CODE
011
012
017
030
031
032
033
034
035
036
096
101
102
105
108
109
130
142
170
171
200
201
202
203
204
207
213
214
215
216
217
218
221
DESCRIPTION
Claim denial (claim level) due to SF message
Line denial (line level) due to SF message
Incorrect Alpha Prefix
Missing service provider zip code (box 32)
Missing pickup zip code on the claim
Billed charges should be zero for home health claim
Hospital based ASC claim can't be submitted on UB form
Service dates are not in the same calendar year
Invalid place of service
Invalid type of bill
Member's gender is not the same between claim and membership
Subscriber not actively enrolled on service date
Member not actively enrolled on service date
No coverage during service period
Benefit not covered for spouse
Benefit not covered for dependent
Submit to Cofinity for Repricing
Type of Bill ‐ Deny Action
Service date after receive date
Date of service before date of birth
Missing diagnosis pointer OR Invalid HIPAA ICD9 code.
Additional digit is required for this ICD9 code
Unknown CPT code ‐ Please resubmit with a HIPAA valid CPT code
Inactive CPT code ‐ Please resubmit with a HIPAA valid CPT code
Unknown Modifier ‐ Please resubmit with a HIPAA valid Modifier
Unknown ICD9 Procedure code ‐ Please resubmit with a valid HIPAA code
Ben Cat Priority config issue
Denied due to B‐notice
Missing Admission source for the Revenue code submitted, for NONPPO provider
Invalid Value Codes for the Revenue codes submitted, for NONPPO provider
HOST claim cannot be submitted with zero total charges
Primary line is denied in inclusive group pricing.
Out of scope in Ancillary claim wrong claim type or wrong payee type.
222
223
228
231
232
233
243
244
245
300
304
333
343
346
348
351
352
357
361
363
369
381
385
407
431
456
500
502
503
511
528
529
530
531
533
539
540
601
602
604
605
606
607
608
609
610
611
Ancillary claim, need to bill local plan.
Referring provider NPI is missing in Ancillary claim.
Host Adjustment claim ‐ Void/adjustment claim
Current claim falls within the history claim date range
Current claim falls outside the history claim date range
Unknown Secondary ICD Code
Invalid Diagnosis Code
Invalid Secondary Diagnosis Code
Invalid Procedure code
Unlisted code ‐ Please resubmit using a more specific code and/or a description of code
Member in Hospice
Family lifetime max limit is met
Exceeded max allowed amount for claim
Member lifetime allowed amount exceeded max
Family annual allowed amount exceeded max
Family life max for benefit category exceeded
Family annual allowed amount for benefit category exceeded max
Member age excludes benefit coverage
Student age limitation in this plan
Service date is after COBRA termination date
Billed charges paid by Member
Void Claim
Fee schedule is not active
Code not in Fee Schedule.
Preexisting conditions
Authorization has been denied
Denied by Rebundler
Duplicate Line Item
Assistant Surgeon limit exceeded for this procedure
Rider Option ‐ Number of visits exceed allowable
Age is out of range for the given Primary Diagnosis
Gender is invalid for the given Primary Diagnosis.
Age is out of range for the given code
Gender code is invalid for the given CPT
MODIFIER NOT CONSIDERED ELIGIBLE BY SIGNATURE CARE ‐ PROV W/O
Claim being denied over filing limit
Total charges not equal to total charges of line items
Paid‐Manual Denied‐ Manual Processed‐Injectable/infusion/Pathology/Lab code requires prior approval by the UR Department
Denied‐ Inappropriate Coding
Denied‐Primary Carrier EOB Required or proof of termination of Primary carrier
Denied‐Not A Covered Benefit
Denied ‐ No Medical Coverage
Denied ‐ No Dental Coverage
Denied ‐ No Vision Coverage
Denied‐Duplicate Claim
612
613
614
615
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
Denied‐ Eligibility Document Required (i.e., Birth Certificate, Marriage License, Divorce Decree)
Denied‐ Exceeds filing limit ‐ Can Not Bill Patient
Denied‐ Investigating Other Insurance
Denied Incidental Procedure
Denied‐ Invalid/Deleted Diagnosis Code
Denied‐ Invalid/Deleted Procedure Code
Denied ‐ Medical Records Must Be Submitted
Denied‐Other Insurance Information Required
Denied‐Part of Global Code
Do not use‐ Do not change
Denied‐Prior/After UR Authorized Dates
Denied ‐ Over Plan Filing Limit
Denied‐Unlisted Procedure ‐ Submit Specific CPT/HCPCS or Description and Medical Necessity
Denied‐Not A Billable Service By This Provider
Denied‐An established patient E/M code should have been used
Denied‐Service Exceeds Plan Limit
Denied‐ Charges Incurred After Term Date
Denied‐ Duplicate line item
Denied‐Claim Exceeds Authorized Visits
Denied ‐No UR Authorization/Authorization not approved Denied‐ Diagnosis Does Not Match Authorized Diagnosis
Penalty ‐ No Out Of Network Authorization
Denied‐ Inappropriate Place of Service Billed
Denied‐ Itemized Statement Required
Denied Related To Workmans Comp
Denied‐Provider Not Properly Credentialed
Paid/Processed as Secondary/No Primary Member Obligation
Denied‐ Charges Incurred Prior To Effective Date
Processed‐Requested Information Received
Denied‐Require Copy Of Operative Report
Denied‐Pending For Medicare Effective Date
Denied‐Age Is Out Of Range For Given CPT
Denied‐Incorrect Patient Demographics
Denied‐Require Attending Physicians Name‐ field 31
Denied Requested Information Not Received
Denied‐Required Description of Primary's Remark Codes
Denied‐Exceeds allowed quantity/frequency
Denied‐Submit to Community Mental Health Paid‐Allowable Applied to the Deductible
Processed‐This Is A Predetermination
Denied‐Eligible for, not enrolled in Medicare
Denied ‐ Subsequent PT/OT/ST visits must be authorized by Navant
Denied‐Submit Original Primary EOB Maximum Pay Amount. Patient Owes Balance Denied‐Resubmit With Anesthesia Code/Modifier
Denied‐Present on Admission Indicator Required, information may be missing or invalid.
Denied‐ Exceeds Yearly Dental Maximum 660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
701
704
708
711
830
852
861
Denied‐Primary diagnosis code not recognized by this DRG Grouper. Please map diagnosis to the prev.
Denied‐Missing Multiple Surgical Modifier Denied‐Srvc not provided by a designated or contracted PCP
Denied‐No Secondary Consideration Until Primary's Request Satisfied
Denied‐Require Primary Carrier's EOB Paid‐Additional Denied‐Split Claim Needed for Non Covered Charges
Denied‐Require facility name and address where services were rendered, box 32
Denied‐ EOB and Claim Do Not Match
Denied ‐ The immunization must be billed with the immunization administration code.
Denied‐ Forward claim to Psychcare 1‐800‐221‐5487
Denied‐Submit claim to ValueOptions‐ PO Box 930321, Wixom, MI 48393
Denied‐ Not Included In Case Rate Resubmit‐ illegible EOB Processed‐Split Payment Due To Benefits Denied ‐ Replacement/void claim received
Denied‐Require Copy of Birth Certificate
Denied‐Require eligibility verification form
Denied ‐Claim Under Review by The Sentinel Group
Denied‐Submit Claim to Occupational Eyewear Network
Denied‐Claim not submitted with contracted TIN / payee information.
Paid per settlement
Denied‐Service Line Pending Fee Schedule Update
Denied‐Non‐Network/Inactive Provider/Non‐contracted Physician Denied by Medical Director after Review
Denied‐ Covered In Contracted Case Rate Denied‐Per primary carrier EOB, This is a provider write‐off Denied‐Exceeds annual maximum benefit limit
Denied‐Resubmission of a claim under review by Sentinel
Denied‐Submit to Cofinity for Pricing
Denied‐Non Emergent Ambulance Dx
Denied‐Not a THC Enrollee/Incorrect Member/Claimant
Denied‐Resubmit with a THC referral
Denied‐Resubmit with Prenatal Dates
Denied‐ Invalid Place of Service
Denied‐Not covered by Medicaid/ Medicare
Denied‐Service Included
Denied‐Previously paid
Denied‐Capitated Service
Denied‐Service is not authorized on the referral or authorization
Number of visit exceeds annual allowable
Claim exceed EOB max pay amount
Missing accident date for accident related claim
Claim had been paid at header level
Exceed maximum allowed time for pended claim ‐ Denied
Denied based on iCES edits
Denied based on pricing reduction
01Z
04Z
08Z
10Z
21Q
24Q
41P
62P
E01
E02
E03
E04
E05
E06
E07
E08
E09
E10
E11
E12
E13
E14
E15
E16
E17
E18
E19
E20
E21
E22
E23
E24
E25
E26
E27
E28
E29
E30
E31
E32
E33
E34
E35
E40
E41
E42
E44
Pricer ‐ No available APC/fee schedule rate.
Not Covered Under OPPS
Pricer ‐ Invalid modifier for pricing
Pricer ‐ Line item denial or rejection from ACE
Present on Admission Indicator Required
Non‐covered claim (Kentucky Medicaid, Virginia Medicaid, and Medicare Inpatient)
Invalid billing of therapy services
Closed or inactive rate record Denied‐Misrepresentation of Diagnosis
Denied‐Failure by referring provider to comply Denied‐ Failure by rendering provider to comply
Denied ‐ Unbundled Service/Exclusive or Incidental Relationship.
Denied‐ Deliberate performance of unwarranted services
Denied‐Billing for services/supplies not provided
Denied‐ Misrepresentation of services/supplies provided
Denied‐Treatment is not in accordance with standard of care
Denied‐No documentation in medical record of services billed; medical record does not support billed
Denied‐Auto insurance primary
Primary payment exceeds allowable
Denied‐ HCPC Code Required
Processed‐THC primary carrier
Denied‐NDC Code Required in HCFA box 24 or in UB service line area per MSA Bulletin 10‐26 Denied‐Invalid/missing or incorrect Modifier
Denied‐ NDC is invalid for the billed service code
Denied‐ Electronic Referral Required
Denied‐Injection is covered under Medicare Part D.
Denied‐Injection pending Part D filing submission
Denied‐No history of inpatient services or observation provided for Transitional Care Management Ser
Denied ‐ DOS is outside of the required timeframe
Denied‐ Include date of visit(s) and EDC
Denied‐ Prenatal global billing must be rebilled as separate services and include DOS and EDC
Denied by Medicare/Primary Insurer Multiple procedure reduction of 50% applied per CMS guidelines
Denied‐ Services not supported by patient history or documentation
Denied‐ No additional payment, paid in full by Medicare/ primary insurer
Denied‐Awaiting eligibility determination from health insurance marketplace; nonpayment of premium Resubmission of a claim under review by TC3
Denied‐ Claim under review by TC3
Denied‐ Medicare is primary
Denied‐ Left against medical advice‐ not a covered benefit
Denied‐The requisition form was not signed by the ordering physician.
Denied‐ Inappropriate use of Modifier ‐59 Denied ‐ Does not meet inpatient hospital claim requirements for newborns Payment requires submission of completed HRA‐ fax to 877‐872‐3163
Denied ‐ Diagnosis describes external cause, or requires the ICD code for first underlying disease.
Denied‐ service or supply may be considered investigational and experimental
Denied‐ Drug code requires name of drug, dosage, and NDC of the drug furnished
F01
F02
F05
F70
XXX
Member not eligible
No saving claims history
Invalid Group
Same problem with account
Visit falls before the event period.
Updated 02/10/2015