1 SNF-No Authorization CO B5 CO 15 N517 SNF-Member Share of Cost Reduced From Contracted 2 Amount CO 142 CO 142 3 Benefit Exhaustion Period Reported CO 119 CO 119 Medicare Crossover QMB 7 processing rules applied CO A1 N192 CO 109 N193 Medicare Crossover Claim 10 Pays at Zero Dollars CO 23 CO 23 11 HMO Guidelines Apply CO 24 CO 24 12 Medicare covered service must be billed to Medicare CO 22 CO 22 14 TPL Claim Pays At Zero Dollars CO 23 CO 23 Service not covered for patients in a Medicaid 15 supported fac CO A1 N106 CO 96 N448 16 No COB Info on Claim Line CO A1 MA04 CO 16 MA04 Xover SQL pays zero dollars 17 based on TOB logic CO B5 CO B5 18 SNF Part A - Claim Pays Zero CO 23 CO 23 Revenue Codes 183 & 185 are 20 Present on Part A Claim CO A1 N30 CO A1 N30 22 Missing or Multiple AAA Codes CO 186 CO 186 Revenue Code Not Valid for 23 SNF Part A Claim CO 185 CO 185 24 NDC is Missing/Invalid CO 16 M119 CO 16 M119 25 NDC is not Rebate Eligible CO 211 CO 96 26 Invalid NDC Units CO 125 M53 CO 16 M53 Page 1 of 27
27 SNF SQL denies claim when one or more lines are in deny stat CO A1 N142 CO A1 N142 28 DOS not within LTC effect & term dates CO B5 CO B5 29 Product Service Not Covered - DESI - for Non-Compound Drug CO 203 CO 96 30 Rehab Services Not Valid for this provider CO 171 CO 171 100 Patient is Expired CO 13 CO 13 101 No active provider contract CO 147 CO B7 N570 Provider not active for Plan on 102 DOS CO 147 CO B7 N570 103 Not an approved service for provider CO B7 CO B7 104 Incomplete provider CO B7 CO B7 105 Provider on Pay hold CO 133 N35 CO 170 No attending physician ID 106 (outpatient) CO 125 N253 CO 16 N253 107 Negative charge on claim line CO 125 M54 CO 16 M54 108 Uncredentialed provider CO 185 CO 185 Claim amt exceeds maximum allowed during mass 109 adjudication CO A1 N220 CO 16 M54 111 Provider Watch CO 197 CO 197 112 Claim amount exceeds the maximum allowed CO 45 CO 170 Specialty code required for 113 provider CO 172 N95 CO 172 N95 114 Provider does not match required type CO 170 CO 170 Page 2 of 27
Annual Benefit Amount 116 Exceeded CO 119 CO 119 117 Lifetime Benefit Max Exceeded CO 35 CO 35 Family Benefit Lifetime Max 119 Exceeded CO 35 CO 35 120 Family Annual Limit exceeded CO 119 CO 119 Validate External Provider's 121 Program CO A1 N220 122 PCP reassignment override days CO A1 N220 123 Individual Lifetime Visits Exceeded CO 119 CO 119 124 Family Lifetime Visits Exceeded CO 119 CO 119 125 Partial Units on Lifetime/Individual Visit Limits CO 119 CO 119 Partial Units on 126 Lifetime/Family Visit Limits CO 119 CO 119 127 Sponsor Watch CO A1 N220 128 Remaining visits less than date span. Units not allocated. CO 125 M53 CO 16 M53 130 Program Watch CO A1 N220 132 Sum of Individual Coinsured Charges Exceeds Maximum CO 2 Page 3 of 27
133 134 135 149 150 151 152 153 Sum of Family Coinsured Charge Maximum Exceeded CO 2 Claim payment amt exceeds max allowed for mass adjudication CO 45 CO 45 Claim payment amount exceeds the maximum allowed CO 45 CO 45 Benefit does NOT meet date criteria of the claim CO 204 CO 204 No contract term found for service CO 185 CO 185 Excluded Contract Term for Service CO 185 CO 185 Provider type does not match type required by benefit CO 170 N95 CO 170 N95 PCP is solely responsible for service: pay as capitated CO 24 CO 24 Benefit requires Specialty 154 Code not found on Provider CO 172 N95 CO 170 N95 155 Benefit has age restriction CO 6 N30 CO 6 N129 156 157 Provider type does NOT match type required by contract term CO 170 CO 170 Contract Term requires Specialty Code not found on Provider CO 8 N95 CO 8 N95 158 Invalid Service Code on DOS CO 181 CO 181 Page 4 of 27
162 Contract term requires documentation CO 16 N29 CO 163 Benefit requires 163 documentation CO 16 N29 CO 163 Contract requires document 164 review CO 16 N29 CO 163 Dental Areas on Claim Line 165 and Benefit do not match CO 168 CO 204 N130 Benefit procedure NOT found 166 in claims history CO 107 N161 CO 107 167 Benefit requires prosthesis designation CO 16 N29 168 Member does NOT meet age criteria for term CO 6 N30 CO 6 N129 Claim and contract term 169 modifiers do NOT match CO 4 CO 4 170 171 172 173 174 175 176 Claim and contract term type of service do NOT match CO A1 N220 Term Applies to assigned members only CO 24 CO 24 Term does NOT meet date criteria of the claim CO 204 CO 204 Diagnosis on claim does NOT match terms valid range CO 167 CO 167 Procedure code on claim does NOT match terms valid procedure CO 204 CO 204 Bill type on claim does NOT match contract term CO 16 MA30 CO 16 MA30 Emergency requirements on claim do NOT match contract term CO 40 N180 CO 40 Page 5 of 27
177 Term is for EPSDT claims only CO A1 N78 178 Member is NOT in capitation and contract term is capitated CO 95 N52 CO 95 N627 Location specific term does 179 NOT match claim CO 5 CO 5 180 No Sponsor Fee for service CO 133 181 Stop Loss Applied to Claim CO 45 CO 45 No external price found for 182 provider CO 147 CO B7 N570 183 Submission date exceeds policy termination run-off period CO 27 CO 27 184 DOS end date exceeds policy termination date CO 27 CO 27 185 Location-specific benefit does NOT match claim CO 5 CO 5 186 No skilled nursing coverage CO 204 CO 204 Benefit requires documents to 187 be reviewed CO 16 N29 188 Noncontracted provider requires EOMB CO 16 N4 CO 252 N4 189 Level of Care Benefit Not Found CO 204 CO 204 190 192 194 Authorization contract overriding contracted provider CO 45 N45 CO 45 N45 Benefit requires contracted (PAR) provider CO 38 CO 38 Restrict Benefit by Date of ONSET CO A1 N130 Page 6 of 27
Date of Onset is Missing on 195 Claim CO 16 MA122 CO 16 MA122 196 Benefit requires noncontracted (NONPAR) provider CO 38 Procedure code on claim NOT 197 valid for benefit CO 204 CO 204 198 Date of Service is after paid through date CO 125 M59 CO 16 M59 199 Benefit Rider not valid for member/dos CO B5 N30 CO B5 N30 200 Benefit Day Limit Exceeded CO 119 CO 119 No enrollment exists for claim 201 start date CO 177 CO 177 202 No Benefit for Service CO 204 CO 204 Benefit is excluded from 203 benefit plan CO 204 CO 204 204 Invalid accommodation days CO 125 M53 CO 16 M53 205 Benefit requires authorization CO 197 CO 197 206 Benefit Visit Limit Exceeded CO 119 CO 119 207 Benefit Dollar Limit Exceeded CO 119 CO 119 208 Benefit Applies to PCP Only CO 24 N52 CO 24 N52 209 Benefit coverage not started CO 26 CO 26 210 Member NOT enrolled on DOS CO 177 CO 177 211 Provider is not part of network required for benefit CO 38 Page 7 of 27
Bill Type does NOT match 214 Benefit CO A1 MA30 CO 16 MA30 215 216 217 218 219 Member's share of cost different than entered value CO 178 CO 178 No COB entered with a Secondary Enrollment CO 22 MA04 CO 22 Member has an active restriction on enrollment CO 177 CO 177 Member lost eligibility during date span CO 239 CO 239 Provider overlap of global days period CO 97 N19 CO 97 N19 221 Assistant surgeon not allowed CO 54 CO 54 222 Co-Surgeon not allowed CO 54 CO 54 223 Team surgeon not allowed CO 54 CO 54 Benefit Requires Manual 224 Review CO 16 N225 CO 16 N225 225 Contract Term Requires Manual Review CO 16 N225 CO 16 N225 226 Reimburse Member On Non- Par Contract CO A1 N220 230 Multiple surgeries detected CO 59 CO 59 Override Reimburse Member 235 option CO A1 N220 236 Benefit requires either authorization or referral document CO 197 CO 197 COB will be manually 237 distributed on claim lines CO A1 N220 238 Invalid Medicare Action Code CO 136 CO 16 N245 Page 8 of 27
240 Not all standard reserve days have been used CO A1 N220 241 Exceeds number of covered days in a standard benefit period CO 119 CO 119 242 243 244 245 246 247 Service days submitted exceed standard reserve days CO 119 CO 119 Service days submitted exceed extended reserve days CO 119 CO 119 No claim in std benefit period before use of reserve days CO 107 CO 107 Multiple surgeries - claim submitted missing modifier 51 CO 4 CO 4 Member has Preexisting Condition on DOS for Diagnosis CO 51 CO 51 Preexisting Condition May Exist CO 51 CO 51 248 Member policy is Suspended CO A1 N220 CO 31 252 253 254 255 Pend claim if COB is 0 on secondary enrollment claim CO 22 MA04 CO 16 MA04 Internal enrollment and COB amounts entered CO 23 N155 CO 16 MA04 Medicare non-allowed claim submitted hard copy CO 22 N4 CO 22 Medicare non-allowed claim submitted electronically CO A1 N220 CO 22 N598 Page 9 of 27
256 Invalid Medicare COB Amount CO 22 CO 22 257 Visit units have been traded CO A1 N220 258 Emergency Claim does not match Emergency Benefit CO A1 N220 CO 40 Pursue and pay for Professional claims with no 260 information CO 22 CO 22 261 Pursue and pay for Institutional claims with no information CO 22 CO 22 262 Claim requires Pursue and Pay CO 22 CO 22 Auto Accident indicated on 263 claim - Pursue and Pay CO 20 CO 20 264 265 266 267 268 269 271 Auto Insurance information on claim - Pursue and Pay CO 20 CO 20 Other Insurance indicated on claim - Pursue and Pay CO 22 CO 22 Other Insurance information unknown - Pursue and Pay CO 22 CO 22 COB: LOI No Response or Outdated - Pursue and Pay CO 16 MA04 CO 16 MA04 COB Coverage Not for Claim Type CO 22 CO 22 Benefit requires authorization and has associated penalty CO 197 CO 197 Benefit Restriction Group Validation Failed CO B5 CO B5 Page 10 of 27
272 Member does not have coverage code required on benefit CO B5 N30 CO B5 N30 Duplicate Claim 300 (member/dos) CO 18 OA 18 Invalid or missing admission 301 date CO 125 MA40 CO 16 MA40 302 Attending Physician Required for Inpatient Claims CO 125 N253 CO 16 N253 303 Claim Total Mismatch CO 125 M54 CO 16 M54 304 Invalid Bill Type CO 16 MA30 CO 16 MA30 Primary diagnosis code is 305 required CO A1 M76 CO 16 M76 306 Discharge status is required for inpatient and SNF claims CO 125 N50 CO 16 N50 307 Duplicate Claim (Same Provider/Member/DOS) CO 18 M86 OA 18 308 Invalid Admit Hour (0-- 23) CO 125 N46 CO 16 N46 309 Invalid Discharge Hour (0 -- 23) CO 125 N317 CO 16 N317 311 312 313 314 Submission Window Exceeded for Claim Start Date CO 29 CO 29 Invalid coinsurance days for 11x bill type CO 125 MA34 CO 16 MA34 Covered days do not match accommodation revcode days CO 125 M53 CO 16 M53 Non-covered days less than leave of absence days CO 125 M53 CO 16 M53 315 Invalid Lifetime Reserve Days CO 125 M53 CO 16 M53 Page 11 of 27
316 Admit type does not match admit source CO 125 MA42 CO 16 MA42 Other agency may be 317 responsible for payment CO A1 N193 CO 22 N598 Invalid coinsurance days for 318 21x bill type CO 125 MA34 CO 16 MA34 319 Coinsurance days exceeds covered days CO 125 MA34 CO 16 MA34 Coinsurance days missing 320 associated value codes CO 125 M49 CO 16 M49 Covered days and coinsured days exceed maximum for 321 hospital CO 125 MA34 CO 16 MA34 Covered days exceeds 322 maximum for hospital CO 119 MA32 CO 119 N130 323 324 325 326 327 Covered days and coinsured days exceed maximum for SNF CO 119 MA34 CO 119 N130 Covered days exceed maximum for SNF CO 119 M53 CO 119 M53 Non-covered days exceed statement-covered period CO 125 M53 CO 16 M53 Life reserve days exceed maximum CO 35 M53 CO 35 Admit type requires 450 revcode CO 125 M50 CO 16 M50 328 Admission Source Required CO 125 MA42 CO 16 MA42 Invalid patient status for bill 329 type CO 125 MA43 CO 16 MA43 330 Invalid diagnosis code for benefit CO 167 N569 CO 11 N657 332 DRG mismatch with DRGActive product CO A8 CO A8 Page 12 of 27
333 DRGActive Product Error CO A1 N220 CO A1 N220 334 APCActive component error CO 147 HIPPS RUGS DOS is not within assessment modifier time 335 period CO 125 MA31 CO 16 MA31 336 HIPPS RUGS billed amount should not have a dollar amount CO 125 M54 CO 16 M54 337 338 339 340 341 342 HIPPS RUG rate code requires rehabilitation therapy CO 16 M50 CO 16 M50 HIPPS RUGS length of stay not in sync with accommodation day CO 16 M53 CO 16 M53 APC claim has lines that have rolled up into other lines CO B15 CO B15 HH PPS too many SCICs detected. Manual review is required. CO 133 HH PPS No Rap present for claim CO A1 N220 HH PPS Therapy threshold not met. Fallback used for payment CO A1 N220 343 No matching RAP claim lines CO A1 N220 No previously processed RAP 344 claim lines CO A1 N220 345 Detail line REV code not 0023 CO 16 M50 CO 16 M50 346 Unable to locate fee schedule CO 147 Page 13 of 27
347 RAP has more than one detail line CO A1 N220 348 Line #1 date must equal episode start date CO A1 N220 CO 16 M52 349 LUPA episode is not 60 days CO 16 MA31 CO 16 MA31 Valid admit date required for 350 HHPPS CO 125 MA40 CO 16 MA40 351 Credit for prior RAP payment CO 23 CO 23 Previous RAP payment 352 exceeds claim amount CO 23 CO 23 353 Detail line REV code not 0022 CO 16 M50 CO 16 M50 Base fee not found or equals 354 $0.00 CO 147 355 SNF provider missing SNF per diem amount CO 147 356 Overlapping RAP episodes CO 18 OA 18 HHPPS RAP From and Through 357 DOS not equal CO 16 MA31 CO 16 MA31 358 Micro-Dyn PricerActive component error CO A8 CO A8 Micro-Dyn DRGActive 359 component error CO A8 CO A8 DRG is NOT in the selected 360 DRG Group CO A8 CO A8 361 No end date on claim configured for Micro-Dyn PricerActive CO 125 M59 CO 16 M59 Provider ID NOT valid for 362 MicroDyn PricerActive CO 125 N290 CO 16 N290 Page 14 of 27
364 365 Pricing requires provider DRG values-values are not defined CO 147 N208 Pricing requires DRG valuesvalues are not defined CO A8 CO A8 366 Workers Compensation Claim CO 19 CO 19 Contract term requires 367 authorization CO 197 CO 197 Contract Term Restriction 376 Group Validation Failed CO 16 N180 CO 16 N190 377 EOB not received on Claim CO 22 MA04 CO 22 378 No COB Amount on claim CO 22 MA04 CO 22 Member has privacy payee 379 defined for claim CO A1 N220 380 Other Carrier Paid exceeds Other Carrier Allowed CO 23 CO 23 382 Global payment allocated CO 97 M15 CO 97 M15 384 Potential Other Accident CO A1 N220 CO 22 N598 Gender is invalid for Medical 400 Policy CO 7 CO 7 401 Age is invalid for Medical Policy CO 6 CO 6 402 Maximum units exceeded for Medical Policy CO 119 CO 119 403 Diagnoses invalid for Medical Policy CO 11 CO 11 404 Place of Service invalid for Medical Policy CO 5 CO 5 405 Provider Type is invalid for Medical Policy CO 170 CO 170 406 Physician specialty is invalid for Medical Policy CO 172 N95 CO 8 N95 Page 15 of 27
407 Modifier(s) is invalid for Medical Policy CO 4 CO 4 408 Line failed for Medical Policy Rule CO A1 N220 CO 50 N130 409 501 Line failed for Medical Policy rule overridden on Cert CO A1 N220 CO 50 N130 Entry in Local Use field is required CO A1 N220 502 Duplicate Line on Same Claim CO 18 OA 18 503 Invalid CPT Modifier CO 182 CO 182 504 Invalid CPT/HCPCS code CO A1 M20 CO 181 M20 505 Invalid Revenue Code CO 16 M50 CO 16 M50 Modifier Required for 506 CPT/HCPCS CO 4 CO 4 507 Revenue Code Requires HCPCS CO 125 M20 CO 16 M20 511 Invalid From DOS CO 125 M52 CO 16 M52 512 Invalid Thru DOS CO 125 M59 CO 16 M59 Invalid Revenue Code for Bill 514 Type CO 16 M50 CO 16 M50 515 Invalid HCPCS for Revenue Code CO 199 CO 199 516 Surgical Procedure Requires HCPCS CO 125 M20 CO 16 M20 518 Admit type required for 11x bill type CO 125 MA41 CO 16 MA41 Duplicate Claim Line (Same 519 Member/DOS/CPT(Rev)) CO 18 OA 18 521 Procedure code not found or invalid for date of service CO 181 CO 181 Page 16 of 27
522 Duplicate Claim Line (Same Provider/Member/DOS/CPT(R ev)) CO 18 OA 18 523 Diagnosis code does not exist CO 16 M64 CO 16 M64 524 525 526 CPT codes billed include bundled and unbundled CPTs CO 97 M15 CO 97 M15 Diagnosis code is not valid on DOS CO 146 CO 146 Claim submitted out of sequence CO A1 N220 CO B5 530 Insufficient units for date span CO 16 M53 CO 16 M53 531 532 533 Duplicate Mem/DOS/Service code/pay To/Modifier CO 18 OA 18 Duplicate Mem/DOS/Service code/pay To/Rendering Phys/Modifie CO 18 OA 18 Duplicate Mem/DOS/Pay To/Rendering Phys/Charges CO 18 OA 18 534 Duplicate Modifer Exact Match CO 18 OA 18 CPT Code is Bundled wth 536 Other CPT CO 236 M15 CO 236 538 539 Diagnosis Pointer Required on Srvce Line for Diagnosis Codes CO 16 M64 CO 16 M64 Date of Service beyond Paid Thru Date and Grace Period Date CO 27 N30 CO 27 N30 Page 17 of 27
540 Date of Service is during the Grace Period CO 27 N30 CO 27 N30 Claim Line Submission 542 Window Overlap CO 45 601 Prior Authorization Is Closed CO 197 CO 197 Prior Authorization Is Awaiting 602 Medical Review CO 197 CO 197 603 Prior Authorization Is Pended CO 197 CO 197 604 Prior Authorization Is Denied CO 39 M62 CO 39 Prior authorization number 606 NOT found CO 15 CO 15 607 Prior authorization not for same member CO 15 N54 CO 15 608 Prior authorization not for same provider CO 15 CO 15 609 Prior authorization dates do not match claim CO 15 N351 CO 15 610 611 612 613 Prior Authorization Services do not match claim CO 15 N54 CO 15 Prior authorization has no available units CO 198 CO 198 Prior authorization has insufficient units remaining CO 198 CO 198 Claim Requires Manual Processing CO 133 614 No Available Bed Days on Auth CO 198 CO 198 Page 18 of 27
Claim Line Exceeds Available 615 Bed Days-Partial Units Paid CO 198 CO 198 616 Authorization Line Denied CO 39 CO 39 617 618 619 620 621 622 623 624 625 627 628 Provider's specialty does not match authorized specialty CO 172 N95 CO 170 N95 Provider's group does not match authorized group CO 15 N54 CO 15 Provider's network does not match authorized network CO 38 Provider's participation status does not match authorized CO B7 CO B7 Provider type does not match authorized provider type CO 170 CO 170 Place of Service does not Match Authorized CO 15 N54 CO 15 NDC Code Mismatch on Authorization CO 15 N54 CO 15 Authorization Line Manually Denied CO 39 N54 CO 198 N54 Authorization Line Manually Pended CO 197 CO 197 Allow manual setting of Benefit Preference on Auth CO 133 Claim Line date span crosses calendar/policy year CO 125 N74 CO 16 N74 Page 19 of 27
629 Multi unit Claim Line date span crosses calendar/policy year CO 125 N74 CO 16 N74 632 No Determining Claims Found CO 107 CO 107 633 634 638 641 642 643 644 645 646 647 A determining claim matched - using that benefit preference CO 133 Benefit preference selection forced manually through the UI CO 45 Allow override of contract amt based on benefit preference CO 45 Multiple Instances of Revenue Code 0024 on Claim CO A1 N220 CO 16 M50 Invalid Bill Type found on an IRF claim CO 125 MA30 CO 16 MA30 Multiple or invalid HIPPS codes found on IRF claim CO A1 N220 Charges were not set to zero on an IRF claim CO 125 M54 CO 16 M54 Non-covered days reported with code 74 not accurate CO 125 M53 CO 16 M53 Days must equal payable days + loa days + non-covered days CO 125 M53 CO 16 M53 Claim line has a revenue code of 018X and a HCPCS/Rate CO 125 M20 CO 16 M20 Page 20 of 27
648 649 Claim line units not = days reflected with span code 74 CO 125 M53 CO 16 M53 Sum of units with accommodation codes not equal covered days CO 125 M53 CO 16 M53 650 Charges not equal to daily room rate multiplied by days CO 125 M54 CO 16 M54 651 Claim is an interrupted stay CO A1 N30 Length of stay on claim was less than average length of 652 stay CO 150 CO 150 653 Claim is a short stay CO 150 CO 150 Benefits were exhausted 654 during stay CO 119 N30 CO 119 655 Benefits were exhausted prior to admission CO 119 N30 CO 119 656 Claim is an Interim IRF bill CO 135 Error encountered with Micro- Dyn IRF Priceractive 657 component CO A8 CO A8 658 Invalid claim data found on IRF claim CO A1 N220 662 Contract for service location on claim was not found CO 5 M77 CO 5 M77 700 Invalid Dental Procedure CO 125 M51 CO 16 M51 701 Invalid Dental Warranty Period CO A1 N220 CO 119 N130 702 Invalid CDT code on DOS CO 181 CO 181 703 Invalid tooth number CO 125 N39 CO 16 N39 704 Invalid tooth surface for tooth CO 125 N75 CO 16 N75 Page 21 of 27
705 Submitted code requires billing package CO A1 N220 706 CDT already billed on this date by same provider CO 18 OA 18 707 CDT already billed on this date CO 18 OA 18 708 Invalid Tooth for CDT CO 125 N37 CO 16 N37 CDT requires tooth surface 709 min/max count CO 125 N75 CO 16 N75 710 Service Line has been Downcoded CO 97 N22 CO 97 N22 711 Replace obsolete code CO 181 CO 181 Inclusively priced ITS claim 750 cannot be priced CO A1 N220 800 Claim Check: Rebundling CO 97 N20 CO 97 N20 Claim Check: Incidental 801 Services CO 97 N19 CO 97 N19 802 Claim Check: Mutually Exclusive Service CO 97 N20 CO 97 N20 803 Claim Check: Assistant Surgeon CO 54 CO 54 804 Claim Check: Age Conflict CO 6 CO 6 805 Claim Check: Age Replacement CO 6 N22 CO 6 N22 806 Claim Check: Gender Conflict CO 7 CO 7 Claim Check: Gender 807 Replacement CO 7 N22 CO 7 N22 808 Claim Check: Cosmetic Surgery CO 50 N30 CO 50 N383 Claim Check: Unlisted 809 Procedure CO A1 N220 CO 16 N350 810 Claim Check: Experimental Procedure CO 55 CO 55 Page 22 of 27
811 Claim Check: Pre-Op Audit CO 97 M15 CO 97 M15 812 Claim Check: Post-Op Audit CO 97 M15 CO 97 M15 813 Claim Check: Medical Visit CO 97 N20 CO 97 N20 Claim Check: New Visit E&M 814 Audit CO B16 N30 CO B16 815 Claim Check: Intensity of Service Audit CO 150 CO 150 Claim Check: Diag to 816 Procedure Audit CO 11 M76 CO 11 Claim Check: Cross Provider 817 Total Audit CO B20 CO B20 818 Claim Check: TPL Audit CO 20 MA04 CO 20 819 Claim Check: Claim Stop audit CO 97 CO 97 821 Claim Check: General Error CO A1 N220 CO A1 N220 Claim Check: Exceeded 40 822 Claim Lines CO A1 N220 824 Claim Check: Future Date of Service Error CO 110 CO 110 825 828 Claim Check: Add modifier 26 or TC to global billed claim CO B20 CO B20 Invalid procedure code/modifier combination. CO 4 CO 4 837 ClaimCheck: Medically Unlikely CO A1 N362 CO 96 N362 911 Invalid For Male CO 7 CO 7 912 Invalid For Female CO 7 CO 7 913 Manual Pend of Claim CO 133 914 Electronic Claim has COB CO 22 MA04 CO 22 N598 Claim has been manually 915 denied CO A1 N220 CO A1 N220 Page 23 of 27
Claim does not have any 916 service lines CO 16 M51 CO 16 M51 917 Manually-altered pay amount CO A1 N220 CO A1 N220 918 Connect requires claim review CO 107 CO 107 919 920 921 922 Contract Price on Service Line has been Manually Overridden CO A1 N220 Contract Price on Service Line Manually Overridden to Zero CO A1 N220 Claim manually priced with no balance checks or validation CO A1 N220 CO A1 N220 Manual Contract Price exceeds Billed Amount on Service Line CO A1 N220 930 ITS: Alim Initialization Failed CO A1 N220 931 ITS: Alim L2 Call Failed CO A1 N220 932 ITS: Alim L3 Call Failed CO A1 N220 933 ITS: Alim 90 Call Failed CO A1 N220 934 ITS: Alim C2 Call Failed CO A1 N220 935 ITS: Alim C3 Call Failed CO A1 N220 938 Unable to Adjust ITS Claim CO A1 N220 Duplicate SCCF number found 939 during SF import CO A1 N220 940 Status change caused by SF Message Code CO A1 N220 941 Previous claim not found for adjustment CO 129 CO 16 N152 942 Previous claim for adjustment not finalized CO 129 CO 16 N152 Page 24 of 27
943 Claim reversal for adjustment failed CO A1 N220 CO 16 N152 944 Multiple enrollments found for member name but no DOB match CO 177 CO 177 945 946 947 948 949 Multiple enrollments found for member name and DOB CO 177 CO 177 SF submitted under incorrect prefix, DF message code 1083 CO A1 N220 Local contracted provider found for claim CO A1 N220 Multiple local contracted providers found for claim CO A1 N220 Must pay provider for assigned ITS Medicare claim CO A1 N220 951 ITS - Initial Global Fee on Claim CO A1 N220 ITS - Follow-up Global Fee on 952 Claim CO A1 N220 953 ITS - Late Follow-up Global Fee on Claim CO A1 N220 954 SF indicates Host plan pays provider for ECRP claim CO A1 N220 955 SF indicates Host plan pays subscriber for ECRP claim CO A1 N220 1000 History group not effective on dates of service CO CO B7 N570 1007 Validate Min/Max Work Units for Occupation Code CO 177 CO 177 1008 Claim Line not eligible for COPC Processing CO 177 CO 177 Page 25 of 27
Operating Physician 1009 Information Required CO 125 N58 CO 16 N58 OP Surgery NO PA - DENY 2000 Entire Claim CO 197 CO 197 3000 Servicing provider does not match member CO 24 CO 24 6000 R&B Denied - DENY Entire Claim CO 16 N180 CO 16 N180 6005 HOSPICE_SQL CO A1 N143 CO 96 N143 6007 Member not AD Waiver on dos CO 177 CO 177 Member is not MRDD Waiver 6008 on dos CO 177 CO 177 6009 Patient Resource Mismatch CO 125 N58 CO 16 N58 6010 Member is not TBI Waiver CO 177 CO 177 6011 Member is not IMD CO 177 CO 177 6012 UB Form Denial CO 125 N34 CO 16 N34 6018 Medically Unlikely Edit CO A1 N435 CO 96 N435 6110 Claim payment exceeds monetary allotment PR 147 N381 PR 147 N381 8001 CCI Incidental CO 236 CO 236 8002 CCI Mutually Exclusive CO 236 CO 236 Line has been modified to add 8004 or remove modifier 51 CO 59 CO 59 8005 8006 8007 8008 Add-on code cannot be billed without the primary procedure CO B15 CO B15 Procedure not appropriate for gender CO 7 CO 7 Co-surgeon is not covered for this procedure CO 54 CO 54 Co-surgeon not covered without documentation CO 16 N29 CO 16 N29 Page 26 of 27
8009 Surgical team is not covered for this procedure CO 54 CO 54 Surgical team not covered 8010 without documentation CO 16 N29 CO 16 N29 Patient has received prior care 8011 from this provider CO B16 CO B16 8012 The number of units does not match the number of days billed CO A1 N345 CO 16 N345 8013 Units does not match the number of site specific modifiers CO A1 M53 CO 16 M53 8280 Invalid procedure-modifier combination per BMS policy CO 4 CO 4 Page 27 of 27