Claim Adjustment Reason Codes

Deductible Amount

Start: 01/01/1995

Coinsurance Amount

Start: 01/01/1995

Co-payment Amount

Start: 01/01/1995

The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 03/01/2020

The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 03/01/2018

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The date of death precedes the date of service.

Start: 01/01/1995

The date of birth follows the date of service.

Start: 01/01/1995

Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. 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.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 03/01/2018

Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)

Start: 01/01/1995 | Last Modified: 06/02/2013

This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

Start: 01/01/1995 | Last Modified: 09/30/2007

This injury/illness is covered by the liability carrier.

Start: 01/01/1995 | Last Modified: 09/30/2007

This injury/illness is the liability of the no-fault carrier.

Start: 01/01/1995 | Last Modified: 09/30/2007

This care may be covered by another payer per coordination of benefits.

Start: 01/01/1995 | Last Modified: 09/30/2007

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

Start: 01/01/1995 | Last Modified: 09/30/2012

Charges are covered under a capitation agreement/managed care plan.

Start: 01/01/1995 | Last Modified: 09/30/2007

Expenses incurred prior to coverage.

Start: 01/01/1995

Expenses incurred after coverage terminated.

Start: 01/01/1995

The time limit for filing has expired.

Start: 01/01/1995

Patient cannot be identified as our insured.

Start: 01/01/1995 | Last Modified: 09/30/2007

Our records indicate the patient is not an eligible dependent.

Start: 01/01/1995 | Last Modified: 03/01/2018

Insured has no dependent coverage.

Start: 01/01/1995 | Last Modified: 09/30/2007

Insured has no coverage for newborns.

Start: 01/01/1995 | Last Modified: 09/30/2007

Lifetime benefit maximum has been reached.

Start: 01/01/1995 | Last Modified: 10/31/2002

Services denied at the time authorization/pre-certification was requested.

Start: 01/01/1995

Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Prompt-pay discount.

Start: 01/01/1995

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)

Start: 01/01/1995 | Last Modified: 07/01/2017

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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Services by an immediate relative or a member of the same household are not covered.

Start: 01/01/1995

Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

Start: 01/01/1995 | Last Modified: 06/01/2008

Adjusted for failure to obtain second surgical opinion

Start: 01/01/1995 | Last Modified: 03/01/2017

Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.

Blood Deductible.

Start: 01/01/1995

Day outlier amount.

Start: 01/01/1995

Cost outlier - Adjustment to compensate for additional costs.

Start: 01/01/1995 | Last Modified: 06/30/2001

Indirect Medical Education Adjustment.

Start: 01/01/1995

Direct Medical Education Adjustment.

Start: 01/01/1995

Disproportionate Share Adjustment.

Start: 01/01/1995

Non-Covered days/Room charge adjustment.

Start: 01/01/1995

Patient Interest Adjustment (Use Only Group code PR)

Start: 01/01/1995 | Last Modified: 07/09/2007

Notes: Only use when the payment of interest is the responsibility of the patient.

Professional fees removed from charges.

Start: 01/01/1995

Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.

Start: 01/01/1995 | Last Modified: 07/01/2017

Dispensing fee adjustment.

Start: 01/01/1995

Processed in Excess of charges.

Start: 01/01/1995

Plan procedures not followed.

Start: 01/01/1995 | Last Modified: 09/30/2007

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.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Payment made to patient/insured/responsible party.

Start: 01/01/1995 | Last Modified: 05/01/2018

Predetermination: anticipated payment upon completion of services or claim adjudication.

Start: 01/01/1995 | Last Modified: 02/28/1999

Major Medical Adjustment.

Start: 01/01/1995

Provider promotional discount (e.g., Senior citizen discount).

Start: 01/01/1995 | Last Modified: 06/30/2001

Managed care withholding.

Start: 01/01/1995

Tax withholding.

Start: 01/01/1995

Patient payment option/election not in effect.

Start: 01/01/1995

The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

Start: 01/01/1995 | Last Modified: 01/29/2012

Billing date predates service date.

Start: 01/01/1995

Not covered unless the provider accepts assignment.

Start: 01/01/1995

Service not furnished directly to the patient and/or not documented.

Start: 01/01/1995 | Last Modified: 09/30/2007

Procedure/product not approved by the Food and Drug Administration.

Start: 01/01/1995

Procedure postponed, canceled, or delayed.

Start: 01/01/1995 | Last Modified: 09/30/2007

The advance indemnification notice signed by the patient did not comply with requirements.

Start: 01/01/1995 | Last Modified: 09/30/2007

Transportation is only covered to the closest facility that can provide the necessary care.

Start: 01/01/1995 | Last Modified: 09/30/2007

ESRD network support adjustment.

Start: 01/01/1995 | Last Modified: 09/30/2007

Benefit maximum for this time period or occurrence has been reached.

Start: 01/01/1995 | Last Modified: 02/29/2004

Indemnification adjustment - compensation for outstanding member responsibility.

Start: 01/01/1995 | Last Modified: 09/30/2007

Psychiatric reduction.

Start: 01/01/1995

Newborn's services are covered in the mother's Allowance.

Start: 02/28/1997

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.)

Start: 02/28/1997 | Last Modified: 01/30/2011

Claim submission fee.

Start: 02/28/1997 | Last Modified: 06/30/2001

Claim specific negotiated discount.

Start: 02/28/1997

Prearranged demonstration project adjustment.

Start: 02/28/1997

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).

Start: 07/01/2014 | Last Modified: 07/01/2017

Technical fees removed from charges.

Start: 10/31/1998

Interim bills cannot be processed.

Start: 10/31/1998 | Last Modified: 09/30/2007

Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

Start: 10/31/1998 | Last Modified: 07/01/2013

Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

Start: 02/28/1999 | Last Modified: 09/30/2007

Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.

Start: 06/30/1999 | Last Modified: 05/01/2018

Patient/Insured health identification number and name do not match.

Start: 06/30/1999

Monthly Medicaid patient liability amount.

Start: 06/30/2000 | Last Modified: 09/30/2007

Portion of payment deferred.

Start: 02/28/2001

Incentive adjustment, e.g. preferred product/service.

Start: 06/30/2001

Diagnosis was invalid for the date(s) of service reported.

Start: 06/30/2002 | Last Modified: 09/30/2007

Provider contracted/negotiated rate expired or not on file.

Start: 06/30/2002

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.)

Start: 06/30/2002 | Last Modified: 09/20/2009

Lifetime benefit maximum has been reached for this service/benefit category.

Start: 10/31/2002

Payer deems the information submitted does not support this level of service.

Start: 10/31/2002 | Last Modified: 09/30/2007

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Start: 10/31/2002 | Last Modified: 01/27/2008

Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 10/31/2002 | Last Modified: 07/01/2017

Payer deems the information submitted does not support this dosage.

Start: 10/31/2002 | Last Modified: 09/30/2007

Payer deems the information submitted does not support this day's supply.

Start: 10/31/2002 | Last Modified: 09/30/2007

Patient refused the service/procedure.

Start: 06/30/2003 | Last Modified: 09/30/2007

Service/procedure was provided as a result of an act of war.

Start: 09/30/2003 | Last Modified: 09/30/2007

Service/procedure was provided outside of the United States.

Start: 09/30/2003 | Last Modified: 09/30/2007

Service/procedure was provided as a result of terrorism.

Start: 09/30/2003 | Last Modified: 09/30/2007

Injury/illness was the result of an activity that is a benefit exclusion.

Start: 09/30/2003 | Last Modified: 09/30/2007

Provider performance bonus

Start: 02/29/2004

Attachment/other documentation referenced on the claim was not received.

Start: 06/30/2004 | Last Modified: 06/02/2013

Attachment/other documentation referenced on the claim was not received in a timely fashion.

Start: 06/30/2004 | Last Modified: 06/02/2013

These services were submitted after this payers responsibility for processing claims under this plan ended.

Start: 02/28/2005

This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

Alternate benefit has been provided.

Start: 06/30/2005 | Last Modified: 09/30/2007

Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

Service/equipment was not prescribed by a physician.

Start: 06/30/2005 | Last Modified: 07/01/2013

Service was not prescribed prior to delivery.

Start: 06/30/2005 | Last Modified: 09/30/2007

Prescription is incomplete.

Start: 06/30/2005 | Last Modified: 09/30/2007

Prescription is not current.

Start: 06/30/2005 | Last Modified: 09/30/2007

Patient has not met the required eligibility requirements.

Start: 06/30/2005 | Last Modified: 09/30/2007

Patient has not met the required spend down requirements.

Start: 06/30/2005 | Last Modified: 09/30/2007

Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 03/01/2017

Patient has not met the required residency requirements.

Start: 06/30/2005 | Last Modified: 09/30/2007

Procedure code was invalid on the date of service.

Start: 06/30/2005 | Last Modified: 09/30/2007

Procedure modifier was invalid on the date of service.

Start: 06/30/2005 | Last Modified: 09/30/2007

The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 | Last Modified: 07/01/2017

Level of care change adjustment.

Start: 06/30/2005 | Last Modified: 09/30/2007

Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)

Start: 06/30/2005 | Last Modified: 01/25/2009

This product/procedure is only covered when used according to FDA recommendations.

Start: 06/30/2005

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

Start: 06/30/2005

Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

Start: 10/31/2005

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 non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.

Start: 10/31/2005 | Last Modified: 07/01/2017

Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.

Start: 02/28/2006 | Last Modified: 01/27/2008

Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.

Start: 02/28/2006 | Last Modified: 09/30/2007

Refund issued to an erroneous priority payer for this claim/service.

Start: 02/28/2006 | Last Modified: 09/30/2007

Precertification/authorization/notification/pre-treatment absent.

Start: 10/31/2006 | Last Modified: 05/01/2018

Precertification/notification/authorization/pre-treatment exceeded.

Start: 10/31/2006 | Last Modified: 05/01/2018

Revenue code and Procedure code do not match.

Start: 10/31/2006

Expenses incurred during lapse in coverage

Start: 10/31/2006

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.)

Start: 10/31/2006 | Last Modified: 09/28/2014

Notes: Not for use by Workers' Compensation payers; use code P3 instead.

Non-covered personal comfort or convenience services.

Start: 02/28/2007 | Last Modified: 09/30/2007

Discontinued or reduced service.

Start: 02/28/2007 | Last Modified: 09/30/2007

This service/equipment/drug is not covered under the patient's current benefit plan

Start: 02/28/2007

Pharmacy discount card processing fee

Start: 07/09/2007

National Provider Identifier - missing.

Start: 07/09/2007 | Last Modified: 09/30/2007

National Provider identifier - Invalid format

Start: 07/09/2007 | Last Modified: 06/01/2008

National Provider Identifier - Not matched.

Start: 07/09/2007 | Last Modified: 09/30/2007

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)

Start: 07/09/2007 | Last Modified: 07/01/2013

Payment adjusted because pre-certification/authorization not received in a timely fashion

Start: 07/09/2007

National Drug Codes (NDC) not eligible for rebate, are not covered.

Start: 07/09/2007

Administrative surcharges are not covered

Start: 11/05/2007

Non-compliance with the physician self referral prohibition legislation or payer policy.

Start: 01/27/2008

Based on subrogation of a third party settlement

Start: 01/27/2008

Based on the findings of a review organization

Start: 01/27/2008

Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).

Start: 01/27/2008 | Last Modified: 07/01/2017

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.

Start: 06/01/2008 | Last Modified: 07/01/2017

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.

Start: 06/01/2008

Patient identification compromised by identity theft. Identity verification required for processing this and future claims.

Start: 06/01/2008

Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)

Start: 06/01/2008

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.)

Start: 09/21/2008 | Last Modified: 07/01/2013

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.)

Start: 09/21/2008 | Last Modified: 09/20/2009

Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication

Start: 09/21/2008

Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)

Start: 01/25/2009 | Last Modified: 07/01/2017

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.

Start: 07/01/2009 | Last Modified: 07/01/2017

Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.

Start: 11/01/2009 | Last Modified: 07/01/2017

Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.

Start: 01/24/2010

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.)

Start: 01/24/2010

Sales Tax

Start: 06/06/2010

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.

Start: 01/30/2011 | Last Modified: 07/01/2013

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.)

Start: 06/05/2011

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)

Start: 03/01/2012 | Last Modified: 07/01/2013

Claim spans eligible and ineligible periods of coverage. Rebill separate claims.

Start: 03/01/2012 | Last Modified: 01/29/2012

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.

Start: 06/03/2012 | Last Modified: 07/01/2017

Low Income Subsidy (LIS) Co-payment Amount

Start: 06/03/2012

Services not provided by network/primary care providers.

Start: 06/03/2012 | Last Modified: 06/02/2013

Notes: This code replaces deactivated code 38

Services not authorized by network/primary care providers.

Start: 06/03/2012 | Last Modified: 06/02/2013

Notes: This code replaces deactivated code 38

Provider performance program withhold.

Start: 09/30/2012

This non-payable code is for required reporting only.

Start: 09/30/2012

Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Start: 09/30/2012

Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).

Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Start: 09/30/2012

Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).

This claim has been identified as a readmission. (Use only with Group Code CO)

Start: 09/30/2012

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).

Start: 09/30/2012 | Last Modified: 06/01/2014

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).

Start: 09/30/2012 | Last Modified: 06/01/2014

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).

Start: 09/30/2012 | Last Modified: 06/02/2013

Sequestration - reduction in federal payment

Start: 06/02/2013 | Last Modified: 11/01/2013

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.

Start: 06/02/2013 | Last Modified: 11/01/2017

Notes: Use CARC 290 if the claim was forwarded.

Service not payable per managed care contract.

Start: 06/02/2013

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)

Start: 11/01/2013 | Last Modified: 06/01/2014

Notes: To be used after the first month of the grace period.

Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.

Start: 11/01/2013

Additional payment for Dental/Vision service utilization.

Start: 01/26/2014

Processed under Medicaid ACA Enhanced Fee Schedule

Start: 01/26/2014

The procedure or service is inconsistent with the patient's history.

Start: 06/01/2014

Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.

Start: 11/01/2014 | Last Modified: 07/01/2017

Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.

Start: 11/01/2014 | Last Modified: 07/01/2017

Adjustment for postage cost. Usage: To be used for pharmaceuticals only.

Start: 11/01/2014 | Last Modified: 07/01/2017

Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.

Start: 11/01/2014 | Last Modified: 07/01/2017

Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.

Start: 11/01/2014 | Last Modified: 07/01/2017

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.)

Start: 11/01/2014 | Last Modified: 04/01/2015

The Claim spans two calendar years. Please resubmit one claim per calendar year.

Start: 11/01/2014

Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 03/01/2015 | Last Modified: 07/01/2017

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.

Start: 07/01/2015 | Last Modified: 11/01/2017

Notes: Use CARC 291 if the claim was forwarded.

Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)

Start: 11/01/2015 | Last Modified: 03/01/2018

Coverage/program guidelines were not met.

Start: 11/01/2015

Coverage/program guidelines were exceeded.

Start: 11/01/2015

Fee/Service not payable per patient Care Coordination arrangement.

Start: 11/01/2015

Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)

Start: 11/01/2015

Services denied by the prior payer(s) are not covered by this payer.

Start: 11/01/2015

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)

Start: 11/01/2015

Notes: To be used during 31 day SHOP grace period.

Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 07/01/2016 | Last Modified: 07/01/2017

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.

Start: 11/01/2016 | Last Modified: 07/01/2017

Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.

Start: 03/01/2017 | Last Modified: 11/01/2017

Notes: Use CARC 292 if the claim was forwarded.

Deductible waived per contractual agreement. Use only with Group Code CO.

Start: 07/01/2017

The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 07/01/2017

Attending provider is not eligible to provide direction of care.

Start: 11/01/2017

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.

Start: 11/01/2017

Appeal procedures not followed

Start: 11/01/2017

Appeal time limits not met

Start: 11/01/2017

Referral exceeded

Start: 11/01/2017

Referral absent

Start: 11/01/2017

Services considered under the dental and medical plans, benefits not available.

Start: 11/01/2017

Notes: Also see CARCs 254, 270 and 280.

Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.

Start: 11/01/2017

Notes: Use CARC 254 if the claim was not forwarded.

Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.

Start: 11/01/2017

Notes: Use CARC 270 if the claim was not forwarded.

Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.

Start: 11/01/2017

Notes: Use CARC 280 if the claim was not forwarded.

Payment made to employer.

Start: 05/01/2018

Payment made to attorney.

Start: 11/01/2017

Pharmacy Direct/Indirect Remuneration (DIR)

Start: 03/01/2018

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.

Start: 07/01/2018

Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.

Start: 03/01/2019

Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.

Start: 03/01/2019

The billing provider is not eligible to receive payment for the service billed.

Start: 07/01/2019

Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.

Start: 07/01/2019

Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.

Start: 07/01/2019

Precertification/notification/authorization/pre-treatment time limit has expired.

Start: 11/01/2020

Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)

Start: 07/01/2021

Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.

Start: 03/01/2022

Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration.

Start: 03/01/2022

Type of bill is inconsistent with the patient status. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 11/01/2023

Patient refund amount.

Start: 01/01/1995

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.) Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available.

Start: 01/01/1995 | Last Modified: 11/16/2022

Medicare Claim PPS Capital Cost Outlier Amount.

Start: 01/01/1995

Prior hospitalization or 30 day transfer requirement not met.

Start: 01/01/1995

Ungroupable DRG.

Start: 01/01/1995 | Last Modified: 09/30/2007

Non-covered visits.

Start: 01/01/1995

Late filing penalty.

Start: 01/01/1995

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.

Start: 01/01/1995 | Last Modified: 07/01/2017

Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

Patient is enrolled in a Hospice.

Start: 01/01/1995 | Last Modified: 09/30/2007

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.

Start: 01/01/1995

The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

Start: 01/01/1995

Services not documented in patient's medical records.

Start: 01/01/1995 | Last Modified: 03/01/2018

Previously paid. Payment for this claim/service may have been provided in a previous payment.

Start: 01/01/1995

Only one visit or consultation per physician per day is covered.

Start: 01/01/1995 | Last Modified: 09/30/2007

This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 07/01/2017

'New Patient' qualifications were not met.

Start: 01/01/1995 | Last Modified: 09/30/2007

Procedure/service was partially or fully furnished by another provider.

Start: 01/01/1995 | Last Modified: 09/30/2007

This payment is adjusted based on the diagnosis.

Start: 01/01/1995 | Last Modified: 02/28/2001

Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.

Start: 01/01/1995 | Last Modified: 09/30/2007

State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code 162

Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code 191

Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)

Start: 11/01/2013

Notes: This code replaces deactivated code 201

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code 214

Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code 217

Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code 218

The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code 220

Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code 221

No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code 230

Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code 244

The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)

Start: 11/01/2013

Notes: This code replaces deactivated code 255

Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code W1

Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code W2

The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code W3

Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.

Start: 11/01/2013

Notes: This code replaces deactivated code W4

Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)

Start: 11/01/2013

Notes: This code replaces deactivated code W5

Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code W6

Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code W7

Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code W8

Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.

Start: 11/01/2013

Notes: This code replaces deactivated code W9

Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2013 | Last Modified: 03/01/2018

Notes: This code replaces deactivated code Y1

Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2013 | Last Modified: 03/01/2018

Notes: This code replaces deactivated code Y2

Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2013 | Last Modified: 07/01/2017

Notes: This code replaces deactivated code Y3

Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. Use only with Group Code CO.

Start: 11/01/2017

Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).

Start: 11/01/2017

Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).

Start: 11/01/2017

Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2017

Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2017

Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.

Start: 11/01/2017

Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.

Start: 11/01/2020

Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.

Start: 11/01/2020

Payment adjusted due to Apportionment.

Start: 08/01/2022