claims-adjudication-codes-and-actions-110416

1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 18 19 20 21 23 24 25 26 27 28 30 31 32 33 35 36 37 38 39 40 41 42 43 44 45 46 47 48 50 51 52 53 54 55 56 57 58

45 92 198 119 29 110 22 204 185 2 59 198 204 18 11 31 140 181 6 9 11 5 208 206 206 119 198 147 46 197 181 181 24 8 198 123 123 125 62 125 125 125 125 18 22 125 22 2 125 125 125 123

Adjusted - Above contract rate Approved Authorized units Exceeded Max Basic Units Exhausted Claim received after billing period Claim submitted before service date Client has other covered insurance (COB) Client not covered by contract Clinician not licensed to provide the service or license has expired Coinsurance Amount Another concurrent service has been approved or waiting to be processed Daily limit exceeded Discontinued Service Duplicate Claim DX code is invalid for service/insurance combination Patient not enrolled on the date of service Incorrect Member – Patient not enrolled on DOS Invalid Service or Service Discontinued Invalid age group and procedure code combination Invalid Diagnosis/Age Combination Invalid PC/DX Combo Missing/incomplete/invalid place of service Missing/incomplete/invalid provider identifier Invalid provider NPI number Invalid rendering/attending provider NPI number Monthly case rate already paid Monthly limit exceeded No rates available Non-billable Service Service is not authorized Service not in contract Service not in provider profile Sub-capitated Provider/Service The procedure code is inconsistent with the provider type/specialty (taxonomy).

Weekly limit exceeded Readju – Audit Payback Readju – Audit Payback Readju – Audit Recoup Readju – Authorization/Treatment Revisions Readju – Billing Days Extended Readju – Billing Terms Revised Readju – Client Manually Matched Readju – Contract Terminated Readju – Duplicate Claims Readju – EOB Required Readju – Other Readju – Other Primary Insurance Readju – Patient Liability Readju – Provider Billing Error Readju – Provider ID Incorrect Readju – Rate Change Overid – Audit Payback

Vaya Health | Claims Adjudication Reason List with AlphaMCS and HIPAA Reason Codes

Finance | Rev. 11.04.2016

59 60 61 62 63 65 66 67 68 69 70 71 72 73 74 75 76 77 78 80 81 82 83 84 85 87 88 89 90 91 92 97 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 123 125 126 127 128 129 130

123 125 62 125 125 18 22 62 125 22 142 125 125 123 123 125 62 125 125 18 22 125 22 2 125 142 11 147 48 199 23 119 125 125 125 5 31 197 22 22 234 8 8 167 23 22 22 133 45 185 78 119 149 23 23 142 2

Overid – Audit Payback Overid – Audit Recoup Overid – Authorization/Treatment Revisions Overid – Billing Terms Revised Overid – Contract Terminated Overid – Duplicate Claims Overid – EOB Required Overid – Missing/incomplete/invalid treatment authorization code Overid – Other Overid – Other Primary Insurance Overid –Patient Liability Overid – Provider Billing Error Overid – Rate Change Revert – Audit Payback Revert – Audit Payback Revert – Audit Recoup Revert – Authorization/Treatment Revisions Revert – Billing Terms Revised Revert – Contract Terminated Revert – Duplicate Claims Revert – EOB Required Revert – Other Revert – Other Primary Insurance Revert – Patient Liability Revert – Provider Billing Error Adjusted Against Co-Insurance Invalid Inpatient/ED DX Code No contract exists or rate is not set up yet Non-Covered Ancillary Services Invalid Revenue Code Excess amount over allowed Medicare copayment Charges are covered under a capitation agreement/managed care plan Loaded from legacy system – No reason available Pended for manual review Pended for COB since patient has no COB on record The procedure code/bill type is inconsistent with the place of service No coverage available for Patient/Service/Provider combo Service is not authorized for the supplied site Revert – Retroactive Medicaid Revert – Medicaid coverage Add-on code cannot be billed by itself The taxonomy code for the billing provider is missing Missing/Incomplete/Invalid attending/rendering taxonomy code Missing/incomplete/invalid diagnosis or condition Adjustment represents the estimated amount the primary payer may have paid Override Medicaid Coverage Override Retroactive Medicaid The disposition of the claim/service is pending further review. (Use only with Group Code OA) Amount exceeded allowable COB amount The rendering provider is not eligible to perform the service billed Non-Covered days/Room charge adjustment Annual frequency exceeded Lifetime frequency exceeded The impact of prior payer(s) adjudication including payments and/or adjustments Amount in excess of prior payer(s) coinsurance Monthly Medicaid patient liability amount Coinsurance amount

Vaya Health | Claims Adjudication Reason List with AlphaMCS and HIPAA Reason Codes

Finance | Rev. 11.04.2016