Reserved for assignment by the NUBC
079X-Clinic –Other
Third Digit (Classification for Other Facility Only)
This coding structure can be used only when the second digit of the TOB indicates
another facility (8).
081X - Hospice (Non-Hospital Based)
082X - Hospice (Hospital-Based)
083X - Ambulatory Surgery Center (ASC)
Note: TOB code 083X does not apply to Hospital Outpatient claims.
Instead, hospitals use TOB codes 013X, 014X or 012X as
Appropriate to report outpatient services.
084X - Freestanding Birthing Center
085X – Critical Access Hospital
086X- Residential Facility (not used)
087X-088X- Reserved for Assignment by the NUBC
089X- Special Facility- Other (not used for Medicare)
Fourth Digit (Bill Frequency)
CODE STRUCTURE:
0XX0 Nonpayment/Zero Claim
-This fourth digit is used to report non payment claims.
- Is used to report to the payer a nonreimbursable period of
Confinement or termination of care
- Use this code when the provider does not expect a payment as a
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Result of submitting this bill
-Use this code when the hospitalization is covered by worker’s
Compensation (WC), automobile medical, no-fault insurance or
Liability insurance or an employer group health plan (EGHP)
0XX1 Admit-Through –Discharge Claim
-This frequency code represent an admit though discharge claim
and is used to report the entire inpatient admission or outpatient
course of treatment
0XX2 Interim-First Claim (Not Valid for PPS Claims)
- This frequency code is used to indicate the first in a series of
Claims to the same third-party payer for the same confinement
or course of treatment
0XX3 Interim-continuing Claim (Not Valid for PPS Claims
-This bill frequency code is used to indicate that a bill is one of a
series of claims for the same confinement or course of
treatment. In other words, the bill has been submitted
previously and further bills are expected.
0XX4 Interim –Last Claim (Not valid for PPS Claims)
-This is used to indicate that a bill is the last of a series of claims
For the same confinement or course of treatment.
0XX5 Late Charges Only Claim
-This code indicates that the provider is submitting charges after
An admit-through discharge claim or last interim claim has been
Submitted. This code is not intended to be used in lieu of an
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130
Adjustment or replacement claim.
0XX6 Reserved for Assignment by the NUBC
0XX7 Replacement of Prior Claim
-This TOB code is used when a specific claim needs to be
Restated in its entirety, except for the identifying information.
The original claim is considered null and void, an Information on this bill
completely replaces the previos Claim.
0XX8Void/Cancel of Prior Claim
-This code indicates that this claim eliminates and cancels a
Previously submitted claim.
-A code OXX7 claim must be submitted to show the
Corrected information.
-In other words, this frequency code cannot be used
Unless you have also submitted a 0XX7 claim
0XX9 Final Claim for a Home health PPS Episode
-This code indicates the home health bill should be processed as
A debit or credit adjustment to the initial HHPS bill.
-This code is specific to home health and does not replace
Frequency codes 7 or 8.
-A claim for an episode billed with TOB code 0329 will be
Processed as an adjustment to the RAP, and will trigger a full
Or final episode payment under HHPPS.
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Example:
-Admit through Discharge Claim (0XX1)
-Interim (First Claim) (0XX2)
-Interim (Continuing Claim –Not valid for PPS-DRG Claims) (0XX3)
-Interim Last Claim (Not valid for PPS-DRG claims) (0XX4)
-Late Charges Only Claim (0XX5)
-Reserved for Assignment by the NUBC – (0XX6)
-Replacement of Prior Claim – (0XX7)
-Void/Cancel of a Prior Claim (0XX8)
-Final Claim for a Home Health PPS Episode (0XX9)
FOURTH DIGIT- Frequency of the Bill-FOR HOSPICE ONLY
0XXA-Admission/Election Notice
0XXB-Hospice/Termination/Revocation Notice
0XXC-Hospice Change of Provider Notice
0XXD-Hospice/Void/Cancel
0XXE-Hospice Change of Ownership
Bill Type Code Samples:
A) Claim with bill type (0111)
0
1
1
1
Leading 0, 2nd digit= hospital Third digit= Inpatient Part A Third Digit = Adm thru
Discharge
B) Claim with bill type (0131)
0
1
3
1
Leading 0, 2nd digit= hospital Third digit= Outpatient, Third Digit = Adm thru Discharge
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C) Claim with bill type (0322)
0
3
2
2
Leading 0, 2nd digit= Home Health, Third digit= Outpatient, Third Digit = 2 (First RAP
claim)
D) Claim with bill type (0329)
0
3
2
9
Leading 0, 2nd digit= Home Health, Third digit= Outpatient, Third Digit = 9 Final claim for
a Home Health Treatment Episode
OTHER BILL TYPES SAMPLES:
011X Hospital Inpatient (Part A)
012XHospital Inpatient Part B only. (Use this TOB to bill for covered ancillary services when the
patient has Part B entitlement only or when Part A benefits are not payable or are
exhausted)
013 X Hospital Outpatient- uses to bill outpatient services rendered in the emergency
or other outpatient department. Single line item date of service for
each revenue code is required)
014X Hospital Non Patient Laboratory Services - Single line item date of service for
each revenue code is required)
021X SNF Inpatient
022X SNF Inpatient Part B only
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023X SNF Outpatient
032X Home Health inpatient (Part B Only) - It is used as a request for anticipated
Payment (RAP) - Plan of treatment when the patient has both Part A and Part B
entitlement
033X Home Health-outpatient /DME under Part A (Single line item date of service for
Each revenue code is required)
034X Home Health not under a Plan of Treatment (Single line item date of service for
Each revenue code is required)
071X Clinical Rural health
072X Hospital Based or Independent Renal Dialysis Center
073X Clinic-Freestanding (Effective April 1, 2010)
074X Clinic- Outpatient Rehabilitation Facility
075X Clinic- Comprehensive Outpatient Rehabilitation Facility
081X Non Hospital based hospice
082X Hospital Based Hospice
083X Special Facility- Ambulatory surgery Center (ASC)
085X Critical Access Hospital
FL- 5 Federal Tax Number
The format is NN-NNNNNNN.
REQUIRED
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FL-6 Statement Covers Period From /Through
The provider enters the beginning and ending dates of the period included on this bill in
numeric fields (MMDDYY).
6 FROM
through
REQUIRED
FL-7
Not used.
FL-8 Patient’s Name/Patient ID
a. Patient Contract Number
b. Patient Name
a
b
3
REQUIRED
FL-9 Patient’s Address
The provider enters the patient’s last name, first name, and, if any, middle initial, along
with patient ID (if different than the subscriber/insured’s ID)
c.
d.
e.
f.
Street Name and Number
Post Office Box Number
City
State
g. ZIP code
9. Patient Address
b
a
R
c
REQUIRED
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135
d
e
FL-10 Patient’s Birth Date
The provider enters the month, day, and year of birth (MMDDCCYY) of patient.
10. BIRTHDATE
REQUIRED
FL-11 Patient’s Sex
The provider enters an “M” (male) or an “F” (female). The patient’s sex is recorded at admission,
outpatient Service, or start of care.
11. SEX
REQUIRED
FL-12 Admission/Start of Care Date
Required For Inpatient and Home Health. The hospital enters the date the patient was admitted for
inpatient care (MMDDYY). The HHA enters the same date of admission that was submitted on the
RAP for the episode.
12. Date
REQUIRED
FL-13 Admission Hour
For inpatient services indicate the hour in which the patient was admitted.
13. Admission Hour
REQUIRED FOR INPATIENT only
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Code Structure:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
12:00 (midnight)-12:59am
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
12:00 (noon)-12:59p.m.
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
FL-14 Type of Admission
This field is required. This is the code indicating priority of this admission.
14. TYPE
REQUIRED
Coding Structure:
1.
2.
3.
4.
5.
Emergency
Urgent
Elective
Newborn
Trauma
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6.
7.
8.
9.
Reserved for Assignment by the NUBC
Reserved for Assignment by the NUBC
Reserved for Assignment by the NUBC
Information Not available- This code should be used rarely, since the provider must indicate
de type of admission of the patient
FL-15 Point for Origin for Admission or Visit
The provider enters the code indicating the source of the referral for this
Admission or visit.
15. SRC
REQUIRED
This is a required field for inpatient and outpatient hospital, home health, inpatient
SNF
Coding Structure (for Emergency, Elective or other type of Admission):
123456789ABCDEFG-
No healthcare Facility Point of Origin
Clinic or Physician’s Office
Reserved for assignment by the NUBC
Transfer from a Hospital (Different Facility)
Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility
(ICF)or Assisted Living Facility (ALF)
Transfer from Another HealthCare Facility
Discontinued effective July 1, 2010
Court/Law Enforcement
Information Not Available
Reserved for assignment by the NUBC
Discontinued effective July 1, 2010
Discontinued effective July 1, 2010
Transfer from One Distinct Unit of the Hospital to Another Distinct Unit of the
same hospital resulting in a separate Claim to the Payer
Transfer from Ambulatory Surgery Center
Transfer from Hospice Facility
Z Reserved for Assignment by the NUBC
Coding Structure: NEWBORN
1. Discontinued
2. Discontinued
3. Discontinued
4. Discontinued
5- Born inside this hospital
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6- Born outside of this Hospital
7- 9 Reserved for Assignment by the NUBC
FL-16 Discharge Hour
16 DHR
SITUATIONAL
First Plus requires that this information is provided only when there is a revenue code 0450
on form locator 42, on inpatient claims.
FL-17 Patient Discharge Status
17 Stat
REQUIRED
The provider must submit the patient status code for all TYPE of claims
CODING STRUCTURE
01- Discharge to Home or Self-Care (Routine Discharge)
02- Discharged/Transferred to a Short-Term General Hospital for Inpatient Care
03- Discharged/Transferred to SNF WITH Medicare Certification in Anticipation of
Skilled Care
04- Discharged/Transferred to a Facility that Provides Custodial or Supportive Care
05- Discharged/Transferred to a Designated Cancer Center or Children’s Hospital
06- Discharged/Transferred to Home Under Care of Organized Home Health Service organization in anticipation of covered Skilled Care
07- Left against medical advice or discontinued care
08- Reserved for Assignment by the NUBC
09- Admitted as an inpatient to this hospital (if a patient is admitted before midnight of
the third day following the day of an outpatient diagnostic service or service related to
the reason for admission, the outpatient services are considered inpatient. Code 09
applies only to services that begin more than three days prior to the admission or were
unrelated to the reason for admission)
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10- 19 Reserved for assignment by the NUBC
20- Expired
21- Discharged/transferred to Court/Law Enforcement
22-29 Reserved for Assignment by the NUBC
30- Still a patient (used on RAP bills for Home Health bill type 032X or 033X)
31-39 Reserved for Assignment by the NUBC
40- Expired at home
41- Expired in a Medical Facility - Hospice (valid only for Medicare and TRICARE
hospice claims only-TOB (FL-4) 081x and 082X)
42- Expired, Place Unknown
43- Discharged/transferred to a Federal Health Care Facility
44-49 Reserved for Assignment by the NUBC
50-Discharged to Hospice-Home (in home hospice services)
51- Discharged to Hospice-Medical Facility (certified) Providing Hospice Level of Care
52-60 Reserved for Assignment by the NUBC
61- Discharged/Transferred within this institution to a Hospital Based Medicare approved
Swing Bed
62- Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF) including
Rehabilitation Distinct Part Units of a Hospital
63- Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH)
64- Discharged/transferred to a Nursing Facility Certified under Medicaid but not certified
under Medicare
65-Discharged/transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a
Hospital
66- Discharged/transfers to a Critical Access Hospital
67-69 Reserved for Assignment by the NUBC
70- Discharged/transferred to another type of Healthcare Institution not defined elsewhere
in this code list
71-99 Reserved for Assignment by the NUBC
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FLs 18 – 28 – Condition Codes
18 19 20 21 22 23 24 25 26 27 28
SITUATIONAL
This field is required if any condition code is applicable to a claim. These fields contain
codes identifying conditions that may affect payer processing of this bill.
INSURANCE CODES:
01-Military Service Related
02-Condition is Employment Related
03-Patient covered by Insurance Not Reflected Here
04-Information Only Bill
05-Lien has been filed (This code indicates that the provider has filed a legal claim to
recover funds potentially due the patient as a result of legal action initiated by or on behalf
of the patient)
06- ESRD Patient in First 30 months of entitlement covered by Employer Group Health
Insurance
07-Treatment of non-terminal Condition for Hospice Patient
08- Beneficiary would not provide information concerning other insurance coverage
09-Neither Patient or Spouse is employed
10- Patient and/or spouse is employed but no EGHP coverage exists
11- Disabled beneficiary, but no Large Group Health Plan (LGHP) coverage
12- Use this code when the services were rendered by a Provider in US. This code is being assigned by FIRSTPLUS for this use only
13- Use this code for COB claims. This code is being assigned by FIRSTPLUS as an indicator of a COB claim. It is intended for this use only. It is required that the provider
submit (electronically or paper) the correspondent additional condition codes related
to the coordination of benefits, as well as the occurrence codes and dates applicable).
The provider must submit in the electronic X-12 (837i) all the related fields related to
the other insurer payment.
14- 16 Codes are for Payer Use only
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17-Patient is homeless
18. Maiden Name retained
19. Child retains mother’s name
20. Beneficiary requested billing (This code indicates that the provider realizes that the
services are not covered or excluded from coverage, but the beneficiary requested a formal
determination of coverage from Medicare or other party)
21. Billing for Denial Notice
22. Patient on multiple drug regimens
23. Home care giver available
24. Home IV patient also receiving Home Health Agency services
25. Patient is a non-U.S. resident
26. VA-Eligible patient chooses to receives services in Medicare-certified facility
27- Patient Referred to a sole community hospital for a diagnostic laboratory test
28-Patient and/or spouse EGHP is Secondary to Medicare
29- Disabled beneficiary and/or family member’s LGHP is Secondary to Medicare
30. Non-research services provided to patients enrolled in a qualified clinical trial
STUDENT STATUS
31- Patient is Student (full-time day)
32- Patient is student (cooperative/work study program)
33- Patient is student (full time night)
34- Patient is student (Part-time)
35- Reserved for assignment by the NUBC
ACCOMODATIONS
36- General care patient in a specific unit
37- Ward accommodation at patient’s request
38- Semiprivate room not available
39- Private room medically necessary
40- same-day transfer
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41- Partial hospitalization (This code indicates that the claim is for partial hospitalization
services. This condition code is required on all hospital outpatient and community access
hospital (CAH) claims for partial hospitalization services (TOB codes 013X and 085X [FL
4] to distinguish partial hospitalization program services from routine outpatient psychiatric
services
42- Continuing Care not related to inpatient admission
43- Continuing care not provided within prescribed Post-discharge window
44- Inpatient admission changed to outpatient
45- Ambiguous Gender category
TRICARE INFORMATION
46- Non-availability statement on file
47- Transfer from another Home Health Agency (effective July 1, 2010)
48- Psychiatric residential treatment center (RTCs) for children and adolescents
49- Product replacement within product lifecycle
50- Product replacement for known recall of a product
51- Attestation of unrelated outpatient non diagnostic services (effective April 1, 2011)This hospital attests that the outpatient non diagnostic service that was provide within three
calendar days (one calendar day for non- subsection (d) hospitals) of the inpatient
admission are not related to the inpatient stay
52-54 Reserved for Assignment by the NUBC
55- SNF bed not available
56- Medical appropriateness
57- SNF readmission
58- Terminated Medicare Advantage Enrollee
59- Non-primary ESRD facility
PROSPECTIVE PAYMENT
60- Day outlier
61- Cost Outlier
62- Payer code (Not used for FIRSTPLUS providers)
63- Payer code (This code is only for payer)
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64- Payer code (This code is only for payer)
65- Payer code (This code is only for payer)
66- Provider does not wish cost outlier payment
67- Beneficiary elects not to use Lifetime Reserve (LTR) days
68- Beneficiary elects to use LTR days
69- IME/DGME/N&AH Payment only (this code indicates that the claim is being
submitted to request a supplemental payment for indirect medical education (IME), direct
graduate medical education (DGME), and nursing and allied health (N&AH)
70- Self-administered Anemia management drug
71- Full care in unit
72- Self-care in unit
73- Self-care training
74- Home
75- Home- 100 percent reimbursement
76- Backup in facility dialysis
OTHER CODES
77- Provider accepts or is obligated/required due to a contractual arrangement or Law to
accept payment by a primary payer as Payment in full
78- New coverage not implemented by Managed care plan
79- CORF Services provided off-site
80- Home dialysis-nursing facility
81-99 Reserved for assignment by the NUBC
SPECIAL PROGRAM INDICATOR CODES
RAO- TRICARE external partnership program
A1- EPSDT/CHAP (indicates this code is related to early and periodic screening
diagnosis and treatment)
A2- Physically handicapped children’s program
A3- Special Federal funding
A4- Family planning
A5- Disability
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A6- Vaccines/Medicare 100% payment
A7- Reserved for assignment by the NUBC
A8- Reserved for assignment by the NUBC
A9- Second Opinion Surgery
AA-Abortion performed due to rape
AB- Abortion performed due to Incest
AC-Abortion performed due to serious fetal genetic defect, deformity, or abnormality
AD-Abortion performed due to a life endangering physical condition
AE- Abortion performed due to physical health of mother that is not life endangering
AF- Abortion performed due to emotional/psychological health of the mother
AG-Abortion performed due to social or economic reasons
AH- Elective abortion
AI- Sterilization
AJ- Payer responsible for copayment
AK- Air ambulance required
AL- Specialized treatment/bed unavailable-alternate facility transport
AM- Non-emergency medically necessary stretcher transport required
AN- Preadmission screening not required
AO- AZ Reserved for assignment by the NUBC
BO- Medicare coordinated care demonstration claim
B1- Beneficiary ineligible for demonstration program
B2- Critical Access Hospital ambulance attestation
B3- Pregnancy indicator
B4- Admission unrelated to discharge on same day
B5-CO- Reserved for assignment by the NUBC
Q10 APPROVAL INDICATOR SERVICES
CO- Reserved for assignment by the NUBC
C1- Approved as billed
C2- Automatic approval as billed based on focused review
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C3-Partial approval
C4- Admission/Services denied
C5-Post payment review applicable
C6- Admission Pre-authorization
C7-Extended authorization
C8-CZReserved for assignment by the NUBC
CLAIM CHANGE REASONS
DO-Changes to Services Dates
D1-Changes to charges
D2-Changes in revenue codes/HCPCS/HIPPS Rate codes
D3-Second or subsequent interim PPS bill
D4-Change in clinical codes (ICD) for diagnosis and/or Procedure codes
D5-Cancel to correct insured or provider ID
D6-Cancel only to repay a duplicate or OIG Overpayment
D7-Change to make Medicare the Secondary Payer
D8-Change to make Medicare the Primary Payer
D9- Any other change
DA-DQ Reserved for Assignment by the NUBC
DR- Disaster Related
DS-DZ Change in Patient Status
E1-FZ Reserved for Assignment by the NUBC
G0- Distinct Medical Visit
G1-GZ- Reserved for Assignment by the NUBC
H0-Delayed filing, Statement of Intent Submitted (use only when there is the
Existence of another third-party liability situation)
H1- Reserved for assignment by the NUBC
H2-Discharge by a Hospice Provider by Cause (Discharges for cause include
Situations where patient safety or hospice staff safety is compromised)
H3-H5- ESRD PPS Reoccurrence indicators (effective January 1 2011)
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H3-Reoccurrence of GI Bleed (MA) Category
H4- Reoccurrence of Pneumonia (MB) Category
H5 -Reoccurrence of Pericarditis (MC) Category
H6-LZ- Reserved for assignment by the NUBC
MO-All inclusive rate for outpatient services (Payer only code)
MI-M9-Reserved for Payer Assignment
MG-MV-Reserved for Payer Assignment
MX-Wrong Surgery on Patient (Payer only code)
MY-Surgery on Wrong Body Part (Payer only code)
MZ-Surgery on Wrong Patient (Payer only code)
NO-OZ-Reserved for Assignment by the NUBC
PO-Reserved for Public Health Reporting Only
P1-Do not Resuscitate Order (DNR) for Public Health Reporting Only
P2-P6 -Reserved for Public Health Reporting Only
P7-Direct Inpatient Admission from the Public Health Reporting Only
P8-PZ -Reserved for Public Health Reporting Only
Q0-VZ-Reserved for Assignment by the NUBC
W0-United mine Workers of America (UMWA) Demonstration Indicator
W1-Reserved for Assignment by the NUBC
W2- Duplicate of Original Bill
W3 -Level 1 Appeal
W4 -Level II Appeal
W5-Level III Appeal
W6-ZZ-Reserved for Assignment by the NUBC
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FL- 29 Accident State
This data element is required when the services reported are related to an auto accident.
29 ACDT
STATE
SITUATIONAL
This data element is required when the services reported are related to an auto accident.
FL-30 Reserved for assignment by the NUBC
FLs 31-34 Occurrence Codes and Dates
OCURRENCE
CODE
Date
_____________________________
SITUATIONAL
The occurrence code and associated date fields define a significant event relating to this bill that
may affect processing. Report in alphanumeric sequence. Report occurrence codes in the
following order: 31ª, 32ª, 33ª, 34ª, 31b, 32b, 33b, and 34b. If additional codes are need to be
reported and there are no occurrence span codes to report, then the additional codes may be
reported in 35ª, 36ª, 35b, 35b, with the date in the “from” date.
ACCIDENT RELATED CODES
01-Accident/Medical Coverage (Provide date of accident or injury)
02 -
No-Fault Insurance Involved- Including Auto Accident/Other
03- Accident/Tort Liability
04-
Accident-Employment Related
05-
Accident/No Medical or Liability Coverage
06-
Crime Victim
07-08 Reserved for Assignment by the NUBC
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MEDICAL CONDITION CODES
09-Start of Infertility Treatment Cycle
10- Last Menstrual Period
11- Onset of Symptoms/Illness
12- Date of Onset for a chronically dependent individual (CDI)
13- 15 Reserved for Assignment by the NUBC
INSURANCE RELATED CODES
16- Date of Last Therapy
17- Date Outpatient Occupational Therapy Plan Established or Last Reviewed
18-
Date of Retirement of Patient/Beneficiary
19- Date of Retirement of Spouse
20- Guarantee of Payment Began
21- UR Notice Related
22- Date Active Care Ended
23- Date of Cancellation of Hospice Election Period
24- Date Insurance Denied (This code and corresponding date indicate the date the
Health Care Facility received the coverage denial from an insurer)
25- Date benefits terminated by Primary Payer (This code and corresponding date
i
indicate the date when insurance coverage (including workers compensation or no-fault
coverage) is no longer available to the patient.
26.
Date SNF Bed became available
27- Date of Hospice Certification or Recertification
28- Date Comprehensive Outpatient Rehabilitation Plan Established or Last Reviewed
Date outpatient Physical Therapy Plan Established or Last Reviewed
30- Date Outpatient Speech-Language Pathology Plan established or Last Reviewed
31- Date Beneficiary Notified of intent to Bill (Accommodations) this code and
corresponding date indicate the date the patient was notified by the hospital that a covered
level of inpatient care was no longer required.
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32- Date Beneficiary Notified of Intent to Bill (Procedures and Treatment). This code and
corresponding date indicate the date the patient was notified by the hospital that the requested
care (diagnostic procedures or treatments) may not be considered reasonable or necessary
33- First Day of the Coordination Period for ESRD Beneficiaries covered by an EGHP
34- Date of Election of Extended Care Services- applies only to religious nonmedical health
care institutions (RNHCIs)
35- Date treatment started for Physical Therapy
36- Date of Inpatient Hospital Discharge for Covered Transplant Patient
37- Date of Inpatient Hospital Discharge for Non-covered Transplant Patient
38- Date Treatment Started for Home IV Therapy
39- Date Discharged on a Continuous Course of IV Therapy
40- Scheduled Date of Admission
41. Date of First Test for Preadmission Testing
42- Date of Discharge
43- Scheduled date of cancelled surgery
44- Date Treatment Started for Occupational Therapy
45- Date Treatment Started for Speech-Language Therapy
46- Date Treatment Started for Cardiac Rehabilitation
47- Date Cost Outlier Status Begins
48-49 Payer codes (These codes are reserved for third-party payer use only and should not be
reported by providers)
50-Assessment date (Effective January 1, 2011)51- Date of Last Kt/V Reading (effective July 1, 2010)
52- Medical Certification/recertification date (Effective January 1, 2011)- This code is used to
report the most recent non-hospice medical certification or recertification of a patient)
53- Reserved for assignment by the NUBC
54- Physician Follow-up date (Effective January 1, 2011)
55-69-Reserved for Assignment by the NUBC
70-99 Reserved for Occurrence Span Code
A0- Reserved for assignment by the NUBC
A1-Birth date-Insured A
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A2-Effective date-Insured A Policy
A3-Benefits Exhausted
A4-Split bill date
A5-AZ- Reserved for Assignment by the NUBC
B0- Reserved for assignment by the NUBC
B1- Birth date-Insured B
B2- Effective Date- Insured B Policy
B3- Benefits Exhausted
B4-BZ- Reserved for assignment by the NUBC
CO- Reserved for assignment by the NUBC
C1- Birth date-Insured C
C2- Effective date- Insured C Policy
C3- Benefits Exhausted
The following Occurrence Codes are reserved for assignment by the NUBC
C4-CZ, D0-DQ,
DR- Reserved for Disaster Related Occurrence Code
DS-DZ, EO -EZ, FO-FZ, GO-GZ, HO-IZ, JO-LZ
MO-ZZ –See Definitions under Occurrence Span Codes
FLs-35-36 OCCURRENCE SPAN CODES AND DATES
OCURRENCE SPAN
CODE
CODE
From
Throught
_____________________________
SITUATIONAL
Occurrence span codes and dates identify an event that relates to payment of the claim. The
provider enters codes and associated beginning and ending dates defining a specific event
relating to this billing period. The valid occurrence span codes are 70-99 and MO-Z9
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CODING STRUCTURE
70- Qualifying Stay dates for SNF use only. This code and corresponding dates indicate the
form and through dates of at least a three day hospital stay (excluding the day of discharge or
death) that qualifies the patient for Medicare payment of the SNF services billed on this claim.
71- Prior Stay dates- This code and corresponding dates indicate the form and through dates
provided by the patient for any hospital stay that ended within 60 days of the current hospital
or SNF admission.
72-First/Last Visit (for outpatient services)
73- Benefit Eligibility Period (period during which TRICARE medical benefits are available to
a sponsor’s beneficiary)
74- Non covered level of care/Leave of Absence dates
75- SNF Level of care
76- Patient Liability (indicate the from and through dates for a period of non- covered care for
which the hospital is allowed to charge the Medicare Beneficiary)
77- Provider Liability period (Indicate the from and through dates for a period of non- covered
care for which the provider is liable)
78- SNF Prior Stay Dates
79- Payer Code- This code is not for provider reporting.
80- Prior same SNF Stay dates payment Ban Purposes
81-99 Reserved for assignment by the NUBC
MO- QIO/UR approved stay dates
M1- Provider Liability-No utilization
M2- Dates of Inpatient Respite Care
M3- ICF Level of Care
M4- Residential Level of Care
M5-MQ- Reserved for assignment by the NUBC
MR- Reserved for Disaster-Related Occurrence Span Code
MS-WZ- Reserved for assignment by the NUBC
XO-ZZ- Reserved for assignment by the NUBC
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FL- 37 Reserved for assignment by the NUBC
FL-38 RESPONSIBLE PARTY NAME AND ADDRESS
REQUIRED FIELD
The name and address of the party responsible for the bill are entered in this field.
FLs 39-41 VALUE CODES AND AMOUNTS
39
Value
code
code Amount
a
b
c
d
SITUATIONAL
These fields contain codes and the related dollar amounts or values that identify data elements that
are necessary to process this claim as qualified by the payer organization.
Home Health agencies must report this field always. Home Health episode payments must be
based on the site at which the beneficiary is served. RAP’s (Request for Anticipated Payments) as
well as final claim will not be processed without code 61, and the correspondent CBSA code.
Home Health Claims that do not include information on this field will be rejected to the
provider.
This field is used to report the point of pick up for ambulance services. The point of pick up is
reported using the five digit ZIP code with value code A0.
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CODING STRUCTURE
01-Most Common Semiprivate Room Rate
02-Hospital has no semiprivate rooms
03-Reserved for assignment by the NUBC
04- Inpatient Professional Component charges which are combined billed
05- Professional Component included in charges and also billed separately to Carrier
06- Medicare Blood Deductible
07- Reserved for Assignment by the NUBC
08- Medicare Lifetime Reserve Amount in the First Calendar Year
09- Medicare Coinsurance amount in the First Calendar Year in billing period
10-Lifetime Reserve Amount in the Second Calendar Year
11- Coinsurance amount for second calendar year
12-Working aged beneficiary/spouse with EGHP
This code and corresponding amount reflect the EGHP payment made on behalf of an aged
beneficiary that the provider is applying to the covered services on this bill.
13-ESRD Beneficiary in a Medicare Coordination period with an EGHP
14-No-Fault, including Auto/other –Reflect the higher priority no-fault (including auto or
other) insurance payment made on behalf of the patient or insured.
15-Worker’s compensation- Reflect the WC insurance payment made on behalf of the patient
or insured.
16- Public Health service (PHS) or other federal agency
17- Operating Outlier amount- Providers do not report this code. It is use for the Payer only.
18- Operating Disproportionate Share Amount- This code is for payer only. Provider does not
report this code.
19-Operating Indirect Medical Education Amount- This code is for payer use only. Providers
not report this code.
20- Payer Only Code- This code is not reported by the providers.
21- Catastrophic
22- Surplus
23-Recurring monthly income
24-Medicaid rate code
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25-Offset to the patient-payment amount-prescription drug
26-Offset to the patient payment amount-hearing and ear services
27- Offset to the patient payment amount-vision and eye services
28- Offset to the patient payment amount-dental services
29-Offset to the patient payment amount- chiropractic services
30- Preadmission testing
31-Patient Liability amount
32-Multiple patient ambulance transport
33- Offset to the patient payment amount-podiatric services
34-Offset to the patient payment amount-other medical services
35-Offset to the patient amount-health insurance premiums
36- Reserved for assignment by the NUBC
37- Units of Blood Furnished
38-Blood deductible units
39-Units of Blood Replaced
40-New coverage not implemented by HMO (for inpatient claims only)
41- Black lung
42- Veterans affairs
43- Disabled beneficiary under age 65 with LGHP
44- Amount provider agreed to accept from the primary insurer when this amount is less than
total charges, but higher than payment received
45-Accident hour
46- Number of grace days
47- Any liability insurance
48-Hemoglobin Reading
49-Hematocrit Reading
50-Physical therapy visits
51-Occupational Therapy Visits
52-Speech-Language Therapy Visits
53-Cardiac Rehabilitation Visits
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54- Newborn Birth weight in grams
55- Eligibility threshold for charity care
HOME HEALTH SPECIFIC
56- Skilled nurse-Home visits hours (HHA only)
This code and corresponding amount indicate the number of hours of skilled nursing provided
during the billing period. The time includes the hours spent in the home and excluded travel
time. Use this code to report the time in whole hours (rounded to the nearest whole hour),
right-justified to the left of the dollar and cents delimiter.
57-Home Health Aid-Home visit hours (HHA only)
This code and corresponding amount indicate the number of hours of home health services
provided during this billing period. Use this value to report the time in whole hours.
58- Arterial Blood Gas (PO2/PA2)
This code and corresponding amount reflect the arterial blood gas value at the beginning of
each reporting period for oxygen therapy.
59- Oxygen Saturation (O2SAT/Oximetry)
This code and corresponding amount reflect the oxygen saturation the beginning of each
reporting period for oxygen therapy.
60- HHA Branch MSA
This code indicates the metropolitan statistical area (MSA) in which the HHA is located.
Reports the MSA when the branch locating is different than the HHA’s location. Report the
number of the MSA in the dollar portion of the form locator, right-justified to the left of the
dollar and cents delimiter.
61- Place of Residence where service is furnished (HHA and Hospice)
This code indicates de CBSA number of the place residence where the home health or hospice
service is delivered). This code is required for First+Plus.
Example: The CBSA for San Juan, Puerto Rico (41980) is entered as 004198000.
Enter the CBSA NUMBER WHERE CARE IS BEING RENDERED, NOT THE AGENCY
LOCATION.
62- HHA Visits- Part A- This code is for payer use only. Providers do not report this code.
63- HHA Visits-Part B- This code is for payer use only. Providers do not report this code.
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64- HHA Reimbursement- Part A. This code is for payer use only. Providers do not report
this code.
65- HHA Reimbursement Part B- This code is for payer use only. Providers do not report
this code.
66- Medicaid Spend Down Amount
67- Peritoneal dialysis- Reflect the number of hours of peritoneal dialysis provided during
the billing period.
68- EPO-Drug- Reflects the number of EPO units administered or supplied for self
administration
69- State Charity Care Percent
70-75- Payer codes
76- Provider’s interim rate ( Payer code)
77- Medicare New Technology Add-On Payment (Payer code)
78-79- Payer codes
80- Covered days – The number of days covered by the primary payer.
81- Non covered days -The number of days non covered by the primary payer.
82- Co-insurance days –The number of Medicare coinsurance days used during this stay.
83- Lifetime Reserve days- The provider must notify the number of lifetime reserve days used
during this stay. Each beneficiary has a lifetime reserve of 60 additional days of inpatient
hospital services after using 90 days of inpatient hospital services during a spell of illness.
The beneficiary should be notified by the UR, admissions or insurance verification department
of his or her right to elect not to use lifetime reserve days before billing for services furnished
after the 90 days in this spell of illness.
If lifetime reserve days are reported, there must be an entry of 08 Medicare lifetime reserve
amount in the first calendar year, or 10 Medicare lifetime reserve amount in the second
calendar year, in the value code and amount fields
84-99 Reserved for assignment by the NUBC
A0- Special ZIP code reporting- This code is used to report the ZIP code of the location
from which the beneficiary is initially placed on board the ambulance.
A1- Deductible Payer A
A2- Coinsurance Payer A
A3- Estimated responsibility Payer A
A4- Covered Self-Administrable Drugs-Emergency
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A5- Covered Self-Administrable Drugs-Not self-administrable in form and situation
A6- Covered Self-Administrable Drugs- Diagnostic Study and other
A7- Co-Payment Payer A
A8- Patient Weight
A9- Patient height
AA- Regulatory Surcharges, Assessments, Allowances or Health Care Related Taxes
Payer A
AB-Other Assessments or Allowances (e.g. medical education) Payer A
AC-AZ- Reserved for Assignment by the NUBC
BO- Reserved for assignment by the NUBC
B1- Deductible Payer B
B2- Coinsurance Payer B
B3- Estimated Responsibility Payer B
B4-B6- Reserved for assignment by the NUBC
B7- Co-Payment Payer B
B8-B9 Reserved for assignment by the NUBC
BA-Regulatory surcharges, assessments, allowances or health care related taxes Payer B
BB- Other assessments or allowances (e.g. medical education) Payer B
BC-CO- Reserved for assignment by the NUBC
C1- Deductible Payer C
C2- Coinsurance Payer C
C3- Estimated Responsibility Payer C
C4-C6 Reserved for assignment by the NUBC
C7- Co-Payment Payer C
C8-C9 Reserved for Assignment by the NUBC
CA- Regulatory surcharges, assessments, allowances or health care related Taxes Payer
CB- Other assessments or Allowances (e.g. medical education) Payer C
CC-CZ- Reserved for assignment by the NUBC
DO-D2- Reserved for Assignment by the NUBC
D3- Estimated Responsibility Patient
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D4- Clinical Trial number assigned by the NLM/NIH (National Library of Medicine/National
Institutes of Health)
D5- Last KT/V Reading
D6-DQ- Reserved for assignment by the NUBC
DR- Reserved for Disaster Related Value
DS-DZ- Reserved for Assignment by the NUBC
EO-EZ- Reserved for assignment by the NUBC
FO-FB-Reserved for assignment by the NUBC
FC- Patient Paid amount
FD- Credit received from the manufacturer for a replaced medical device
FE-FZ- Reserved for Assignment by the NUBC
GO-G7- Reserved for assignment by the NUBC
G8- Facility where inpatient hospice service is delivered
G9-GZ- Reserved for assignment by the NUBC
HO-OZ- Reserved for assignment by the NUBC
PO-PZ- Reserved for Assignment by the NUBC
QO-YO- Reserved for assignment by the NUBC
Y1- Part A demonstration Payment
Y2- Part B demonstration Payment
Y3- Part B Coinsurance
Y4- Conventional Provider Payment for Non-demonstration Claims
Y5-ZZ- Reserved for Assignment by the NUBC
FL 42- REVENUE CODE
Field #42 allows for a four-digit revenue code that represents the specific accommodation,
ancillary services or billing calculation. Use this field to report the appropriate numeric code
corresponding to each narrative description or standard abbreviation that identifies a specific
accommodation and/or ancillary service that is contracted with the provider. Remember that
you should refer to your contract with FirstPlus to report the correspondent revenue codes
contracted with your facility. For Non-contracted provider you should report the
correspondent revenue code for the services provided to the patient.
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42 REV CD
REQUIRED
The revenue codes are available from the NUBC (www.nubc.org) via the NUBC’s official
UB-04 Specifications Manual.
Below please find some of the most common revenue codes use by the providers:
ACCOMMODATION REVENUE CODES
0001-Total Charges
0022-Skilled Nursing Health Prospective Payment System
0023- Home Health Prospective Payment System (for First Plus)
-This revenue code should appear on both requests for anticipated payment
(RAP) (TOB code [FL 4] 0322), and claims (TOB 0329).
-This code indicates that the claim is being paid under the HHPPS.
-Under HHPPS, the unit of payment is a 60-day episode of care. Each episode
Split into two bills. A RAP is sent at the beginning of the episode using Type
Of bill 0322 and one claim is billed at the end of the episode using TOB code
0329.
-Only one revenue code line is required on the RAP. This line is used to report
A single HIPPS code, which is the basis of the anticipated payment
-Line item detail reporting should appear only on the claim TOB 0329
-The HHPPS claim will be edited to ensure that the service date (FL 45)
Reported with revenue code 0023, the admission date (FL 12), and the first
Revenue code date, other than revenue code 0023, all match on an initial
Episode of continuous care
-New HIPPS code for home health resource groups (HHRG) are required in
FL 44 (HCPCS/Rates/HIPPS), adjacent to this revenue code
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0024- Inpatient Rehabilitation Facility prospective payment system (for First+Plus)
-Inpatient Rehabilitation facility (IRF) claims must be billed with TOB code 011X
(FL 4)
-This code indicates that the claim is being paid under the IRF PPS. It is used in
Conjunction with a HIPPS rate code (FL 44) to identify the case-mix group
(CMG) into which the beneficiary is classified. It may appears only once on a
Claim
-Service units (FL 46) must contain the number of covered days for the HIPPS
Rate code and must be equal to or greater than 1.
-A five-digit HIPPS rate/CMG code is required in FL 44 HCPCS/Rates/HIPPS,
Adjacent to this revenue code
0100- All-inclusive room and board plus ancillary
This revenue code can be billed with the following TOB codes (FL 4): 011X,
018X, 012X, and 028X
0110- Private room-(One Bed)
0120- Semi- private room (Two beds) general
0121- Semi-private room medical/surgical/GYN
0122- Semi-private room OB
0123- Semi-private room Pediatric
0124- Semi-private room Psychiatric
0125- Semi-private room Hospice
0126- Semi-private room Detoxification
0127- Semi-private room Oncology
0128- Semi-private room Rehabilitation
0129- Semi-private room other
0130- Semi-private Three and four beds general
0140- Deluxe Private- General
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0150- Room and Board Ward- general
0160 Other room and board-general
0169- Other room and board- Other
0170- Nursery general
0190- Sub acute care-general Level I
0200- Intensive care- general
0201- Intensive care surgical
0202- Intensive care medical
0203- Intensive care pediatric
0204- Intensive care Psychiatric
0206- Intermediate intensive care unit (ICU)
0207- Intensive care- Burn care
0208- Intensive care-Trauma
0209- Other intensive care
0210- Coronary Care- general
0211- Coronary Care- Myocardial Infarction
0212- Coronary Care- Pulmonary
0213- Coronary Care- Heart Transplant
0214- Intermediary Coronary Care unit (CCU)
0219- Other Coronary Care
ANCILLARY SERVICES REVENUE CODES
0220- Special Charges- general
0240- All inclusive Ancillary- general
0250- Pharmacy general (also see 063X, an extension of 025X)
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0251- Generic Drugs
0252- Non generic Drugs
0253- Take home drugs
0254- Drugs incident to other diagnostic services
0255- Drugs incident to radiology
0256- Experimental Drugs
0258- IV solutions
0259- Other Pharmacy
0260- IV Therapy general
0261- Infusion Pump
0270- Medical/Surgical supplies and devices general (see also 062X)
0272- Sterile Supply
0274- Prosthetic/orthotic devices
0275- Pacemaker
0276- Intraocular Lens
0278- Other implants
0279- Other supplies/devices
0280- Oncology General
0290- DME (other than renal)- general
0291- DME Rental
0292- Purchase of new DME
0293- Purchase of used DME
0294- Supplies/drugs for DME effectiveness (HHAs Only)
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0299- Other Equipment
0300- Laboratory general
0301- Laboratory Chemistry
0302- Laboratory- Immunology
0303- Renal Patient (home)
0304- Nonroutine dialysis
0305- Hematology
0306- Bacteriology and microbiology
0307- Urology
0309- Other laboratory
0310 Laboratory Pathological general
0311 Cytology
0312 Histology
0314 Biopsy
0320- Radiology –Diagnostic-general
0321- Angiocardiography
0322- Arthrography
0323- Arteriography
0324- Chest x ray
0329- Other radiology
0330- Radiology Therapeutic and/or chemotherapy administration- general
0331- Chemotherapy administration- Injected
0332- Chemotherapy administration-oral
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0333- Radiation therapy
0335- Chemotherapy Administration-IV
0340- Nuclear Medicine- general
0341- Diagnostic procedure
0342- Therapeutic procedures
0343- Diagnostic radiopharmaceuticals
0344- Therapeutic radiopharmaceuticals
0350- Scans (computed tomography CT scans
0351- Head Scan
0352- Body Scan
0359- Other CT scans
0360- Operating room services-general
This revenue code must be reported by acute care hospitals for all inpatient surgery admission
(emergency or schedule). This is a requirement to comply with CMS HEDIS Reporting
mandate statistics.
0361- Minor Surgery
0362- Organ transplant- other than kidney
0367- Kidney transplant
0369- Other OR services
0370- Anesthesia- general
0371- Anesthesia incident to radiology
0372- Anesthesia incident to other diagnostic Services
0374-Acupuncture
0379- Other Anesthesia
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0380- Blood and Blood components- general
0381- Packed red cells
0382- Whole Blood
0383- Plasma
0384- Platelets
0385- Leukocytes
0386- Other components
0387- Other derivatives (cryoprecipitate)
0389-Other blood
0390- Administration, Processing and Storage for Blood and Blood ComponentsGeneral
0391- Administration (e.g. transfusions)
0392- Processing and storage
0399- Other processing and storage
0400- Other imaging services-general
0401- Diagnostic mammography
0402- Ultrasound
0403- Screening mammography
0404- Positron emission tomography (PET)
0410- Respiratory services- treatments general
0412- Inhalation services
0413- Hyperbaric oxygen therapy
0420- Treatments- Physical Therapy general
0421- Visit charge
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0422- Hourly charge
0423- Group rate
0424- Evaluation of re-evaluation
0429- Other Physical Therapy
0430- Treatments-Occupational Therapy
0431- Visit Charge
0432- Hourly charge
0433- Group rate
0434- Evaluation of re-evaluation
0439- Other occupational therapy (may include restorative therapy)
0440- Treatments- Speech-Language Therapy Pathology-general
0441- Visit charge
0442- Hourly charge
0443- Group rate
0444- Evaluation of re-evaluation
0449- Other Speech-language pathology
0450- Visits- EMERGENCY ROOM
0451- EMTALA emergency medical screening services
0452- ER beyond EMTALA screening
0456- URGENT CARE
0459- Other Emergency Services
0460- Pulmonary Function general
0469- Other pulmonary function
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0470- Audiology general
0471- Audiology Diagnostic
0472- Audiology Treatment
0480- Cardiology general
0481- Cardiac Cath Lab
0482- Stress Test
0483- Echocardiology
0489- Other cardiology
0490- AMBULATORY SURGICAL CARE
0500- OUTPATIENT SERVICES (This code indicates outpatient charges for
Services rendered to an outpatient who is admitted as an inpatient
Before midnight of the day following the date of services.
0510- VISITS CLINIC- general
0511- Chronic pain center
0512- Dental Clinic
0513- Psychiatric Clinic
0514- OB/GYN clinic
0515- Pediatric Clinic
0516- Urgent Care Clinic
0517- Family Practice Clinic
0519- Other Clinic
0520- Freestanding Clinic visits
0530- Osteopathic Services-general
0540- Ambulance- general. Provider must report this revenue code for all
Ambulance services.
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0541- Supplies
0542- Medical Transport
0543- Heart Mobile
0544- Oxygen
0545- Air Ambulance
0546- Neonatal ambulance services
0547- Pharmacy
0549- Other ambulance
0550- Visits Skilled Nursing- general
0551- Visit charge
0552- Hourly charge
0559- Other skilled nursing
0560- Home Health- Medical Social Services
0570- Home Health Aide
0580- Home Health-Other visits
0590- Home Health, Units of Service
0600- Rental Months- Home Health Oxygen
0610- Magnetic Resonance Technology (MRT) tests
0611- MRI- Brain/brain stem
0612- MRI- Spinal Cord/spine
0614- MRI other
0615- MRA Head and Neck
0616- MRA Lower extremities
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0618- MRA- Other
0619- Other MRT
0621- Medical/surgical supplies extension of 027X revenue code
(supplies incident to radiology)
0623- Surgical dressing
0624- FDA investigational devices
0631- Pharmacy extension of 025X revenue codes
(Single Source drug)
0633- Restrictive prescription
0634- Erythropoietin (EPO) less than 10,000 units
0635- Erythropoietin (EPO) 10,000 or more units
0636- Drugs requiring detailed coding
0640- Home IV Therapy Services general
0650- Hospice services general
0657- Hospice Physician services
0700- Cast Room general
0720- Labor room/delivery general
0730- EKG/ECG (electrocardiogram)- general
0731- Holter monitor
0732- Telemetry
0739- Other EKG/ECG
0740- EEG (Electroencephalogram)- general
0750- Gastrointestinal Services general
0769- Observation services on outpatient claims
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0770- Preventive Care Services (general)
0780- Telemedicine- general
0790- Extra Corporeal Shock Wave Therapy
0800- Inpatient renal dialysis sessions- general
0801- Inpatient hemodialysis
0802- Inpatient peritoneal (non-CAPD)
0803- Inpatient continuous ambulatory peritoneal dialysis (CAPD)
0804- Inpatient continuous cycling peritoneal dialysis (CCPD)
0809- Other inpatient dialysis
0810- Acquisition of Body Components
0811- Living Donor
0812- Cadaver donor
0813- Unknown donor
0814- Unsuccessful organ search-donor bank charges
0819- other donor
0820- Hemodialysis sessions-outpatient or Home-general
0821- Hemodialysis/composite or other rate
0822- Home supplies
0823- Home equipment
0824- Maintenance/100 percent
0825- Support Services
0829- Other outpatient hemodialysis
0830- Peritoneal dialysis outpatient or Home sessions- general
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0831- Peritoneal/composite or other rate
0832- Home supplies
0833- Home equipment
0834- Maintenance/100 percent
0835- Support Services
0840- CAPD outpatient or home - general
0841- CAPD/composite or other rate
0842- Home supplies
0843- Home equipment
0844- Maintenance/100 percent
0845- Support Services
0850- CCPD- outpatient or home days- general
0851- CCPD/composite or other rate
0852- Home supplies
0853- Home equipment
0854- Maintenance/100 percent
0855- Support Services
0859- Other outpatient CCPD
0860- Magneto encephalography (MEG)- general classification
0880- Miscellaneous dialysis
0900- Behavioral Health Treatments/services (also see 091X an extension of
090X)
0901- Electroshock treatment (ECT)
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0902- Milieu therapy
0903- Play therapy
0904- Activity therapy
0905- Intensive outpatient services-psychiatric
0906- Intensive outpatient services-chemical dependency
0911- Rehabilitation (Behavioral Health Treatments/services-extension of 090X)
0912- Partial hospitalization- less intensive
0913- Partial hospitalization- intensive
0914- Individual Therapy
0915- Group Therapy
0916- Family Therapy
0920- Other diagnostic services-general
0921- Peripheral vascular lab
0922- Electromyelogram
0923- Pap smear
0924- Allergy test
0925- Pregnancy test
0929- Other diagnostic service
0940- Other therapeutic services (see also 095X, an extension of 094X)-general
0941- Recreational therapy
0942- Education/Training
0943- Cardiac Rehabilitation
0944- Drug Rehabilitation
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0945- Alcohol Rehabilitation
0948- Pulmonary Rehabilitation
0949- Other therapeutic services
0960- Professional Fees (see also 097X abd 098X)-general
0963- Anesthesiologist (MD)
0964- Anesthetist (CRNA)
FL 43 Revenue Descriptions
This field contains a narrative description or standard abbreviation for each revenue code
Category reports don this claim. (FL 42).
43 Description
REQUIRED
FL 44 –HCPCS/CPT/RATES/HIPPS RATES CODES
The provider must submit the correspondent RATE, HCPCS, CPT, or HIPPS code that is
associated to the Revenue Code on FL 42 when applicable. This field contains the Healthcare
Common Procedure Coding System (HCPCS) code, CPT code applicable to ancillary services,
outpatient services, and/or over perdiems. Also, the HIPPS code is also required depending on the
bill type submitted and the type of facility; i.e. home health services, Inpatient Rehabilitation
facilities.
44 HCPCS/ RATE/HIPPS CODE
REQUIRED depending on the revenue code submitted on the bill and or contracting arrangements
with the provider.
For some inpatient services the provider must submit the daily accommodation rate on the
correspondent revenue codes. For Home Health claims the provider must submit the HIPPS code.
Also, the Inpatient Rehabilitation facilities must submit the correspondent HIPPS code.
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FL-45 Service Date
This field contains the date on which the indicated service was provided.
45 SERV DATE
REQUIRED
First Plus requires that the service date be reported for all ancillaries and over perdiem services on
an inpatient stay.
It is require that every revenue code have an associated line-item date of service or dates of service
range for bill types 012X, 013X, 014X,022X, 023X, 032X, 033X, 034X, 071X, 072X, 073X,
074X, 075X, 076X, 081X, 082X, 083X, and 085X
Under HHPPS, RC 0023 must include the date of the first billable services provided under the
HIPPS code reported on that line.
FL- 46 Units of Service
This field contains a quantitative measure of services rendered, by revenue, category, to or for
the patient, including items such as the number of accommodation days, visits, miles, pints of
blood, units or treatments.
46 Service Units
REQUIRED
Zero or negative values are not allowed for inpatient or outpatient claims.
FL- 47 Total Charges
This field contains the total charges pertaining to the related revenue code for the current
billing period as entered in the Statement Covers Period field (FL 6).
47 Total Charges
REQUIRED
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Under HHPPS, on the RAP and the claim, zero charges must be reported with RC 0023.
Under the IRF PPS, the covered charges reported with RC 0024 (FL 42) should be zero.
FL-48 Non covered Charges
This field contains the total non- covered charges for the destination payer pertaining to a
particular revenue code.
48 Non-Covered Charges
SITUATIONAL
FL- 49 (Untitled)
RESERVED for assignment by the NUBC.
FL-50 A-C Payer Name
This field contains the name of the health plan from which the provider might expect some
Payment for the bill for each correspondent line from a through c.
A
50 Payer Name
B
C
REQUIRED
FL- 51 A - C Health Plan National Identification Number
51 Health Plan ID
A
B
C
SITUATIONAL
Report the HIPAA National Plan Identifier when it is mandated for use. Until that
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Occurs, report the legacy or proprietary number as defined in trading partner agreements.
FIRSTPLUS has determined that until this field becomes HIPAA Mandatory the provider must
leave this field blank for UB-04 paper claims.
FL-52 A-C Release of Information Certification Indicator
The provider must indicate a Y (yes) in this field. A “Y” indicates that the provider
has a signed statement permitting release of medical billing data related to a claim]
52 REL INF
A
B
C
REQUIRED
FL-53 A, B, C.- Assignment of Benefits Certification Indicator
This field shows whether the provider has a signed form authorizing the third-party insurer to pay
the provider directly for the services. This indicator applies to the payers listed in FL 50 lines A,
B, and C.
53 ASSN BEN
A
B
C
SITUATIONAL
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FL- 54 A, B, C. Prior Payments
The amount in this field represents the amount the hospital has received to date
toward payment of this bill for the payer indicated in FL 50 on lines A, B, and C
54 Prior payments
A
B
C
SITUATIONAL
FL-55 A, B, AND C- Estimated amount due-Payer
The amount in this field represents an estimate by the hospital of the amount due from
The indicated payer in FL 50 on lines A, B, and C.
55 EST AMOUNT DUE
A
B
C
SITUATIONAL
FL-56 National Provider Identifier-Billing Provider (NPI)
This field contains the unique identification number assigned to the provider submitting the
bill.
56
NPI
REQUIRED
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FL- 57 Other (Billing) Provider Identifiers
Providers contracted under PPS as well as HHA must submit the number assigned by
Medicare (Six digits Medicare Provider Number) on this field.
57
A
PROV
ID
C
OTHER
B
SITUATIONAL
FL-58 A, B, AND C - Insured Name
This field contains the name of the patient or insured individual in whose name the
insurance is issued as qualified by the payer organization listed in FL 50 on lines A, B, and
C.
58 INSURED NAME
A
B
C
Form Locator 58 A is required.
Form Locator 58 B is situational
Form Locator 58C is situational
FL-59 A, B, AND C – Patient’s relationship to Insured
This field contains the code that indicates the relationship of the patient to the insured
individuals identified in FL 58 on lines A, B, and C.
59 P REL
REQUIRED
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CODING STRUCTURE for UB-04 ONLY:
01-Spouse
18-Self
19-Child
20-Employee
21-Unknown
39-Organ Donor
40-Cadaver Donor
53-LIfe Partner
G8-Other Relationship
FL-60 A, B, AND C Insured’s Unique Identifier
This field contains the insured’s unique identification number assigned by the payer
organization. Please refer to the FIRSTPLUS Insurance Card. The provider must enter the
complete number.
60 INSURED UNIQUE ID
60 A is a required field.
60B- is situational
60C- is situational
FL-61 A, B, AND C Insurance Group Name
This field contains the name of the group or plan through which the health insurance
coverage is provided to the insured. If the group name is available enter the information in
the correspondent line (A, B, or C)
61 GROUP NAME
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61 A is situational.
61 B is situational.
61C is situational
FL-62 A, B, AND C – Insurance Group Number
This field contains the identification number, the control number or the code that is
assigned by the insurance company or claims administrator to identify the group under
which the individual is covered.
62 INSURANCE GROUP
NUMBER
A
B
C
FL 62 A Required if the insured’s identification card shows a group number.
FL 62 B is a situational field.
FL 62 C is a situational field.
FL- 63 Treatment Authorization Code
This field identifies a number or other indicator that designates that the treatment is
covered by this bill has been authorized by the payer indicated in FL 50 on lines A, B, and
C.
63. TREATMENT
AUTHORIZATION CODES
A
B
C
REQUIRED FOR HOME HEALTH
This is a situational field. The provider must complete the field when applicable (when an
authorization or referral number is assigned by the payer.)
For Home Health Agencies under First Plus this is a required field. The Home Health
Agency must complete this field. Under HHPPS, on the RAP and on the HHA claim, the
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home health agencies must enter the treatment authorization code from the OASIS
software. This data element links the RAP record to the specific OASIS assessment used
to produce the HIPPS code reported on FL 44. The treatment authorization is an 18position code.
Note: Claims with missing, invalid or incomplete treatment authorization codes will be
rejected back to the provider as a non-processable claim. The provider must correct and
returned the claim along with the non procesable form letter within the time frame establish
by the Prompt Payment Law of Puerto Rico,
FL- 64 Document Control Number (DCN)
This is the internal control number (ICN) or document control number (DCN) assigned to
the original bill by the health plan. This number appears on the Explanation of Payment to
the provider (EOP-paper /835-electronic)
64. DOCUMENT CONTROL NUMBER
This is a required field when the providers resubmit a claim for adjustment or a
reconciliation process to FIRSTPLUS. Please refer to the CLAIM ID number in the EOP.
FL- 65 Employer Name (of the Insured)
This field contains the name of the employer that provides (or may provide) health care
coverage for the insured individual identified in FL 58 on lines A, B, and C.
65. EMPLOYEER NAME
This is a situational field, and applies when there is a WC (Workers Compensation) or a
EGHP (Employer Group Health Plan). The provider enters the name of the employer that
provider the health coverage for the individual identifies on the same lines in FL 58.
This information is required when that payer is either primary or secondary and the MA is
the secondary or tertiary insurer.
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FL-66 Diagnosis and Procedure Code Qualifier (ICD version)
This code identifies the version of the International Classification of Diseases (ICD) being
reported.
66 DX
This is a required field.
Code Structure:
9-Ninth Edition
0-Tenth Edition
Note: When ICD-10 is implemented on October 1st 2014, the provider must ensure that the
correct qualifier is selected based on service or (discharge) date.
FL- 67 Principal Diagnosis Code
This field contains the full ICD-9-CM diagnosis code, including the fourth and fifth digits,
if applicable, that describes the principal diagnosis (the condition established after study to
be chiefly responsible for causing the hospitalization or use of other hospital services). All
diagnosis code must be a valid code. FIRSTPLUS will not accept truncated codes.
67 Principal Diagnoses
REQUIRED
To prevent claim errors, ICD-9-CM codes should be used at the highest level of specificity.
You are required to assign the most precise ICD-9-CM code that most fully explains the
narrative description in the chart of symptoms or diagnosis. Vague or nonspecific
diagnosis codes may cause you claim to edit for medical necessity. Also, claims submitted
with three-or four-digit codes, where four-or five-digit are available will be rejected.
Note: Claims with missing, invalid or incomplete principal diagnosis code will be rejected
as non-processable claims. The provider must correct and returned the claim along with the
non procesable form letter within the time frame establish by the Prompt Payment Law of
Puerto Rico.
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Under the Home Health prospective payment System (HHPPS) on the request for
anticipated payment (RAP) and on the final claims, or any other claim submitted, home
health agencies must enter the ICD-9-CM code for the principal diagnosis.
For inpatients, the condition established after study to be chiefly responsible for the
admission of the patient for care should be listed as the principal diagnosis, even though
another diagnosis may be more severe.
The Medicare code editors as well as the Outpatient Code Editor are applications that are
used to identify data inconsistencies on inpatient hospital and outpatient claims. Claims are
edited to check each diagnosis code on the claim against a table of valid ICD-9-CM.
Invalid codes will be rejected.
Edits such as invalid diagnosis code, admitting diagnosis, procedure code will be validated.
Invalid fourth or fifth digit of an ICD-9-CM diagnosis code or procedure code will be
rejected. E codes use as the principal diagnosis when the E codes describe the
circumstances that caused an injury rather than the nature of the injury. Also, age conflicts,
sex conflicts, or unacceptable principal diagnosis will be edited and rejected back to the
provider.
Certain trauma diagnosis codes are used to identify claims involving patients who may be
covered under automobile insurance, no-fault, worker’s compensation or other liability
insurance for which we should be the secondary payer. Claims with trauma-related
diagnosis codes may be delayed or rejected due to missing or incomplete information. We
can also due post payment review to investigate any trauma code report don the claim
whether the claim is listed as primary, secondary or other diagnosis.
There might also be what we consider questionable admissions but that may be covered
depending upon the medical circumstances. The following table lists questionable ICD-9CM codes for which First Plus may request additional documentation.
Manifestation code as principal diagnosis
Manifestation codes describe the manifestation of an underlying dis-ease, not the disease itself, and
therefore should not be used as a principal diagnosis.
The following list contains some samples of ICD-9-CM diagnoses with corresponding descriptions
identified as manifestation codes.
Manifestations not allowed as principal diagnosis
2842
28952
28983
29410
29411
Myelophthisis
Splenic sequestration
Myelofibrosis
Dementia w/o behav dist
Dementia w behavior dist
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3207
3210
3211
36642
36643
36644
37044
37105
37215
37231
4211
4220
42491
4257
4258
44381
45620
60491
60881
61611
61651
6281
71110
Mening in oth bact dis
Cryptococcal meningitis
Mening in oth fungal dis
Tetanic cataract
Myotonic cataract
Cataract w syndrome NEC
Keratitis in exanthema
Phthisical cornea
Parasitic conjunctivitis
Rosacea conjunctivitis
Ac endocardit in oth dis
Ac myocardit in oth dis
Endocarditis in oth dis
Metabolic cardiomyopathy
Cardiomyopath in oth dis
Angiopathy in other dis
Bleed esoph var oth dis
Orchitis in oth disease
Male gen dis in oth dis
Vaginitis in oth disease
Vulvar ulcer in oth dis
Infertil-pituitary orig
Reiter arthritis-unspec
Questionable admission
Some diagnoses are not usually sufficient justification for admission to an acute care hospital. For
example, if a patient is given code 4011 for benign hypertension, then the patient would have a
questionable admission, since benign hypertension is not normally sufficient justification for admission to a hospital.
The following list contains some diagnosis codes with corresponding descriptions identified as
questionable admission when used as a principal diagnosis.
Questionable admissions - principal diagnosis only
25000
27800
3804
4011
4262
4263
4264
79093
7962
9999
V08
DMII wo cmp nt st uncntr
Obesity NOS
Impacted cerumen
Benign hypertension
Left bb hemiblock
Left bb block NEC
Rt bundle branch block
Elvtd prstate spcf antgn
Elev bl pres w/o hypertn
Complic med care NEC/NOS
Asymp hiv infectn status
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V5331
V5332
V5339
Ftng cardiac pacemaker
Ftng autmtc dfibrillator
Ftng oth cardiac device
Unacceptable principal diagnosis
There are selected codes that describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due
to an under-lying cause. These codes are considered unacceptable as a principal diagnosis.
There are a few usually unacceptable principal diagnosis codes that are considered “acceptable”
when a secondary diagnosis is also coded on the record. If no secondary diagnosis is present for
this subset of codes, the message REQUIRES SECONDARY DX will appear.
The following list contain a some samples of codes with corresponding descriptions identified as
unacceptable when entered as principal diagnosis.
➤ Note: Codes that require a secondary diagnosis are indicated with an asterisk (*).
Unacceptable principal diagnoses
1992
23877
27950
27951
27952
27953
3051
3533
35831
36570
36571
36572
36573
36574
3708
4142
4143
4144
41512
4233
4404
449
51282
5735
6113
69550
Malig neopl-transp organ
Post tp lymphprolif dis
Graft-versus-host NOS
Ac graft-versus-host dis
Chronc graft-vs-host dis
Ac on chrn grft-vs-host
Tobacco use disorder
Thoracic root lesion NEC
Lambert-Eaton synd neopl
Glaucoma stage NOS
Mild stage glaucoma
Moderate stage glaucoma
Severe stage glaucoma
Indeterm stage glaucoma
Keratitis NEC
Chr tot occlus cor artry
Cor ath d/t lpd rch plaq
Cor ath d/t calc cor lsn
Septic pulmonary embolsm
Cardiac tamponade
Chr tot occl art extrem
Septic arterial embolism
Sec spont pneumothorax
Hepatopulmonary syndrome
Fat necrosis of breast
Exfol d/t eryth <10% bdy
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69551
69552
69553
78951
7981
7982
7989
99802
V010
V011
V012
V013
V014
V015
V016
V0181
V0189
V019
V020
V021
V0252
V0253
V0254
V0259
V0260
V0261
V0262
V0269
V027
V028
V029
V030
V031
V032
V037
V0381
V0382
V0389
V039
V040
V041
V047
V0481
V0482
V0489
V050
Exfl d/t eryth 10-19 bdy
Exfl d/t eryth 20-29 bdy
Exfl d/t eryth 30-39 bdy
Malignant ascites
Instantaneous death
Death within 24 hr sympt
Unattended death
Postop shock, septic
Cholera contact
Tuberculosis contact
Poliomyelitis contact
Smallpox contact
Rubella contact
Rabies contact
Venereal dis contact
Contact/exposure-anthrax
Communic dis contact NEC
Communic dis contact NOS
Cholera carrier
Typhoid carrier
Streptococus carrier NEC
Meth susc Staph carrier
Meth resis Staph carrier
Bacteria dis carrier NEC
Viral hep carrier NOS
Hepatitis B carrier
Hepatitis C carrier
Viral hep carrier NEC
Gonorrhea carrier
Venereal dis carrier NEC
Carrier NEC
Vaccin for cholera
Vacc-typhoid-paratyphoid
Vaccin for tuberculosis
Tetanus toxoid inoculat
Nd vac hmophlus inflnz b
Nd vac strptcs pneumni b
Nd other specf vacnation
Vaccin for bact dis NOS
Vaccin for poliomyelitis
Vaccin for smallpox
Vaccin for common cold
Vaccin for influenza
Vaccination for RSV
Vaccn/inoc viral dis NEC
Arbovirus enceph vaccin
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V051
V052
V053
V054
V058
V059
V060
V061
V062
V063
V064
V065
V066
V068
V069
V071
V072
V0731
V074
V0751
V0752
V0759
V079
V090
V091
V092
V0990
V0991
V1000
V1001
V1002
V1003
V1004
* V571
* V5721
* V5722
* V573
V574
V5781
*V5789
* V579
Vacc arboviral dis NEC
Vaccin for leishmaniasis
Need prphyl vc vrl hepat
Need prphyl vc varicella
Vaccin for disease NEC
Vaccin for singl dis NOS
Vaccin for cholera + tab
Vaccination for DTP-DTaP
Vaccin for dtp + tab
Vaccin for dtp + polio
Vac-measle-mumps-rubella
Vaccination for Td-DT
Nd vac strp pnumn/inflnz
Vac-dis combinations NEC
Vac-dis combinations NOS
Desensitiza to allergens
Prophylact immunotherapy
Prophylac fluoride admin
Hormone replaces postmeno
Use of SERMs
Use aromatase inhibitors
Use oth agnt af estrogen
Prophyl or tx meas NOS
Inf mcrg rstn pncllins
Inf mcrg rstn b-lactam
Inf mcrg rstn macrolides
Infc mcrg drgrst mult
Infc mcrg drgrst mult
Hx of GI malignancy NOS
Hx of tongue malignancy
Hx-oral/pharynx malign NEC
Hx-esophageal malignancy
Hx of gastric malignancy
Physical therapy NEC
Encntr occupatnal therapy
Encntr vocational therapy
Speech-language therapy
Orthotic training
Orthotic training
Rehabilitation proc NEC
Rehabilitation proc NOS
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FL-67A-67Q Other Diagnosis Codes
This field contains the full ICD-9-CM diagnosis codes (including the fourth and fifth digits,
if applicable) corresponding to all conditions that coexist at the time of admission, that
develop subsequently, or that affect the treatment received and/or the length of stay.
Diagnoses that relate to an earlier episode, which have no bearing on the current hospital
stay, should be excluded.
Other diagnosis code fields
I
A
J
B
K
C
D
L
M
E
N
F
O
G
P
H
Q
This is a required field when there are conditions that result as secondary diagnosis.
NOTE: Present on Admission Indicator
The present on admission indicator (POA) applies to diagnosis codes (i.e., principal, secondary
and E codes) for inpatient claims to general acute-care hospitals or other facilities as required
by law or regulation for public health reporting. It is the eighth digit attached to the
corresponding diagnosis code.
Effective January 1, 2011 the Deficit Reduction Act of 2005 will require all claims that include
an inpatient admission to general acute care hospitals or other facilities to contain POA
information.
Any hospital that is currently contracted under First Plus -DRG methodology of payment must
report the POA indicator. All hospital inpatient services rendered by Non-contracted providers
must also submit the POA indicator in all the diagnosis related fields.
As a general rule, all hospital inpatient admission to general acute care hospitals must report
the POA indicator on their claims. We encourage providers to submit the POA indicator on
their inpatient acute care admissions regardless their contracted reimbursement methodology.
Additional information related to POA guidelines can be obtained from ICD-9-CM Official
Guidelines for Coding and Reporting that are available on the NCHS website at
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm
FL-68 Reserved-Not in used currently.
FL-69 Admitting Diagnosis
This field is for reporting the complete ICD-9-CM code describing the patient’s diagnosis
at the time of admission, including fourth and fifth digits when appropriate.
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69.
ADM
DX
This is a required field for inpatient admission claims and encounters, and Part B only
claims (TOB’s 012X, and 022X in FL 4).
Enter the patient’s admitting diagnosis using a complete and accurate ICD-9-CM code.
The ICD-9-CMN admitting diagnosis code describes a significant finding representing
patient distress, an abnormal finding on an examination, a possible diagnosis base on
significant findings, a diagnosis established from a previous encounter or admission, an
injury, a poisoning, or a reason or condition (not an illness or injury) such as follow up or
pregnancy in labor.
FL-70 A-C Patient’s reason for visit
This field is for reporting the complete ICD-9-CM code describing the patient’s reason for
the visit at the time of admission or outpatient registration, including fourth and fifth digits
when appropriate.
70. PATIENT REASON
A
B
C
DX
Patient’s Reason for Visit is required for all un-scheduled outpatient visits.
Unscheduled outpatient visits are defined as TOB 013X or 085X with a priority or type of
admission (FL 14) of 1, 2, or 5 and revenue codes of 045X, 0516, 0526, or 0762.
FL-71 Prospective Payment System (PPS) code
Required Field. The hospital must report the correspondent DRG code related to an acute care
admission on this field. This code it is usually available from the medical records coding system of
the hospital. This code might identify those emergency or schedule admissions related to
Surgeries. CMS requires that surgery admissions be identified properly.
Note: For those providers that submit electronic claims (837 I) please report the DRG CODE on
LOOP 2300 –Claim Information/Segment HI Diagnosis Related Group (DRG) Information.
71.
PPS
CODE
REQUIRED FIELD
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FL-72 a-c External Cause of Injury (ECI)-E Code
This field contains up to three full ICD-9-CM codes, including the fourth and fifth digits if
applicable, pertaining to the external cause of injury, poisoning or adverse effect. Health
Care facilities are encouraged to report an E code whenever there is a diagnosis of an
injury, poisoning or other adverse effect.
72.
ECI
CODE
This is a Situational field.
FL-73 Reserved.
FL-74 Principal Procedure Code and Date
This field contains the ICD-9CM code for the inpatient principal procedure performed at
the claim level during the period covered by this bill and the corresponding date on which
the principal procedure was performed.
HIPAA code set requirements do not allow the use of ICD-9-CM procedure codes on
outpatient claims.
74. PRINCIPAL PROCEDURE
CODE
DATE
This is a situational field.
Note: All inpatient surgery admissions must be reported with the correspondent ICD-9CM procedure codes. Remember CMS requires that all surgery admissions be reported
accordingly.
74A-74E Other Procedure Codes and Dates
This field allows reporting of up to five ICD-9-CM codes to identify the significant
procedures performed during the billing period, other than the principal procedure, and the
corresponding dates on which the procedures were performed. Report those that are most
important for the episode of care and specifically any therapeutic procedures closely related
to the principal diagnosis.
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HIPAA code set requirements do not allow the use of ICD-9-CM procedure codes on
outpatient claims.
CODE
DATE
Completion of this field is required for inpatient Part A claims only. Inpatient hospital
claims require reporting the principal procedure if a significant procedure occurred during
the hospitalization. The principal procedure is the procedure performed for definitive
treatment rather than for diagnostic or exploratory purposes, or which was necessary to
take care of complication. It is also the procedure most closely related to the principal
diagnosis. Enter the full ICD-9-CM code, including the fourth digit when applicable, and
the date of the principal procedure.
This is a situational field.
Note: All inpatient surgery admissions must be reported with the correspondent ICD-9-CM
procedure codes. Remember CMS requires that all surgery admissions be reported
accordingly.
FL- 75 Reserved
FL-76 Attending Provider Name and Identifiers (including NPI)
This field identifies the name and identifying number of the attending provider. The
attending provider is the individual who has overall responsibility for the patient’s medical
care and treatment reported on this claim.
76.
ATTENDING
NPI
This is a required field
Note: Effective January 1st, 2012 CMS requires that field 76 be completed.
FL-77 Operating Physician Name and Identifiers
This field identifies the name and identification number of the individual with the primary
responsibility for performing the surgical procedure(s).
77.
OPERATING
NPI
This is a situational field.
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FL-78 and 79 Other Provider Names and Identifiers
These fields contain the name and identification number of the provider that corresponds to
the indicated provider type on this claim.
78. OTHER
NPI
This is a situational field.
FL-80 Remarks
This field is used to capture additional information necessary to adjudicate the claim. Provide any
additional information that is necessary to adjudicate the claim or otherwise fulfill the payer’s
reporting requirements. Enter any information that is not reported elsewhere on the bill but that
may be necessary for reimbursement.
80. Remarks
This is a situational field.
FL-81 Code-Code field
This field is used to report overflow or additional codes related to field locators or to report
externally maintained codes approved by the NUBC for inclusion in the institutional data
set.
81
CC
A
B
C
D
This is a situational field
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ADA DENTAL CLAIM FORM
The following fields are required ADA Dental Health Insurance Claim Form:
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HEADER INFORMATION
Box 1
Type of Transaction
Required Field
Indicate whether Actual Service or Request for Predetermination/Preauthorization
Box 2
Predetermination/Preauthorization Number
Situational Field
Enter Prior Authorization Number, if applicable
Box 3
Insurance Company/Dental Plan Benefit Information
Required Field
Indicate Insurance Company claim submission address
• Refer to your provider billing manuals for information on the mailing address for
claims submission
OTHER COVERAGE
Box 4
Other Dental or Medical Coverage?
Situational Field- Complete if there is another coverage
Check Yes or No
• If yes, please complete box 5-11
Box 5
Name of Policy Holder/Subscriber in box 4
Situational Field
If box 4 is completed, then this field must be completed
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Box 6
Date of Birth
Situational Field
If box 4 is completed, then this field must be completed
Box 7
Gender
Situational Field
If box 4 is completed, then this field must be completed
Box 8
Policyholder/Subscriber ID (SSN or ID#)
Situational Field
If box 4 is completed, then this field must be completed
Box 9
Plan/Group Number
Situational Field
If box 4 is completed, then this field must be completed
Box 10
Patient’s Relationship to Person Named in Box 5
Situational Field
If box 4 is completed, then this field must be completed
Box 11
Other Company/Dental Benefit Plan Name, Address, City, State, Zip Code
Situational Field
Indicate the “other insurance plan(s)” Name and address
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POLICYHOLDER/SUBSCRIBER INFORMATION
Box 12
Policy Holder/Subscriber Name
Required Field
Indicate subscriber’s name and Address
Box 13
Date of Birth
Required Field
Enter patient’s date of birth
Box 14
Gender
Required Field
Check the correspondent box
Box 15
Policyholder/Subscriber ID
Required Field
Enter patient’s contract number as appear on the First+Plus Insurance Card
Must have 9 characters
Note: claim with missing, incorrect, or incomplete contract number will be rejected as nonprocessable. The provider must correct the claim and return it to First+Plus along with the
non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Box 16
Plan/Group Number
Situational
Enter the group number as appears on the member insurance card
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Box 17
Employer Name
Situational Field
If applicable enter the employer name
PATIENT INFORMATION
Box 18
Relationship to Policyholder/Subscriber in #12 Above
Situational Field
Check the correspondent box as appropriate
Box 19
Student Status
Not use by First+Plus
Box 20
Name, Address, City, State, Zip Code
Required field
Enter the name, address, city, State, Zip Code of the patient.
Box 21
Date of Birth
Required Field
Enter the patient Date of Birthday
Box 22
Gender
Required Field
Enter the patient gender
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Box 23
Patient ID/Account #
Required field
If you enter the patient’s account number, we will report it back to you on your remittance advice (RA)/Explanation of payment (EOP)
Up to 12 characters, any combination of alpha characters or numbers
RECORD OF SERVICES PROVIDED
Box 24 through 31
Required Fields ( unless otherwise noted)
Repeat Boxes 24-31 for any additional services/procedures rendered, up to a total of
10 lines per claim form
Box 24
Procedure Date
Required Field
Enter the date of the service
Must be in mmddccyy format, e.g., 08152012
Note: claim with missing, incorrect, or incomplete procedure date will be rejected as nonprocessable. The provider must correct the claim and return it to First+Plus along with the
non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Box 25
Area of Oral Cavity
Situational Field
Report when restoration procedures are involved
Box 26
Tooth System
Situational
Indicate the tooth system if service require the notification of the system
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Box 27
Tooth Number(s) or Letter(s)
Required Field, except for preventive services
Enter number of tooth , as applicable
Must be no more than two (2) characters (1-32)
Note: claim with missing, incorrect or incomplete Tooth number, if required, will be rejected
as non-processable. The provider must correct the claim and return it to First+Plus along
with the non-processable form letter within the timeframe establish by the Prompt Payment
Law of Puerto Rico.
Box 28
Tooth Surface
Required Field, when the procedure requires submission of the tooth number
Enter tooth surface, as applicable
Up to five (5)surfaces, one character each
Surface
o M-Mesial
o 0- Oclusal
o I- Incisal
o B- Bucal
o D-Distal
o F- Facial
o L- Lingual
Note: claim with missing, incorrect or incomplete tooth surface, if required, will be rejected
as non-processable. The provider must correct the claim and return it to First+Plus along
with the non-processable form letter within the timeframe establish by the Prompt Payment
Law of Puerto Rico.
Box 29
Procedure Code
Required Field
Enter the applicable CDT procedure code
Must be five (5) characters beginning with a “D”
Note: claim with missing, incorrect, or incomplete procedure code will be rejected as nonprocessable. The provider must correct the claim and return it to First+Plus along with the
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non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Box 30
Description
Required Field
Enter description of procedure according to CDT guidelines
Box 31
Fee
Required Field
Note: claim with missing, incorrect, or incomplete information will be rejected as nonprocessable. The provider must correct the claim and return it to First+Plus along with the
non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Enter fee charged for procedure
Must be in a valid currency format: dd.cc, e.g., 24.00
Box 32
Other Fee(s)
Not used by First+Plus
Box 33
Total fee
Required Field
Enter your total charge (per page)
Must equal the total of all fees entered in Box 31
Up to nine (9) digits
Must be in a valid currency format, dd.cc, e.g., 24.00
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MISSING TEETH INFORMATION
Box 34
Situational Field
Check appropriate number when the procedure requires that the missing tooth be
reported
Box 35
Remarks
Use this field to report any other relevant information needed for the Payer to make a
determination on the claim, such as emergency services justification, etc.
Situational Field
AUTHORIZATIONS
Box 36
Patient/Guardian Signature
Required Field
By signing this field the Patient acknowledge notification of the treatment plan and
associated fees. The patient agrees to be responsible for all charges for dental services
and materials not paid by the dental benefit plan.
Note: claim with missing, incorrect, or incomplete patient/guardian signature will be rejected
as non-processable. The provider must correct the claim and return it to First+Plus along
with the non-processable form letter within the timeframe establish by the Prompt Payment
Law of Puerto Rico.
Box 37 Subscriber Signature/Date
Required Field
The Subscriber must sign the Claim Form or “Signature on File” can be provided. By
given a statement of “Signature on File” the provider is attesting that there is an authorization on file for the release of any medical or other information necessary to
process and/or adjudicate the claim, and that the subscriber is authorizing payment of
the dental services to the dentist or dental entity included on the Claim Form
Note: claim with missing, incorrect, or incomplete Subscriber signature will be rejected as
non-processable. The provider must correct the claim and return it to First+Plus along with
the non-processable form letter within the timeframe establish by the Prompt First+Plus
payment law of Puerto Rico.
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ANCILLARY CLAIM/TREATMENT INFORMATION
Box 38
Place of Treatment
Required Field
Check the applicable box
• Must have one box checked
Box 39
Number of enclosures
Situational Field
Check appropriate box
DO NOT send radiographs to First+Plus for claims processing, except when root
canal procedures are performed, or if a request is generated by First+Plus for
claim processing and medical necessity review
Box 40
Is the treatment for orthodontics?
Not used by First+Plus
Box 41
Date Appliance Placed
Not used by First+Plus
Box 42
Months of Treatment Remaining
Not used by First+Plus
Box 43
Replacement of Prosthesis
Situational Field
Check Yes or No
• Must have one box checked
• If No, do not complete fields 41 and 42
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Box 44
Date Prior Placement
Situational Field, if box 43 is checked Yes
Enter date of prior placement in mmddccyy format, e.g.,08152013
Box 45
Treatment Resulting from
Situational Field
If the treatment is the result of an occupational illness/injury, auto accident, or other accident
Check appropriate box
If Box is checked, enter date of occupational illness/injury, auto or other accident in
mmddccyy format, e.g.,08152013
Box 46
Situational Field, if any box in 45 is checked must enter date
Enter date of occupational illness/injury, auto or other accident in mmddccyy format,
e.g., 08152013
Box 47
Auto Accident State
Situational Field
Indicate the state in which the auto accident took place
BILLING DENTIST OR DENTAL ENTITY
Box 48
Name, Address, City State, Zip Code of the billing Dentist
Required Field
Enter the name of the billing dentist or group
• The provider name entered in this field is the provider name that services will be reimbursed to and under which the monies will be reported to the Internal Revenue
Service
• The provider name must be entered the same way the provider is enrolled in
First+Plus ; either
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• Individual providers billing and seeking reimbursement under their individual provider name; or
• Group practices billing and seeking reimbursement under a group provider name
Note: claim with missing, incorrect, or incomplete billing dentist name and address, will be
rejected as non-processable. The provider must correct the claim and return it to First+Plus along
with the non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Enter the address of the billing dentist or group
Box 49
NPI
Required Field
Enter the 10-digit billing provider’s NPI ( National Provider Identifier)
Note: claim with missing, incorrect, or incomplete billing provider NPI number will be
rejected as non-processable. The provider must correct the claim and return it to First+Plus
along with the non-processable form letter within the timeframe establish by the Prompt
Payment Law of Puerto Rico.
Box 50
License number
Required Field
Note: claim with missing, incorrect, or incomplete license number will be rejected as nonprocessable. The provider must correct the claim and return it to First+Plus along with the
non-processable form letter within the timeframe establish by the Prompt Payment Law of
Puerto Rico.
Box 51
Social Security Number (SSN) or Tax Identification Number (TIN)
Required Field
Enter the Billing Dentist or Dental Entity TIN or SSN
• This number must match what First+Plus has in your contract file
Note: claim with missing, incorrect, or incomplete SSN will be rejected as non-processable.
The provider must correct the claim and return it to First+Plus along with the nonprocessable form letter within the timeframe establish by the Prompt Payment Law of Puerto
Rico.
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Box 52
Phone Number
Required Field
Enter phone number for billing provider, in the event that First+Plus might need to contact you for further information
Box 52a
Additional Provider ID
Situational Field
Treating Dentist And Treatment Location Information
Box 53
Signature or name of treating dentist and date
Required field
Enter the performing provider’s full name
Enter date
• Must be in mmddccyy format, e.g., 08152013
• Must be on or after the date of service
Note: claim with missing, or incomplete signature will be rejected as non-processable. The
provider must correct the claim and return it to First+Plus along with the non-processable
form letter within the timeframe establish by the Prompt Payment Law of Puerto Rico.
Box 54
Treating dentist NPI
Required Field
Enter the 10-digit performing provider’s NPI ( National Provider Identifier)
Note: claim with missing, incorrect, or incomplete treating dentist NPI number will be
rejected as non-processable. The provider must correct the claim and return it to First+Plus
along with the non-processable form letter within the timeframe establish by the Prompt
Payment Law of Puerto Rico.
Box 55
License Number (of treating dentist)
Required Field
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Box 56
Treating dentist Address, City, State, Zip Code
Required Field
Enter address for the treating provider
Box 56a
Provide specialty code
Situational Field
If an NPI is in Box 54
• Enter the corresponding 10 digit taxonomy code
• Strongly suggested that a taxonomy code be provided when an NPI is in box 54
• The NPI number and corresponding taxonomy code must be on file with First+Plus
Box 57
Phone Number
Required Field
The number First+Plus can use to contact you if there are questions re: your claim
Box 58
Additional Provider ID
Situational Field
Other Relevant Information:
Dental Services does not require pre-authorization. However, the provider must verify
eligibility and confirm that the services and/or benefit have not been exhausted by the
patient.
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ADJUSTMENT REASON CODES
Adjustment Reason Codes are codes that describe the reason of the action taken on a claim
line, or entire claim during the adjudication process. This allows the provider to review the
payment or denial of a service for the required corrective action, if needed.
The Adjustment Reason Codes are standard HIPAA CODES that are reviewed from time to
time. A list of REMARK CODES associated with the Adjustment Reason Codes is
included. Also, a list of User Defined Adj. Reason Codes is included for your reference.
These codes are included on your EOP (Explanation of Payments).
ADJUSTMENT REASON CODES USER DEFINED-CLAIMS DEPARTMENT
ADJ
REASON
CODE
DESCRIPTION
U02
U06
U07
U08
U09
U11
U13
U17
U18
U19
U20
U21
U23
U24
U25
U26
AMAF
Balance billing does not apply
Original Medicare limiting charge
Foreign Hospital -Member Reimbursement
COB Information not received
Settlement Claim
Provider settlement -no payment
Re-Coding HH Services
No Legible claim
Complete mouth x-rays limited to 3 yrs intervals
Report does not justify emergency exam
Non processable through CMS-1500 and/or 837P. Submit AMAF
HHPPS RAP Claim Adjustment
HHPPS Final Bill Payment
Original payment void
Full payment on final bill
U28
Negative amount represents collection against receivable created in prior overpayment
U29
U30
U31
U32
U34
U35
U36
U37
U38
Adjustment as result of MPFS fee update
COB Claim
Payment based on a contractual amount or agreement
LUPA Payment
For reporting purposes-No reimbursement to member applies
Member has PDP coverage only
OIG Exclusion List Provider
Hospice Covered Service Claim-Bill Original MEDICARE
Bill original MEDICARE for non-Hospice Services
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U39
U40
U41
U42
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U60
U61
U62
U63
U64
U65
U66
U67
Hospice Claim----Submit correspondent Modifier
No Cost-Sharing Hospice Payment Applies
Hospice Claim-Submit correspondent Condition Code
Service covered by Hospice Provider
Revenue code submitted does not correspondent to the hospital review document
VA Copayments not covered per MEDICARE Regulation
Previous interest payment adjustment
Service not contracted by provider
Service not authorized
Level of service not authorized by Medical Review
Adjustment due to incorrect member ID
Adjustment due to payment to incorrect provider
Adjustment due to fee amounts
Adjustment due to service code changes from the provider
Adjustment due to changes in number of units
Adjustment due to changes on dates
Adjustment due to changes on level of service
Adjustment due to combination of revenue codes and CPT
Adjustment due to incorrect place of service
Adjustment due to service date
Adjustment due for corrections on Pointer
Adjustment due to payment rules
Adjustment due for duplicate payment
Information submitted does not justify payment of this claim
Service does not covered
Benefit limit
COB does not proceed
Claim paid in full
U68
No claim level adjustment
U69
U70
U72
U73
U74
U76
U77
U78
U79
Medicare Secondary Payer Adjusted amount
Procedure postponed, cancelled or delayed
Missing invoice- Claim cannot be adjusted
Level of care change per hospital review
Level of care not approved by hospital review
Denial days as per Hospital review determination
claim denied -No supporting documentation submitted for review
Incorrect revenue code submitted for service-see Contract
Revenue code change- according to service provided and Contract
U81
U86
Coverage not in effect at the time the service was provided
Adjustment request received outside time limit
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U87
U88
U89
U91
U95
U96
U97
Hospital Review revenue code change-payment process on another line
Same level of service but different revenue code as per hospital review
Supplemental information for line of service is required
Re-process due to original claim lines incomplete processing
Claim line service dates are in conflict with related procedure code date of services
Informative-Additional Day(s) -contracted surgery package
Informative-Approved hospital days included on the contracted surgery package
U104
Additional adjustment done on claim
No payments proceed. Patient is responsible for payment of deductibles, co-payment
and/or co-insurance according to the benefit coverage
Charge(s) exceed the fee of the dental service code billed
The procedure service code performed is required in addition to the billed code
Please specify place of service
Service previously processed and/or paid for the same tooth and/or surface under another
dental procedure code
Supplementary (Suppletory) prior to transplant
Service not covered, usually use for orthodoncy services or major facial surgery
Adjustment or repairs only proceed after six (6) months of insertion of denture or prosthesis
Case was evaluated by dental consultant
Not paid under OPPS
AMAF
Balance billing does not apply
Original Medicare limiting charge
Foreign hospital-member reimbursement
COB information not received
Settlement claim
Provider settlement-no payment
Re-coding HH services
No legible claim
Complete mouth x-rays limited to 3 yrs. intervals
report does not justify emergency exam
Non processable through cms-1500 and/or 837p. submit AMAF
HHPPS rap claim adjustment
HHPPS final bill payment
Original payment void
Full payment on final bill
Negative amount represents collection against receivable created in prior overpayment
Adjustment as result of MPFS fee update
COB claim
Payment based on a contractual amount or agreement
U105
U106
U107
U109
U110
U111
U112
U113
U114
U115
U02
U06
U07
U08
U09
U11
U13
U17
U18
U19
U20
U21
U23
U24
U25
U26
U28
U29
U30
U31
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U32
U34
U35
U36
U37
U38
U39
U40
U41
U42
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U60
U61
U62
U63
U64
U65
U66
U67
Lupa payment
For reporting purposes-no reimbursement to member applies
Member has PDP coverage only
OIG exclusion list provider
Hospice covered service claim-bill original Medicare
Bill original Medicare for non-hospice services
Hospice claim submit correspondent modifier
No cost-sharing hospice payment applies
Hospice claim submit correspondent condition code
Service covered by hospice provider
Revenue code submitted is not correct according with audit
Copayments not covered per Medicare regulation
Previous interest payment adjustment
Service not contracted by provider
Service not authorized
Level of service not authorized by medical review
Adjustment incorrect affiliate number
Adjustment payment to the provider wrong
Adjustment for differences in rates
Adjustment for changes in codes by the providers
Adjustment for difference in number of units
Adjustment for change in dates
Adjustment for change in level of service
Adjustment by combination of revenue code with CPT
Adjustment wrong place of services
Adjustment in date of services
Adjustment pointer corrección
Adjustment payment rule
Adjustment duplicated payment
Information submitted does not justify the payment of this claim
Service not covered
Benefit Limit
COB does not proceed
Claim paid in full
U68
No claim level adjustment
U69
U70
U72
U73
U74
U76
Medicare secondary payer adjustment amount
Procedure postponed, canceled or delayed
Missing invoice- claims cannot be adjusted
Level of care change per hospital review
Level of care not approved by hospital review
Denial days as per Hospital review determination
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U77
U78
U79
Claim denied -No supporting documentation submitted for review
Incorrect revenue code submitted for service-see Contract
Revenue code change- according to service provided and Contract
U81
U86
U87
U88
U89
U91
U95
U96
U97
U104
Coverage not in effect at the time the service was provided
Adjustment Request received out the stipulated time
Hospital Review revenue code change-payment process on another line
Same level of service but different revenue code as per hospital review
Supplemental information for line of service is required
Re-process due to original claim lines incomplete processing
Claim line service dates are in conflict with related procedure code date of services
Informativo-Día(s) adicional(es)-paquete de cirugía contratado
Informativo-Días de estadía aprobados incluidos en paquete de cirugía contratado
Additional adjustment done on claim
Not applicable payment. Patient is responsible for payment, deductibles, copayments and /
or coinsurance according with benefits covered
Charges exceed dental code rate
Code is required procedure performed service in addition to code billed
Please specify place of service
U105
U106
U107
U109
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CLAIM ADJUSTMENT REASON CODES
1
Deductible Amount
Start: 01/01/1995
2
Coinsurance Amount
Start: 01/01/1995
3
Co-payment Amount
Start: 01/01/1995
4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
13
The date of death precedes the date of service.
Start: 01/01/1995
14
The date of birth follows the date of service.
Start: 01/01/1995
15
The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
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.) This change effective 11/1/2013: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code
for claims attachment(s). At least one Remark Code must be provided (may be comprised of ei-
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ther 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.
Start: 01/01/1995 | Last Modified: 01/20/2013
17
Requested information was not provided or was insufficient/incomplete. At least one Remark
Code must be provided (may be comprised of either the Remittance Advice Remark Code or
NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/2009
18
Exact duplicate claim/service (Use only with Group Code OA)
Start: 01/01/1995 | Last Modified: 01/20/2013
19
This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
20
This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21
This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22
This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23
The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with
Group Code OA)
Start: 01/01/1995 | Last Modified: 09/30/2012
24
Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
25
Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008
26
Expenses incurred prior to coverage.
Start: 01/01/1995
27
Expenses incurred after coverage terminated.
Start: 01/01/1995
28
Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.
29
The time limit for filing has expired.
Start: 01/01/1995
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting,
or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
31
Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32
Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995
33
Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34
Insured has no coverage for newborns.
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Start: 01/01/1995 | Last Modified: 09/30/2007
35
Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
36
Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003
37
Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003
38
Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/30/2003 | Stop: 01/01/2013
39
Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995
40
Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
41
Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003
42
Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007
43
Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006
44
Prompt-pay discount.
Start: 01/01/1995
45
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use
Group Codes PR or CO depending upon liability). This change effective 7/1/2013: Charge exceeds
fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group
Codes PR or CO depending upon liability)
Start: 01/01/1995 | Last Modified: 09/30/2012
46
This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006
48
This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
49
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. This change effective 11/1/2013: This is
a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 01/20/2013
50
These are non-covered services because this is not deemed a 'medical necessity' by the payer.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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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.
Start: 01/01/1995 | Last Modified: 09/20/2009
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the
service billed.
Start: 01/01/1995 | Stop: 02/01/2006
53
Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995
54
Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
55
Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
56
Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the
835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if
present.
Start: 01/01/1995 | Last Modified: 09/20/2009
57
Payment denied/reduced because the payer deems the information submitted does not support
this level of service, this many services, this length of service, this dosage, or this day's supply.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Split into codes 150, 151, 152, 153 and 154.
58
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of
service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
59
Processed based on multiple or concurrent procedure rules. (For example multiple surgery or
diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
60
Charges for outpatient services are not covered when performed within a period of time prior to
or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
61
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007
63
Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003
64
Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003
65
Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003
66
Blood Deductible.
Start: 01/01/1995
67
Lifetime reserve days. (Handled in QTY, QTY01=LA)
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Start: 01/01/1995 | Stop: 10/16/2003
68
DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003
69
Day outlier amount.
Start: 01/01/1995
70
Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
71
Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.
72
Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003
73
Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003
74
Indirect Medical Education Adjustment.
Start: 01/01/1995
75
Direct Medical Education Adjustment.
Start: 01/01/1995
76
Disproportionate Share Adjustment.
Start: 01/01/1995
77
Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003
78
Non-Covered days/Room charge adjustment.
Start: 01/01/1995
79
Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003
80
Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003
81
Discharges.
Start: 01/01/1995 | Stop: 10/16/2003
82
PIP days.
Start: 01/01/1995 | Stop: 10/16/2003
83
Total visits.
Start: 01/01/1995 | Stop: 10/16/2003
84
Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003
85
Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient.
86
Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.
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87
Transfer amount.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012
88
Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
89
Professional fees removed from charges.
Start: 01/01/1995
90
Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2009
91
Dispensing fee adjustment.
Start: 01/01/1995
92
Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003
93
No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.
94
Processed in Excess of charges.
Start: 01/01/1995
95
Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either
the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note:
Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
98
The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003
99
Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003
100
Payment made to patient/insured/responsible party/employer.
Start: 01/01/1995 | Last Modified: 01/27/2008
101
Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999
102
Major Medical Adjustment.
Start: 01/01/1995
103
Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001
104
Managed care withholding.
Start: 01/01/1995
105
Tax withholding.
Start: 01/01/1995
106
Patient payment option/election not in effect. Start: 01/01/1995
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107
The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
108
Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
109
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Start: 01/01/1995 | Last Modified: 01/29/2012
110
Billing date predates service date.
Start: 01/01/1995
111
Not covered unless the provider accepts assignment.
Start: 01/01/1995
112
Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
113
Payment denied because service/procedure was provided outside the United States or as a result
of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.
114
Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995
115
Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116
The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117
Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118
ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119
Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004
120
Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.
121
Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122
Psychiatric reduction.
Start: 01/01/1995
123
Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
124
Payer refund amount - not our patient.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
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125
Submission/billing error(s). At least one Remark Code must be provided (may be comprised of
either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013
126
Deductible -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.
127
Coinsurance -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 2.
128
Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997
129
Prior processing information appears incorrect. At least one Remark Code must be provided
(may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code
that is not an ALERT.)
Start: 02/28/1997 | Last Modified: 01/30/2011
130
Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
131
Claim specific negotiated discount.
Start: 02/28/1997
132
Prearranged demonstration project adjustment.
Start: 02/28/1997
133
The disposition of the claim/service is pending further review. (Use only with Group Code OA)
Start: 02/28/1997 | Last Modified: 01/20/2013
134
Technical fees removed from charges.
Start: 10/31/1998
135
Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136
Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective
7/1/2013: Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
Start: 10/31/1998 | Last Modified: 09/30/2012
137
Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
138
Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007
139
Contracted funding agreement - Subscriber is employed by the provider of services.
Start: 06/30/1999
140
Patient/Insured health identification number and name do not match.
Start: 06/30/1999
141
Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012
142
Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143
Portion of payment deferred.
Start: 02/28/2001
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144
Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001
145
Premium payment withholding
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
146
Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147
Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002
148
Information from another provider was not provided or was insufficient/incomplete. At least one
Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or
Remittance Advice Remark Code that is not an ALERT.)
Start: 06/30/2002 | Last Modified: 09/20/2009
149
Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150
Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151
Payment adjusted because the payer deems the information submitted does not support this
many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008
152
Payer deems the information submitted does not support this length of service. Note: Refer to the
835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if
present.
Start: 10/31/2002 | Last Modified: 09/20/2009
153
Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154
Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155
Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
156
Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009
157
Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158
Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159
Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160
Injury/illness was the result of an activity that is benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161
Provider performance bonus
Start: 02/29/2004
162
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for
specific explanation.
Start: 02/29/2004
Provider Manual 2013
221
163
Attachment referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007
164
Attachment referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007
165
Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007
166
These services were submitted after this payers responsibility for processing claims under this
plan ended.
Start: 02/28/2005
167
This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
168
Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007
169
Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170
Payment is denied when performed/billed by this type of provider. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
173
Service was not prescribed by a physician. This change effective 7/1/2013: Service/equipment
was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2012
174
Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175
Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176
Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177
Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178
Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179
Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
180
Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
181
Procedure code was invalid on the date of service. Start: 06/30/2005 | Last Modified: 09/30/2007
Provider Manual 2013
222
182
Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183
The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
186
Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187
Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009
188
This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005
189
'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a
specific procedure code for this procedure/service
Start: 06/30/2005
190
Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
191
Not a work related injury/illness and thus not the liability of the workers' compensation carrier
Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the
835 Insurance Policy Number Segments (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and
the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF)
Start: 10/31/2005 | Last Modified: 10/17/2010
192
Nonstandard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction
only. This code is only used when the non-standard code cannot be reasonably mapped to an
existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 09/30/2007
193
Original payment decision is being maintained. Upon review, it was determined that this claim
was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008
194
Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195
Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
196
Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.
197
Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007
Provider Manual 2013
223
198
Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007
199
Revenue code and Procedure code do not match.
Start: 10/31/2006
200
Expenses incurred during lapse in coverage
Start: 10/31/2006
201
Workers' Compensation case settled. Patient is responsible for amount of this claim/service
through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR). This
change effective 7/1/2013: Workers Compensation case settled. Patient is responsible for amount
of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use only
with Group Code PR)
Start: 10/31/2006 | Last Modified: 09/30/2012
202
Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203
Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204
This service/equipment/drug is not covered under the patient’s current benefit plan
Start: 02/28/2007
205
Pharmacy discount card processing fee
Start: 07/09/2007
206
National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207
National Provider identifier - Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008
208
National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209
Per regulatory or other agreement. The provider cannot collect this amount from the patient.
However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use
Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. The provider
cannot collect this amount from the patient. However, this amount may be billed to subsequent
payer. Refund to patient if collected. (Use only with Group code OA)
Start: 07/09/2007 | Last Modified: 09/30/2012
210
Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
211
National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007
212
Administrative surcharges are not covered
Start: 11/05/2007
213
Non-compliance with the physician self-referral prohibition legislation or payer policy.
Start: 01/27/2008
214
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or
service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider
should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the
payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010
Provider Manual 2013
224
215
Based on subrogation of a third party settlement
Start: 01/27/2008
216
Based on the findings of a review organization
Start: 01/27/2008
217
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee
arrangement. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
218
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send
and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other
Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at
the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment information REF). To be used for Workers'
Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010
219
Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the
provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line
Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 01/27/2008 | Last Modified: 10/17/2010
220
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill
with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided
and supporting documentation if required. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
221
Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the
payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This
change effective 7/1/2013: Claim is under investigation. Note: If adjustment is at the Claim Level,
the payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To
be used by Property & Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
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.
Start: 06/01/2008 | Last Modified: 09/20/2009
223
Adjustment code for mandated federal, state or local law/regulation that is not already covered by
another code and is mandated before a new code can be created.
Start: 06/01/2008 SEQUESTRATION ONLY - IS DONE BY THE EZCAP SYSTEM AUTOMATICALLY
224
Patient identification compromised by identity theft. Identity verification required for processing
this and future claims.
Start: 06/01/2008
225
Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the
837)
Start: 06/01/2008
226
Information requested from the Billing/Rendering Provider was not provided or 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.) This
change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not
provided or not provided timely or was insufficient/incomplete. At least one Remark Code must
be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.) Start: 09/21/2008 | Last Modified: 09/30/2012
Provider Manual 2013
225
227
Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the
NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/20/2009
228
Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008
229
Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X.
Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim
submission to a prior payer. Use Group Code PR. This change effective 7/1/2013: Partial charge
amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This
code can only be used in the 837 transaction to convey Coordination of Benefits information
when the secondary payer's cost avoidance policy allows providers to bypass claim submission
to a prior payer. (Use only with Group Code PR)
Start: 01/25/2009 | Last Modified: 09/30/2012
230
No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009
231
Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2009 | Last Modified: 09/20/2009
232
Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG
amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009
233
Services/charges related to the treatment of a hospital-acquired condition or preventable medical
error.
Start: 01/24/2010
234
This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not
an ALERT.)
Start: 01/24/2010
235
Sales Tax
Start: 06/06/2010
236
This procedure or procedure/modifier combination is not compatible with another procedure or
procedure/modifier combination provided on the same day according to the National Correct
Coding Initiative. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the
same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
Start: 01/30/2011 | Last Modified: 09/30/2012
237
Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of
either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/05/2011
238
Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). This change effective 7/1/2013: Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
Start: 03/01/2012 | Last Modified: 09/30/2012
239
Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
Start: 03/01/2012 | Last Modified: 01/29/2012
240
The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Provider Manual 2013
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Start: 06/03/2012
241
Low Income Subsidy (LIS) Co-payment Amount
Start: 06/03/2012
242
Services not provided by network/primary care providers.
Start: 06/03/2012
243
Services not authorized by network/primary care providers.
Start: 06/03/2012
244
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
Start: 09/30/2012
245
Provider performance program withhold.
Start: 09/30/2012
246
This non-payable code is for required reporting only.
Start: 09/30/2012
247
248
249
Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act
(PPACA).
Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act
(PPACA).
This claim has been identified as a readmission. (Use only with Group Code CO)
Start: 09/30/2012
250
The attachment content received is inconsistent with the expected content.
Start: 09/30/2012
251
The attachment content received did not contain the content required to process this claim or
service.
Start: 09/30/2012
252
An attachment is required to adjudicate this claim/service. At least one Remark Code must be
provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT).
Start: 09/30/2012
A0
Patient refund amount.
Start: 01/01/1995
A1
Claim/Service denied. At least one Remark Code must be provided (may be comprised of either
the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009
A2
Contractual adjustment.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3
Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003
A4
Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Provider Manual 2013
227
A5
Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995
A6
Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995
A7
Presumptive Payment Adjustment
Start: 01/01/1995
A8
Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
B1
Non-covered visits.
Start: 01/01/1995
B2
Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003
B3
Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003
B4
Late filing penalty.
Start: 01/01/1995
B5
Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007
B6
This payment is adjusted when performed/billed by this type of provider, by this type of provider
in this type of facility, or by a provider of this specialty.
Start: 01/01/1995 | Stop: 02/01/2006
B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
B9
Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10
Allowed amount has been reduced because a component of the basic procedure/test was paid.
The beneficiary is not liable for more than the charge limit for the basic procedure/test.
Start: 01/01/1995
B11
The claim/service has been transferred to the proper payer/processor for processing.
Claim/service not covered by this payer/processor.
Start: 01/01/1995
B12
Services not documented in patients' medical records.
Start: 01/01/1995
B13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995
B14
Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15
This service/procedure requires that a qualifying service/procedure be received and covered. The
qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 09/20/2009
Provider Manual 2013
228
B16
'New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B17
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to
delivery, the prescription is incomplete, or the prescription is not current.
Start: 01/01/1995 | Stop: 02/01/2006
B18
This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009
B19
Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003
B20
Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B21
The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003
B22
This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001
B23
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA)
proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
D1
Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D2
Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D4
Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D5
Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D6
Claim/service denied. Claim did not include patient's medical record for the service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D7
Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D8
Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less
discounts or the type of intraocular lens used.
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229
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D10
Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D11
Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or
the amount you were charged for the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D13
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician
has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D14
Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D15
Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D16
Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].
D17
Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D18
Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D19
Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D20
Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D21
This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007
D22
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note:
To be used for Workers' Compensation only) - Temporary code to be added for timeframe only
until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to
replace or strategy to use another existing code.
Start: 01/27/2008 | Stop: 01/01/2009
Provider Manual 2013
230
D23
This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least
one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason
Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2009 | Stop: 01/01/2012
W1
Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim
Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line
Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 02/29/2000 | Last Modified: 10/17/2010
W2
Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level,
the payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be
used for Workers' Compensation only.
Start: 10/17/2010
W3
The Benefit for this Service is included in the payment/allowance for another service/procedure
that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
Start: 09/30/2012
W4
Workers' Compensation Medical Treatment Guideline Adjustment.
Start: 09/30/2012
Y1
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP)
Benefits jurisdictional regulations or payment policies, use only if no other code is applicable.
Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the
835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier
'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and
the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
Y2
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection
(PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer
to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF
qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must
send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
Y3
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee
schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other
Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the
provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
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The Remittance Advice Remark Code List
M1
X-ray not taken within the past 12 months or near enough to the start of treatment.
Start: 01/01/1997
M2
Not paid separately when the patient is an inpatient.
Start: 01/01/1997
M3
Equipment is the same or similar to equipment already being used.
Start: 01/01/1997
M4
Alert: This is the last monthly installment payment for this durable medical equipment.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997
M6
Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.
Start: 01/01/1997 | Last Modified: 03/01/2009
Notes: (Modified 4/1/07, 3/1/2009)
M7
No rental payment after the item is purchased, or after the total of issued rental payments equals the purchase price.
Start: 01/01/1997
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.
Start: 01/01/1997
M9
Alert: This is the tenth rental month. You must offer the patient the choice of changing
the rental to a purchase agreement.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
M10
Equipment purchases are limited to the first or the tenth month of medical necessity.
Start: 01/01/1997
M11
DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.
Start: 01/01/1997
M12
Diagnostic tests performed by a physician must indicate whether purchased services are
included on the claim.
Start: 01/01/1997
M13
Only one initial visit is covered per specialty per medical group.
Start: 01/01/1997 | Last Modified: 06/30/2007
Notes: (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.
Start: 01/01/1997
M15
Separately billed services/tests have been bundled as they are considered components
of the same procedure. Separate payment is not allowed.
Start: 01/01/1997
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M16
Alert: Please see our web site, mailings, or bulletins for more details concerning this
policy/procedure/decision.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07)
M17
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
M19
Missing oxygen certification/re-certification.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N234
M20
Missing/incomplete/invalid HCPCS.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M21
Missing/incomplete/invalid place of residence for this service/item provided in a home.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M22
Missing/incomplete/invalid number of miles traveled.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M23
Missing invoice.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)
M24
Missing/incomplete/invalid number of doses per vial.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M25
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 an 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.
Start: 01/01/1997 | Last Modified: 11/01/2010
Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07, 11/1/10)
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M26
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.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)
M27
Alert: The patient has been relieved of liability of payment of these items and services
under the limitation of liability provision of the law. The provider is 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.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)
M28
This does not qualify for payment under Part B when Part A coverage is exhausted or
not otherwise available.
Start: 01/01/1997
M29
Missing operative note/report.
Start: 01/01/1997 | Last Modified: 07/01/2008
Notes: (Modified 2/28/03, 7/1/2008) Related to N233
M30
Missing pathology report.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 2/28/03) Related to N236
M31
Missing radiology report.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 2/28/03) Related to N240
M32
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
M33
Missing/incomplete/invalid UPIN for the ordering/referring/performing provider.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using M68
M34
Claim lacks the CLIA certification number.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA120
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M35
Missing/incomplete/invalid pre-operative photos or visual field results.
Start: 01/01/1997 | Stop: 02/05/2005
Notes: 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.
Start: 01/01/1997
M37
Not covered when the patient is under age 35.
Start: 01/01/1997 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
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.
Start: 01/01/1997
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.
Start: 01/01/1997 | Last Modified: 11/01/2012
Notes: (Modified 2/1/04, 4/1/07, 11/1/09, 11/1/12) Related to N563
M40
Claim must be assigned and must be filed by the practitioner's employer.
Start: 01/01/1997
M41
We do not pay for this as the patient has no legal obligation to pay for this.
Start: 01/01/1997
M42
The medical necessity form must be personally signed by the attending physician.
Start: 01/01/1997
M43
Payment for this service previously issued to you or another provider by another carrier/intermediary.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using Reason Code 23
M44
Missing/incomplete/invalid condition code.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M45
Missing/incomplete/invalid occurrence code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N299
M46
Missing/incomplete/invalid occurrence span code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N300
M47
Missing/incomplete/invalid internal or document control number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using M97
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M49
Missing/incomplete/invalid value code(s) or amount(s).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M50
Missing/incomplete/invalid revenue code(s).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M51
Missing/incomplete/invalid procedure code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N301
M52
Missing/incomplete/invalid “from” date(s) of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M53
Missing/incomplete/invalid days or units of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M54
Missing/incomplete/invalid total charges.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
M56
Missing/incomplete/invalid payer identifier.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M57
Missing/incomplete/invalid provider identifier.
Start: 01/01/1997 | Stop: 06/02/2005
M58
Missing/incomplete/invalid claim information. Resubmit claim after corrections.
Start: 01/01/1997 | Stop: 02/05/2005
M59
Missing/incomplete/invalid “to” date(s) of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M60
Missing Certificate of Medical Necessity.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (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.
Start: 01/01/1997
M62
Missing/incomplete/invalid treatment authorization code.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M63
We do not pay for more than one of these on the same day.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using M86
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M64
Missing/incomplete/invalid other diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
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.
Start: 01/01/1997
M67
Missing/incomplete/invalid other procedure code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N302
M68
Missing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.
Start: 01/01/1997 | Stop: 06/02/2005
M69
Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
M70
Alert: The 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.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/2007, 8/1/07)
M71
Total payment reduced due to overlap of tests billed.
Start: 01/01/1997
M72
Did not enter full 8-digit date (MM/DD/CCYY).
Start: 01/01/1997 | Stop: 10/16/2003
Notes: 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.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04)
M74
This service does not qualify for a HPSA/Physician Scarcity bonus payment.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)
M75
Multiple automated multichannel tests performed on the same day combined for payment.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)
M76
Missing/incomplete/invalid diagnosis or condition.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
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M77
Missing/incomplete/invalid place of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M78
Missing/incomplete/invalid HCPCS modifier.
Start: 01/01/1997 | Stop: 05/18/2006 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03,) Consider using Reason Code 4
M79
Missing/incomplete/invalid charge.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M80
Not covered when performed during the same session/date as a previously processed
service for the patient.
Start: 01/01/1997 | Last Modified: 10/31/2002
Notes: (Modified 10/31/02)
M81
You are required to code to the highest level of specificity.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
M82
Service is not covered when patient is under age 50.
Start: 01/01/1997
M83
Service is not covered unless the patient is classified as at high risk.
Start: 01/01/1997
M84
Medical code sets used must be the codes in effect at the time of service
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
M85
Subjected to review of physician evaluation and management services.
Start: 01/01/1997
M86
Service denied because payment already made for same/similar procedure within set
time frame.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
M87
Claim/service(s) subjected to CFO-CAP prepayment review.
Start: 01/01/1997
M88
We cannot pay for laboratory tests unless billed by the laboratory that did the work.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using Reason Code B20
M89
Not covered more than once under age 40.
Start: 01/01/1997
M90
Not covered more than once in a 12 month period.
Start: 01/01/1997
M91
Lab procedures with different CLIA certification numbers must be billed on separate
claims.
Start: 01/01/1997
M92
Services subjected to review under the Home Health Medical Review Initiative.
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Start: 01/01/1997 | Stop: 08/01/2004
M93
Information supplied supports a break in therapy. A new capped rental period began
with delivery of this equipment.
Start: 01/01/1997
M94
Information supplied does not support a break in therapy. A new capped rental period
will not begin.
Start: 01/01/1997
M95
Services subjected to Home Health Initiative medical review/cost report audit.
Start: 01/01/1997
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.
Start: 01/01/1997
M97
Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.
Start: 01/01/1997
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.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using M99
M99
Missing/incomplete/invalid Universal Product Number/Serial Number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
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.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using M78
M102
Service not performed on equipment approved by the FDA for this purpose.
Start: 01/01/1997
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.
Start: 01/01/1997
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.
Start: 01/01/1997
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.
Start: 01/01/1997
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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.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using MA 31
M107
Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded
36.5%.
Start: 01/01/1997
M108
Missing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test.
Start: 01/01/1997 | Stop: 06/02/2005
M109
We have provided you with a bundled payment for a tele-consultation. You must send 25
percent of the tele-consultation payment to the referring practitioner.
Start: 01/01/1997
M110
Missing/incomplete/invalid provider identifier for the provider from whom you purchased
interpretation services.
Start: 01/01/1997 | Stop: 06/02/2005
M111
We do not pay for chiropractic manipulative treatment when the patient refuses to have
an x-ray taken.
Start: 01/01/1997
M112
Reimbursement for this item is based on the single payment amount required under the
DMEPOS Competitive Bidding Program for the area where the patient resides.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)
M113
Our records indicate that this patient began using this item/service prior to the current
contract period for the DMEPOS Competitive Bidding Program.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)
M114
This service was processed in accordance with rules and guidelines under the DMEPOS
Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 8/1/06, 11/5/07)
M115
This item is denied when provided to this patient by a non-contract or nondemonstration supplier.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/2007)
M116
Processed under a demonstration project or program. Project or program is ending and
additional services may not be paid under this project or program.
Start: 01/01/1997 | Last Modified: 03/08/2011
Notes: (Modified 2/1/04, 3/15/11)
M117
Not covered unless submitted via electronic claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
M118
Letter to follow containing further information.
Start: 01/01/1997 | Stop: 01/01/2011 | Last Modified: 11/01/2009
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Notes: Consider using N202
M119
Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (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.
Start: 01/01/1997 | Stop: 06/02/2005
M121
We pay for this service only when performed with a covered cryosurgical ablation.
Start: 01/01/1997
M122
Missing/incomplete/invalid level of subluxation.
Start: 01/01/1997 | Last Modified: 02/28/2006
Notes: (Modified 2/28/03)
M123
Missing/incomplete/invalid name, strength, or dosage of the drug furnished.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M124
Missing indication of whether the patient owns the equipment that requires the part or
supply.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M126
Missing/incomplete/invalid individual lab codes included in the test.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M127
Missing patient medical record for this service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N237
M128
Missing/incomplete/invalid date of the patient’s last physician visit.
Start: 01/01/1997 | Stop: 06/02/2005
M129
Missing/incomplete/invalid indicator of x-ray availability for review.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (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.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N231
M131
Missing physician financial relationship form.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N239
M132
Missing pacemaker registration form.
Start: 01/01/1997 | Last Modified: 02/28/2003
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Notes: (Modified 2/28/03) Related to N235
M133
Claim did not identify who performed the purchased diagnostic test or the amount you
were charged for the test.
Start: 01/01/1997
M134
Performed by a facility/supplier in which the provider has a financial interest.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
M135
Missing/incomplete/invalid plan of treatment.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M136
Missing/incomplete/invalid indication that the service was supervised or evaluated by a
physician.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
M137
Part B coinsurance under a demonstration project or pilot program.
Start: 01/01/1997 | Last Modified: 11/01/2012
Notes: (Modified 11/1/12)
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.
Start: 01/01/1997
M139
Denied services exceed the coverage limit for the demonstration.
Start: 01/01/1997
M140
Service not covered until after the patient’s 50th birthday, i.e., no coverage prior to the
day after the 50th birthday
Start: 01/01/1997 | Stop: 01/30/2004
Notes: Consider using M82
M141
Missing physician certified plan of care.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N238
M142
Missing American Diabetes Association Certificate of Recognition.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N226
M143
The provider must update license information with the payer.
Start: 01/01/1997 | Last Modified: 12/01/2006
Notes: (Modified 12/1/06)
M144
Pre-/post-operative care payment is included in the allowance for the surgery/procedure.
Start: 01/01/1997
MA01
Alert: 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.
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Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 4/1/07)
MA02
Alert: If you do not agree with this determination, you have the right to appeal. You must
file a written request for an appeal within 180 days of the date you receive this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 12/29/05, 8/1/06, 4/1/07)
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.
Start: 01/01/1997 | Stop: 10/01/2006 | Last Modified: 11/18/2005
Notes: Consider using MA02 (Modified 10/31/02, 6/30/03, 8/1/05, 11/18/05)
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.
Start: 01/01/1997
MA05
Incorrect admission date patient status or type of bill entry on claim.
Start: 01/01/1997 | Stop: 10/16/2003
Notes: Consider using MA30, MA40 or MA43
MA06
Missing/incomplete/invalid beginning and/or ending date(s).
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA31
MA07
Alert: The claim information has also been forwarded to Medicaid for review.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA08
Alert: Claim information was not forwarded because the supplemental coverage is not
with a Medigap plan, or you do not participate in Medicare.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA09
Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.
Start: 01/01/1997
MA10
Alert: The patient's payment was in excess of the amount owed. You must refund the
overpayment to the patient.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: 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).
Start: 01/01/1997
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MA13
Alert: You may be subject to penalties if you bill the patient for amounts not reported
with the PR (patient responsibility) group code.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA14
Alert: The 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.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/07, 8/1/07)
MA15
Alert: Your claim has been separated to expedite handling. You will receive a separate
notice for the other services reported.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997
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.
Start: 01/01/1997
MA18
Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA19
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
MA21
SSA records indicate mismatch with name and sex.
Start: 01/01/1997
MA22
Payment of less than $1.00 suppressed.
Start: 01/01/1997
MA23
Demand bill approved as result of medical review.
Start: 01/01/1997
MA24
Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
MA25
A patient may not elect to change a hospice provider more than once in a benefit period.
Start: 01/01/1997
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MA26
Alert: Our records indicate that you were previously informed of this rule.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA27
Missing/incomplete/invalid entitlement number or name shown on the claim.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA28
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA29
Missing/incomplete/invalid provider name, city, state, or zip code.
Start: 01/01/1997 | Stop: 06/02/2005
MA30
Missing/incomplete/invalid type of bill.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA31
Missing/incomplete/invalid beginning and ending dates of the period billed.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA32
Missing/incomplete/invalid number of covered days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA33
Missing/incomplete/invalid noncovered days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA34
Missing/incomplete/invalid number of coinsurance days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA35
Missing/incomplete/invalid number of lifetime reserve days.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA36
Missing/incomplete/invalid patient name.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA37
Missing/incomplete/invalid patient's address.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA38
Missing/incomplete/invalid birth date.
Start: 01/01/1997 | Stop: 06/02/2005
MA39
Missing/incomplete/invalid gender.
Start: 01/01/1997 | Last Modified: 02/28/2003
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Notes: (Modified 2/28/03)
MA40
Missing/incomplete/invalid admission date.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA41
Missing/incomplete/invalid admission type.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA42
Missing/incomplete/invalid admission source.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA43
Missing/incomplete/invalid patient status.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA44
Alert: No appeal rights. Adjudicative decision based on law.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA45
Alert: As previously advised, a portion or all of your payment is being held in a special
account.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA46
The new information was considered but additional payment will not be issued.
Start: 01/01/1997 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)
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.
Start: 01/01/1997
MA48
Missing/incomplete/invalid name or address of responsible party or primary payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA76
MA50
Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved
clinical trial services.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA51
Missing/incomplete/invalid CLIA certification number for laboratory services billed by
physician office laboratory.
Start: 01/01/1997 | Stop: 02/05/2005
Notes: Consider using MA120
MA52
Missing/incomplete/invalid date.
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Start: 01/01/1997 | Stop: 06/02/2005
MA53
Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
MA54
Physician certification or election consent for hospice care not received timely.
Start: 01/01/1997
MA55
Not covered as patient received medical health care services, automatically revoking
his/her election to receive religious non-medical health care services.
Start: 01/01/1997
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.
Start: 01/01/1997
MA57
Patient submitted written request to revoke his/her election for religious non-medical
health care services.
Start: 01/01/1997
MA58
Missing/incomplete/invalid release of information indicator.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA59
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA60
Missing/incomplete/invalid patient relationship to insured.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA61
Missing/incomplete/invalid social security number or health insurance claim number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA62
Alert: This is a telephone review decision.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/07, 8/1/07)
MA63
Missing/incomplete/invalid principal diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
MA65
Missing/incomplete/invalid admitting diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
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MA66
Missing/incomplete/invalid principal procedure code.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N303
MA67
Correction to a prior claim.
Start: 01/01/1997
MA68
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA69
Missing/incomplete/invalid remarks.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA70
Missing/incomplete/invalid provider representative signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA71
Missing/incomplete/invalid provider representative signature date.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA72
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
MA73
Informational remittance associated with a Medicare demonstration. No payment issued
under fee-for-service Medicare as patient has elected managed care.
Start: 01/01/1997
MA74
This payment replaces an earlier payment for this claim that was either lost, damaged or
returned.
Start: 01/01/1997
MA75
Missing/incomplete/invalid patient or authorized representative signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA76
Missing/incomplete/invalid provider identifier for home health agency or hospice when
physician is performing care plan oversight services.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03, 2/1/04)
MA77
Alert: 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.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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.
Start: 01/01/1997 | Stop: 01/31/2004
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Notes: Consider using MA59
MA79
Billed in excess of interim rate.
Start: 01/01/1997
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.
Start: 01/01/1997
MA81
Missing/incomplete/invalid provider/supplier signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA82
Missing/incomplete/invalid provider/supplier billing number/identifier or billing name,
address, city, state, zip code, or phone number.
Start: 01/01/1997 | Stop: 06/02/2005
MA83
Did not indicate whether we are the primary or secondary payer.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (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.
Start: 01/01/1997
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.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA92
MA86
Missing/incomplete/invalid group or policy number of the insured for the primary coverage.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA92
MA87
Missing/incomplete/invalid insured's name for the primary payer.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using MA92
MA88
Missing/incomplete/invalid insured's address and/or telephone number for the primary
payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA89
Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA90
Missing/incomplete/invalid employment status code for the primary insured.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03).
MA91
This determination is the result of the appeal you filed.
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Start: 01/01/1997
MA92
Missing plan information for other insurance.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04) Related to N245
MA93
Non-PIP (Periodic Interim Payment) claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (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.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (Reactivated 4/1/04, Modified 8/1/05)
MA95
A not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA1500.
Start: 01/01/1997 | Stop: 01/01/2004 | Last Modified: 02/28/2003
Notes: (Deactivated 2/28/2003) (Erroneous description corrected 9/2/2008) Consider
using M51
MA96
Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not
enrolled in a Medicare managed care plan.
Start: 01/01/1997
MA97
Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or
clinical trial registry number.
Start: 01/01/1997 | Last Modified: 02/29/2008
Notes: (Modified 2/29/08)
MA98
Claim Rejected. Does not contain the correct Medicare Managed Care Demonstration
contract number for this beneficiary.
Start: 01/01/1997 | Stop: 10/16/2003
Notes: Consider using MA97
MA99
Missing/incomplete/invalid Medigap information.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA100
Missing/incomplete/invalid date of current illness or symptoms
Start: 01/01/1997 | Last Modified: 03/30/2005
Notes: (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.
Start: 01/01/1997 | Stop: 01/01/2011 | Last Modified: 06/30/2003
Notes: Consider using N538
MA102
Missing/incomplete/invalid name or provider identifier for the rendering/referring/ ordering/ supervising provider.
Start: 01/01/1997 | Stop: 08/01/2004
Notes: Consider using M68
MA103
Hemophilia Add On.
Start: 01/01/1997
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MA104
Missing/incomplete/invalid date the patient was last seen or the provider identifier of the
attending physician.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using M128 or M57
MA105
Missing/incomplete/invalid provider number for this place of service.
Start: 01/01/1997 | Stop: 06/02/2005
MA106
PIP (Periodic Interim Payment) claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
MA107
Paper claim contains more than three separate data items in field 19.
Start: 01/01/1997
MA108
Paper claim contains more than one data item in field 23.
Start: 01/01/1997
MA109
Claim processed in accordance with ambulatory surgical guidelines.
Start: 01/01/1997
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.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA111
Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA112
Missing/incomplete/invalid group practice information.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
MA114
Missing/incomplete/invalid information on where the services were furnished.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/1997
Notes: (Reactivated 4/1/04)
MA117
This claim has been assessed a $1.00 user fee.
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Start: 01/01/1997
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.
Start: 01/01/1997
MA119
Provider level adjustment for late claim filing applies to this claim.
Start: 01/01/1997 | Stop: 05/01/2008 | Last Modified: 11/05/2007
Notes: Consider using Reason Code B4
MA120
Missing/incomplete/invalid CLIA certification number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
MA121
Missing/incomplete/invalid x-ray date.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)
MA122
Missing/incomplete/invalid initial treatment date.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)
MA123
Your center was not selected to participate in this study, therefore, we cannot pay for
these services.
Start: 01/01/1997
MA124
Processed for IME only.
Start: 01/01/1997 | Stop: 01/31/2004
Notes: Consider using Reason Code 74
MA125
Per legislation governing this program, payment constitutes payment in full.
Start: 01/01/1997
MA126
Pancreas transplant not covered unless kidney transplant performed.
Start: 10/12/2001
MA127
Reserved for future use.
Start: 10/12/2001 | Stop: 06/02/2005
MA128
Missing/incomplete/invalid FDA approval number.
Start: 10/12/2001 | Last Modified: 03/30/2005
Notes: (Modified 2/28/03, 3/30/05)
MA129
This provider was not certified for this procedure on this date of service.
Start: 10/12/2001 | Stop: 01/31/2004 | Last Modified: 01/31/2004
Notes: 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 un-processable. Please submit a new claim with the complete/correct information.
Start: 10/12/2001
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.
Start: 10/12/2001
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MA132
Adjustment to the pre-demonstration rate.
Start: 10/12/2001
MA133
Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient
stay.
Start: 10/12/2001
MA134
Missing/incomplete/invalid provider number of the facility where the patient resides.
Start: 10/12/2001
N1
Alert: 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.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 2/28/03, 4/1/07)
N2
This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.
Start: 01/01/2000
N3
Missing consent form.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N228
N4
Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.
Start: 01/01/2000 | Last Modified: 03/06/2012
Notes: (Modified 2/28/03, 3/6/2012)
N5
EOB received from previous payer. Claim not on file.
Start: 01/01/2000
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.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N7
Processing of this claim/service has included consideration under Major Medical provisions.
Start: 01/01/2000
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.
Start: 01/01/2000
N9
Adjustment represents the estimated amount a previous payer may pay.
Start: 01/01/2000 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)
N10
Payment based on the findings of a review organization/professional consult/manual
adjudication/medical or dental advisor.
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 10/31/02, 7/1/08)
N11
Denial reversed because of medical review.
Start: 01/01/2000
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N12
Policy provides coverage supplemental to Medicare. As the member does not appear to
be enrolled in the applicable part of Medicare, the member is responsible for payment of
the portion of the charge that would have been covered by Medicare.
Start: 01/01/2000 | Last Modified: 08/01/2007
Notes: (Modified 8/1/07)
N13
Payment based on professional/technical component modifier(s).
Start: 01/01/2000
N14
Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
Start: 01/01/2000 | Stop: 10/01/2007
Notes: Consider using Reason Code 45
N15
Services for a newborn must be billed separately.
Start: 01/01/2000
N16
Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.
Start: 01/01/2000
N17
Per admission deductible.
Start: 01/01/2000 | Stop: 08/01/2004
Notes: Consider using Reason Code 1
N18
Payment based on the Medicare allowed amount.
Start: 01/01/2000 | Stop: 01/31/2004
Notes: Consider using N14
N19
Procedure code incidental to primary procedure.
Start: 01/01/2000
N20
Service not payable with other service rendered on the same date.
Start: 01/01/2000
N21
Alert: Your line item has been separated into multiple lines to expedite handling.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 8/1/05, 4/1/07)
N22
This procedure code was added/changed because it more accurately describes the services rendered.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 10/31/02, 2/28/03)
N23
Alert: Patient liability may be affected due to coordination of benefits with other carriers
and/or maximum benefit provisions.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 8/13/01, 4/1/07)
N24
Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (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.
Start: 01/01/2000
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N26
Missing itemized bill/statement.
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 2/28/03, 7/1/2008) Related to N232
N27
Missing/incomplete/invalid treatment number.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N28
Consent form requirements not fulfilled.
Start: 01/01/2000
N29
Missing documentation/orders/notes/summary/report/chart.
Start: 01/01/2000 | Last Modified: 08/01/2005
Notes: (Modified 2/28/03, 8/1/05) Related to N225
N30
Patient ineligible for this service.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
N31
Missing/incomplete/invalid prescribing provider identifier.
Start: 01/01/2000 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)
N32
Claim must be submitted by the provider who rendered the service.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
N33
No record of health check prior to initiation of treatment.
Start: 01/01/2000
N34
Incorrect claim form/format for this service.
Start: 01/01/2000 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)
N35
Program integrity/utilization review decision.
Start: 01/01/2000
N36
Claim must meet primary payer’s processing requirements before we can consider payment.
Start: 01/01/2000
N37
Missing/incomplete/invalid tooth number/letter.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N38
Missing/incomplete/invalid place of service.
Start: 01/01/2000 | Stop: 02/05/2005
Notes: Consider using M77
N39
Procedure code is not compatible with tooth number/letter.
Start: 01/01/2000
N40
Missing radiology film(s)/image(s).
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 2/1/04, 7/1/08) Related to N242
N41
Authorization request denied.
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Start: 01/01/2000 | Stop: 10/16/2003
Notes: Consider using Reason Code 39
N42
No record of mental health assessment.
Start: 01/01/2000
N43
Bed hold or leave days exceeded.
Start: 01/01/2000
N44
Payer’s share of regulatory surcharges, assessments, allowances or health care-related
taxes paid directly to the regulatory authority.
Start: 01/01/2000 | Stop: 10/16/2003
Notes: Consider using Reason Code 137
N45
Payment based on authorized amount.
Start: 01/01/2000
N46
Missing/incomplete/invalid admission hour.
Start: 01/01/2000
N47
Claim conflicts with another inpatient stay.
Start: 01/01/2000
N48
Claim information does not agree with information received from other insurance carrier.
Start: 01/01/2000
N49
Court ordered coverage information needs validation.
Start: 01/01/2000
N50
Missing/incomplete/invalid discharge information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N51
Electronic interchange agreement not on file for provider/submitter.
Start: 01/01/2000
N52
Patient not enrolled in the billing provider's managed care plan on the date of service.
Start: 01/01/2000
N53
Missing/incomplete/invalid point of pick-up address.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N54
Claim information is inconsistent with pre-certified/authorized services.
Start: 01/01/2000
N55
Procedures for billing with group/referring/performing providers were not followed.
Start: 01/01/2000
N56
Procedure code billed is not correct/valid for the services billed or the date of service
billed.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N57
Missing/incomplete/invalid prescribing date.
Start: 01/01/2000 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N304
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N58
Missing/incomplete/invalid patient liability amount.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N59
Please refer to your provider manual for additional program and provider information.
Start: 01/01/2000 | Last Modified: 11/01/2009
Notes: (Modified 4/1/07, 11/1/09)
N60
A valid NDC is required for payment of drug claims effective October 02.
Start: 01/01/2000 | Stop: 01/31/2004
Notes: Consider using M119
N61
Rebill services on separate claims.
Start: 01/01/2000
N62
Dates of service span multiple rate periods. Resubmit separate claims.
Start: 01/01/2000 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N63
Rebill services on separate claim lines.
Start: 01/01/2000
N64
The “from” and “to” dates must be different.
Start: 01/01/2000
N65
Procedure code or procedure rate count cannot be determined, or was not on file, for the
date of service/provider.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N66
Missing/incomplete/invalid documentation.
Start: 01/01/2000 | Stop: 02/05/2005
Notes: 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 nondemonstration facility on the new claim.
Start: 01/01/2000
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.
Start: 01/01/2000
N69
PPS (Prospective Payment System) code changed by claims processing system.
Start: 01/01/2000 | Last Modified: 07/01/2012
Notes: (Modified 6/30/03, 7/1/12)
N70
Consolidated billing and payment applies.
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Start: 01/01/2000 | Last Modified: 11/05/2007
Notes: (Modified 2/28/02, 11/5/07)
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.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 2/21/02, 6/30/03)
N72
PPS (Prospective Payment System) code changed by medical reviewers. Not supported
by clinical records.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (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.
Start: 01/01/2000 | Stop: 01/31/2004
Notes: Consider using MA101 or N200
N74
Resubmit with multiple claims, each claim covering services provided in only one calendar month.
Start: 01/01/2000
N75
Missing/incomplete/invalid tooth surface information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N76
Missing/incomplete/invalid number of riders.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N77
Missing/incomplete/invalid designated provider number.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N78
The necessary components of the child and teen checkup (EPSDT) were not completed.
Start: 01/01/2000
N79
Service billed is not compatible with patient location information.
Start: 01/01/2000
N80
Missing/incomplete/invalid prenatal screening information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)
N81
Procedure billed is not compatible with tooth surface code.
Start: 01/01/2000
N82
Provider must accept insurance payment as payment in full when a third party payer
contract specifies full reimbursement.
Start: 01/01/2000
N83
No appeal rights. Adjudicative decision based on the provisions of a demonstration project.
Start: 01/01/2000
N84
Alert: Further installment payments are forthcoming.
Start: 01/01/2000 | Last Modified: 04/01/2007
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Notes: (Modified 4/1/07, 8/1/07)
N85
Alert: This is the final installment payment.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07, 8/1/07)
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.
Start: 01/01/2000
N87
Home use of biofeedback therapy is not covered.
Start: 01/01/2000
N88
Alert: 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.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N89
Alert: 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.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N90
Covered only when performed by the attending physician.
Start: 01/01/2000
N91
Services not included in the appeal review.
Start: 01/01/2000
N92
This facility is not certified for digital mammography.
Start: 01/01/2000
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.
Start: 01/01/2000
N94
Claim/Service denied because a more specific taxonomy code is required for adjudication.
Start: 01/01/2000
N95
This provider type/provider specialty may not bill this service.
Start: 07/31/2001 | Last Modified: 02/28/2003
Notes: (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.
Start: 08/24/2001
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.
Start: 08/24/2001
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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.
Start: 08/24/2001
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.
Start: 08/24/2001
N100
PPS (Prospect Payment System) code corrected during adjudication.
Start: 09/14/2001 | Last Modified: 06/30/2003
Notes: (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.
Start: 10/31/2001 | Stop: 01/31/2004
Notes: 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.
Start: 10/31/2001
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
he or she is in a Federal facility, or while he or she is 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.
Start: 10/31/2001 | Last Modified: 07/01/2012
Notes: (Modified 6/30/03, 7/1/12)
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.gov.
Start: 01/29/2002 | Last Modified: 07/01/2010
Notes: (Modified 10/31/02, 7/1/10)
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.
Start: 01/29/2002
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.
Start: 01/31/2002
N107
Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.
Start: 01/31/2002
N108
Missing/incomplete/invalid upgrade information.
Start: 01/31/2002 | Last Modified: 02/28/2003
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Notes: (Modified 2/28/03)
N109
This claim/service was chosen for complex review and was denied after reviewing the
medical records.
Start: 02/28/2002 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)
N110
This facility is not certified for film mammography.
Start: 02/28/2002
N111
No appeal right except duplicate claim/service issue. This service was included in a
claim that has been previously billed and adjudicated.
Start: 02/28/2002
N112
This claim is excluded from your electronic remittance advice.
Start: 02/28/2002
N113
Only one initial visit is covered per physician, group practice or provider.
Start: 04/16/2002 | Last Modified: 06/30/2003
Notes: (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.
Start: 05/30/2002
N115
This decision was based on a Local Coverage Determination (LCD). An LCD provides a
guide to assist in determining whether a particular item or service is covered. A copy of
this policy is available at www.cms.gov/mcd, or if you do not have web access, you may
contact the contractor to request a copy of the LCD.
Start: 05/30/2002 | Last Modified: 07/01/2010
Notes: (Modified 4/1/04, 7/1/10)
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.
Start: 06/30/2002
N117
This service is paid only once in a patient’s lifetime.
Start: 07/30/2002 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)
N118
This service is not paid if billed more than once every 28 days.
Start: 07/30/2002
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.
Start: 07/30/2002 | Last Modified: 06/30/2003
Notes: (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.
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Start: 08/09/2002 | Last Modified: 06/30/2003
Notes: (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.
Start: 09/09/2002 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 6/30/03)
N122
Add-on code cannot be billed by itself.
Start: 09/12/2002 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)
N123
This is a split service and represents a portion of the units from the originally submitted
service.
Start: 09/24/2002
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.
Start: 09/26/2002
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.
Start: 09/26/2002 | Last Modified: 08/01/2005
Notes: (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.
Start: 10/17/2002
N127
This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.
Start: 10/31/2007 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04
N128
This amount represents the prior to coverage portion of the allowance.
Start: 10/31/2002
N129
Not eligible due to the patient's age.
Start: 10/31/2002 | Last Modified: 08/01/2007
Notes: (Modified 8/1/07)
N130
Consult plan benefit documents/guidelines for information about restrictions for this
service.
Start: 10/31/2002 | Last Modified: 11/01/2009
Notes: (Modified 4/1/07, 7/1/08, 11/1/09)
Provider Manual 2013
262
N131
Total payments under multiple contracts cannot exceed the allowance for this service.
Start: 10/31/2002
N132
Alert: Payments will cease for services rendered by this US Government debarred or
excluded provider after the 30 day grace period as previously notified.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N133
Alert: Services for predetermination and services requesting payment are being processed separately.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N134
Alert: This represents your scheduled payment for this service. If treatment has been
discontinued, please contact Customer Service.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N135
Record fees are the patient's responsibility and limited to the specified co-payment.
Start: 10/31/2002
N136
Alert: 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.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N137
Alert: 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.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 8/1/04, 2/28/03, 4/1/07)
N138
Alert: 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.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N139
Alert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 a nonparticipating 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.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
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263
N140
Alert: 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.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N141
The patient was not residing in a long-term care facility during all or part of the service
dates billed.
Start: 10/31/2002
N142
The original claim was denied. Resubmit a new claim, not a replacement claim.
Start: 10/31/2002
N143
The patient was not in a hospice program during all or part of the service dates billed.
Start: 10/31/2002
N144
The rate changed during the dates of service billed.
Start: 10/31/2002
N145
Missing/incomplete/invalid provider identifier for this place of service.
Start: 10/31/2002 | Stop: 06/02/2005
N146
Missing screening document.
Start: 10/31/2002 | Last Modified: 08/01/2004
Notes: (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.
Start: 10/31/2002
N148
Missing/incomplete/invalid date of last menstrual period.
Start: 10/31/2002
N149
Rebill all applicable services on a single claim.
Start: 10/31/2002
N150
Missing/incomplete/invalid model number.
Start: 10/31/2002
N151
Telephone contact services will not be paid until the face-to-face contact requirement
has been met.
Start: 10/31/2002
N152
Missing/incomplete/invalid replacement claim information.
Start: 10/31/2002
N153
Missing/incomplete/invalid room and board rate.
Start: 10/31/2002
N154
Alert: This payment was delayed for correction of provider's mailing address.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N155
Alert: Our records do not indicate that other insurance is on file. Please submit other
insurance information for our records.
Start: 10/31/2002 | Last Modified: 04/01/2007
Provider Manual 2013
264
Notes: (Modified 4/1/07)
N156
Alert: The patient is responsible for the difference between the approved treatment and
the elective treatment.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N157
Transportation to/from this destination is not covered.
Start: 02/28/2003 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
N158
Transportation in a vehicle other than an ambulance is not covered.
Start: 02/28/2003
N159
Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Start: 02/28/2003
N160
The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Start: 02/28/2003 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)
N161
This drug/service/supply is covered only when the associated service is covered.
Start: 02/28/2003
N162
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.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N163
Medical record does not support code billed per the code definition.
Start: 02/28/2003
N164
Transportation to/from this destination is not covered.
Start: 02/28/2003 | Stop: 01/31/2004
Notes: Consider using N157
N165
Transportation in a vehicle other than an ambulance is not covered.
Start: 02/28/2003 | Stop: 01/31/2004
Notes: Consider using N158)
N166
Payment denied/reduced because mileage is not covered when the patient is not in the
ambulance.
Start: 02/28/2003 | Stop: 01/31/2004
Notes: Consider using N159
N167
Charges exceed the post-transplant coverage limit.
Start: 02/28/2003
N168
The patient must choose an option before a payment can be made for this procedure/
equipment/ supply/ service.
Start: 02/28/2003 | Stop: 01/31/2004
Notes: Consider using N160
N169
This drug/service/supply is covered only when the associated service is covered.
Start: 02/28/2003 | Stop: 01/31/2004
Provider Manual 2013
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Notes: Consider using N161
N170
A new/revised/renewed certificate of medical necessity is needed.
Start: 02/28/2003
N171
Payment for repair or replacement is not covered or has exceeded the purchase price.
Start: 02/28/2003
N172
The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.
Start: 02/28/2003
N173
No qualifying hospital stay dates were provided for this episode of care.
Start: 02/28/2003
N174
This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'.
Start: 02/28/2003
N175
Missing review organization approval.
Start: 02/28/2003 | Last Modified: 02/29/2008
Notes: (Modified 8/1/04, 2/29/08) 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.
Start: 02/28/2003
N177
Alert: We did not send this claim to patient’s other insurer. They have indicated no additional payment can be made.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 6/30/03, 4/1/07)
N178
Missing pre-operative photos or visual field results.
Start: 02/28/2003 | Last Modified: 08/01/2004
Notes: (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.
Start: 02/28/2003
N180
This item or service does not meet the criteria for the category under which it was billed.
Start: 02/28/2003
N181
Additional information is required from another provider involved in this service.
Start: 02/28/2003 | Last Modified: 12/01/2006
Notes: (Modified 12/1/06)
N182
This claim/service must be billed according to the schedule for this plan.
Start: 02/28/2003
N183
Alert: 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.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N184
Rebill technical and professional components separately.
Start: 02/28/2003
Provider Manual 2013
266
N185
Alert: Do not resubmit this claim/service.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N186
Non-Availability Statement (NAS) required for this service. Contact the nearest Military
Treatment Facility (MTF) for assistance.
Start: 02/28/2003
N187
Alert: 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.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N188
The approved level of care does not match the procedure code submitted.
Start: 02/28/2003
N189
Alert: This service has been paid as a one-time exception to the plan's benefit restrictions.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N190
Missing contract indicator.
Start: 02/28/2003 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04) Related to N229
N191
The provider must update insurance information directly with payer.
Start: 02/28/2003
N192
Patient is a Medicaid/Qualified Medicare Beneficiary.
Start: 02/28/2003
N193
Specific federal/state/local program may cover this service through another payer.
Start: 02/28/2003
N194
Technical component not paid if provider does not own the equipment used.
Start: 02/25/2003
N195
The technical component must be billed separately.
Start: 02/25/2003
N196
Alert: Patient eligible to apply for other coverage which may be primary.
Start: 02/25/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N197
The subscriber must update insurance information directly with payer.
Start: 02/25/2003
N198
Rendering provider must be affiliated with the pay-to provider.
Start: 02/25/2003
N199
Additional payment/recoupment approved based on payer-initiated review/audit.
Start: 02/25/2003 | Last Modified: 08/01/2006
Notes: (Modified 8/1/06)
N200
The professional component must be billed separately.
Start: 02/25/2003
Provider Manual 2013
267
N201
A mental health facility is responsible for payment of outside providers who furnish
these services/supplies to residents.
Start: 02/25/2003 | Stop: 01/01/2011
Notes: Consider using N538
N202
Additional information/explanation will be sent separately
Start: 06/30/2003 | Last Modified: 11/01/2009
Notes: (Modified 4/1/07, 11/1/09)
N203
Missing/incomplete/invalid anesthesia time/units
Start: 06/30/2003
N204
Services under review for possible pre-existing condition. Send medical records for prior
12 months
Start: 06/30/2003
N205
Information provided was illegible
Start: 06/30/2003
N206
The supporting documentation does not match the information sent on the claim.
Start: 06/30/2003 | Last Modified: 03/06/2012
Notes: (Modified 3/6/12)
N207
Missing/incomplete/invalid weight.
Start: 06/30/2003 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)
N208
Missing/incomplete/invalid DRG code
Start: 06/30/2003
N209
Missing/incomplete/invalid taxpayer identification number (TIN).
Start: 06/30/2003 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N210
Alert: You may appeal this decision
Start: 06/30/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N211
Alert: You may not appeal this decision
Start: 06/30/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N212
Charges processed under a Point of Service benefit
Start: 02/01/2004
N213
Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information
Start: 04/01/2004
N214
Missing/incomplete/invalid history of the related initial surgical procedure(s)
Start: 04/01/2004
N215
Alert: 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.
Start: 04/01/2004 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
Provider Manual 2013
268
N216
We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package
Start: 04/01/2004 | Last Modified: 03/01/2010
Notes: (modified 3/1/2010)
N217
We pay only one site of service per provider per claim
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 contract or
coverage manual.
Start: 08/01/2004
N219
Payment based on previous payer's allowed amount.
Start: 08/01/2004
N220
Alert: See the payer's web site or contact the payer's Customer Service department to
obtain forms and instructions for filing a provider dispute.
Start: 08/01/2004 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N221
Missing Admitting History and Physical report.
Start: 08/01/2004
N222
Incomplete/invalid Admitting History and Physical report.
Start: 08/01/2004
N223
Missing documentation of benefit to the patient during initial treatment period.
Start: 08/01/2004
N224
Incomplete/invalid documentation of benefit to the patient during initial treatment period.
Start: 08/01/2004
N225
Incomplete/invalid documentation/orders/notes/summary/report/chart.
Start: 08/01/2004 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)
N226
Incomplete/invalid American Diabetes Association Certificate of Recognition.
Start: 08/01/2004
N227
Incomplete/invalid Certificate of Medical Necessity.
Start: 08/01/2004
N228
Incomplete/invalid consent form.
Start: 08/01/2004
N229
Incomplete/invalid contract indicator.
Start: 08/01/2004
N230
Incomplete/invalid indication of whether the patient owns the equipment that requires
the part or supply.
Start: 08/01/2004
N231
Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.
Start: 08/01/2004
N232
Incomplete/invalid itemized bill/statement.
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
Provider Manual 2013
269
N233
Incomplete/invalid operative note/report.
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N234
Incomplete/invalid oxygen certification/re-certification.
Start: 08/01/2004
N235
Incomplete/invalid pacemaker registration form.
Start: 08/01/2004
N236
Incomplete/invalid pathology report.
Start: 08/01/2004
N237
Incomplete/invalid patient medical record for this service.
Start: 08/01/2004
N238
Incomplete/invalid physician certified plan of care
Start: 08/01/2004
N239
Incomplete/invalid physician financial relationship form.
Start: 08/01/2004
N240
Incomplete/invalid radiology report.
Start: 08/01/2004
N241
Incomplete/invalid review organization approval.
Start: 08/01/2004 | Last Modified: 02/29/2008
Notes: (Modified 2/29/08)
N242
Incomplete/invalid radiology film(s)/image(s).
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N243
Incomplete/invalid/not approved screening document.
Start: 08/01/2004
N244
Incomplete/invalid pre-operative photos/visual field results.
Start: 08/01/2004
N245
Incomplete/invalid plan information for other insurance
Start: 08/01/2004
N246
State regulated patient payment limitations apply to this service.
Start: 12/02/2004
N247
Missing/incomplete/invalid assistant surgeon taxonomy.
Start: 12/02/2004
N248
Missing/incomplete/invalid assistant surgeon name.
Start: 12/02/2004
N249
Missing/incomplete/invalid assistant surgeon primary identifier.
Start: 12/02/2004
N250
Missing/incomplete/invalid assistant surgeon secondary identifier.
Start: 12/02/2004
N251
Missing/incomplete/invalid attending provider taxonomy.
Start: 12/02/2004
Provider Manual 2013
270
N252
Missing/incomplete/invalid attending provider name.
Start: 12/02/2004
N253
Missing/incomplete/invalid attending provider primary identifier.
Start: 12/02/2004
N254
Missing/incomplete/invalid attending provider secondary identifier.
Start: 12/02/2004
N255
Missing/incomplete/invalid billing provider taxonomy.
Start: 12/02/2004
N256
Missing/incomplete/invalid billing provider/supplier name.
Start: 12/02/2004
N257
Missing/incomplete/invalid billing provider/supplier primary identifier.
Start: 12/02/2004
N258
Missing/incomplete/invalid billing provider/supplier address.
Start: 12/02/2004
N259
Missing/incomplete/invalid billing provider/supplier secondary identifier.
Start: 12/02/2004
N260
Missing/incomplete/invalid billing provider/supplier contact information.
Start: 12/02/2004
N261
Missing/incomplete/invalid operating provider name.
Start: 12/02/2004
N262
Missing/incomplete/invalid operating provider primary identifier.
Start: 12/02/2004
N263
Missing/incomplete/invalid operating provider secondary identifier.
Start: 12/02/2004
N264
Missing/incomplete/invalid ordering provider name.
Start: 12/02/2004
N265
Missing/incomplete/invalid ordering provider primary identifier.
Start: 12/02/2004
N266
Missing/incomplete/invalid ordering provider address.
Start: 12/02/2004
N267
Missing/incomplete/invalid ordering provider secondary identifier.
Start: 12/02/2004
N268
Missing/incomplete/invalid ordering provider contact information.
Start: 12/02/2004
N269
Missing/incomplete/invalid other provider name.
Start: 12/02/2004
N270
Missing/incomplete/invalid other provider primary identifier.
Start: 12/02/2004
N271
Missing/incomplete/invalid other provider secondary identifier.
Start: 12/02/2004
N272
Missing/incomplete/invalid other payer attending provider identifier.
Provider Manual 2013
271
Start: 12/02/2004
N273
Missing/incomplete/invalid other payer operating provider identifier.
Start: 12/02/2004
N274
Missing/incomplete/invalid other payer other provider identifier.
Start: 12/02/2004
N275
Missing/incomplete/invalid other payer purchased service provider identifier.
Start: 12/02/2004
N276
Missing/incomplete/invalid other payer referring provider identifier.
Start: 12/02/2004
N277
Missing/incomplete/invalid other payer rendering provider identifier.
Start: 12/02/2004
N278
Missing/incomplete/invalid other payer service facility provider identifier.
Start: 12/02/2004
N279
Missing/incomplete/invalid pay-to provider name.
Start: 12/02/2004
N280
Missing/incomplete/invalid pay-to provider primary identifier.
Start: 12/02/2004
N281
Missing/incomplete/invalid pay-to provider address.
Start: 12/02/2004
N282
Missing/incomplete/invalid pay-to provider secondary identifier.
Start: 12/02/2004
N283
Missing/incomplete/invalid purchased service provider identifier.
Start: 12/02/2004
N284
Missing/incomplete/invalid referring provider taxonomy.
Start: 12/02/2004
N285
Missing/incomplete/invalid referring provider name.
Start: 12/02/2004
N286
Missing/incomplete/invalid referring provider primary identifier.
Start: 12/02/2004
N287
Missing/incomplete/invalid referring provider secondary identifier.
Start: 12/02/2004
N288
Missing/incomplete/invalid rendering provider taxonomy.
Start: 12/02/2004
N289
Missing/incomplete/invalid rendering provider name.
Start: 12/02/2004
N290
Missing/incomplete/invalid rendering provider primary identifier.
Start: 12/02/2004
N291
Missing/incomplete/invalid rendering provider secondary identifier.
Start: 12/02/2004 | Last Modified: 11/01/2010
N292
Missing/incomplete/invalid service facility name.
Start: 12/02/2004
Provider Manual 2013
272
N293
Missing/incomplete/invalid service facility primary identifier.
Start: 12/02/2004
N294
Missing/incomplete/invalid service facility primary address.
Start: 12/02/2004
N295
Missing/incomplete/invalid service facility secondary identifier.
Start: 12/02/2004
N296
Missing/incomplete/invalid supervising provider name.
Start: 12/02/2004
N297
Missing/incomplete/invalid supervising provider primary identifier.
Start: 12/02/2004
N298
Missing/incomplete/invalid supervising provider secondary identifier.
Start: 12/02/2004
N299
Missing/incomplete/invalid occurrence date(s).
Start: 12/02/2004
N300
Missing/incomplete/invalid occurrence span date(s).
Start: 12/02/2004
N301
Missing/incomplete/invalid procedure date(s).
Start: 12/02/2004
N302
Missing/incomplete/invalid other procedure date(s).
Start: 12/02/2004
N303
Missing/incomplete/invalid principal procedure date.
Start: 12/02/2004
N304
Missing/incomplete/invalid dispensed date.
Start: 12/02/2004
N305
Missing/incomplete/invalid accident date.
Start: 12/02/2004
N306
Missing/incomplete/invalid acute manifestation date.
Start: 12/02/2004
N307
Missing/incomplete/invalid adjudication or payment date.
Start: 12/02/2004
N308
Missing/incomplete/invalid appliance placement date.
Start: 12/02/2004
N309
Missing/incomplete/invalid assessment date.
Start: 12/02/2004
N310
Missing/incomplete/invalid assumed or relinquished care date.
Start: 12/02/2004
N311
Missing/incomplete/invalid authorized to return to work date.
Start: 12/02/2004
N312
Missing/incomplete/invalid begin therapy date.
Start: 12/02/2004
N313
Missing/incomplete/invalid certification revision date.
Provider Manual 2013
273
Start: 12/02/2004
N314
Missing/incomplete/invalid diagnosis date.
Start: 12/02/2004
N315
Missing/incomplete/invalid disability from date.
Start: 12/02/2004
N316
Missing/incomplete/invalid disability to date.
Start: 12/02/2004
N317
Missing/incomplete/invalid discharge hour.
Start: 12/02/2004
N318
Missing/incomplete/invalid discharge or end of care date.
Start: 12/02/2004
N319
Missing/incomplete/invalid hearing or vision prescription date.
Start: 12/02/2004
N320
Missing/incomplete/invalid Home Health Certification Period.
Start: 12/02/2004
N321
Missing/incomplete/invalid last admission period.
Start: 12/02/2004
N322
Missing/incomplete/invalid last certification date.
Start: 12/02/2004
N323
Missing/incomplete/invalid last contact date.
Start: 12/02/2004
N324
Missing/incomplete/invalid last seen/visit date.
Start: 12/02/2004
N325
Missing/incomplete/invalid last worked date.
Start: 12/02/2004
N326
Missing/incomplete/invalid last x-ray date.
Start: 12/02/2004
N327
Missing/incomplete/invalid other insured birth date.
Start: 12/02/2004
N328
Missing/incomplete/invalid Oxygen Saturation Test date.
Start: 12/02/2004
N329
Missing/incomplete/invalid patient birth date.
Start: 12/02/2004
N330
Missing/incomplete/invalid patient death date.
Start: 12/02/2004
N331
Missing/incomplete/invalid physician order date.
Start: 12/02/2004
N332
Missing/incomplete/invalid prior hospital discharge date.
Start: 12/02/2004
N333
Missing/incomplete/invalid prior placement date.
Start: 12/02/2004
Provider Manual 2013
274
N334
Missing/incomplete/invalid re-evaluation date
Start: 12/02/2004
N335
Missing/incomplete/invalid referral date.
Start: 12/02/2004
N336
Missing/incomplete/invalid replacement date.
Start: 12/02/2004
N337
Missing/incomplete/invalid secondary diagnosis date.
Start: 12/02/2004
N338
Missing/incomplete/invalid shipped date.
Start: 12/02/2004
N339
Missing/incomplete/invalid similar illness or symptom date.
Start: 12/02/2004
N340
Missing/incomplete/invalid subscriber birth date.
Start: 12/02/2004
N341
Missing/incomplete/invalid surgery date.
Start: 12/02/2004
N342
Missing/incomplete/invalid test performed date.
Start: 12/02/2004
N343
Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start
date.
Start: 12/02/2004
N344
Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end
date.
Start: 12/02/2004
N345
Date range not valid with units submitted.
Start: 03/30/2005
N346
Missing/incomplete/invalid oral cavity designation code.
Start: 03/30/2005
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.
Start: 03/30/2005
N348
You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.
Start: 08/01/2005
N349
The administration method and drug must be reported to adjudicate this service.
Start: 08/01/2005
N350
Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC)
code or for an Unlisted/By Report procedure.
Start: 08/01/2005 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N351
Service date outside of the approved treatment plan service dates.
Start: 08/01/2005
Provider Manual 2013
275
N352
Alert: There are no scheduled payments for this service. Submit a claim for each patient
visit.
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N353
Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N354
Incomplete/invalid invoice
Start: 08/01/2005
N355
Alert: The law permits exceptions to the refund requirement in two cases: - If you did not
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 appeal 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
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 11/18/05, Modified 4/1/07)
N356
Not covered when performed with, or subsequent to, a non-covered service.
Start: 08/01/2005 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N357
Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.
Start: 11/18/2005
N358
Alert: This decision may be reviewed if additional documentation as described in the
contract or plan benefit documents is submitted.
Start: 11/18/2005 | Last Modified: 04/01/2007
Provider Manual 2013
276
Notes: (Modified 4/1/07)
N359
Missing/incomplete/invalid height.
Start: 11/18/2005
N360
Alert: Coordination of benefits has not been calculated when estimating benefits for this
pre-determination. Submit payment information from the primary payer with the secondary claim.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N361
Payment adjusted based on multiple diagnostic imaging procedure rules
Start: 11/18/2005 | Stop: 10/01/2007 | Last Modified: 12/01/2006
Notes: (Modified 12/1/06) Consider using Reason Code 59
N362
The number of Days or Units of Service exceeds our acceptable maximum.
Start: 11/18/2005
N363
Alert: in the near future we are implementing new policies/procedures that would affect
this determination.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N364
Alert: According to our agreement, you must waive the deductible and/or coinsurance
amounts.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)
N365
This procedure code is not payable. It is for reporting/information purposes only.
Start: 04/01/2006
N366
Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.
Start: 04/01/2006
N367
Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.
Start: 04/01/2006 | Last Modified: 07/01/2008
Notes: (Modified 4/1/07, 11/5/07, 7/1/08)
N368
You must appeal the determination of the previously adjudicated claim.
Start: 04/01/2006
N369
Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
Start: 04/01/2006
N370
Billing exceeds the rental months covered/approved by the payer.
Start: 08/01/2006
N371
Alert: title of this equipment must be transferred to the patient.
Start: 08/01/2006
N372
Only reasonable and necessary maintenance/service charges are covered.
Start: 08/01/2006
N373
It has been determined that another payer paid the services as primary when they were
not the primary payer. Therefore, we are refunding to the payer that paid as primary on
your behalf.
Provider Manual 2013
277
Start: 12/01/2006
N374
Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice
is required.
Start: 12/01/2006
N375
Missing/incomplete/invalid questionnaire/information required to determine dependent
eligibility.
Start: 12/01/2006
N376
Subscriber/patient is assigned to active military duty, therefore primary coverage may be
TRICARE.
Start: 12/01/2006
N377
Payment based on a processed replacement claim.
Start: 12/01/2006 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)
N378
Missing/incomplete/invalid prescription quantity.
Start: 12/01/2006
N379
Claim level information does not match line level information.
Start: 12/01/2006
N380
The original claim has been processed, submit a corrected claim.
Start: 04/01/2007
N381
Consult our contractual agreement for restrictions/billing/payment information related to
these charges.
Start: 04/01/2007
N382
Missing/incomplete/invalid patient identifier.
Start: 04/01/2007
N383
Not covered when deemed cosmetic.
Start: 04/01/2007 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N384
Records indicate that the referenced body part/tooth has been removed in a previous
procedure.
Start: 04/01/2007
N385
Notification of admission was not timely according to published plan procedures.
Start: 04/01/2007 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)
N386
This decision was based on a National Coverage Determination (NCD). An NCD provides
a coverage determination as to whether a particular item or service is covered. A copy of
this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access,
you may contact the contractor to request a copy of the NCD.
Start: 04/01/2007 | Last Modified: 07/01/2010
Notes: (Modified 7/1/2010)
N387
Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information.
Start: 04/01/2007 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)
N388
Missing/incomplete/invalid prescription number
Provider Manual 2013
278
Start: 08/01/2007
N389
Duplicate prescription number submitted.
Start: 08/01/2007
N390
This service/report cannot be billed separately.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N391
Missing emergency department records.
Start: 08/01/2007
N392
Incomplete/invalid emergency department records.
Start: 08/01/2007
N393
Missing progress notes/report.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N394
Incomplete/invalid progress notes/report.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)
N395
Missing laboratory report.
Start: 08/01/2007
N396
Incomplete/invalid laboratory report.
Start: 08/01/2007
N397
Benefits are not available for incomplete service(s)/undelivered item(s).
Start: 08/01/2007
N398
Missing elective consent form.
Start: 08/01/2007
N399
Incomplete/invalid elective consent form.
Start: 08/01/2007
N400
Alert: Electronically enabled providers should submit claims electronically.
Start: 08/01/2007
N401
Missing periodontal charting.
Start: 08/01/2007
N402
Incomplete/invalid periodontal charting.
Start: 08/01/2007
N403
Missing facility certification.
Start: 08/01/2007
N404
Incomplete/invalid facility certification.
Start: 08/01/2007
N405
This service is only covered when the donor's insurer(s) do not provide coverage for the
service.
Start: 08/01/2007
N406
This service is only covered when the recipient's insurer(s) do not provide coverage for
the service.
Start: 08/01/2007
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N407
You are not an approved submitter for this transmission format.
Start: 08/01/2007
N408
This payer does not cover deductibles assessed by a previous payer.
Start: 08/01/2007
N409
This service is related to an accidental injury and is not covered unless provided within a
specific time frame from the date of the accident.
Start: 08/01/2007
N410
Not covered unless the prescription changes.
Start: 08/01/2007 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N411
This service is allowed one time in a 6-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N412
This service is allowed 2 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N413
This service is allowed 2 times in a benefit year. (This temporary code will be deactivated
on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N414
This service is allowed 4 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N415
This service is allowed 1 time in an 18-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N416
This service is allowed 1 time in a 3-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N417
This service is allowed 1 time in a 5-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)
Start: 08/01/2007 | Stop: 02/01/2009
N418
Misrouted claim. See the payer's claim submission instructions.
Start: 08/01/2007
N419
Claim payment was the result of a payer's retroactive adjustment due to a retroactive
rate change.
Start: 08/01/2007
N420
Claim payment was the result of a payer's retroactive adjustment due to a Coordination
of Benefits or Third Party Liability Recovery.
Start: 08/01/2007
N421
Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.
Start: 08/01/2007 | Last Modified: 05/08/2008
Notes: (Modified 2/29/08, typo fixed 5/8/08)
N422
Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program.
Start: 08/01/2007 | Last Modified: 05/08/2008
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Notes: (Typo fixed 5/8/08)
N423
Claim payment was the result of a payer's retroactive adjustment due to a non standard
program.
Start: 08/01/2007
N424
Patient does not reside in the geographic area required for this type of payment.
Start: 08/01/2007
N425
Statutorily excluded service(s).
Start: 08/01/2007
N426
No coverage when self-administered.
Start: 08/01/2007
N427
Payment for eyeglasses or contact lenses can be made only after cataract surgery.
Start: 08/01/2007
N428
Not covered when performed in this place of service.
Start: 08/01/2007 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N429
Not covered when considered routine.
Start: 08/01/2007 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N430
Procedure code is inconsistent with the units billed.
Start: 11/05/2007
N431
Not covered with this procedure.
Start: 11/05/2007 | Last Modified: 03/08/2011
Notes: (Modified 3/8/11)
N432
Adjustment based on a Recovery Audit.
Start: 11/05/2007
N433
Resubmit this claim using only your National Provider Identifier (NPI)
Start: 02/29/2008
N434
Missing/Incomplete/Invalid Present on Admission indicator.
Start: 07/01/2008
N435
Exceeds number/frequency approved /allowed within time period without support documentation.
Start: 07/01/2008
N436
The injury claim has not been accepted and a mandatory medical reimbursement has
been made.
Start: 07/01/2008
N437
Alert: If the injury claim is accepted, these charges will be reconsidered.
Start: 07/01/2008
N438
This jurisdiction only accepts paper claims
Start: 07/01/2008
N439
Missing anesthesia physical status report/indicators.
Start: 07/01/2008
N440
Incomplete/invalid anesthesia physical status report/indicators.
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Start: 07/01/2008
N441
This missed appointment is not covered.
Start: 07/01/2008
N442
Payment based on an alternate fee schedule.
Start: 07/01/2008
N443
Missing/incomplete/invalid total time or begin/end time.
Start: 07/01/2008
N444
Alert: This facility has not filed the Election for High Cost Outlier form with the Division
of Workers' Compensation.
Start: 07/01/2008
N445
Missing document for actual cost or paid amount.
Start: 07/01/2008
N446
Incomplete/invalid document for actual cost or paid amount.
Start: 07/01/2008
N447
Payment is based on a generic equivalent as required documentation was not provided.
Start: 07/01/2008
N448
This drug/service/supply is not included in the fee schedule or contracted/legislated fee
arrangement
Start: 07/01/2008
N449
Payment based on a comparable drug/service/supply.
Start: 07/01/2008
N450
Covered only when performed by the primary treating physician or the designee.
Start: 07/01/2008
N451
Missing Admission Summary Report.
Start: 07/01/2008
N452
Incomplete/invalid Admission Summary Report.
Start: 07/01/2008
N453
Missing Consultation Report.
Start: 07/01/2008
N454
Incomplete/invalid Consultation Report.
Start: 07/01/2008
N455
Missing Physician Order.
Start: 07/01/2008
N456
Incomplete/invalid Physician Order.
Start: 07/01/2008
N457
Missing Diagnostic Report.
Start: 07/01/2008
N458
Incomplete/invalid Diagnostic Report.
Start: 07/01/2008
N459
Missing Discharge Summary.
Start: 07/01/2008
N460
Incomplete/invalid Discharge Summary.
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Start: 07/01/2008
N461
Missing Nursing Notes.
Start: 07/01/2008
N462
Incomplete/invalid Nursing Notes.
Start: 07/01/2008
N463
Missing support data for claim.
Start: 07/01/2008
N464
Incomplete/invalid support data for claim.
Start: 07/01/2008
N465
Missing Physical Therapy Notes/Report.
Start: 07/01/2008
N466
Incomplete/invalid Physical Therapy Notes/Report.
Start: 07/01/2008
N467
Missing Report of Tests and Analysis Report.
Start: 07/01/2008
N468
Incomplete/invalid Report of Tests and Analysis Report.
Start: 07/01/2008
N469
Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).
Start: 07/01/2008
N470
This payment will complete the mandatory medical reimbursement limit.
Start: 07/01/2008
N471
Missing/incomplete/invalid HIPPS Rate Code.
Start: 07/01/2008
N472
Payment for this service has been issued to another provider.
Start: 07/01/2008
N473
Missing certification.
Start: 07/01/2008
N474
Incomplete/invalid certification
Start: 07/01/2008
N475
Missing completed referral form.
Start: 07/01/2008
N476
Incomplete/invalid completed referral form
Start: 07/01/2008
N477
Missing Dental Models.
Start: 07/01/2008
N478
Incomplete/invalid Dental Models
Start: 07/01/2008
N479
Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
Start: 07/01/2008
N480
Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
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Start: 07/01/2008
N481
Missing Models.
Start: 07/01/2008
N482
Incomplete/invalid Models
Start: 07/01/2008
N483
Missing Periodontal Charts.
Start: 07/01/2008
N484
Incomplete/invalid Periodontal Charts
Start: 07/01/2008
N485
Missing Physical Therapy Certification.
Start: 07/01/2008
N486
Incomplete/invalid Physical Therapy Certification.
Start: 07/01/2008
N487
Missing Prosthetics or Orthotics Certification.
Start: 07/01/2008
N488
Incomplete/invalid Prosthetics or Orthotics Certification
Start: 07/01/2008
N489
Missing referral form.
Start: 07/01/2008
N490
Incomplete/invalid referral form
Start: 07/01/2008
N491
Missing/Incomplete/Invalid Exclusionary Rider Condition.
Start: 07/01/2008
N492
Alert: A network provider may bill the member for this service if the member requested
the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.
Start: 07/01/2008
N493
Missing Doctor First Report of Injury.
Start: 07/01/2008
N494
Incomplete/invalid Doctor First Report of Injury.
Start: 07/01/2008
N495
Missing Supplemental Medical Report.
Start: 07/01/2008
N496
Incomplete/invalid Supplemental Medical Report.
Start: 07/01/2008
N497
Missing Medical Permanent Impairment or Disability Report.
Start: 07/01/2008
N498
Incomplete/invalid Medical Permanent Impairment or Disability Report.
Start: 07/01/2008
N499
Missing Medical Legal Report.
Start: 07/01/2008
N500
Incomplete/invalid Medical Legal Report.
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Start: 07/01/2008
N501
Missing Vocational Report.
Start: 07/01/2008
N502
Incomplete/invalid Vocational Report.
Start: 07/01/2008
N503
Missing Work Status Report.
Start: 07/01/2008
N504
Incomplete/invalid Work Status Report.
Start: 07/01/2008
N505
Alert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time.
Start: 11/01/2008
N506
Alert: This is an estimate of the member’s liability based on the information available at
the time the estimate was processed. Actual coverage and member liability amounts will
be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment.
Start: 11/01/2008
N507
Plan distance requirements have not been met.
Start: 11/01/2008
N508
Alert: This real time claim adjudication response represents the member responsibility
to the provider for services reported. The member will receive an Explanation of Benefits
electronically or in the mail. Contact the insurer if there are any questions.
Start: 11/01/2008
N509
Alert: A current inquiry shows the member’s Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the
Consumer Spending Account will depend on the availability of funds and determination
of eligible services at the time of payment processing.
Start: 11/01/2008
N510
Alert: A current inquiry shows the member’s Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and
determination of eligible services at the time of payment processing.
Start: 11/01/2008
N511
Alert: Information on the availability of Consumer Spending Account funds to cover the
member liability on this claim/service is not available at this time.
Start: 11/01/2008
N512
Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without
change to the adjudication.
Start: 11/01/2008
N513
Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a
change to the adjudication.
Start: 11/01/2008
N514
Consult plan benefit documents/guidelines for information about restrictions for this
service.
Start: 11/01/2008 | Stop: 01/01/2011
Notes: Consider using N130
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N515
Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead)
Start: 11/01/2008 | Stop: 10/01/2009
N516
Records indicate a mismatch between the submitted NPI and EIN.
Start: 03/01/2009
N517
Resubmit a new claim with the requested information.
Start: 03/01/2009
N518
No separate payment for accessories when furnished for use with oxygen equipment.
Start: 03/01/2009
N519
Invalid combination of HCPCS modifiers.
Start: 07/01/2009
N520
Alert: Payment made from a Consumer Spending Account.
Start: 07/01/2009
N521
Mismatch between the submitted provider information and the provider information
stored in our system.
Start: 11/01/2009
N522
Duplicate of a claim processed, or to be processed, as a crossover claim.
Start: 11/01/2009 | Last Modified: 03/01/2010
N523
The limitation on outlier payments defined by this payer for this service period has been
met. The outlier payment otherwise applicable to this claim has not been paid.
Start: 03/01/2010
N524
Based on policy this payment constitutes payment in full.
Start: 03/01/2010
N525
These services are not covered when performed within the global period of another service.
Start: 03/01/2010
N526
Not qualified for recovery based on employer size.
Start: 03/01/2010
N527
We processed this claim as the primary payer prior to receiving the recovery demand.
Start: 03/01/2010
N528
Patient is entitled to benefits for Institutional Services only.
Start: 03/01/2010 | Last Modified: 07/01/2010
Notes: (Modified 7/1/10)
N529
Patient is entitled to benefits for Professional Services only.
Start: 03/01/2010 | Last Modified: 07/01/2010
Notes: (Modified 7/1/10)
N530
Not Qualified for Recovery based on enrollment information.
Start: 03/01/2010 | Last Modified: 07/01/2010
Notes: (Modified 7/1/10)
N531
Not qualified for recovery based on direct payment of premium.
Start: 03/01/2010
N532
Not qualified for recovery based on disability and working status.
Start: 03/01/2010
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N533
Services performed in an Indian Health Services facility under a self-insured tribal Group
Health Plan.
Start: 07/01/2010
N534
This is an individual policy, the employer does not participate in plan sponsorship.
Start: 07/01/2010
N535
Payment is adjusted when procedure is performed in this place of service based on the
submitted procedure code and place of service.
Start: 07/01/2010
N536
We are not changing the prior payer's determination of patient responsibility, which you
may collect, as this service is not covered by us.
Start: 07/01/2010
N537
We have examined claims history and no records of the services have been found.
Start: 07/01/2010
N538
A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.
Start: 07/01/2010
N539
Alert: We processed appeals/waiver requests on your behalf and that request has been
denied.
Start: 07/01/2010
N540
Payment adjusted based on the interrupted stay policy.
Start: 11/01/2010
N541
Mismatch between the submitted insurance type code and the information stored in our
system.
Start: 11/01/2010
N542
Missing income verification.
Start: 03/08/2011
N543
Incomplete/invalid income verification
Start: 03/08/2011
N544
Alert: Although this was paid, you have billed with a referring/ordering provider that
does not match our system record. Unless, corrected, this will not be paid in the future.
Start: 07/01/2011
N545
Payment reduced based on status as an unsuccessful prescriber per the Electronic Prescribing (eRx) Incentive Program.
Start: 07/01/2011
N546
Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.
Start: 07/01/2011
N547
A refund request (Frequency Type Code 8) was processed previously.
Start: 03/06/2012
N548
Alert: Patient's calendar year deductible has been met.
Start: 03/06/2012
N549
Alert: Patient's calendar year out-of-pocket maximum has been met.
Start: 03/06/2012
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N550
Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a
payment hold in the near future.
Start: 03/06/2012
N551
Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting
Program.
Start: 03/06/2012
N552
Payment adjusted to reverse a previous withhold/bonus amount.
Start: 03/06/2012
N553
Payment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status
change.
Start: 03/06/2012 | Stop: 11/01/2012
N554
Missing/Incomplete/Invalid Family Planning Indicator
Start: 07/01/2012
N555
Missing medication list.
Start: 07/01/2012
N556
Incomplete/invalid medication list.
Start: 07/01/2012
N557
This claim/service is not payable under our service area. The claim must be filed to the
Payer/Plan in whose service area the specimen was collected.
Start: 07/01/2012
N558
This claim/service is not payable under our service area. The claim must be filed to the
Payer/Plan in whose service area the equipment was received.
Start: 07/01/2012
N559
This claim/service is not payable under our service area. The claim must be filed to the
Payer/Plan in whose service area the Ordering Physician is located.
Start: 07/01/2012
N560
The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.
Start: 11/01/2012
N561
The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on
this readmission.
Start: 11/01/2012
N562
The provider number of your incoming claim does not match the provider number on the
processed Notice of Admission (NOA) for this bundled payment.
Start: 11/01/2012
N563
Missing required provider/supplier issuance of advance patient notice of non-coverage.
The patient is not liable for payment for this service.
Start: 11/01/2012
Notes: Related to M39
N564
Patient did not meet the inclusion criteria for the demonstration project or pilot program.
Start: 11/01/2012
N565
Alert: This non-payable reporting code requires a modifier. Future claims containing this
non-payable reporting code must include an appropriate modifier for the claim to be
processed.
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Start: 11/01/2012 | Last Modified: 03/01/2013
Notes: (Modified 3/1/13)
N566
Alert: This procedure code requires functional reporting. Future claims containing this
procedure code must include an applicable non-payable code and appropriate modifiers
for the claim to be processed.
Start: 11/01/2012
N567
Not covered when considered preventative.
Start: 03/01/2013
N568
Alert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.
Start: 03/01/2013
N569
Not covered when performed for the reported diagnosis.
Start: 03/01/2013
N570
Missing/incomplete/invalid credentialing data
Start: 03/01/2013
N571
Alert: Payment will be issued quarterly by another payer/contractor.
Start: 03/01/2013
N572
This procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted.
Start: 03/01/2013
N573
Alert: You have been overpaid and must refund the overpayment. The refund will be requested separately by another payer/contractor.
Start: 03/01/2013
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CLAIM ADJUSTMENT REASON CODES
1
Deductible Amount
Start: 01/01/1995
2
Coinsurance Amount
Start: 01/01/1995
3
Co-payment Amount
Start: 01/01/1995
4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
13
The date of death precedes the date of service.
Start: 01/01/1995
14
The date of birth follows the date of service.
Start: 01/01/1995
15
The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
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.) This change effective 11/1/2013: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code
for claims attachment(s). At least one Remark Code must be provided (may be comprised of ei-
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ther 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.
Start: 01/01/1995 | Last Modified: 01/20/2013
17
Requested information was not provided or was insufficient/incomplete. At least one Remark
Code must be provided (may be comprised of either the Remittance Advice Remark Code or
NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/2009
18
Exact duplicate claim/service (Use only with Group Code OA)
Start: 01/01/1995 | Last Modified: 01/20/2013
19
This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
20
This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21
This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22
This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23
The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with
Group Code OA)
Start: 01/01/1995 | Last Modified: 09/30/2012
24
Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
25
Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008
26
Expenses incurred prior to coverage.
Start: 01/01/1995
27
Expenses incurred after coverage terminated.
Start: 01/01/1995
28
Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.
29
The time limit for filing has expired.
Start: 01/01/1995
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting,
or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
31
Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32
Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995
33
Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34
Insured has no coverage for newborns.
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Start: 01/01/1995 | Last Modified: 09/30/2007
35
Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
36
Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003
37
Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003
38
Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/30/2003 | Stop: 01/01/2013
39
Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995
40
Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
41
Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003
42
Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007
43
Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006
44
Prompt-pay discount.
Start: 01/01/1995
45
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use
Group Codes PR or CO depending upon liability). This change effective 7/1/2013: Charge exceeds
fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group
Codes PR or CO depending upon liability)
Start: 01/01/1995 | Last Modified: 09/30/2012
46
This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006
48
This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
49
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. This change effective 11/1/2013: This is
a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 01/20/2013
50
These are non-covered services because this is not deemed a 'medical necessity' by the payer.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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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.
Start: 01/01/1995 | Last Modified: 09/20/2009
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the
service billed.
Start: 01/01/1995 | Stop: 02/01/2006
53
Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995
54
Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
55
Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
56
Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the
835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if
present.
Start: 01/01/1995 | Last Modified: 09/20/2009
57
Payment denied/reduced because the payer deems the information submitted does not support
this level of service, this many services, this length of service, this dosage, or this day's supply.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Split into codes 150, 151, 152, 153 and 154.
58
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of
service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
59
Processed based on multiple or concurrent procedure rules. (For example multiple surgery or
diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
60
Charges for outpatient services are not covered when performed within a period of time prior to
or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
61
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007
63
Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003
64
Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003
65
Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003
66
Blood Deductible.
Start: 01/01/1995
67
Lifetime reserve days. (Handled in QTY, QTY01=LA)
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Start: 01/01/1995 | Stop: 10/16/2003
68
DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003
69
Day outlier amount.
Start: 01/01/1995
70
Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
71
Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.
72
Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003
73
Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003
74
Indirect Medical Education Adjustment.
Start: 01/01/1995
75
Direct Medical Education Adjustment.
Start: 01/01/1995
76
Disproportionate Share Adjustment.
Start: 01/01/1995
77
Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003
78
Non-Covered days/Room charge adjustment.
Start: 01/01/1995
79
Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003
80
Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003
81
Discharges.
Start: 01/01/1995 | Stop: 10/16/2003
82
PIP days.
Start: 01/01/1995 | Stop: 10/16/2003
83
Total visits.
Start: 01/01/1995 | Stop: 10/16/2003
84
Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003
85
Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient.
86
Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.
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87
Transfer amount.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012
88
Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
89
Professional fees removed from charges.
Start: 01/01/1995
90
Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2009
91
Dispensing fee adjustment.
Start: 01/01/1995
92
Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003
93
No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.
94
Processed in Excess of charges.
Start: 01/01/1995
95
Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either
the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note:
Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
98
The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003
99
Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003
100
Payment made to patient/insured/responsible party/employer.
Start: 01/01/1995 | Last Modified: 01/27/2008
101
Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999
102
Major Medical Adjustment.
Start: 01/01/1995
103
Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001
104
Managed care withholding.
Start: 01/01/1995
105
Tax withholding.
Start: 01/01/1995
106
Patient payment option/election not in effect.
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Start: 01/01/1995
107
The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
108
Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
109
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Start: 01/01/1995 | Last Modified: 01/29/2012
110
Billing date predates service date.
Start: 01/01/1995
111
Not covered unless the provider accepts assignment.
Start: 01/01/1995
112
Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
113
Payment denied because service/procedure was provided outside the United States or as a result
of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.
114
Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995
115
Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116
The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117
Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118
ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119
Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004
120
Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.
121
Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122
Psychiatric reduction.
Start: 01/01/1995
123
Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
124
Payer refund amount - not our patient.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
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Notes: Refer to implementation guide for proper handling of reversals.
125
Submission/billing error(s). At least one Remark Code must be provided (may be comprised of
either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013
126
Deductible -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.
127
Coinsurance -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 2.
128
Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997
129
Prior processing information appears incorrect. At least one Remark Code must be provided
(may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code
that is not an ALERT.)
Start: 02/28/1997 | Last Modified: 01/30/2011
130
Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
131
Claim specific negotiated discount.
Start: 02/28/1997
132
Prearranged demonstration project adjustment.
Start: 02/28/1997
133
The disposition of the claim/service is pending further review. (Use only with Group Code OA)
Start: 02/28/1997 | Last Modified: 01/20/2013
134
Technical fees removed from charges.
Start: 10/31/1998
135
Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136
Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective
7/1/2013: Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
Start: 10/31/1998 | Last Modified: 09/30/2012
137
Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
138
Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007
139
Contracted funding agreement - Subscriber is employed by the provider of services.
Start: 06/30/1999
140
Patient/Insured health identification number and name do not match.
Start: 06/30/1999
141
Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012
142
Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143
Portion of payment deferred.
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Start: 02/28/2001
144
Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001
145
Premium payment withholding
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
146
Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147
Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002
148
Information from another provider was not provided or was insufficient/incomplete. At least one
Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or
Remittance Advice Remark Code that is not an ALERT.)
Start: 06/30/2002 | Last Modified: 09/20/2009
149
Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150
Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151
Payment adjusted because the payer deems the information submitted does not support this
many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008
152
Payer deems the information submitted does not support this length of service. Note: Refer to the
835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if
present.
Start: 10/31/2002 | Last Modified: 09/20/2009
153
Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154
Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155
Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
156
Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009
157
Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158
Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159
Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160
Injury/illness was the result of an activity that is benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161
Provider performance bonus
Start: 02/29/2004
162
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for
specific explanation.
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Start: 02/29/2004
163
Attachment referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007
164
Attachment referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007
165
Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007
166
These services were submitted after this payers responsibility for processing claims under this
plan ended.
Start: 02/28/2005
167
This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
168
Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007
169
Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170
Payment is denied when performed/billed by this type of provider. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
173
Service was not prescribed by a physician. This change effective 7/1/2013: Service/equipment
was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2012
174
Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175
Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176
Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177
Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178
Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179
Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
180
Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
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181
Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
182
Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183
The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
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.
Start: 06/30/2005 | Last Modified: 09/20/2009
186
Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187
Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009
188
This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005
189
'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a
specific procedure code for this procedure/service
Start: 06/30/2005
190
Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
191
Not a work related injury/illness and thus not the liability of the workers' compensation carrier
Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the
835 Insurance Policy Number Segments (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and
the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF)
Start: 10/31/2005 | Last Modified: 10/17/2010
192
Nonstandard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction
only. This code is only used when the non-standard code cannot be reasonably mapped to an
existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 09/30/2007
193
Original payment decision is being maintained. Upon review, it was determined that this claim
was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008
194
Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195
Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
196
Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.
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197
Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007
198
Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007
199
Revenue code and Procedure code do not match.
Start: 10/31/2006
200
Expenses incurred during lapse in coverage
Start: 10/31/2006
201
Workers' Compensation case settled. Patient is responsible for amount of this claim/service
through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR). This
change effective 7/1/2013: Workers Compensation case settled. Patient is responsible for amount
of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use only
with Group Code PR)
Start: 10/31/2006 | Last Modified: 09/30/2012
202
Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203
Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204
This service/equipment/drug is not covered under the patient’s current benefit plan
Start: 02/28/2007
205
Pharmacy discount card processing fee
Start: 07/09/2007
206
National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207
National Provider identifier - Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008
208
National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209
Per regulatory or other agreement. The provider cannot collect this amount from the patient.
However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use
Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. The provider
cannot collect this amount from the patient. However, this amount may be billed to subsequent
payer. Refund to patient if collected. (Use only with Group code OA)
Start: 07/09/2007 | Last Modified: 09/30/2012
210
Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
211
National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007
212
Administrative surcharges are not covered
Start: 11/05/2007
213
Non-compliance with the physician self-referral prohibition legislation or payer policy.
Start: 01/27/2008
214
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or
service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider
should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the
payer must send and the provider should refer to the 835 Healthcare Policy Identification Seg-
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301
ment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010
215
Based on subrogation of a third party settlement
Start: 01/27/2008
216
Based on the findings of a review organization
Start: 01/27/2008
217
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee
arrangement. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
218
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send
and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other
Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at
the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment information REF). To be used for Workers'
Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010
219
Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the
provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line
Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 01/27/2008 | Last Modified: 10/17/2010
220
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill
with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided
and supporting documentation if required. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
221
Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the
payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This
change effective 7/1/2013: Claim is under investigation. Note: If adjustment is at the Claim Level,
the payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To
be used by Property & Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012
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.
Start: 06/01/2008 | Last Modified: 09/20/2009
223
Adjustment code for mandated federal, state or local law/regulation that is not already covered by
another code and is mandated before a new code can be created.
Start: 06/01/2008 SEQUESTRATION ONLY - IS DONE BY THE EZCAP SYSTEM AUTOMATICALLY
224
Patient identification compromised by identity theft. Identity verification required for processing
this and future claims.
Start: 06/01/2008
225
Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the
837)
Start: 06/01/2008
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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.) This
change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not
provided or not provided timely or was insufficient/incomplete. At least one Remark Code must
be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/30/2012
227
Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the
NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/20/2009
228
Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008
229
Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X.
Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim
submission to a prior payer. Use Group Code PR. This change effective 7/1/2013: Partial charge
amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This
code can only be used in the 837 transaction to convey Coordination of Benefits information
when the secondary payer's cost avoidance policy allows providers to bypass claim submission
to a prior payer. (Use only with Group Code PR)
Start: 01/25/2009 | Last Modified: 09/30/2012
230
No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009
231
Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2009 | Last Modified: 09/20/2009
232
Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG
amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009
233
Services/charges related to the treatment of a hospital-acquired condition or preventable medical
error.
Start: 01/24/2010
234
This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not
an ALERT.)
Start: 01/24/2010
235
Sales Tax
Start: 06/06/2010
236
This procedure or procedure/modifier combination is not compatible with another procedure or
procedure/modifier combination provided on the same day according to the National Correct
Coding Initiative. This change effective 7/1/2013: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the
same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
Start: 01/30/2011 | Last Modified: 09/30/2012
237
Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of
either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/05/2011
238
Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). This change effective 7/1/2013: Claim spans eligible and ineligible pe-
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303
riods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
Start: 03/01/2012 | Last Modified: 09/30/2012
239
Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
Start: 03/01/2012 | Last Modified: 01/29/2012
240
The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/03/2012
241
Low Income Subsidy (LIS) Co-payment Amount
Start: 06/03/2012
242
Services not provided by network/primary care providers.
Start: 06/03/2012
243
Services not authorized by network/primary care providers.
Start: 06/03/2012
244
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
Start: 09/30/2012
245
Provider performance program withhold.
Start: 09/30/2012
246
This non-payable code is for required reporting only.
Start: 09/30/2012
247
Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
248
Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
249
This claim has been identified as a readmission. (Use only with Group Code CO)
Start: 09/30/2012
250
The attachment content received is inconsistent with the expected content.
Start: 09/30/2012
251
The attachment content received did not contain the content required to process this claim or
service.
Start: 09/30/2012
252
An attachment is required to adjudicate this claim/service. At least one Remark Code must be
provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT).
Start: 09/30/2012
A0
Patient refund amount.
Start: 01/01/1995
A1
Claim/Service denied. At least one Remark Code must be provided (may be comprised of either
the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009
A2
Contractual adjustment.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
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Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3
Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003
A4
Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008
A5
Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995
A6
Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995
A7
Presumptive Payment Adjustment
Start: 01/01/1995
A8
Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
B1
Non-covered visits.
Start: 01/01/1995
B2
Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003
B3
Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003
B4
Late filing penalty.
Start: 01/01/1995
B5
Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007
B6
This payment is adjusted when performed/billed by this type of provider, by this type of provider
in this type of facility, or by a provider of this specialty.
Start: 01/01/1995 | Stop: 02/01/2006
B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
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.
Start: 01/01/1995 | Last Modified: 09/20/2009
B9
Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10
Allowed amount has been reduced because a component of the basic procedure/test was paid.
The beneficiary is not liable for more than the charge limit for the basic procedure/test.
Start: 01/01/1995
B11
The claim/service has been transferred to the proper payer/processor for processing.
Claim/service not covered by this payer/processor.
Start: 01/01/1995
B12
Services not documented in patients' medical records.
Start: 01/01/1995
B13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995
Provider Manual 2013
305
B14
Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15
This service/procedure requires that a qualifying service/procedure be received and covered. The
qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
B16
'New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B17
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to
delivery, the prescription is incomplete, or the prescription is not current.
Start: 01/01/1995 | Stop: 02/01/2006
B18
This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009
B19
Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003
B20
Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B21
The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003
B22
This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001
B23
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA)
proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
D1
Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D2
Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D4
Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D5
Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D6
Claim/service denied. Claim did not include patient's medical record for the service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D7
Claim/service denied. Claim lacks date of patient's most recent physician visit.
Provider Manual 2013
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Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D8
Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less
discounts or the type of intraocular lens used.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D10
Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D11
Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or
the amount you were charged for the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D13
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician
has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D14
Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D15
Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D16
Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].
D17
Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D18
Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D19
Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D20
Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
Provider Manual 2013
307
D21
This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007
D22
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note:
To be used for Workers' Compensation only) - Temporary code to be added for timeframe only
until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to
replace or strategy to use another existing code
Start: 01/27/2008 | Stop: 01/01/2009
D23
This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least
one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason
Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2009 | Stop: 01/01/2012
W1
Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim
Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line
Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 02/29/2000 | Last Modified: 10/17/2010
W2
Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level,
the payer must send and the provider should refer to the 835 Insurance Policy Number Segment
(Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If
adjustment is at the Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be
used for Workers' Compensation only.
Start: 10/17/2010
W3
The Benefit for this Service is included in the payment/allowance for another service/procedure
that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
Start: 09/30/2012
W4
Workers' Compensation Medical Treatment Guideline Adjustment.
Start: 09/30/2012
Y1
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP)
Benefits jurisdictional regulations or payment policies, use only if no other code is applicable.
Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the
835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier
'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and
the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
Y2
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection
(PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer
to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF
qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must
send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
Y3
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee
schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other
Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the
provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF). To be used for P&C Auto only.
Start: 09/30/2012
Provider Manual 2013
308
VE CODE
V1
V10
V100
V101
V102
V103
V104
V105
V106
V107
V108
V109
V11
V110
V111
V112
V113
V114
V115
V116
V117
V118
V119
V12
V120
V121
V122
V123
V124
V125
V126
V127
V128
V129
V13
V130
V131
V132
V133
V134
Provider Manual 2013
VE CODE DESCRIPTION
Compound with comprehensive
Mutually exclusive
Dos integrity
Endoscopy
Endoscopy 51
Reduced services
Reduced services
Reduced services
Repeat surgery
Unlisted
Unusual procedure
Reduced services
Included in E&M
Discontinued procedure
Separate procedure
Separate procedure
Global ER
Mod 26 review
Psych
UROLOGY(catheter)
Included in E&M
Application of cast
Casting & strapping
Included in E&M
Diagnostic laparoscopy
CMS bundled
Bundled/excluded CMS
Injections / misc
Reserved
Included in E&M
Cast/ splint/ strap
E&M counseling
E&M w/psych
E&M neonatal #1
Quantitative and qualitative
E&M neonatal #2
E&M critical care
Separate procedure
User denied
Delivery
309
V135
V136
V137
V138
V139
V14
V140
V141
V142
V143
V144
V145
V146
V147
V148
V149
V15
V150
V151
V152
V153
V154
V155
V156
V157
V158
V159
V16
V160
V161
V162
V163
V164
V165
V166
V167
V168
V169
V17
V170
V171
Provider Manual 2013
Sex conflict
Modifier 51
Modifier 50
Copay check
Lab/x-ray read
Mutually exclusive
Global already billed
Repeat global procedure
No auth
Non-facility setting
Anesthesia up code
Billed less than paid
Not valid mod
New patient visit
Ob visits
Global ob
Global orthopedic
Office visit w/ ob care
Office visit w/delivery
Decision for surgery
Invalid 26/tc modifier
Incident to
Pt service
25 mod
Distinct procedure
Prolonged E&M service
Prolonged service
Global procedure
E&m with bat
Sleep study
Lab panel
Critical care qty
Timely filing
Cob/tpl
Benefit check
Add-on procedure
Add-on procedure
Invalid facility
Incidental procedure
Cosmetic (never payable)
Cosmetic/reconstructive
310
V172
V173
V174
V175
V176
V177
V178
V18
V180
V181
V182
V183
V184
V185
V19
V190
V191
V192
V196
V197
V198
V199
V2
V20
V21
V22
V23
V24
V25
V26
V27
V271
V272
V273
V274
V275
V28
V29
V3
V30
V301
Provider Manual 2013
Cosmetic/reconstructive
Cosmetic/reconstructive
Cosmetic/reconstructive
Cosmetic/reconstructive
Chiropractic rad
Chiropractor acute treatment
Add-on
Blood collection
Professional / technical
Surgical modifier
Radiology modifier
Pathology modifier
E&M modifier
CMS non-covered
Exploration included
Return to surgery(major)
Return to surgery(minor)
Drug administration
The diagnosis for this service cannot be primary
Medically unlikely edit
Never events
No consults
Lab unbundling
Separate procedure
Separate procedure
Global procedure
Separate procedure
Anesthesia included
Surgery w/ specimen handling
Global procedure
Global procedure
Decision for minor surgery
Global decision
Global period
Global period
Global period
Unbundled
Unbundled
Global anesthesia
With vs. Without conflict
CCI Edits
311
V31
V32
V33
V34
V340
V35
V36
V37
V38
V39
V4
V40
V400
V401
V402
V403
V404
V41
V410
V411
V412
V413
V42
V43
V44
V45
V46
V47
V48
V49
V5
V50
V51
V52
V53
V54
V55
V56
V57
V58
V59
Provider Manual 2013
Compound with comprehensive
Compound with comprehensive
Compound with comprehensive
Compound with comprehensive
Null
Compound with comprehensive
Compound with comprehensive
Compound with comprehensive
Compound with comprehensive
Compound with comprehensive
Mutually exclusive
Compound with comprehensive
Transfers
Not physician svc
Non billable code
Non-covered
Invalid admit
Laboratory panels
Esrd (ov)
Esrd (monthly)
Esrd (day)
Esrd (medical)
Medicare fee
Quantity check
All inclusive
Incident to
Incident to
Asst on self
Duplicate procedure
Duplicate procedure
Sigmoidoscopy precedence
Multiple 1 day visits
Invalid sex
Invalid place of service
Invalid member age
Day mismatch with billed qty
Included in E&M
Compound with comprehensive
Compound with comprehensive
Global anesthesia
Global anesthesia
312
V6
V60
V61
V62
V63
V64
V65
V66
V67
V68
V69
V7
V70
V701
V702
V71
V72
V73
V74
V75
V76
V77
V78
V8
V80
V81
V82
V83
V84
V85
V86
V87
V88
V89
V9
V90
V91
V92
V93
V94
V95
Provider Manual 2013
Basically same procedure
Ob conflict
Once in lifetime
Global emergency
Endoscopic
Colonoscopy
Signoidoscopy
Compound with comprehensive
Dialysis quantity
Compound with comprehensive
Asst/cosrg mismatch
Excision includes wound repair
Invalid modifier
Invalid CPT
Invalid dx
Decision for minor surgery
Global decision
Global period
Global period
Global period
Sos rule
Srg tray
Global procedure
Global endoscopic
Case rate
Dx detail
Rad reduction
Null
Bilateral
Up code
Assistant surgeon
Assistant surgeon
Invalid co-surgeon
Invalid co-surgeon
Incidental procedure
No team surgeon
No team surgeon
Bad date of service
Terminated code
Terminated code
Ineligible
313
V96
V97
V98
V99
VEX
XX1
ZZZ
V420
Provider Manual 2013
Surgical qty
Invalid dx
Unauthorized
Duplicate procedure
Plan override of VE edit
Invalid eob
Automatic adjustment MPFS
Functional G-Code
314
ELECTRONIC BILLING (EDI)
First+Plus will accept electronic claims in the Standard HIPAA transactions. First+Plus accepts
electronics claims from all active Clearing House’s in Puerto Rico, therefore providers should
coordinate with their respective contracted Clearing House in order to submit electronic claims to
First Plus.
Contracted providers could also submit electronic claims directly with First Plus, but before
submitting them, the provider has to complete the configuration process. We encourage providers
to submit their claims electronically for more efficiency and effective payment process.
X12 and HIPAA Compliance Checking, and Business Edits
First Plus returns a 999 Functional Acknowledgment to the submitter for every inbound 837
transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If it
successfully passes X12 syntax edits, a 999 Functional Acknowledgement is returned indicating
acceptance of the transaction. If the transaction fails X12 syntax compliance, the 999Functional
Acknowledgement will also report the Level 1 errors in the AK segments and, depending on where
the error occurred, will indicate that the entire interchange, functional group or transaction set has
been rejected.
Claim Status Report (277CA Transaction)
First Plus returns a Claim Status Report (277CA) for each received file detailing the acceptance or
rejection of each claim within the transaction. This report is sent to the transmitter of the X12 file.
For example, if First Plus receives a file from a Clearinghouse the claim status report is sent to the
Clearinghouse. It is responsibility of the provider to request that report from its Clearinghouse. In
the Claim Status Report the claim status category code A1 means claim acceptance and A3 means
claim rejection by First Plus. Usually the claim status category code is followed by the claim
status code that describes the error. These codes are standardized through the industry and your
system should interpret them. A complete list of the claim status codes as well as Claim
Adjustment Reason Codes (CARC), and Remittance Advice Remark Codes (RARC) can be found at:
http://www.wpc-edi.com/reference/
Provider Manual 2013
315
Claims Status Category-277CA
A0
Acknowledgement/Forwarded-The claim/encounter has been forwarded to
another entity.
Start: 01/01/1995
A1
Acknowledgement/Receipt-The claim/encounter has been received. This does
not mean that the claim has been accepted for adjudication.
Start: 01/01/1995
A2
Acknowledgement/Acceptance into adjudication system-The claim/encounter
has been accepted into the adjudication system.
Start: 01/01/1995
A3
Acknowledgement/Returned as unprocessable claim-The claim/encounter
has been rejected and has not been entered into the adjudication system.
A4
Start: 01/01/1995
Acknowledgement/Not Found-The claim/encounter can not be found in the
adjudication system.
A5
Start: 01/01/1995
Acknowledgement/Split Claim-The claim/encounter has been split upon acceptance into the adjudication system.
A6
A7
Start: 02/28/2002
Acknowledgement/Rejected for Missing Information - The claim/encounter
is missing the information specified in the Status details and has been rejected.
Start: 10/31/2002
Acknowledgement/Rejected for Invalid Information - The claim/encounter
has invalid information as specified in the Status details and has been rejected.
Start: 10/31/2002
A8
P0
Acknowledgement / Rejected for relational field in error.
Start: 10/31/2004
Pending: Adjudication/Details-This is a generic message about a pended
claim. A pended claim is one for which no remittance advice has been issued,
or only part of the claim has been paid.
Start: 01/01/1995
P1
Pending/In Process-The claim or encounter is in the adjudication system.
Start: 01/01/1995
P2
P3
P4
Pending/Payer Review-The claim/encounter is suspended and is pending review (e.g. medical review, repricing, Third Party Administrator processing).
Start: 01/01/1995 | Last Modified: 01/27/2008
Pending/Provider Requested Information - The claim or encounter is waiting
for information that has already been requested from the provider. (Note: A
Claim Status Code identifying the type of information requested, must be
reported)
Start: 01/01/1995 | Last Modified: 01/27/2008
Pending/Patient Requested Information - The claim or encounter is waiting
for information that has already been requested from the patient. (Note: A
status code identifying the type of information requested must be sent)
Start: 01/01/1995 | Last Modified: 01/27/2008
P5
Provider Manual 2013
Pending/Payer Administrative/System hold Start: 10/31/2006
316
F0
Finalized-The claim/encounter has completed the adjudication cycle and no
more action will be taken.
Start: 01/01/1995
F1
Finalized/Payment-The claim/line has been paid.
Start: 01/01/1995
F2
Finalized/Denial-The claim/line has been denied.
Start: 01/01/1995
F3
F3F
F3N
F4
Finalized/Revised - Adjudication information has been changed
Start: 02/28/2001
Finalized/Forwarded-The claim/encounter processing has been completed.
Any applicable payment has been made and the claim/encounter has been
forwarded to a subsequent entity as identified on the original claim or in this
payer's records.
Start: 01/01/1995
Finalized/Not Forwarded-The claim/encounter processing has been completed. Any applicable payment has been made. The claim/encounter has NOT
been forwarded to any subsequent entity identified on the original claim.
Start: 01/01/1995
Finalized/Adjudication Complete - No payment forthcoming-The
claim/encounter has been adjudicated and no further payment is forthcoming.
Start: 01/01/1995
F5
Finalized/Cannot Process
R0
Start: 01/01/1995 | Stop: 10/16/2003
Requests for additional Information/General Requests-Requests that don't
fall into other R-type categories.
Start: 01/01/1995
R1
Requests for additional Information/Entity Requests-Requests for information about specific entities (subscribers, patients, various providers).
Start: 01/01/1995
R3
Requests for additional Information/Claim/Line-Requests for information
that could normally be submitted on a claim.
Start: 01/01/1995 | Last Modified: 02/28/1998
R4
R5
Requests for additional Information/Documentation-Requests for additional
supporting documentation. Examples: certification, x-ray, notes.
Start: 01/01/1995 | Last Modified: 02/28/1998
Request for additional information/more specific detail-Additional information as a follow up to a previous request is needed. The original information was received but is inadequate. More specific/detailed information is
requested.
Start: 01/01/1995 | Last Modified: 06/30/1998
R6
Requests for additional information – Regulatory requirements
R7
Start: 02/28/2007
Requests for additional information – Confirm care is consistent with Health
Plan policy coverage
R8
Start: 02/28/2007
Requests for additional information – Confirm care is consistent with health
plan coverage exceptions Start: 02/28/2007
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R9
Requests for additional information – Determination of medical necessity
Start: 02/28/2007
R10
Requests for additional information – Support a filed grievance or appeal
Start: 02/28/2007
R11
Requests for additional information – Pre-payment review of claims
R12
Start: 02/28/2007
Requests for additional information – Clarification or justification of use for
specified procedure code
Start: 02/28/2007
R13
Requests for additional information – Original documents submitted are not
readable. Used only for subsequent request(s).
Start: 02/28/2007
R14
R15
Requests for additional information – Original documents received are not
what was requested. Used only for subsequent request(s).
Start: 02/28/2007
Requests for additional information – Workers Compensation coverage determination.
Start: 02/28/2007
R16
Requests for additional information – Eligibility determination
Start: 02/28/2007
R17
RQ
Replacement of a Prior Request. Used to indicate that the current attachment request replaces a prior attachment request.
Start: 01/20/2013
General Questions (Yes/No Responses)-Questions that may be answered by a
simple 'yes' or 'no'.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008
E0
Response not possible - error on submitted request data
Start: 01/01/1995 | Last Modified: 02/28/2002
E1
Response not possible - System Status
Start: 02/29/2000
E2
Information Holder is not responding; resubmit at a later time.
Start: 06/30/2003
E3
E4
Correction required - relational fields in error.
Start: 01/24/2010
Trading partner agreement specific requirement not met: Data correction
required. (Note: A status code identifying the type of information requested
must be sent)
Start: 01/30/2011
D0
Data Search Unsuccessful - The payer is unable to return status on the requested claim(s) based on the submitted search criteria.
Start: 01/01/1995 | Last Modified: 09/20/2009
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FRAUD, WASTE & ABUSE
Health care fraud and abuse is a federal offense. First+Plus has a strict zero-tolerance policy
toward fraud, waste and abuse. The purpose of investigating these activities is to protect the
member, government, and/or First+Plus from paying more for a service than it is obligated to pay.
However, First+Plus’ zero-tolerance policy is not limited to cases of fraud or abuse. First+Plus
also investigates instances of waste as well as any inappropriate activities.
Our policies in this area reflect that First+Plus, its providers, their staff and agents are subject to
federal and state laws designed to prevent fraud and abuse in government programs (e.g., Medicare
and Medicaid), federally funded contracts and private insurance. First+Plus complies with all
applicable laws, including the Federal False Claims Act, applicable whistleblower protection laws,
the Deficit Reduction Act of 2005, the American Recovery and Reinvestment Act of 2009, the
Patient Protection and Affordable Care Act of 2010 and applicable state and federal billing
requirements for state-funded programs, federally funded health care programs (e.g., Medicare
Advantage, SCHIP and Medicaid) and other payers. First+Plus expectation is that you fully
cooperate and participate in its fraud, waste and abuse programs. This includes, but not limited to,
permitting First+Plus access to member records and allowing for on-site audits or reviews. Also,
First+Plus may interview Members as part of an investigation, without provider interference.
What is Fraud?
Fraud means an intentional deception or misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized benefit to him / herself for some other person.
It includes any act that constitutes fraud under applicable federal or state law.
What is Abuse?
Abuse means provider practices that are inconsistent with sound fiscal, business, or medical
practices, and result in an unnecessary cost to government-sponsored programs, and other health
care programs/plans, or in reimbursement for services that are not medically necessary or that fail
to meet professionally recognized standards for health care. It also includes recipient practices that
result in unnecessary cost to federally and/or state-funded health care programs, and other payers.
What is Waste?
Waste means over-utilization of services or other practices that result in unnecessary costs.
Examples of Fraud, Waste and Abuse include, but are not limited to:
• Billing more than once for the same service
• Billing for services never performed or provided
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•
•
•
•
•
•
•
Performing inappropriate or unnecessary services
Routinely waiving patient deductibles or co-payments
Providing lower cost or used equipment and billing for higher cost or new equipment
Using someone else’s identity
Altering or falsifying pharmacy prescriptions
Providing services in a method that conflicts with regulatory requirement
Prescribing a medication for 30 days with a refill when it is not known if the medication
will be needed.
FWA Training:
First+Plus providers are responsible for administering the necessary training on Fraud, Waste and
Abuse to its new employees within the first 90 days of employment, including managers, directors,
contractors, subcontractors, and board members and annually thereafter. The provider must keep a
copy of this training and proof of its delivery in case First+Plus and/or any government agency
requests it and must acknowledge, annually, that it has complied with this requirement.
CMS has developed a web-based training module that can be used to satisfy the FWA training and
education requirements. Using CMS’ training and education module is optional. However, this
training meets CMS’ FWA training requirements and is accepted by First+Plus as an appropriate
training tool. The FWA training and education module is available through the CMS’ Medicare
Learning Network (MLN). To take a web-based training course, go to
http://www.cms.gov/MLNProducts.
There is one exception to the FWA training and education requirement. Regulations effective June
7, 2010 implemented a “deeming” exception which exempts providers who are enrolled in
Medicare Parts A or B from annual FWA education and training (42 CFR §
422.503(b)(4)(vi)(C)(2) and 42 CFR§ 423.504(b)(4)(vi)(C)(3)). Therefore, if an entity or an
individual is enrolled in Medicare Parts A or B, the FWA training and education requirement has
already been satisfied. In the case of chains, such as chain pharmacies, each individual location
must be enrolled in Medicare Part A or Part B to be “deemed”. The deeming exception for FWA
training and education does not apply to the Medicare Parts C and D compliance training and
education requirement. Therefore, even if a health care provider, entity or supplier is deemed for
FWA training and education, the requirement for compliance training and education must still be
fulfilled.
It is important that you keep training logs, demonstrating who was trained, including training dates
and certificates of completion. For your convenience, a certificate of completion, which can be
filled out by the person completing the FWA training, is included as the last slide of CMS’ FWA
training and education module.
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Reporting Fraud, Waste and Abuse:
First+Plus expects providers, their staff and agents to report any suspected cases of fraud, waste or
abuse. First+Plus will not retaliate against you if you inform us, the federal government, state
government or any other regulatory agency with oversight authority of any suspected cases of
fraud, waste or abuse.
If a violation of federal law has taken place, the case will be referred to the Centers of Medicare &
Medicaid Services (OIG), Department of Health and Human Service Office of Inspector General
(OIG), and/or other law enforcement agencies, as appropriate.
Overpayments for prescription drugs require immediate corrective action in the form of repayment.
All employees, members, and providers shall report all alleged Fraud, Waste, and Abuse cases and
other inappropriate activities to the Special Investigations Unit (SIU) Department. All such
activities will be subject to investigation and forwarded to the applicable government agency for
further investigation, if warranted.
Reports of potential or actual compliance issues related to First+Plus Medicare Part C or Part D
program must be self-reported to the Centers for Medicare & Medicaid Services (CMS), Office of
the Inspector General (OIG), the Medicare Drug Integrity Contractors (MEDICs) and/or the Office
of the Commissioner of Insurance for further investigation.
An individual who engages in any fraud, waste, and abuse activity, alone or in collaboration with
other employees, patients, or providers, are subject to immediate disciplinary action up to and
including termination of contract.
An employee, member or provider must report any alleged inappropriate activity but may do so
voluntarily without disclosing his/her name and information.
First+Plus will not tolerate retaliation in any form, and regards any form of retaliatory action
toward any reporter of potential fraud, waste or abuse as a very serious regulatory/legal violation.
Any questions involving inappropriate activities or clarification should be forwarded to the SIU
Department.
Reports to the Fraud, Waste and Abuse Hotline may be made 24 hours a day/seven days a week.
Callers may choose to remain anonymous. All calls will be investigated and remain confidential.
Fraud, Waste and Abuse reports may be made through one of the following:
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•
•
Fraud, Waste and Abuse Hotline at (866) 933-9336
Fraud, Waste and Abuse email: [email protected]
In writing to:
•
First+Plus
Special Investigations Unit
PO Box 191580
San Juan, PR 00918-1580
The informant needs to provide the SIU Department with as much detail as possible on the
incident. If available, provide:
•
•
•
•
•
Description of the incident
When informant became aware of the incident
Date(s) the incident occurred
Specific individuals involved in the incident
If available, provide documentation/evidence.
If not anonymous, the informant should be prepared to provide his/her name and contact phone
number in the event additional information and/or follow up is required.
The SIU Department creates a file and begins the investigation. Please note, the SIU Department
will not update the informant of the status or results of the investigation as such information is
confidential.
You may also contact the following:
U.S. Department of Health and Human Services (HHS)
Office of Inspector General (OIG)
OIG’s National Hotline: 1-800-323-8603
Fax: 202-254-4292
Email: [email protected]
Centers for Medicare & Medicaid Services (CMS)
1-800-633-4227
Website: http://www.cms.gov
Important Laws against Health Care Fraud that you must know
There are a number of laws that address health care fraud. These laws define fraud and establish
the framework for the prosecution of criminal acts and the initiation of civil suits by injured
parties. Listed below are a few of the laws that address health care fraud. We encourage you to
review Chapter 9 of the Prescription Drug Benefit Manual or Chapter 21 of the Medicare Manage
care Manual, specifically Appendix B which includes other laws which you may need to be
compliant with.
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Federal False Claims Act (FCA) – 31 U.S.C. Titles 1347
The False Claims Act addresses any person or entity that does any of the following:
• Knowingly presents, or causes to be presented, to an employee of the United States government a
false or fraudulent claim for payment or approval
• Knowingly makes, uses or causes to be made or used, a false record or statement to get a false or
fraudulent claim paid or approved by the government
• Conspires to defraud the government by getting a false or fraudulent claim allowed or paid
• Knowingly makes, uses or causes to be made or used, a false record or statement to conceal,
avoid or decrease an obligation to pay or transmit money to the government
• Has actual knowledge of the information
• Acts in deliberate ignorance of the truth or falsity of the information
• Acts in reckless disregard of the truth or falsity of the information; no proof of specific intent to
defraud is required.
The False Claims Act imposes two sorts of liability:
• The submitter of the false claim or statement is liable for a civil penalty, regardless of whether
the submission of a claim actually causes the government any damages and even if the claim is
rejected.
• The submitter of the claim is liable for damages that the government sustains because of the
submission of the false claim.
Under the False Claims Act, those who knowingly submit or cause another person to submit false
claims for payment by the government, are liable for three times the government’s damages plus
civil penalties of $5,000 to $10,000 per false claim.
Note: The federal government does not consider an innocent mistake as a legitimate defense for
submitting a false claim and the violation could result in a multitude of penalties.
Whistleblower (Qui Tam) Protection – 31 United States Code Service (USC) 3730 (h)
The whistleblower provision protects employees who assist the federal government in
investigation and prosecution of violations of the False Claims Act. Whistleblower protections
apply only to actions taken in furtherance of a viable False Claims Act case, which has been, or is
about to be, filed. The provision prevents retaliation against employees such as firing them for
assisting in the investigation and prosecution. If any retaliation does occur, the employee has a
right to obtain legal counsel to defend the actions taken.
Note: A whistleblower (Qui Tam) is someone, such as an employee, who reports suspected
misconduct that would be considered an action against company policy or federal laws or
regulations. In 1994 alone, false claims act litigation resulted in payment to people/plaintiffs of
$379 million.
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Physician Self-Referral Prohibition Statute commonly referred to as the “Stark Law” 1877
of the Social Security Act (42 USC 1395)
This statute prohibits physicians from referring Medicare patients for certain designated health
services (DHS) to an entity with which the physician or a member of the physician’s immediate
family has a financial relationship, unless an exception applies. It also prohibits an entity from
presenting or causing to be presented a bill or claim to anyone for a DHS furnished as a result of a
prohibited referral.
Anti-Kickback Statute Section 1128(b) of the Social Security Act (42 USC 1320a-7b (b))
The federal anti-kickback laws that apply to Medicare and Medicaid prohibit health care
professionals, entities and vendors from knowingly offering, paying, soliciting or receiving
remuneration of any kind to induce the referral of business under a federal program. In addition,
most states have laws that prohibit kickbacks and rebates. Remuneration under the federal antikickback statute includes the transfer of anything of value, directly or indirectly, overtly or
covertly, in cash or in kind.
Violators are subject to criminal sanctions such as imprisonment, as well as high fines, exclusion
from Medicare and Medicaid, very costly civil penalties and possible prosecution under many
similar state laws.
The anti-kickback law is extremely broad and covers a wider range of activities than just
traditional kickbacks. Federal regulations include safe harbors that protect certain technically
prohibited activities from prosecution. If you are unsure whether an activity violates the antikickback law, you should seek the advice of a legal professional.
Fraud and Abuse, Privacy and Security Provisions of the Health Insurance Portability and
Accountability Act, as modified by HITECH Act
This act could be considered an extension of HIPAA, as it enabled the U.S. Department of Health
and Human Services to promote and expand the adoption of health information technology. It
addresses:
• Use of electronic health records, including incentives for adopting them and requirements
around their disclosure
• How to secure protected health information appropriately
• When and to whom notifications should made in regard to data breaches of unsecured
protected health information (PHI)
http://www.healthit.gov/policy-researchers-implementers/final-rules-regulations
Antitrust Laws
State and federal antitrust laws prohibit monopolistic conduct and agreements that restrain trade.
First+Plus is committed to competition and consumer choice in the marketplace. All health care
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professionals, entities and vendors must adhere to the antitrust laws and must avoid any
agreements or understandings with competitors on price, customers, markets or other terms of
dealing and avoid trade practices that unfairly or unreasonably restrain competition in dealings
with providers or customers.
Civil Monetary Penalties Law
The OIG may seek civil penalties and sometimes exclusion for a wide variety of conduct and is
authorized to seek different amounts of penalties and assessments based on type of violation at
issue.
Penalties range from $10,000 to $50,000 per violation and include:
• Presenting a claim that the person knows or should know is for an item or
• Service that was not provided or is false or fraudulent or for which payment may not be
made.
• Violating Medicare assignment provisions.
• Violating the Medicare physician agreement.
• Providing false or misleading information expected to influence a decision or discharge.
• Making false statements or misrepresentations on application or contracts to participate in
Federal Health Care programs.
• Violations of the Anti-Kickback statute and/or Stark Law.
The Beneficiary Anti-Inducement Statute (42 U.S.C. § 1320a-7a (a) (5)
This federal statute declares that any person who gives or offers to give anything of value* to a
Medicare or Medicaid beneficiary that the person knows or should know is likely to influence a
beneficiary’s choice of a particular health care provider, practitioner, or supplier to buy or rent a
Medicare or Medicaid covered item from the provider, practitioner, or supplier may be liable for
civil money penalties of up to $10,000 for each wrongful act.
http://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7subchapXI-partAsec1320a-7a.pdf
* The OIG stated in guidance that there is a “nominal value” exception that allows a health care
provider to give:
• A gift to a beneficiary as long as the gift has a retail value of $10 or less
• Multiple gifts of $10 or less over a 12-month period, as long as the total retail value of the
gifts does not exceed $50
Any such gift must not be in cash or cash equivalents, so it should not be a gift card or gift
certificate.
Types of gifts and their value(s) are detailed in a Special Advisory Bulletin from the OIG:
https://oig.hhs.gov/fraud/docs/alertsandbulletins/SABGiftsandInducements.pdf
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Additional Resources
• CMS Prescription Drug Manual – Chapter 9:
o http://www.cms.gov/manuals/downloads/Pub100_18.pdf
• Code of Federal Register: (see 42 CFR 422.503 and 42 CFR 422.504)
• Office of the Inspector General:
o http://www.oig.hhs.gov/compliance/compliance-guidance/index.asp
• Federal Sentencing Guidelines:
o http://ussc.gov/Guidelines
• Health Insurance Portability and Accountability Act (HIPAA):
o http://aspe.hhs.gov/admnsimp/pl104191.htm
• False Claims Act:
o http://www.justice.gov/jmd/ls/legislative_histories/pl99-562/pl99-562.html
• Anti-Kickback Statute (see section 1128B(b):
o http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm#f
First+Plus does not knowingly tolerate fraudulent activity by any of its providers, its employees
and/or agents and will investigate and report any such known activity to the appropriate regulatory,
federal and state agencies for further action and investigation.
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ADDITIONAL INFORMATION:
• First+Plus does not deny, limit or condition the coverage or furnishing of benefits to individuals
eligible to enrolling First+Plus on the basis of health status. (ESRD excluded)
• No referrals are needed to access care provided by contracting or non-contracting providers under
PPO coverage’s. Some services may require precertification or may not be covered when rendered
by an out of network provider.
• First+Plus members have direct access to mammography and influenza vaccines as well as to
women’s specialist for routine and preventive services
• No additional co-payment beyond an office visit co-payment if applicable may be charged for
influenza vaccines or the pneumococcal vaccine
• First+Plus receives federal payments under the Medicare Advantage program. It complies with
all laws and regulation applicable to entities receiving federal funds including, but not limited to,
Title VI of the Civil Rights Act of 1964, the Age discrimination Act of 1975, the Americans with
Disabilities Act and the Rehabilitation Act of 1973
• First+Plus monitors and reports to quality and performance including but not limited to: member
satisfaction, disenrollment, and health outcomes.
• Provider agrees to provide reasonable continuity of care as required by CMS regulation to
beneficiaries eligible for such care.
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