Quickly find and understand Claim Adjustment Reason Codes (CARCs) used by health insurance payers to explain claim adjustments and denials. Search our comprehensive CARC list by code or keyword to identify adjustment reasons, understand why a claim was reduced or denied, and help your billing team determine the appropriate next steps for resolution.
| CARC # | Claim Adjustment Reason Code Description |
|---|---|
| 1 | Denial code 1 is for Deductible Amount. It means the patient needs to pay a certain amount before insurance coverage kicks in. |
| 2 | Denial code 2 is for coinsurance amount. It refers to the portion of the medical bill that the patient is responsible for paying after their insurance has paid its share. |
| 3 | Denial code 3 is for co-payment amount. It indicates that the patient's insurance claim was denied due to an unpaid or incorrect co-payment. |
| 4 | Denial code 4 means the procedure code doesn't match the modifier used. Check the 835 Healthcare Policy Identification Segment for more information. |
| 5 | Denial code 5 means the procedure code or type of bill doesn't match the place of service. Check the 835 Healthcare Policy Identification Segment for more details. |
| 6 | Denial code 6 means the procedure or revenue code doesn't match the patient's age. Check the 835 Healthcare Policy Identification Segment for more details. |
| 7 | Denial code 7 means the procedure or revenue code doesn't match the patient's gender. Check the 835 Healthcare Policy Identification Segment for more details. |
| 8 | Denial code 8 means the procedure code doesn't match the provider's specialty. Check the 835 Healthcare Policy Identification Segment for more info. |
| 10 | Denial code 10 means the diagnosis doesn't match the patient's gender. Check the 835 Healthcare Policy Identification Segment for more details. |
| 11 | Denial code 11 means the diagnosis doesn't match the procedure. Check the 835 Healthcare Policy Identification Segment for more details. |
| 12 | Denial code 12 means the diagnosis doesn't match the provider type. Check the 835 Healthcare Policy Identification Segment for more details. |
| 13 | Denial code 13 means the date of death comes before the date of service. |
| 14 | Denial code 14 means the patient's date of birth is after the date of service. |
| 16 | Denial code 16 is for claims with missing or incorrect information. A remark code must be provided. Do not use for attachments or documentation. |
| 18 | Denial code 18 is for an exact duplicate claim or service. It is used with Group Code OA, except in cases where state workers’ compensation regulations require CO. |
| 19 | Denial code 19 is when the insurance company denies payment because they believe the injury or illness is related to work and should be covered by Worker's Compensation. |
| 20 | Denial code 20: Injury/illness covered by liability carrier. Understand why your healthcare claim was denied. |
| 21 | Denial code 21: The no-fault carrier is responsible for this injury/illness. |
| 22 | Denial code 22 is when the healthcare service may be covered by another insurance provider due to coordination of benefits. |
| 23 | Denial code 23 is used when a prior payer's decision affects the payment or adjustments made. (Group Code OA) |
| 24 | Denial code 24 means charges are covered under a capitation agreement/managed care plan. |
| 26 | Denial code 26 is when expenses are incurred before insurance coverage starts. |
| 27 | Denial code 27 is when expenses are incurred after coverage has ended, resulting in a claim denial. |
| 29 | Denial code 29 means the healthcare provider missed the deadline for submitting a claim. |
| 31 | Denial code 31 means the patient cannot be recognized as our insured. |
| 32 | Denial code 32 means the patient is not eligible as a dependent according to our records. |
| 33 | Denial code 33 means the insured person does not have coverage for dependents. |
| 34 | Denial code 34: Insured has no coverage for newborns. Understand why insurance claims get denied and how to resolve them. Expert healthcare revenue cycle management advice. |
| 35 | Denial code 35: Lifetime benefit maximum has been reached. Understand why your healthcare claim was denied and how to address it. |
| 39 | Denial code 39 means services were denied when authorization/pre-certification was requested. |
| 40 | Denial code 40 means charges don't qualify as emergent/urgent care. Check the 835 Healthcare Policy Identification Segment for more info. |
| 44 | Denial code 44 is for prompt-pay discount. |
| 45 | Denial code 45 is when the charge for a service exceeds the maximum fee allowed by the payer. This adjustment cannot be the same as previous payments or reductions. |
| 49 | Denial code 49 means the service is not covered because it is a routine/preventive exam or a diagnostic/screening procedure done with a routine/preventive exam. Check the 835 Healthcare Policy Identification Segment for more details. |
| 50 | Denial code 50 means the service is not covered because it's not considered medically necessary by the insurance company. Check the 835 Healthcare Policy Identification Segment for more details. |
| 51 | Denial code 51 means the service is not covered due to a pre-existing condition. Check the 835 Healthcare Policy Identification Segment for more details. |
| 53 | Denial code 53: Services by a relative or household member not covered. Understand why your healthcare claim was denied. |
| 54 | Denial code 54 means that multiple physicians/assistants are not covered in this case. Refer to the 835 Healthcare Policy Identification Segment for more information. |
| 55 | Denial code 55 means the payer considers the procedure/treatment/drug as experimental/investigational. Check the 835 Healthcare Policy Identification Segment for more details. |
| 56 | Denial code 56 means the payer doesn't consider the procedure/treatment effective. Check the 835 Healthcare Policy Identification Segment for more details. |
| 58 | Denial code 58 means the treatment was done in the wrong place. Check the 835 Healthcare Policy Identification Segment for more details. |
| 59 | Denial code 59 is for claims that were processed based on multiple or concurrent procedure rules. It's important to refer to the 835 Healthcare Policy Identification Segment for more information. |
| 60 | Denial code 60 means outpatient services aren't covered when done close to inpatient services. |
| 61 | Denial code 61 is when a claim is rejected because the provider did not obtain a second surgical opinion as required. |
| 66 | Denial code 66 is for Blood Deductible. It means the insurance company won't cover the cost of blood transfusions until the deductible is met. |
| 69 | Denial code 69 is for day outlier amount. |
| 70 | Denial code 70 is a code used by healthcare providers to indicate that an adjustment has been made to compensate for additional costs related to a cost outlier. |
| 74 | Denial code 74 is an Indirect Medical Education Adjustment that can affect healthcare providers' revenue cycle management. |
| 75 | Denial code 75 is a Direct Medical Education Adjustment that can affect healthcare providers' revenue cycle management. |
| 76 | Denial code 76 is for Disproportionate Share Adjustment. It means the healthcare provider's claim for additional payment was denied due to certain eligibility criteria not being met. |
| 78 | Denial code 78 is for non-covered days or room charge adjustments. |
| 85 | Denial code 85 is a Patient Interest Adjustment. It is used with Group code PR. |
| 89 | Denial code 89 is when professional fees are taken out from the charges. |
| 90 | Denial code 90 is for ingredient cost adjustment in healthcare billing. It is used specifically for pharmaceuticals. |
| 91 | Denial code 91 is a dispensing fee adjustment that may affect healthcare providers' revenue cycle management. |
| 94 | Denial code 94 means the claim was processed for more than the allowed charges. |
| 95 | Denial code 95 means the insurance company won't cover the procedure because the proper plan guidelines weren't followed. |
| 96 | Denial code 96 is for non-covered charges. It means that there is missing information in the claim, such as a remark code. Check the 835 Healthcare Policy Identification Segment for more details. |
| 97 | Denial code 97 means the payment for this service is already included in another service that has been processed. Check the @Q4F Maalethrara Daliew idantitiratinn Canmant far mnro cotaila |
| 100 | Denial code 100 is when the payment is made directly to the patient, insured, or responsible party instead of the healthcare provider. |
| 101 | Denial code 101 is for predetermination, which means the payment is expected after services or claim processing. |
| 102 | Denial code 102 is a Major Medical Adjustment that indicates a claim has been denied or adjusted due to a significant medical reason. |
| 103 | Denial code 103 is when a healthcare provider's promotional discount, like a senior citizen discount, is not accepted by the insurance company. |
| 104 | Denial code 104 is when a managed care organization withholds payment for a healthcare service. |
| 105 | Denial code 105 is for tax withholding. Learn why this code may be affecting your healthcare revenue cycle management. |
| 106 | Denial code 106 is when the patient's chosen payment option is not in effect. |
| 107 | Denial code 107 means the claim doesn't have the necessary information to link it to the related service. Check the 835 Healthcare Policy Identification Segment for more details. |
| 108 | Denial code 108 means the guidelines for renting or purchasing were not followed. Check the 835 Healthcare Policy Identification Segment for more information. |
| 109 | Denial code 109 is when the claim or service is not covered by the payer/contractor. You need to send it to the right one. |
| 110 | Denial code 110 is when the billing date is before the service date. |
| 111 | Denial code 111 is when a service is not covered unless the provider accepts assignment. |
| 112 | Denial code 112 is when the service was not provided directly to the patient and/or not properly documented. |
| 114 | Denial code 114 is when a procedure or product is not approved by the FDA. |
| 115 | Denial code 115 means that a medical procedure was postponed, canceled, or delayed. Find out why and how to resolve it for proper reimbursement. |
| 116 | Denial code 116 is when the patient's advance indemnification notice doesn't meet the necessary requirements. |
| 117 | Denial code 117 means transportation is only covered to the closest facility that can provide the necessary care. |
| 118 | Denial code 118 is for ESRD network support adjustment. Learn why your healthcare provider may have received this denial code and how to address it. |
| 119 | Denial code 119 means the maximum benefit for this time period or occurrence has been reached. |
| 121 | Denial code 121 is an adjustment made to compensate for any outstanding member responsibility in healthcare billing. |
| 122 | Denial code 122 is a reduction in payment for psychiatric services. Understand why this code is important for healthcare providers and how to address it. |
| 128 | Denial code 128: Newborn's services are covered in the mother's Allowance. |
| 129 | Denial code 129 is when there is incorrect prior processing information. At least one Remark Code must be provided. |
| 130 | Denial code 130 is for claim submission fee. Learn why your healthcare provider may receive this denial code and how to avoid it. |
| 131 | Denial code 131 is when a claim is denied because it includes a negotiated discount that is specific to that claim. |
| 132 | Denial code 132 is a prearranged demonstration project adjustment that may affect healthcare provider's revenue cycle management. |
| 133 | Denial code 133 is a temporary status for a healthcare service that is under review. It requires correction once the review is complete. |
| 134 | Denial code 134 is when technical fees are taken out from the charges. |
| 135 | Denial code 135 is when interim bills cannot be processed. |
| 136 | Denial code 136 is for failure to follow prior payer's coverage rules. It is used with Group Code OA. |
| 137 | Denial code 137 is for regulatory surcharges, assessments, allowances, or health-related taxes that were not approved for reimbursement. |
| 139 | Denial code 139 is for a contracted funding agreement where the subscriber is employed by the provider of services. Use with Group Code CO. |
| 140 | Denial code 140 is when the patient's or insured's health identification number and name do not match. |
| 142 | Denial code 142 is for the monthly Medicaid patient liability amount. |
| 143 | Denial code 143 is when a portion of the payment is deferred, meaning it is not immediately approved or paid by the insurance company. |
| 144 | Denial code 144 is an incentive adjustment, like a preferred product or service, that has been denied for reimbursement. |
| 146 | Denial code 146 means the diagnosis reported for the service date(s) was not valid. |
| 147 | Denial code 147 is when the provider's negotiated rate has expired or is not on file. |
| 148 | Denial code 148 means that the information from another provider was not given or was incomplete. At least one remark code must be provided. |
| 149 | Denial code 149: Lifetime benefit max reached for this service/benefit category. Understand why your healthcare claim was denied. |
| 150 | Denial code 150 is when the payer believes the information provided does not justify the level of service. |
| 151 | Denial code 151 is when the payer believes that the information provided does not justify the number or frequency of services. |
| 152 | Denial code 152 means the payer doesn't think the information provided justifies the length of service. Check the 835 Healthcare Policy Identification Segment for more details. |
| 153 | Denial code 153 is when the payer believes that the information provided does not justify the prescribed dosage. |
| 154 | Denial code 154 is when the payer determines that the information provided does not justify the amount of medication or supplies for that day. |
| 155 | Denial code 155 is when the patient refuses the service or procedure. |
| 157 | Denial code 157 is when a service or procedure is denied because it was provided due to an act of war. |
| 158 | Denial code 158 is when the service/procedure was provided outside of the United States. |
| 159 | Denial code 159 is "Service/procedure provided due to terrorism." Understand why healthcare providers may face denials related to this unique circumstance. |
| 160 | Denial code 160 is for injuries/illnesses caused by activities not covered by insurance. |
| 161 | Denial code 161 is a provider performance bonus that has been denied for reimbursement. |
| 163 | Denial code 163 means that the requested documents for the claim were not received. |
| 164 | Denial code 164 is when the required documents for a claim were not received on time. |
| 166 | Denial code 166 is when services are submitted after the payer's responsibility for processing claims under the plan has ended. |
| 167 | Denial code 167 means the diagnosis is not covered. Check the 835 Healthcare Policy Identification Segment for more information. |
| 169 | Denial code 169: Alternate benefit has been provided. Understand why your healthcare claim was denied and how to resolve it. |
| 170 | Denial code 170 means payment is denied for services provided by this type of provider. Refer to the 835 Healthcare Policy Identification Segment for more information. |
| 171 | Denial code 171 means payment is denied for services provided by a specific type of provider in a specific type of facility. Check the 835 Healthcare Policy Identification Segment for more information. |
| 172 | Denial code 172 means payment is adjusted for services performed by a provider of a specific specialty. Check the 835 Healthcare Policy Identification Segment for more details. |
| 173 | Denial code 173 is when a physician did not prescribe the service or equipment. |
| 174 | Denial code 174 is when the service was not prescribed before it was delivered. |
| 175 | Denial code 175 is for an incomplete prescription. |
| 176 | Denial code 176: Prescription is not current. Understand why healthcare providers may face this issue and how to address it effectively. |
| 177 | Denial code 177: Patient has not met the required eligibility requirements. Simplify your healthcare revenue cycle management with our expert guidance. effectively. |
| 178 | Denial code 178: Patient has not met spend down requirements. Understand why insurance claims are denied & how to resolve them. Expert healthcare revenue cycle management advice. |
| 179 | Denial code 179 means the patient hasn't fulfilled the waiting requirements. Check the 835 Healthcare Policy Identification Segment for more details. |
| 180 | Denial code 180 is when the patient does not meet the necessary residency requirements. |
| 181 | Denial code 181 is when the procedure code used was not valid on the date of service. |
| 182 | Denial code 182 is when the procedure modifier used on the date of service is not valid. |
| 183 | Denial code 183 means the referring provider is not authorized to refer the service billed. Check the 835 Healthcare Policy Identification Segment for more details. |
| 184 | Denial code 184 means the provider is not authorized to prescribe the service. Check the 835 Healthcare Policy Identification Segment for more details. |
| 185 | Denial code 185 means the provider is not allowed to perform the service billed. Check the 835 Healthcare Policy Identification Segment for more details. |
| 186 | Denial code 186 is a level of care change adjustment that may result in a claim being denied by insurance companies. |
| 187 | Denial code 187 is for Consumer Spending Account payments, like Flexible Spending Account or Health Savings Account, that were not approved. |
| 188 | Denial code 188 is when a product or procedure is not covered unless it is used as recommended by the FDA. |
| 189 | Denial code 189 means a procedure code was billed that doesn't have a specific code for that service. |
| 190 | Denial code 190 means payment is already covered for a qualified stay at a Skilled Nursing Facility (SNF). |
| 192 | Denial code 192 is a non-standard adjustment code used by providers/payers to provide Coordination of Benefits information to another payer. It is used when the non-standard code cannot be mapped to an existing Claims Adjustment Reason Code for Deductible, Coinsurance, and Co-payment. |
| 193 | Denial code 193 is when the original payment decision is being maintained because the claim was processed correctly. |
| 194 | Denial code 194 is for anesthesia performed by the operating physician, assistant surgeon, or attending physician. |
| 195 | Denial code 195 is when a refund is mistakenly given to the wrong payer for a claim or service. |
| 197 | Denial code 197 is when precertification/authorization/notification/pre-treatment is missing. |
| 198 | Denial code 198 is when the precertification, notification, authorization, or pre-treatment requirements have been exceeded. |
| 199 | Denial code 199 is when the revenue code and procedure code don't match, causing a claim to be rejected by the insurance company. |
| 200 | Denial code 200 is when expenses are not covered due to a lapse in insurance coverage. |
| 201 | Denial code 201 means the patient is responsible for the claim amount due to an agreement. A remark code must be provided. |
| 202 | Denial code 202 is for services that are not covered by insurance, such as personal comfort or convenience services. |
| 203 | Denial code 203 is when a healthcare provider's claim is rejected because the service was discontinued or reduced. |
| 204 | Denial code 204 is when a service, equipment, or drug is not covered by the patient's insurance plan. |
| 205 | Denial code 205 is for the pharmacy discount card processing fee. |
| 206 | Denial code 206 is when the National Provider Identifier (NPI) is missing, which can result in a claim being denied by insurance companies. |
| 207 | Denial code 207 is for an invalid format of the National Provider Identifier (NPI. |
| 208 | Denial code 208 is when the National Provider Identifier (NPI) does not match. |
| 209 | Denial code 209 is when the provider cannot collect a certain amount from the patient due to regulatory or other agreements. However, this amount can be billed to another payer. If collected, it must be refunded to the patient. (Use with Group code OA) |
| 210 | Denial code 210 means payment was adjusted because pre-certification/authorization was not received on time. |
| 211 | Denial code 211: NDCs not eligible for rebate, not covered. Understand why your healthcare provider may receive this code and how to address it. av VMeliial COGS L210 Meals PayYINell Was GUJUSLEU VEUGUSe PIC CEIMUNICGONM/aUlhOrniZatiOl! Wds HOt feCeived OFF LTE. |
| 212 | Denial code 212: Administrative surcharges are not covered. Understand why your healthcare claim was denied and how to address it. |
| 213 | Denial code 213 is when a healthcare provider does not follow the rules about referring patients to other doctors or facilities, according to the law or the insurance company's policy. |
| 215 | Denial code 215 is when a claim is denied because it is based on the subrogation of a third party settlement. |
| 216 | Denial code 216 is issued when a review organization determines that the claim does not meet the necessary requirements for reimbursement. |
| 219 | Denial code 219 is based on the extent of injury. Providers should refer to the insurance policy number or healthcare policy identification for jurisdictional regulations. |
| 222 | Denial code 222 means the provider has exceeded the agreed limit for hours/days/units. Check the 835 Healthcare Policy Identification Segment for more details. |
| 223 | Denial code 223 is for a mandated law or regulation that is not covered by another code and must be followed before a new code can be created. |
| 224 | Denial code 224 is when a patient's identity is stolen, and additional verification is needed to process their claims. |
| 225 | Denial code 225 is for penalty or interest payment by payer, used for plan to plan encounter reporting within the 837. |
| 226 | Denial code 226 means the billing or rendering provider did not provide requested information on time or it was incomplete. A Remark Code is needed. |
| 227 | Denial code 227 means the patient or responsible party did not provide enough or complete information. A Remark Code is needed to explain the reason for denial. |
| 228 | Denial code 228 is when a claim is denied because the provider, another provider, or the subscriber did not provide the necessary information to a previous payer for review. |
| 229 | Denial code 229 is when Medicare doesn't consider a partial charge due to the claim type. It's used to convey coordination of benefits info in the 837 transaction. (Use with Group Code PR) |
| 231 | Denial code 231 means that certain procedures cannot be performed on the same day or in the same setting. Check the 835 Healthcare Policy Identification Segment for more information. |
| 232 | Denial code 232 explains the difference in DRG amount when a patient's care involves multiple institutions. Applies to institutional claims only. |
| 233 | Denial code 233 is for services/charges related to hospital-acquired conditions or preventable medical errors. |
| 234 | Denial code 234 is when a procedure is not paid separately. At least one Remark Code must be provided. |
| 235 | Denial code 235 is for sales tax. It indicates that the claim was denied due to issues related to sales tax calculations or documentation. |
| 236 | Denial code 236 means that a procedure or combination of procedures is not compatible with another procedure or combination provided on the same day, as per coding guidelines or workers compensation regulations/fee schedules. |
| 237 | Denial code 237 is a Legislated/Regulatory Penalty. It means that there must be at least one Remark Code provided, which can be either the NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT. |
| 238 | Denial code 238 is for claims that cover both eligible and ineligible periods of coverage. It indicates a reduction for the ineligible period and is used with Group Code PR. |
| 239 | Denial code 239 means the claim covers both eligible and ineligible periods. Separate claims need to be rebilled. |
| 240 | Denial code 240 means the diagnosis doesn't match the patient's birth weight. Check the 835 Healthcare Policy Identification Segment for more details. |
| 241 | Denial code 241 is for the Low Income Subsidy (LIS) co-payment amount in healthcare billing. |
| 242 | Denial code 242 means services were not provided by network or primary care providers. Learn how to handle this common billing issue. |
| 243 | Denial code 243 means services were not approved by your network or primary care providers. Learn how to resolve this issue and get your claims paid. |
| 245 | Denial code 245 is a provider performance program withhold that affects healthcare revenue cycle management. |
| 246 | Denial code 246 is a non-payable code used for reporting purposes only. |
| 247 | Denial code 247 is when the deductible for a professional service is billed on an institutional claim in a healthcare setting. |
| 248 | Denial code 248 is when there is a coinsurance issue for a professional service provided in a hospital or institutional setting and billed on an institutional claim. |
| 249 | Denial code 249 is for claims identified as readmissions. (Use with Group Code CO) |
| 250 | Denial code 250 is when the incorrect attachment/document was received or the expected attachment/document is still missing. A Remark Code must be provided. |
| 251 | Denial code 251 means the documentation received was incomplete. More information is needed to process the claim. |
| 252 | Denial code 252: An attachment is needed to process this claim. Provide a Remark Code (NCPDP Reject Reason Code or Remittance Advice Remark Code) that is not an ALERT. |
| 253 | Denial code 253 is a reduction in federal payment known as sequestration. |
| 254 | Denial code 254 is when the dental plan received the claim, but the benefits are not covered. Submit these services to the patient's medical plan for further consideration. |
| 256 | Denial code 256 is when a healthcare provider's service is not covered by a managed care contract, resulting in non-payment. |
| 257 | Denial code 257 is when a claim or service is not determined during the grace period for premium payment. It will be corrected once the grace period ends. |
| 258 | Denial code 258 is when a claim or service is not covered because the patient is in custody or incarcerated. The claim/service may be covered by a relevant authority. |
| 259 | Denial code 259 is for additional payment denial for Dental/Vision service utilization. |
| 260 | Denial code 260 is when a claim is processed under the Medicaid ACA Enhanced Fee Schedule and is not approved for payment. |
| 261 | Denial code 261 means the procedure or service doesn't match the patient's medical history. |
| 262 | Denial code 262 is an adjustment for delivery cost. It is used specifically for pharmaceuticals. |
| 263 | Denial code 263 is an adjustment for shipping cost. It is used specifically for pharmaceuticals. |
| 264 | Denial code 264 is an adjustment for postage cost. It is used specifically for pharmaceuticals. |
| 265 | Denial code 265 is an adjustment for administrative cost. It is used specifically for pharmaceuticals. |
| 266 | Denial code 266 is an adjustment for the cost of compound preparations in healthcare billing. It is specifically used for pharmaceuticals. |
| 267 | Denial code 267 is for claims that span multiple months. It requires at least one Remark Code to be provided, which can be either an NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT. |
| 268 | Denial code 268 is when a claim spans two calendar years. Resubmit one claim per calendar year. |
| 269 | Denial code 269 means anesthesia is not covered for this service/procedure. Refer to the 835 Healthcare Policy Identification Segment for more information. |
| 270 | Denial code 270 is when the medical plan received the claim, but the benefits are not covered. You should submit these services to the patient's dental plan for further consideration. |
| 271 | Denial code 271 is for prior contractual reductions on a current payment schedule when deferred amounts were already reported. (Use with Group Code OA) |
| 272 | Denial code 272 is when the healthcare provider's services did not meet the coverage or program guidelines. |
| 273 | Denial code 273 is when the healthcare provider exceeded the coverage or program guidelines, resulting in the claim being denied. |
| 274 | Denial code 274 is when a healthcare provider's fee/service is not payable due to a patient care coordination arrangement. |
| 275 | Denial code 275 is when the prior payer does not cover the patient's responsibility, like deductibles or co-payments. (Use with Group Code PR) |
| 276 | Denial code 276 means that the services rejected by the previous payer are not covered by the current payer. |
| 277 | Denial code 277 is when a claim or service is not determined during the premium payment grace period. It will be reversed and corrected once the grace period ends. |
| 278 | Denial code 278 is when the performance program requirements are not met. Refer to the 835 Healthcare Policy Identification Segment for more information. |
| 279 | Denial code 279 is for services not provided by Preferred network providers. It's used when there are limitations on using contracted providers outside of the member's network. |
| 280 | Denial code 280 is when the medical plan received the claim, but the benefits are not covered. Submit the services to the patient's Pharmacy plan for further consideration. |
| 281 | Denial code 281 is for when the deductible is waived as per the contractual agreement. Use it only with Group Code CO. |
| 282 | Denial code 282 means the procedure or revenue code doesn't match the type of bill. Check the 835 Healthcare Policy Identification Segment for more information. |
| 283 | Denial code 283: Attending provider not eligible to direct care. Understand why your claim was denied and how to resolve it. |
| 284 | Denial code 284: Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. |
| 285 | Denial code 285 is when appeal procedures are not followed. Learn why this code may impact healthcare providers' revenue cycle management. |
| 286 | Denial code 286 is when the appeal time limits for a healthcare claim are not met. Learn how to handle this common issue in healthcare revenue cycle management. |
| 287 | Denial code 287 means the referral for healthcare services has exceeded the allowed limit. |
| 288 | Denial code 288 is when a referral is missing or not provided, resulting in a claim denial. |
| 289 | Denial code 289 is when services are not covered by dental and medical plans, so benefits are not available. |
| 290 | Denial code 290 is when the dental plan does not cover the benefits claimed. The claim is then sent to the patient's medical plan for review. |
| 291 | Denial code 291 means the medical plan does not cover the benefits claimed. The claim has been sent to the patient's dental plan for review. |
| 292 | Denial code 292 is when the medical plan does not cover the benefits for the claim. The claim is then sent to the patient's pharmacy plan for review. |
| 293 | Denial code 293 is when the payment is made to the employer instead of the healthcare provider. |
| 294 | Denial code 294 is when a payment is made directly to an attorney instead of the healthcare provider. |
| 295 | Denial code 295 is related to Pharmacy Direct/Indirect Remuneration (DIR) in healthcare revenue cycle management (RCM). |
| 296 | Denial code 296 is when the precertification/authorization/notification/pre-treatment number is valid but doesn't apply to the provider. |
| 297 | Denial code 297 is when the medical plan received the claim, but the benefits are not covered. Submit the services to the patient's vision plan for further consideration. |
| 298 | Denial code 298 is when the medical plan received the claim, but the benefits are not covered under this plan. The claim has been sent to the patient's vision plan for review. |
| 299 | Denial code 299 means the billing provider cannot get paid for the service they billed. |
| 300 | Denial code 300 means the claim was received by the Medical Plan, but benefits are not available. It has been forwarded to the patient's Behavioral Health Plan for further review. |
| 301 | Denial code 301 means the claim was received by the Medical Plan, but the benefits are not covered. Submit the services to the patient's Behavioral Health Plan for further consideration. |
| 302 | Denial code 302 means that the time limit for obtaining pre-approval or authorization for a medical treatment has expired. |
| 303 | Denial code 303 is when the prior payer does not cover the patient's responsibility (deductible, coinsurance, co-payment) for Qualified Medicare and Medicaid Beneficiaries. |
| 304 | Denial code 304 means the medical plan received the claim, but the benefits are not covered. Submit these services to the patient's hearing plan for further consideration. |
| 305 | Denial code 305 is when the medical plan received the claim, but the benefits are not covered under this plan. The claim is then sent to the patient's hearing plan for further review. |
| A0 | Denial code A0 is for patient refund amount. |
| A1 | Denial code A1 is a claim or service denial. It means that a remark code must be provided, which can be a NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT. This code should be used when a more specific Claim Adjustment Reason Code is not available. |
| A5 | Denial code A5 is for Medicare Claim PPS Capital Cost Outlier Amount. |
| A6 | Denial code A6 is when a patient's hospitalization or transfer doesn't meet the requirement of prior hospitalization or 30 days. |
| A8 | Denial code A8 is for an ungroupable DRG, which means the diagnosis-related group (DRG) code assigned to a patient's medical claim cannot be categorized properly. |
| B1 | Denial code B1 is for non-covered visits. It means that the healthcare provider's services are not covered by the patient's insurance plan. |
| B4 | Denial code B4 is a late filing penalty that healthcare providers may encounter when submitting claims for reimbursement. |
| B7 | Denial code B7 means the provider was not certified/eligible to be paid for a specific procedure/service on a certain date. Check the 835 Healthcare Policy Identification Segment for more information. |
| B8 | Denial code B8 means alternative services were available and should have been used. Check the 835 Healthcare Policy Identification Segment for more info. |
| B9 | Denial code B9 means the patient is enrolled in a Hospice. |
| B10 | Denial code B10 is when the allowed amount is reduced because a part of the procedure/test was already paid. The patient is not responsible for paying more than the charge limit for the procedure/test. |
| B11 | Denial code B11 is when the claim or service has been sent to the correct payer/processor for processing, but it is not covered by that payer/processor. |
| B12 | Denial code B12 is when the services provided are not properly documented in the patient's medical records. |
| B13 | Denial code B13 is for previously paid claims. It means that payment for this service may have already been provided in a previous payment. |
| B14 | Denial code B14 means only one visit or consultation per physician per day is covered. |
| B15 | Denial code B15 means a required service/procedure is missing or not covered. Check the 835 Healthcare Policy Identification Segment for more details. |
| B16 | Denial code B16: New Patient qualifications were not met. Understand why your healthcare claim was denied. Learn more about denial codes. |
| B20 | Denial code B20 means that the procedure or service was already provided by another healthcare provider. |
| B22 | Denial code B22 is a payment adjustment based on the diagnosis. |
| B23 | Denial code B23 is when the procedure billed is not authorized according to your CLIA proficiency test. |
| P1 | Denial code P1 is for state-mandated requirements for Property and Casualty claims. Check Claim Payment Remarks Code for more details. Only applicable to Property and Casualty. |
| P2 | Denial code P2 is for non-work related injuries/illnesses not covered by workers' compensation. Providers should refer to the insurance policy number or healthcare policy identification for jurisdictional regulations. Workers' compensation use only. |
| P3 | Denial code P3 is used when a Workers' Compensation case has been settled and the patient is responsible for the claim/service cost through a specific arrangement. This code is only applicable for Workers' Compensation cases. |
| P4 | Denial code P4 is when a Workers' Compensation claim is deemed non-compensable. The payer is not responsible for the claim or service/treatment. For more information, providers should refer to the 835 Insurance Policy Number Segment or the 835 Healthcare Policy Identification Segment. This code is specific to Workers' Compensation claims. |
| P5 | Denial code P5 is used when a payer determines that the fees charged by a healthcare provider are not reasonable and customary. This code is specific to Property and Casualty claims. |
| P6 | Denial code P6 is based on entitlement to benefits. Providers should refer to the insurance policy number segment or healthcare policy identification segment for jurisdictional regulations. Used for Property and Casualty only. |
| P7 | Denial code P7 is when the billed code is not found in the fee schedule/fee database. Resubmit the bill with the correct code and supporting documentation. For Property and Casualty only. |
| P8 | Denial code P8 is for claims under investigation. Providers should refer to the 835 Insurance Policy Number Segment or the 835 Healthcare Policy Identification Segment for more information. Property and Casualty only. |
| P9 | Denial code P9 is used when there is no appropriate code to describe a service. It is specifically for Property and Casualty cases. |
| P10 | Denial code P10 is used when payment is reduced to zero due to ongoing litigation. More details will be provided after the litigation is resolved. Only applicable for Property and Casualty cases. |
| P11 | Denial code P11 is used when the status of an injury or illness claim is pending due to legal action. It is specific to Property and Casualty claims. (Group Code OA) |
| P12 | Denial code P12 is a fee schedule adjustment related to workers' compensation claims. The payer and provider need to refer to specific segments in the 835 electronic remittance advice for more information. This code is applicable only for workers' compensation cases. |
| P13 | Denial code P13 is used when a payment is reduced or denied based on workers' compensation regulations. It is important for providers to refer to the insurance policy number or healthcare policy identification to understand the specific regulations that apply. This code is specific to Workers' Compensation claims. |
| P14 | Denial code P14 means the payment for this service is already included in another service performed on the same day. Check the 835 Healthcare Policy Identification Segment for more details. For Property and Casualty use only. |
| P15 | Denial code P15 is for Workers' Compensation Medical Treatment Guideline Adjustment. It is specific to Workers' Compensation claims. |
| P16 | Denial code P16 means the medical provider is not authorized to treat injured workers in this area. It's used for Workers’ Compensation claims. (Use with Group Code CO or OA) |
| P17 | Denial code P17 is used when a referral is not authorized by the attending physician as required by regulations. This code is specific to Property and Casualty cases. |
| P18 | Denial code P18 is when a procedure is not listed in the fee schedule, but an allowance is made for a similar service. This code is specific to Property and Casualty claims. |
| P19 | Denial code P19 means no payment is due for a procedure because it has a value of zero in the fee schedule. It is only used for Property and Casualty claims. |
| P20 | Denial code P20 is used when a service is not paid according to the allowed outpatient facility fee schedule. It is specific to Property and Casualty cases. |
| P21 | Denial code P21 is a payment denial based on jurisdictional regulations or payment policies for Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. It is used for Property and Casualty Auto claims. |
| P22 | Denial code P22 is used when a payment is adjusted based on the jurisdictional regulations or payment policies related to Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits. It is specific to Property and Casualty Auto claims. |
| P23 | Denial code P23 is a fee schedule adjustment related to Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits. It is important for providers to refer to specific segments in the 835 document for further information. This code is applicable only for Property and Casualty Auto claims. |
| P24 | Denial code P24 is a payment adjustment based on a Preferred Provider Organization (PPO). It is used for Property and Casualty claims and should be referred to the 835 Class of Contract Code Identification Segment or the 835 Healthcare Policy Identification Segment for more information. Use with Group Code CO. |
| P25 | Denial code P25 is used when a payment is adjusted based on the Medical Provider Network (MPN). It is specific to Property and Casualty claims and should be referred to the appropriate code identification segments in the 835 transaction. |
| P26 | Denial code P26 is used when a payment is adjusted based on the Voluntary Provider network (VPN). It is specific to Property and Casualty claims and should be referred to in the 835 Class of Contract Code Identification Segment or the 835 Healthcare Policy Identification Segment, depending on the level of adjustment. |
| P27 | Denial code P27 is a payment denial based on jurisdictional regulations and/or payment policies for liability coverage benefits. Providers should refer to the insurance policy number segment or healthcare policy identification segment in the 835 for more information. Only applicable for Property and Casualty Auto. |
| P28 | Denial code P28 is for payment adjustments based on liability coverage benefits regulations. Providers should refer to the insurance policy number segment or healthcare policy identification segment in the 835 for more information. Only applicable for Property and Casualty Auto. |
| P29 | Denial code P29 is a fee schedule adjustment related to liability benefits. It can be at the claim or line level and requires the payer to send specific information to the provider. This code is applicable to Property and Casualty Auto only. |
| P30 | Denial code P30 is used when payment is denied for an exacerbation due to incomplete supporting documentation. Only applicable for Property and Casualty cases. |
| P31 | Denial code P31 is used when payment is denied for an exacerbation when the treatment exceeds the allowed time. It is specific to Property and Casualty cases. |
| P32 | Denial code P32 is when a payment is adjusted because it needs to be divided among multiple parties. |
