Adjustment Reason Code T-MSIS Analytic Files (TAF) Claims Research Identifiable Files (RIFs), CCW Codebook, V1, November 2019 001 = Deductible Amount 002 = Coinsurance Amount 003 = Co-payment Amount 004 = The procedure code is inconsistent with the modifier used or a required modifier is missing 005 = The procedure code/type of bill is inconsistent with the place of service 006 = The procedure/revenue code is inconsistent with the patient's age 007 = The procedure/revenue code is inconsistent with the patient's gender 008 = The procedure code is inconsistent with the provider type/specialty (taxonomy) 009 = The diagnosis is inconsistent with the patient's age 010 = The diagnosis is inconsistent with the patient's gender 011 = The diagnosis is inconsistent with the procedure 012 = The diagnosis is inconsistent with the provider type 013 = The date of death precedes the date of service 014 = The date of birth follows the date of service 015 = The authorization number is missing, invalid, or does not apply to the billed services or provider 016 = Claim/service lacks information or has 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.) 017 = Requested information was not provided or was insufficient/incomplete 018 = Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) 019 = This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier 020 = This injury/illness is covered by the liability carrier 021 = This injury/illness is the liability of the no-fault carrier 022 = This care may be covered by another payer per coordination of benefits 023 = The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) 024 = Charges are covered under a capitation agreement/managed care plan 025 = Payment denied. Your Stop loss deductible has not been met 026 = Expenses incurred prior to coverage 027 = Expenses incurred after coverage terminated 028 = Coverage not in effect at the time the service was provided. Notes: Redundant to codes 026&027. 029 = The time limit for filing has expired 030 = Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements 031 = Patient cannot be identified as our insured 032 = Our records indicate the patient is not an eligible dependent 033 = Insured has no dependent coverage 034 = Insured has no coverage for newborns 035 = Lifetime benefit maximum has been reached 036 = Balance does not exceed co-payment amount 037 = Balance does not exceed deductible 039 = Services denied at the time authorization/pre-certification was requested 040 = Charges do not meet qualifications for emergent/urgent care 041 = Discount agreed to in Preferred Provider contract 042 = Charges exceed our fee schedule or maximum allowable amount 043 = Gramm-Rudman reduction 044 = Prompt-pay discount 045 = Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) 046 = This (these) service(s) is (are) not covered. (No longer used: 10/16/2003, Use code 096). 047 = This (these) diagnosis(es) is (are) not covered, missing, or are invalid 048 = This (these) procedure(s) is (are) not covered. (No longer used: 10/16/2003, Use code 096). 049 = 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 050 = These are non-covered services because this is not deemed a 'medical necessity' by the payer 051 = These are non-covered services because this is a pre-existing condition 052 = The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed 053 = Services by an immediate relative or a member of the same household are not covered 054 = Multiple physicians/assistants are not covered in this case 055 = Procedure/treatment/drug is deemed experimental/investigational by the payer 056 = Procedure/treatment has not been deemed 'proven to be effective' by the payer 057 = 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. (No longer used: 06/30/2007, Split into codes 150, 151, 152, 153 and 154). 058 = Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service 059 = Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) 060 = Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services 061 = Adjusted for failure to obtain second surgical opinion 062 = Payment denied/reduced for absence of, or exceeded, precertification/authorization 063 = Correction to a prior claim 064 = Denial reversed per Medical Review 065 = Procedure code was incorrect. This payment reflects the correct code. 066 = Blood Deductible 067 = Lifetime reserve days. (Handled in QTY, QTY01=LA) 068 = DRG weight. (Handled in CLP12) 069 = Day outlier amount 070 = Cost outlier - Adjustment to compensate for additional costs 071 = Primary Payer amount. (No longer used: 06/30/2000, Use code 023). 072 = Coinsurance day. (Handled in QTY, QTY01=CD) 073 = Administrative days 074 = Indirect Medical Education Adjustment 075 = Direct Medical Education Adjustment 076 = Disproportionate Share Adjustment 077 = Covered days. (Handled in QTY, QTY01=CA) 078 = Non-Covered days/Room charge adjustment 079 = Cost Report days. (Handled in MIA15) 080 = Outlier days. (Handled in QTY, QTY01=OU) 081 = Discharges 082 = PIP days 083 = Total visits 084 = Capital Adjustment. (Handled in MIA) 085 = Patient Interest Adjustment (Use Only Group code PR). Notes: Only use when the payment of interest is the responsibility of the patient. 086 = Statutory Adjustment. Notes: Duplicative of code 045. 087 = Transfer amount 088 = Adjustment amount represents collection against receivable created in prior overpayment 089 = Professional fees removed from charges 090 = Ingredient cost adjustment. Usage: To be used for pharmaceuticals only. 091 = Dispensing fee adjustment 092 = Claim Paid in full 093 = No Claim level Adjustments. Notes: As of 004010, CAS at the claim level is optional. 094 = Processed in Excess of charges 095 = Plan procedures not followed 096 = 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). 097 = The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. 098 = The hospital must file the Medicare claim for this inpatient non-physician service 099 = Medicare Secondary Payer Adjustment Amount 100 = Payment made to patient/insured/responsible party 101 = Predetermination: anticipated payment upon completion of services or claim adjudication 102 = Major Medical Adjustment 103 = Provider promotional discount (e.g., Senior citizen discount). 104 = Managed care withholding 105 = Tax withholding 106 = Patient payment option/election not in effect. 107 = The related or qualifying claim/service was not identified on this claim. 108 = Rent/purchase guidelines were not met 109 = Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor 110 = Billing date predates service date 112 = Service not furnished directly to the patient and/or not documented 117 = Transportation is only covered to the closest facility that can provide the necessary care 118 = ESRD network support adjustment 119 = Benefit maximum for this time period or occurrence has been reached 121 = Indemnification adjustment - compensation for outstanding member responsibility 123 = Payer refund due to overpayment 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.) 126 = Deductible -- Major Medical. (No longer used: 04/01/2008, Use Group Code PR and code 1). 127 = Coinsurance -- Major Medical. (No longer used: 04/01/2008, Use Group Code PR and code 2). 128 = Newborn's services are covered in the mother's Allowance 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.) 130 = Claim submission fee 131 = Claim specific negotiated discount 132 = Prearranged demonstration project adjustment 133 = The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). 135 = Interim bills cannot be processed 136 = Failure to follow prior payer's coverage rules. (Use only with Group Code OA) 137 = Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. 139 = Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO. 140 = Patient/Insured health identification number and name do not match 141 = Claim spans eligible and ineligible periods of coverage 142 = Monthly Medicaid patient liability amount 143 = Portion of payment deferred 144 = Incentive adjustment, e.g. preferred product/service 145 = Premium payment withholding. (No longer used: 04/01/2008, Use Group Code CO and code 45). 146 = Diagnosis was invalid for the date(s) of service reported 147 = Provider contracted/negotiated rate expired or not on file 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.) 149 = Lifetime benefit maximum has been reached for this service/benefit category 150 = Payer deems the information submitted does not support this level of service 151 = Payment adjusted because the payer deems the information submitted does not support this many/frequency of services 152 = Payer deems the information submitted does not support this length of service 153 = Payer deems the information submitted does not support this dosage 154 = Payer deems the information submitted does not support this day's supply 159 = Service/procedure was provided as a result of terrorism 163 = Attachment/other documentation referenced on the claim was not received 164 = Attachment/other documentation referenced on the claim was not received in a timely fashion 165 = Referral absent or exceeded 166 = These services were submitted after this payers responsibility for processing claims under this plan ended 167 = This (these) diagnosis(es) is (are) not covered 168 = Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan 169 = Alternate benefit has been provided 170 = Payment is denied when performed/billed by this type of provider 171 = Payment is denied when performed/billed by this type of provider in this type of facility. 172 = Payment is adjusted when performed/billed by a provider of this specialty 173 = Service/equipment was not prescribed by a physician 174 = Service was not prescribed prior to delivery 176 = Prescription is not current 177 = Patient has not met the required eligibility requirements 178 = Patient has not met the required spend down requirements 179 = Patient has not met the required waiting requirements. 180 = Patient has not met the required residency requirements 181 = Procedure code was invalid on the date of service 182 = Procedure modifier was invalid on the date of service 183 = The referring provider is not eligible to refer the service billed 184 = The prescribing/ordering provider is not eligible to prescribe/order the service billed 185 = The rendering provider is not eligible to perform the service billed 186 = Level of care change adjustment 187 = Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) 189 = 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service 190 = Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay 192 = Non standard adjustment code from paper remittance. Usage: 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 nonstandard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. 193 = Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. 194 = Anesthesia performed by the operating physician, the assistant surgeon or the attending physician 196 = Claim/service denied based on prior payer's coverage determination. (No longer used: 02/01/2007, Use code 136). 197 = Precertification/authorization/notification/pre-treatment absent 198 = Precertification/notification/authorization/pre-treatment exceeded 199 = Revenue code and Procedure code do not match 200 = Expenses incurred during lapse in coverage 201 = Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) 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.) 202 = Non-covered personal comfort or convenience services 203 = Discontinued or reduced service 204 = This service/equipment/drug is not covered under the patient’s current benefit plan 206 = National Provider Identifier - missing 207 = National Provider identifier - Invalid format 208 = National Provider Identifier - Not matched 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 only with Group code OA) 210 = Payment adjusted because pre-certification/authorization not received in a timely fashion 211 = National Drug Codes (NDC) not eligible for rebate, are not covered. 215 = Based on subrogation of a third party settlement 216 = Based on the findings of a review organization 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). (No longer used: 07/01/2014, Use code P5). 222 = Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. 225 = Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) 226 = 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.) 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.) 231 = Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 232 = Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 233 = Services/charges related to the treatment of a hospital-acquired condition or preventable medical error 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.) 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 or workers compensation state regulations/ fee schedule requirements. 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.) 238 = Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR) 239 = Claim spans eligible and ineligible periods of coverage. Rebill separate claims. 240 = The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 242 = Services not provided by network/primary care providers. Notes: This code replaces deactivated code 038 243 = Services not authorized by network/primary care providers. Notes: This code replaces deactivated code 038 246 = This non-payable code is for required reporting only. 247 = Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. 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. Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). 250 = The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. 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). 251 = The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. 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). 252 = An attachment/other documentation 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). 253 = Sequestration - reduction in federal payment 254 = Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. Notes: Use CARC 290 if the claim was forwarded. 256 = Service not payable per managed care contract. 258 = Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. 259 = Additional payment for Dental/Vision service utilization. 260 = Processed under Medicaid ACA Enhanced Fee Schedule 265 = Adjustment for administrative cost. Usage: To be used for pharmaceuticals only. 266 = Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only. 267 = Claim/service spans multiple months. 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.) 270 = Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration. Notes: Use CARC 291 if the claim was forwarded. 272 = Coverage/program guidelines were not met 273 = Coverage/program guidelines were exceeded 275 = Prior payer's (or payers') patient responsibility (deductible, coinsurance, copayment) not covered. (Use only with Group Code PR) 276 = Services denied by the prior payer(s) are not covered by this payer 279 = Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network. 283 = Attending provider is not eligible to provide direction of care 284 = Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. 285 = Appeal procedures not followed 286 = Appeal time limits not met 288 = Referral absent 289 = Services considered under the dental and medical plans, benefits not available. Notes: Also see CARCs 254, 270 and 280. A0 = Patient refund amount 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.) A2 = Contractual adjustment. (No longer used: 01/01/2008, Use code 45 with Group Code 'CO' or use another appropriate specific adjustment code). A6 = Prior hospitalization or 30 day transfer requirement not met A7 = Presumptive Payment Adjustment A8 = Ungroupable DRG B1 = Non-covered visits B5 = Coverage/program guidelines were not met or were exceeded. (No longer used: 05/01/2016, This code has been replaced by 272 and 273). B7 = This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B8 = Alternative services were available, and should have been utilized B9 = Patient is enrolled in a Hospice 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. B11 = The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. B12 = Services not documented in patient's medical records B13 = Previously paid. Payment for this claim/service may have been provided in a previous payment B14 = Only one visit or consultation per physician per day is covered B15 = This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. B16 = 'New Patient' qualifications were not met B20 = Procedure/service was partially or fully furnished by another provider B22 = This payment is adjusted based on the diagnosis B23 = Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test P14 = The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Notes: This code replaces deactivated code W3