This code set is an external code set maintained by X12 https://x12.org/codes *******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES. List may not be complete or current******* **************POSITIONS 1 and 2 OF ANSI CODE*************** CO = Contractual Obligations — this group code should be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write-off for the provider and are not billed to the patient CR = Corrections and Reversals — this group code should be used for correcting a prior claim. It applies when there is a change to a previously adjudicated claim OA = Other Adjustments — this group code should be used when no other group code applies to the adjustment PI = Payer Initiated Reductions — this group code should be used when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments) PR = Patient Responsibility — this group should be used when the adjustment represents an amount that should be billed to the patient or insured. This group would typically be used for deductible and copay adjustments ***********Claim Adjustment Reason Codes*************** ***********POSITIONS 3 through 5 of ANSI CODE********** 1 = Deductible Amount 2 = Coinsurance Amount 3 = Co-pay Amount 4 = The procedure code is inconsistent with the modifier used or a required modifier is missing 5 = The procedure code/bill type is inconsistent with the place of service 6 = The procedure code is inconsistent with the patient's age 7 = The procedure code is inconsistent with the patient's gender 8 = The procedure code is inconsistent with the provider type 9 = The diagnosis is inconsistent with the patient's age 10 = The diagnosis is inconsistent with the patient's gender 11 = The diagnosis is inconsistent with the procedure 12 = The diagnosis is inconsistent with the provider type 13 = The date of death precedes the date of service 14 = The date of birth follows the date of service 15 = Claim/service adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider 16 = Claim/service lacks information which is needed for adjudication 17 = Claim/service adjusted because requested information was not provided or was insufficient/incomplete 18 = Duplicate claim/service 19 = Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier 20 = Claim denied because this injury/illness is covered by the liability carrier 21 = Claim denied because this injury/illness is the liability of the no-fault carrier 22 = Claim adjusted because this care may be covered by another payer per coordination of benefits 23 = Claim adjusted because charges have been paid by another payer 24 = Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan 25 = Payment denied. Your Stop loss deductible has not been met 26 = Expenses incurred prior to coverage 27 = Expenses incurred after coverage terminated 28 = Coverage not in effect at the time the service was provided 29 = The time limit for filing has expired 30 = Claim/service adjusted because the patient hasnot met the required eligibility, spend down, waiting, or residency requirements 31 = Claim denied as patient cannot be identified as our insured 32 = Our records indicate that this dependent is not an eligible dependent as defined 33 = Claim denied. Insured has no dependent coverage 34 = Claim denied. Insured has no coverage for newborns 35 = Benefit maximum has been reached 36 = Balance does not exceed copayment amount 37 = Balance does not exceed deductible amount 38 = Services not provided or authorized by designated (network) providers 39 = Services denied at the time authorization/pre-certification was requested 40 = Charges do not meet qualifications for emergency/urgent care 41 = Discount agreed to in Preferred Provider contract 42 = Charges exceed our fee schedule or maximum allowable amount 43 = Gramm-Rudman reduction 44 = Prompt-pay discount 45 = Charges exceed your contracted/legislated fee arrangement 46 = This (these) service(s) is(are) not covered 47 = This (these) diagnosis(es) is(are) not covered, missing, or are invalid 48 = This (these) procedure(s) is(are) not covered 49 = These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam 50 = These are non-covered services because this is not deemed a 'medical necessity' by the payer 51 = These are non-covered services because this a pre-existing condition 52 = The referring/prescribing/ rendering provider is not eligible to refer/prescribe/order/perform the service billed 53 = Services by an immediate relative or a member of the same household are not covered 54 = Multiple physicians/assistants are not covered in this case 55 = Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer 56 = Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by payer 57 = Claim/service adjusted because the payer deems the information submitted does not support this level of service, this many services, this length of service, or this dosage 58 = Claim/service adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service 59 = Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules 60 = Charges for outpatient services with the proximity to inpatient services are not covered 61 = Charges adjusted as penalty for failure to obtain second surgical opinion 62 = Claim/service denied/reduced for absence of, or exceeded, precertification/authorization 63 = Correction to a prior claim. INACTIVE 64 = Denial reversed per Medical Review. INACTIVE 65 = Procedure code was incorrect. This payment reflects the correct code. INACTIVE 66 = Blood Deductible 67 = Lifetime reserve days. INACTIVE 68 = DRG weight. INACTIVE 69 = Day outlier amount 70 = Cost outlier amount 71 = Primary Payer amount 72 = Coinsurance day. INACTIVE 73 = Administrative days. INACTIVE 74 = Indirect Medical Education Adjustment 75 = Direct Medical Education Adjustment 76 = Disproportionate Share Adjustment 77 = Covered days. INACTIVE 78 = Non-covered days/room charge adjustment 79 = Cost report days. INACTIVE 80 = Outlier days. INACTIVE 81 = Discharges. INACTIVE 82 = PIP days. INACTIVE 83 = Total visits. INACTIVE 84 = Capital adjustments. INACTIVE 85 = Interest amount. INACTIVE 86 = Statutory adjustment. INACTIVE 87 = Transfer amounts 88 = Adjustment amount represents collection against receivable created in prior overpayment 89 = Professional fees removed from charges 90 = Ingredient cost adjustment 91 = Dispensing fee adjustment 92 = Claim paid in full. INACTIVE 93 = No claim level adjustment. INACTIVE 94 = Process in excess of charges 95 = Benefits adjusted. Plan procedures not followed 96 = Non-covered charges 97 = Payment is included in allowance for another service/procedure 98 = The hospital must file the Medicare claim for this inpatient non-physician service. INACTIVE 99 = Medicare Secondary Payer Adjustment Amount. INACTIVE 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 (i.e., Senior citizen discount) 104 = Managed care withholding 105 = Tax withholding 106 = Patient payment option/election not in effect 107 = Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim 108 = Claim/service reduced because rent/purchase guidelines were not met 109 = Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor 110 = Billing date predates service date 111 = Not covered unless the provider accepts assignment 112 = Claim/service adjusted as not furnished directly to the patient and/or not documented 113 = Claim denied because service/procedure was provided outside the United States or as a result of war 114 = Procedure/Product not approved by the Food and Drug Administration 115 = Claim/service adjusted as procedure postponed or canceled 116 = Claim/service denied. The advance indemnification notice signed by the patient did not comply with requirements 117 = Claim/service adjusted because transportation is only covered to the closest facility that can provide the necessary care 118 = Charges reduced for ESRD network support 119 = Benefit maximum for this time period has been reached 120 = Patient is covered by a managed care plan. INACTIVE 121 = Indemnification adjustment 122 = Psychiatric reduction 123 = Payer refund due to overpayment. INACTIVE 124 = Payer refund amount — not our patient. INACTIVE 125 = Claim/service adjusted due to a submission/billing error(s) 126 = Deductible — major Medical 127 = Coinsurance — major Medical 128 = Newborn's services are covered in the mother's allowance 129 = Claim denied — prior processing information appears incorrect 130 = Paper claim submission fee 131 = Claim specific negotiated discount 132 = Prearranged demonstration project adjustment 133 = The disposition of this claim/service is pending further review 134 = Technical fees removed from charges 135 = Claim denied. Interim bills cannot be processed 136 = Claim adjusted. Plan procedures of a prior payer were not followed 137 = Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes 138 = Claim/service denied. Appeal procedures not followed, or time limits not met 139 = Contracted funding agreement — subscriber is employed by the provider of services 140 = Patient/Insured health identification number and name do not match 141 = Claim adjustment because the claim spans eligible and ineligible periods of coverage 142 = Claim adjusted by the monthly Medicaid patient liability amount A0 = Patient refund amount A1 = Claim denied charges A2 = Contractual adjustment A3 = Medicare Secondary Payer liability met. INACTIVE A4 = Medicare Claim PPS Capital Day Outlier Amount A5 = Medicare Claim PPS Capital Cost Outlier Amount A6 = Prior hospitalization or 30-day transfer requirement not met A7 = Presumptive Payment Adjustment A8 = Claim denied; ungroupable DRG B1 = Non-covered visits B2 = Covered visits. INACTIVE B3 = Covered charges. INACTIVE B4 = Late filing penalty B5 = Claim/service adjusted because coverage/program guidelines were not met or were exceeded B6 = This service/procedure is adjusted when performed/billed by this type of provider, by this type of facility, or by a provider of this specialty B7 = This provider was not certified/eligible to be paid for this procedure/service on this date of service B8 = Claim/service not covered/reduced because alternative services were available and should have been utilized B9 = Services not covered because the 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 patients' medical records B13 = Previously paid. Payment for this claim/service may have been provided in a previous payment B14 = Claim/service denied because only one visit or consultation per physician per day is covered B15 = Claim/service adjusted because this procedure/service is not paid separately B16 = Claim/service adjusted because 'New Patient' qualifications were not met B17 = Claim/service 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 B18 = Claim/service denied because this procedure code/modifier was invalid on the date of service or claim submission B19 = Claim/service adjusted because of the finding of a Review Organization. INACTIVE B20 = Charges adjusted because procedure/service was partially or fully furnished by another provider B21 = The charges were reduced because the service/care was partially furnished by another physician. INACTIVE B22 = This claim/service is adjusted based on the diagnosis B23 = Claim/service denied because this provider has failed an aspect of a proficiency testing program W1 = Workers Compensation State Fee Schedule Adjustment