1 Deductible Amount

2 Coinsurance Amount

3 Co-payment Amount

4 The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy

5 The procedure code/type of bill is inconsistent with the place of service.

6 The procedure/revenue code is inconsistent with the patient's age.

7 The procedure/revenue code is inconsistent with the patient's gender.

8 The procedure code is inconsistent with the provider type/specialty (taxonomy

9 The diagnosis is inconsistent with the patient's age.

10 The diagnosis is inconsistent with the patient's gender.

11 The diagnosis is inconsistent with the procedure.

12 The diagnosis is inconsistent with the provider type.

13 The date of death precedes the date of service.

14 The date of birth follows the date of service.

15 The authorization number is missing, invalid, or does not apply to the billed services or provider.

16 Claim/service lacks information or has submission/billing error(s

17 Requested information was not provided or was insufficient/incomplete.

18 Exact duplicate claim/service

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

20 This injury/illness is covered by the liability carrier.

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

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

23 The impact of prior payer(s) adjudication including payments and/or adjustments. (

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

25 Payment denied. Your Stop loss deductible has not been met.

26 Expenses incurred prior to coverage.

27 Expenses incurred after coverage terminated.

28 Coverage not in effect at the time the service was provided.

29 The time limit for filing has expired.

30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.

31 Patient cannot be identified as our insured.

32 Our records indicate the patient is not an eligible dependent.

33 Insured has no dependent coverage.

34 Insured has no coverage for newborns.

35 Lifetime benefit maximum has been reached.

36 Balance does not exceed co-payment amount.

37 Balance does not exceed deductible.

38 Services not provided or authorized by designated (network/primary care) providers.

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

40 Charges do not meet qualifications for emergent/urgent care.

41 Discount agreed to in Preferred Provider contract.

42 Charges exceed our fee schedule or maximum allowable amount.

43 Gramm-Rudman reduction.

44 Prompt-pay discount.

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement..

46 This (these) service(s) is (are) not covered.

47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

48 This (these) procedure(s) is (are) not covered.

49
This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a

50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.

51 These are non-covered services because this is a pre-existing condition.

52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service

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

54 Multiple physicians/assistants are not covered in this case.

55 Procedure/treatment/drug is deemed experimental/investigational by the payer.

56 Procedure/treatment has not been deemed 'proven to be effective' by the payer.

57
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many servic

58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

59 Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anest

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

61 Adjusted for failure to obtain second surgical opinion

62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.

63 Correction to a prior claim.

64 Denial reversed per Medical Review.

65 Procedure code was incorrect. This payment reflects the correct code.

66 Blood Deductible.

67 Lifetime reserve days.

68 DRG weight.

69 Day outlier amount.

70 Cost outlier - Adjustment to compensate for additional costs.

71 Primary Payer amount.

72 Coinsurance day.

73 Administrative days.
74 Indirect Medical Education Adjustment.

75 Direct Medical Education Adjustment.

76 Disproportionate Share Adjustment.

77 Covered days.

78 Non-Covered days/Room charge adjustment.

79 Cost Report days. (Handled in MIA15)

80 Outlier days.

81 Discharges.

82 PIP days.

83 Total visits.

84 Capital Adjustment. (Handled in MIA)

85 Patient Interest Adjustment (Use Only Group code PR)

86 Statutory Adjustment.

87 Transfer amount.

88 Adjustment amount represents collection against receivable created in prior overpayment.

89 Professional fees removed from charges.

90 Ingredient cost adjustment.

91 Dispensing fee adjustment.

92 Claim Paid in full.

93 No Claim level Adjustments.

94 Processed in Excess of charges.

95 Plan procedures not followed.

96 Non-covered charge(s).
97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

98 The hospital must file the Medicare claim for this inpatient non-physician service.

99 Medicare Secondary Payer Adjustment Amount.

100 Payment made to patient/insured/responsible party.

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

102 Major Medical Adjustment.

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

104 Managed care withholding.

105 Tax withholding.

106 Patient payment option/election not in effect.

107 The related or qualifying claim/service was not identified on this claim.

108 Rent/purchase guidelines were not met.

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

110 Billing date predates service date.

111 Not covered unless the provider accepts assignment.

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

113 Payment denied because service/procedure was provided outside the United States or as a result of war.

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

115 Procedure postponed, canceled, or delayed.

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

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

118 ESRD network support adjustment.

119 Benefit maximum for this time period or occurrence has been reached.
120 Patient is covered by a managed care plan..

121 Indemnification adjustment - compensation for outstanding member responsibility.

122 Psychiatric reduction.

123 Payer refund due to overpayment.

124 Payer refund amount - not our patient.

125 Submission/billing error(s).

126 Deductible -- Major Medical

127 Coinsurance -- Major Medical

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

129 Prior processing information appears incorrect.

130 Claim submission fee.

131 Claim specific negotiated discount.

132 Prearranged demonstration project adjustment.

133 The disposition of this service line is pending further review.

134 Technical fees removed from charges.

135 Interim bills cannot be processed.

136 Failure to follow prior payer's coverage rules.

137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

138 Appeal procedures not followed or time limits not met.

139 Contracted funding agreement - Subscriber is employed by the provider of services.

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

141 Claim spans eligible and ineligible periods of coverage.

142 Monthly Medicaid patient liability amount.

143 Portion of payment deferred.

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

145 Premium payment withholding

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

147 Provider contracted/negotiated rate expired or not on file.

148
Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (

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

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

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

152
Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identifica

153 Payer deems the information submitted does not support this dosage.

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

155 Patient refused the service/procedure.

156 Flexible spending account payments. Note: Use code 187.

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

158 Service/procedure was provided outside of the United States.

159 Service/procedure was provided as a result of terrorism.

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

161 Provider performance bonus

162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
163 Attachment/other documentation referenced on the claim was not received.

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

165 Referral absent or exceeded.

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

167
This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service P

168 Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.

169 Alternate benefit has been provided.

170
Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segmen

171
Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy

172
Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification

173 Service/equipment was not prescribed by a physician.

174 Service was not prescribed prior to delivery.

175 Prescription is incomplete.

176 Prescription is not current.

177 Patient has not met the required eligibility requirements.

178 Patient has not met the required spend down requirements.

179
Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110

180 Patient has not met the required residency requirements.

181 Procedure code was invalid on the date of service.

182 Procedure modifier was invalid on the date of service.

183
The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (lo

184
The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Ide

185
The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segmen

186 Level of care change adjustment.

187
Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health R

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

189
'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this pro

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

191
Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim

192
Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination

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

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

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

196 Claim/service denied based on prior payer's coverage determination.

197 Precertification/authorization/notification/pre-treatment absent.

198 Precertification/notification/authorization/pre-treatment exceeded.

199 Revenue code and Procedure code do not match.

200 Expenses incurred during lapse in coverage

201
Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group C

202 Non-covered personal comfort or convenience services.

203 Discontinued or reduced service.

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

205 Pharmacy discount card processing fee

206 National Provider Identifier - missing.

207 National Provider identifier - Invalid format

208 National Provider Identifier - Not matched.

209
Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed t

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

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

212 Administrative surcharges are not covered

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

214

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjus

215 Based on subrogation of a third party settlement

216 Based on the findings of a review organization

217
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used fo
218
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to th

219
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

220
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fe

221
Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 83

222
Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: R

223
Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated b

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

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

226
Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete

227
Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Rem

228
Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their

229
Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be use

230 No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
231
Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Seg

232
Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patien

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

234
This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject

235 Sales Tax

236
This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination p

237
Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason

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

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

240
The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop

241 Low Income Subsidy (LIS) Co-payment Amount

242 Services not provided by network/primary care providers.

243 Services not authorized by network/primary care providers.

244
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for P

245 Provider performance program withhold.

246 This non-payable code is for required reporting only.

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

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

250
The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/documen

251
The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to pro

252
An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may

253 Sequestration - reduction in federal payment

254
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for

255 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code

256 Service not payable per managed care contract.

257
The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange re

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

259 Additional payment for Dental/Vision service utilization.

260 Processed under Medicaid ACA Enhanced Fee Schedule

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

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

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

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

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

267
Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject

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

269
Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Serv

270
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for

271
Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amoun

272 Coverage/program guidelines were not met.

273 Coverage/program guidelines were exceeded.

274 Fee/Service not payable per patient Care Coordination arrangement.

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

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

277
The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Excha

278
Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcar

279
Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For exam

280
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan

281 Deductible waived per contractual agreement. Use only with Group Code CO.
282
The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (

283 Attending provider is not eligible to provide direction of care.

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

285 Appeal procedures not followed

286 Appeal time limits not met

287 Referral exceeded

288 Referral absent

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

290
Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical pla

291
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental pla

292
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy

293 Payment made to employer.

294 Payment made to attorney.

295 Pharmacy Direct/Indirect Remuneration (DIR)

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

297
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for

298
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision pla

299 The billing provider is not eligible to receive payment for the service billed.
300
Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavior

301
Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral He

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

303
Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Med

304
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan fo

305
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing p

A0 Patient refund amount.

A1
Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, o

A2 Contractual adjustment.

A3 Medicare Secondary Payer liability met.

A4 Medicare Claim PPS Capital Day Outlier Amount.

A5 Medicare Claim PPS Capital Cost Outlier Amount.

A6 Prior hospitalization or 30 day transfer requirement not met.

A7 Presumptive Payment Adjustment

A8 Ungroupable DRG.

B1 Non-covered visits.

B2 Covered visits.

B3 Covered charges.

B4 Late filing penalty.

B5 Coverage/program guidelines were not met or were exceeded.

B6
This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a pro

B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthca

B8
Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segmen

B9 Patient is enrolled in a Hospice.

B10
Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more

B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/proce

B12 Services not documented in patient's medical records.

B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

B14 Only one visit or consultation per physician per day is covered.

B15
This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedur

B16 'New Patient' qualifications were not met.

B17
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incom

B18 This procedure code and modifier were invalid on the date of service.

B19 Claim/service adjusted because of the finding of a Review Organization.

B20 Procedure/service was partially or fully furnished by another provider.

B21 The charges were reduced because the service/care was partially furnished by another physician.

B22 This payment is adjusted based on the diagnosis.

B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
D1 Claim/service denied. Level of subluxation is missing or inadequate.

D2 Claim lacks the name, strength, or dosage of the drug furnished.

D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing

D4 Claim/service does not indicate the period of time for which this will be needed.

D5 Claim/service denied. Claim lacks individual lab codes included in the test.

D6 Claim/service denied. Claim did not include patient's medical record for the service.

D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.

D8 Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'

D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular

D10 Claim/service denied. Completed physician financial relationship form not on file.

D11 Claim lacks completed pacemaker registration form.

D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the

D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.

D14 Claim lacks indication that plan of treatment is on file.

D15 Claim lacks indication that service was supervised or evaluated by a physician.
D16 Claim lacks prior payer payment information.

D17 Claim/Service has invalid non-covered days.

D18 Claim/Service has missing diagnosis information.

D19 Claim/Service lacks Physician/Operative or other supporting documentation

D20 Claim/Service missing service/product information.

D21 This (these) diagnosis(es) is (are) missing or are invalid

D22
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensa

D23
This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provide

P1
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used fo

P2

Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim

P3
Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrang

P4

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adju

P5
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Prop
P6
Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to t

P7
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fe

P8
Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 8

P9 No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.

P10
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for P

P11
The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and

P12
Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and

P13

Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other cod

P14
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the sam

P15 Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.

P16
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Com
P17 Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.

P18
Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Prope

P19
Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Ca

P20 Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.

P21

Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional r

P22

Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional

P23

Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If a

P24

Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must sen

P25

Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and

P26
Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send an
P27

Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment i

P28

Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustmen

P29
Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the pr

P30 Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.

P31 Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.

P32 Payment adjusted due to Apportionment.

W1
Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and

W2

Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other cod

W3
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the sam

W4 Workers' Compensation Medical Treatment Guideline Adjustment.

W5 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO o

W6 Referral not authorized by attending physician per regulatory requirement.

W7 Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.

W8 Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.

W9 Service not paid under jurisdiction allowed outpatient facility fee schedule.

Y1

Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulation

Y2
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulati
only

if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to t

Y3

Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If ad