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0900196654, 02/19/2020, 124.50
0900196654, 02/19/2020, 124.44
0900196654, 02/19/2020, 199.14
0900196654, 02/19/2020, 49.80
0900196654, 02/19/2020, 124.44
0900196654, 02/19/2020, 0.00
0900196654, 02/19/2020, 199.14
, 02/26/2020, 0.00
0900198096, 02/26/2020, 149.34
895162388, 02/27/2020, 177.31
2020022610500103, 02/26/2020, 0.00
2020022610500103, 02/26/2020, 0.00
2020022610500103, 02/26/2020, 0.00
C20055N09001380, 02/24/2020, 0.00
C20055E11419180, 02/26/2020, 161.81
895158255, 02/26/2020, 304.90
895158255, 02/26/2020, 360.25
895158255, 02/26/2020, 144.45
895158255, 02/26/2020, 177.31
895158255, 02/26/2020, 848.09
T20045E09468870, 02/18/2020, 164.94
T20045E09468870, 02/18/2020, 189.84
T20055E09625620, 02/25/2020, 319.88
T20055E09625620, 02/25/2020, 298.68
C20048N08516060, 02/17/2020, 0.00
C20048N08516060, 02/17/2020, 0.00
T20041E09370280, 02/11/2020, 294.19
C20041E10392610, 02/12/2020, 15.56
C20041E10392610, 02/12/2020, 30.30
3154976, 02/24/2020, 195.16
3152202, 02/24/2020, 174.24
3152202, 02/24/2020, 124.44
3152202, 02/24/2020, 49.79
3152202, 02/24/2020, 174.24
3151090, 02/18/2020, 24.89
3150425, 02/17/2020, 97.56
3147693, 02/17/2020, 149.34
3143855, 02/10/2020, 224.04
895137337, 02/19/2020, 177.31
895137337, 02/19/2020, 118.27
895149694, 02/24/2020, 421.64
T20041E09370280, 02/11/2020, 224.04
T20041E09370280, 02/11/2020, 239.64
C20041E10392610, 02/12/2020, 190.60
T20038E09271240, 02/10/2020, 149.34
T20036E09239540, 02/06/2020, 124.44
C20034E09874220, 02/05/2020, 637.11
T20031E09140210, 02/03/2020, 174.24
C20034N07531310, 02/03/2020, 0.00
1506177445, 02/07/2020, 148.49
C19315E05553750, 11/13/2019, 308.28
T19340E08058150, 12/09/2019, 228.79
1504434791, 01/31/2020, 304.92
1499758378, 01/14/2020, 227.42
C20006E07955030, 01/08/2020, 92.97
1TR49666881, 01/06/2020, 0.00
1TR49666881, 01/06/2020, 468.73
1TR49666881, 01/06/2020, 118.34
000420012959666, 01/17/2020, 181.34
3143855, 02/10/2020, 174.24
3143855, 02/10/2020, 224.04
3143855, 02/10/2020, 124.44
3143855, 02/10/2020, 224.04
3143855, 02/10/2020, 124.44
3143855, 02/10/2020, 224.04
3138184, 01/31/2020, 6.86
3138184, 01/31/2020, 224.04
3138184, 01/31/2020, 224.04
3134364, 01/27/2020, 228.79
3134364, 01/27/2020, 149.34
3130353, 01/21/2020, 253.69
3130353, 01/21/2020, 248.94
3130353, 01/21/2020, 174.30
3129329, 01/13/2020, 102.27
3126582, 01/13/2020, 199.14
3126582, 01/13/2020, 174.24
3126582, 01/13/2020, 174.23
3123152, 01/06/2020, 154.09
3106600, 12/14/2019, 253.69
3106600, 12/14/2019, 278.59
3106600, 12/14/2019, 253.69
3106600, 12/14/2019, 228.79
3106600, 12/14/2019, 228.79
3106600, 12/14/2019, 253.69
3112529, 12/21/2019, 378.19
3112529, 12/21/2019, 203.89
3116026, 12/23/2019, 228.79
3116026, 12/23/2019, 228.79
3118425, 12/28/2019, 253.69
3118425, 12/28/2019, 124.44
3105593, 12/09/2019, 300.01
3103206, 12/09/2019, 203.89
3103206, 12/09/2019, 203.89
T19324E07740920, 11/21/2019, 253.69
000420012801180, 11/25/2019, 375.06
T19315E07559480, 11/12/2019, 228.79
C19315E05553750, 11/13/2019, 308.28
T19312E07517050, 11/12/2019, 228.79
T19312E07517050, 11/12/2019, 178.99
000420012734766, 11/01/2019, 229.77
T19305E07399170, 11/04/2019, 228.79
T19305E07399170, 11/04/2019, 382.65
T19305E07399170, 11/04/2019, 178.99
3088232, 11/11/2019, 154.09
3088232, 11/11/2019, 203.89
3088232, 11/11/2019, 228.79
3088232, 11/11/2019, 253.69
3088232, 11/11/2019, 203.89
3088232, 11/11/2019, 178.99
3088232, 11/11/2019, 278.59
3088232, 11/11/2019, 203.89
3088232, 11/11/2019, 203.89
3088232, 11/11/2019, 6.86
3088232, 11/11/2019, 6.86
3088232, 11/11/2019, 203.89
3088232, 11/11/2019, 228.79
3088232, 11/11/2019, 228.79
3088232, 11/11/2019, 253.69
3088232, 11/11/2019, 178.99
3088232, 11/11/2019, 0.00
3091648, 11/11/2019, 360.72
3091648, 11/11/2019, 300.01
3092922, 11/18/2019, 228.79
3092922, 11/18/2019, 228.79
3092922, 01/18/2020, 228.79
3096710, 11/25/2019, 203.89
3099094, 11/27/2019, 278.59
3066506, 10/07/2019, 253.69
3066506, 10/07/2019, 228.79
3066506, 10/07/2019, 203.89
Date of Service
Clear
Procedure Code
99443
96116
H2011
T1016
96130
96132
99367
90791
99231
99239
DNB
99255
99254
99253
99251
99252
99233
99215
99214
99213
99212
99211
99205
99204
99203
99202
99201
96146
96139
96138
96137
96136
96130
90870
90853
90849
90847
90846
90838
90837
90836
90834
90833
90832
90785
SELF PAY
99238
99232
90792
99308
99305
99222
Value
Status
Patient Responsability
Paid
Denied
In Progress
Not Started
Reason
CO - 133, The disposition of the claim/service is pending further review. (Use only with Group Code OA). This change effective 11/01/2014: The disposition of this service line is pending further review
28, DENY: COVERAGE NOT IN EFFECT WHEN SERVICE PROVIDED
OA-258, Other Adjustment - Claim/Service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
IH031 - PCFSC, DENIED: PRINCIPAL DIAGNOSIS INAPPROPRIATELY CODED - PRICED PER FEE SCHEDULE RATE
PR - 2, Coinsurance Amount.
CO - 204, This service/equipment/drug is not covered under the patient's current benefit plan
ce, ADD’L INFO REQ’D BY MEDICARE. CLAIM WILL BE REPROCESSED ONCE INFO REC’D
TF-30, DENY - FILING LIMIT EXCEEDED - MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
PI-16, Payer initiated reductions - Claim/service lacks information or has submission/billing error(s).
CO-31, Contractual Obligation - Patient cannot be identified as our insured.
MA18 , Alert: The claim information is also being forwarded to the patient's supplemental insurer.Send any questions regarding supplemental benefits to them.
d1-RD, ICD 10 DIAGNOSIS CODES THAT REQUIRE ADDITIONAL CHARACTERS - DENY: REVENUE CODE AND DIAGNOSIS ARE NOT COMPATIBLE PLEASE RESUBMIT
PR-96, Patient Responsibility - 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.
92-SP-SC, PAID ACCORDING TO CONTRACT PROCESSING GUIDELINES - PAY: AMOUNT APPLIED TO SPENDDOWN - INFO: KS SpendDown Member - Coordinate Benefits using SpendDown Process
PR-1, Patient Responsibility - Deductible Amount
CO-22, Contractual Obligation. - This care may be covered by another payer per coordination of benefits.
CO-300, Contractual Obligation - Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patients Behavioral Health Plan for further consideration.
CO-PR-2-253, Coinsurance Amount - Sequestration - reduction in federal payment
PR-26, Expenses incurred prior to coverage.
PM-92, PM: PAY: PCP IS NOT EFFECTIVE AT THE TIME OF SERVICE - 92: PAID ACCORDING TO CONTRACT STATE PROCESSING GUIDELINES
18-5L, 18: DENY: DUPLICATE CLAIM SERVICE - 5L: DENY: BENEFIT LIMIT FOR SERVICES WITHOUT AN AUTHORIZATION HAS BEEN MET
OA-PR-23-27, PR: Patient Responsibility - OA: Other Adjustments - 23: The impact of prior payer(s) adjudication including payments and/or adjustments. - 27: Expenses incurred after coverage terminated.
OA-23, OA: Other Adjustments - 23: The impact of prior payer(s) adjudication including payments and/or adjustments.
CE006, UNBUNDLED PROCEDURE
PR-31, Patient cannot be identified as our insured.
CO-96, Contractual Obligation - 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.
CO-109, Contractual Obligation - Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
CO-58, Contractual Obligations - 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.
PR-227, Patient Responsibility - 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.)
CO-234, Contractual Obligation - 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.)
4R 3O, OCE86 MANIFESTATION CODE NOT ALLOWED AS PRINCIPAL DIAGNOSIS CODE-MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
RF-3O, DENY: CPT & LOCATION ARE NOT COMPATIBLE, PLEASE RESUBMIT-MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
yq-3O, DUPLICATE CLAIMS OR MULTIPLE PROVIDERS BILLING SAME/SIMILAR CODE(S)-MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
151, Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
LO, DENY: CPT HCPC REV CODE & LOCATION ARE NOT COMPATIBLE, PLEASE RESUBMIT.
46, DENY: SERVICE NOT COVERED, PROVIDER RESPONSIBILITY, DO NOT BILL MEMBER
Pr-27, Expenses incurred after coverage terminated.
MX, PAY: MAXIMUM ALLOWABLE HAS BEEN PAID BY PRIME INS
97, The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
CO-16, Contractual Obligation - Claim/service lacks information or has submission/billing error(s).
B13, Previously paid. Payment for this claim/service may have been provided in a previous payment.
xD, CMS MUE QUANTITY LIMIT EXCEEDED
CO-253, Contractual Obligation. Amount for which the provider is financially liable. The patient may not be billed for this amount. - Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CO-45, Contractual Obligation. Amount for which the provider is financially liable. The patient may not be billed for this amount.- Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
OA, Other Adjustment
CO-146, Diagnosis was invalid for the date(s) of service reported.
18-Aa, DENY: DUPLICATE CLAIM SERVICE - PAY: SERVICE PROCESSED THRU COB AUTOMATION
83 3O, 83 DENY - DUPLICATE OF PREVIOUS SUBMITTED CLAIM 3O MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
CO-197, Contractual Obligation - Precertification/authorization/notification/pre-treatment absent
CO-29, Contractual Obligation - The time limit for filing has expired.
29, The time limit for filing has expired
CO, Contractual Obligation
92, PAID ACCORDING TO CONTRACT PROCESSING GUIDELINES
ys, REIMBURSEMENT INCLUDED IN ANOTHER CODE PER CMS/AMA/MEDICAL GUIDELINES
SR, PAYMENT REDUCTION DUE TO THE MEDICARE SEQUESTRATION
mg, NO AUTHORIZATION ON FILE FOR ASSOCIATED INPATIENT ADMISSION.
x9, PROCEDURE CODE PAIRS INCIDENTAL, MUTUALLY EXCLUSIVE OR UNBUNDLED
SR 3O, SR PAYMENT REDUCTION DUE TO THE MEDICARE SEQUESTRATION 3O MEDICARE CROSSOVER CLAIM FORWARDED TO MEDICAID FOR SECONDARY PAYMENT
cD Aa, cD NO ACTION NEEDED WILL BE REPROCESSED AFTER STATE REV OF IIH PILOT Aa PAY: SERVICE PROCESSED THRU COB AUTOMATION
d1 RD, d1 ICD 10 DIAGNOSIS CODES THAT REQUIRE ADDITIONAL CHARACTERS RD DENY: REVENUE CODE AND DIAGNOSIS ARE NOT COMPATIBLE PLEASE RESUBMIT
d1 RM, d1 ICD 10 DIAGNOSIS CODES THAT REQUIRE ADDITIONAL CHARACTERS RM DENY: INAPPROPRIATE TAXONOMY SUBMITTED FOR SERVICES PROVIDED
ys Aa , ys REIMBURSEMENT INCLUDED IN ANOTHER CODE PER CMS/AMA/MEDICAL GUIDELINES Aa PAY: SERVICE PROCESSED THRU COB AUTOMATION
92 Aa, 92 PAID ACCORDING TO CONTRACT PROCESSING GUIDELINES Aa PAY: SERVICE PROCESSED THRU COB AUTOMATION
18 ZL, 18 DENY: DUPLICATE CLAIM SERVICE ZL DENY: SERVICE IS LIMITED TO ONE PER DAY
ce Aa, Aa PAY: SERVICE PROCESSED THRU COB AUTOMATION ce ADD’L INFO REQ’D BY MEDICARE. CLAIM WILL BE REPROCESSED ONCE INFO REC’D
PR-27 OA-23, 27=Expenses incurred after coverage terminated. 23=The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
PR-27 OA-23 CO-45, 27=Expenses incurred after coverage terminated. 23=The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) 45=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)
PI-B13, PI=Payor Initiated Reductions B13=Previously paid. Payment for this claim/service may have been provided in a previous payment.
B11, B11=The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
PR 1, GROUP CODE(S): PR=Patient Responsibility CLAIM ADJUSTMENT REASON CODE(S): 1=Deductible Amount
B11, B11=The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
272, Coverage/program guidelines were not met.
253 , Sequestration - reduction in federal payment.
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. 253 Sequestration - reduction in federal payment.
, GROUP CODE(S): PR=Patient Responsibility OA=Other Adjustments CLAIM ADJUSTMENT REASON CODE(S): 27=Expenses incurred after coverage terminated. 23=The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
N619, Coverage terminated for non-payment of premium
PR-27 OA-23, 27=Expenses incurred after coverage terminated. 23=The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
CO-97, 97= 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. CO=Contractual Obligations.
45, 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.
151, Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
FFS DENY, PRECERTIFICATION, PREAUTHORIZATION
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