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About Claim Adjustment Group Codes

Did you receive a code from a health plan, such as: PR32 or CO286? The "PR" is a Claim Adjustment Group Code and the description for "32" is below. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and definitions are below:

‍

COContractual ObligationCRCorrections and ReversalNote: This value is not to be used with 005010 and up.OAOther AdjustmentPIPayer Initiated ReductionsPRPatient Responsibility

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1
Deductible Amount
Start: 01/01/1995

2
Coinsurance Amount
Start: 01/01/1995

3
Co-payment Amount
Start: 01/01/1995

4
The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2020

5
The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2018
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6
The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

7
The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

8
The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

9
The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

10
The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
------------------------------------------------------------------
11
The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

12
The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

13
The date of death precedes the date of service.
Start: 01/01/1995

14
The date of birth follows the date of service.
Start: 01/01/1995

15
The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 11/01/2017 | Stop: 05/01/2018
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16
Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2018

17
Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/2009

18
Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
Start: 01/01/1995 | Last Modified: 06/02/2013

19
This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007

20
This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
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21
This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007

22
This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007

23
The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
Start: 01/01/1995 | Last Modified: 09/30/2012

24
Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007

25
Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008
------------------------------------------------------------------
26
Expenses incurred prior to coverage.
Start: 01/01/1995

27
Expenses incurred after coverage terminated.
Start: 01/01/1995

28
Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.

29
The time limit for filing has expired.
Start: 01/01/1995

30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
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31
Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007

32
Our records indicate the patient is not an eligible dependent.
Start: 01/01/1995 | Last Modified: 03/01/2018

33
Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007

34
Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007

35
Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
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36
Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003

37
Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003

38
Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/02/2013 | Stop: 01/01/2013
Notes: CARC codes 242 and 243 are replacements for this deactivated code

39
Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995

40
Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
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41
Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003

42
Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007

43
Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006

44
Prompt-pay discount.
Start: 01/01/1995

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)
Start: 01/01/1995 | Last Modified: 07/01/2017
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46
This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.

47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006

48
This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.

49
This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

50
These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
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51
These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Start: 01/01/1995 | Stop: 02/01/2006

53
Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995

54
Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

55
Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
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56
Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

57
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Split into codes 150, 151, 152, 153 and 154.

58
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

59
Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

60
Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
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61
Adjusted for failure to obtain second surgical opinion
Start: 01/01/1995 | Last Modified: 03/01/2017
Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.

62
Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007

63
Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003

64
Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003

65
Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003
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66
Blood Deductible.
Start: 01/01/1995

67
Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 01/01/1995 | Stop: 10/16/2003

68
DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003

69
Day outlier amount.
Start: 01/01/1995

70
Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
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71
Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.

72
Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003

73
Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003

74
Indirect Medical Education Adjustment.
Start: 01/01/1995

75
Direct Medical Education Adjustment.
Start: 01/01/1995
------------------------------------------------------------------
76
Disproportionate Share Adjustment.
Start: 01/01/1995

77
Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003

78
Non-Covered days/Room charge adjustment.
Start: 01/01/1995

79
Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003

80
Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003
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81
Discharges.
Start: 01/01/1995 | Stop: 10/16/2003

82
PIP days.
Start: 01/01/1995 | Stop: 10/16/2003

83
Total visits.
Start: 01/01/1995 | Stop: 10/16/2003

84
Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003

85
Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient.
------------------------------------------------------------------
86
Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.

87
Transfer amount.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012

88
Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007

89
Professional fees removed from charges.
Start: 01/01/1995

90
Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2017
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91
Dispensing fee adjustment.
Start: 01/01/1995

92
Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003

93
No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.

94
Processed in Excess of charges.
Start: 01/01/1995

95
Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
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96
Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

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

98
The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003

99
Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003

100
Payment made to patient/insured/responsible party.
Start: 01/01/1995 | Last Modified: 05/01/2018
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101
Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999

102
Major Medical Adjustment.
Start: 01/01/1995

103
Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001

104
Managed care withholding.
Start: 01/01/1995

105
Tax withholding.
Start: 01/01/1995
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106
Patient payment option/election not in effect.
Start: 01/01/1995

107
The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

108
Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

109
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Start: 01/01/1995 | Last Modified: 01/29/2012

110
Billing date predates service date.
Start: 01/01/1995
------------------------------------------------------------------
111
Not covered unless the provider accepts assignment.
Start: 01/01/1995

112
Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007

113
Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.

114
Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995

115
Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
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116
The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007

117
Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007

118
ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007

119
Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004

120
Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.
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121
Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007

122
Psychiatric reduction.
Start: 01/01/1995

123
Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.

124
Payer refund amount - not our patient.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.

125
Submission/billing error(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.)
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013
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126
Deductible -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.

127
Coinsurance -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 2.

128
Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997

129
Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 02/28/1997 | Last Modified: 01/30/2011

130
Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
------------------------------------------------------------------
131
Claim specific negotiated discount.
Start: 02/28/1997

132
Prearranged demonstration project adjustment.
Start: 02/28/1997

133
The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).
Start: 07/01/2014 | Last Modified: 07/01/2017

134
Technical fees removed from charges.
Start: 10/31/1998

135
Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
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136
Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
Start: 10/31/1998 | Last Modified: 07/01/2013

137
Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007

138
Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 11/01/2017 | Stop: 05/01/2018

139
Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.
Start: 06/30/1999 | Last Modified: 05/01/2018

140
Patient/Insured health identification number and name do not match.
Start: 06/30/1999
------------------------------------------------------------------
141
Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012

142
Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007

143
Portion of payment deferred.
Start: 02/28/2001

144
Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001

145
Premium payment withholding
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
------------------------------------------------------------------
146
Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007

147
Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002

148
Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/30/2002 | Last Modified: 09/20/2009

149
Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002

150
Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
------------------------------------------------------------------
151
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008

152
Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 10/31/2002 | Last Modified: 07/01/2017

153
Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007

154
Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007

155
Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
------------------------------------------------------------------
156
Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009

157
Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007

158
Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007

159
Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007

160
Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
------------------------------------------------------------------
161
Provider performance bonus
Start: 02/29/2004

162
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
Start: 02/29/2004 | Stop: 07/01/2014
Notes: Use code P1

163
Attachment/other documentation referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 06/02/2013

164
Attachment/other documentation referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 06/02/2013

165
Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 11/01/2017 | Stop: 05/01/2018
------------------------------------------------------------------
166
These services were submitted after this payers responsibility for processing claims under this plan ended.
Start: 02/28/2005

167
This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017

168
Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 11/01/2017 | Stop: 05/01/2018

169
Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007

170
Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
------------------------------------------------------------------
171
Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017

172
Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017

173
Service/equipment was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 07/01/2013

174
Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007

175
Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
------------------------------------------------------------------
176
Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007

177
Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007

178
Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007

179
Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 03/01/2017

180
Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
------------------------------------------------------------------
181
Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007

182
Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007

183
The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017

184
The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017

185
The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
------------------------------------------------------------------
186
Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007

187
Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009

188
This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005

189
'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
Start: 06/30/2005

190
Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
------------------------------------------------------------------
191
Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)
Start: 10/31/2005 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P2

192
Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 07/01/2017

193
Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008

194
Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007

195
Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
------------------------------------------------------------------
196
Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.

197
Precertification/authorization/notification/pre-treatment absent.
Start: 10/31/2006 | Last Modified: 05/01/2018

198
Precertification/notification/authorization/pre-treatment exceeded.
Start: 10/31/2006 | Last Modified: 05/01/2018

199
Revenue code and Procedure code do not match.
Start: 10/31/2006

200
Expenses incurred during lapse in coverage
Start: 10/31/2006
------------------------------------------------------------------
201
Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 10/31/2006 | Last Modified: 09/28/2014
Notes: Not for use by Workers' Compensation payers; use code P3 instead.

202
Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007

203
Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007

204
This service/equipment/drug is not covered under the patient's current benefit plan
Start: 02/28/2007

205
Pharmacy discount card processing fee
Start: 07/09/2007
------------------------------------------------------------------
206
National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007

207
National Provider identifier - Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008

208
National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007

209
Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)
Start: 07/09/2007 | Last Modified: 07/01/2013

210
Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
------------------------------------------------------------------
211
National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007

212
Administrative surcharges are not covered
Start: 11/05/2007

213
Non-compliance with the physician self referral prohibition legislation or payer policy.
Start: 01/27/2008

214
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P4

215
Based on subrogation of a third party settlement
Start: 01/27/2008
------------------------------------------------------------------
216
Based on the findings of a review organization
Start: 01/27/2008

217
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P5

218
Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P6

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 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 01/27/2008 | Last Modified: 07/01/2017

220
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P7
------------------------------------------------------------------
221
Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)
Start: 01/27/2008 | Last Modified: 07/01/2013 | Stop: 07/01/2014
Notes: Use code P8

222
Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/01/2008 | Last Modified: 07/01/2017

223
Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
Start: 06/01/2008

224
Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
Start: 06/01/2008

225
Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
Start: 06/01/2008
------------------------------------------------------------------
226
Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 07/01/2013

227
Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/20/2009

228
Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008

229
Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)
Start: 01/25/2009 | Last Modified: 07/01/2017

230
No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009 | Stop: 07/01/2014
Notes: Use code P9
------------------------------------------------------------------
231
Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2009 | Last Modified: 07/01/2017

232
Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009 | Last Modified: 07/01/2017

233
Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
Start: 01/24/2010

234
This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/24/2010

235
Sales Tax
Start: 06/06/2010
------------------------------------------------------------------
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.
Start: 01/30/2011 | Last Modified: 07/01/2013

237
Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/05/2011

238
Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
Start: 03/01/2012 | Last Modified: 07/01/2013

239
Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
Start: 03/01/2012 | Last Modified: 01/29/2012

240
The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/03/2012 | Last Modified: 07/01/2017
------------------------------------------------------------------
241
Low Income Subsidy (LIS) Co-payment Amount
Start: 06/03/2012

242
Services not provided by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38

243
Services not authorized by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38

244
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P10

245
Provider performance program withhold.
Start: 09/30/2012
------------------------------------------------------------------
246
This non-payable code is for required reporting only.
Start: 09/30/2012

247
Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).

248
Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).

249
This claim has been identified as a readmission. (Use only with Group Code CO)
Start: 09/30/2012

250
The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014
------------------------------------------------------------------
251
The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014

252
An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/02/2013

253
Sequestration - reduction in federal payment
Start: 06/02/2013 | Last Modified: 11/01/2013

254
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
Start: 06/02/2013 | Last Modified: 11/01/2017
Notes: Use CARC 290 if the claim was forwarded.

255
The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P11
------------------------------------------------------------------
256
Service not payable per managed care contract.
Start: 06/02/2013

257
The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
Start: 11/01/2013 | Last Modified: 06/01/2014
Notes: To be used after the first month of the grace period.

258
Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
Start: 11/01/2013

259
Additional payment for Dental/Vision service utilization.
Start: 01/26/2014

260
Processed under Medicaid ACA Enhanced Fee Schedule
Start: 01/26/2014
------------------------------------------------------------------
261
The procedure or service is inconsistent with the patient's history.
Start: 06/01/2014

262
Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017

263
Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017

264
Adjustment for postage cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017

265
Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
------------------------------------------------------------------
266
Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017

267
Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2014 | Last Modified: 04/01/2015

268
The Claim spans two calendar years. Please resubmit one claim per calendar year.
Start: 11/01/2014

269
Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 03/01/2015 | Last Modified: 07/01/2017

270
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration.
Start: 07/01/2015 | Last Modified: 11/01/2017
Notes: Use CARC 291 if the claim was forwarded.
------------------------------------------------------------------
271
Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)
Start: 11/01/2015 | Last Modified: 03/01/2018

272
Coverage/program guidelines were not met.
Start: 11/01/2015

273
Coverage/program guidelines were exceeded.
Start: 11/01/2015

274
Fee/Service not payable per patient Care Coordination arrangement.
Start: 11/01/2015

275
Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)
Start: 11/01/2015
------------------------------------------------------------------
276
Services denied by the prior payer(s) are not covered by this payer.
Start: 11/01/2015

277
The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
Start: 11/01/2015
Notes: To be used during 31 day SHOP grace period.

278
Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2016 | Last Modified: 07/01/2017

279
Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network.
Start: 11/01/2016 | Last Modified: 07/01/2017

280
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.
Start: 03/01/2017 | Last Modified: 11/01/2017
Notes: Use CARC 292 if the claim was forwarded.
------------------------------------------------------------------
281
Deductible waived per contractual agreement. Use only with Group Code CO.
Start: 07/01/2017

282
The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2017

283
Attending provider is not eligible to provide direction of care.
Start: 11/01/2017

284
Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.
Start: 11/01/2017

285
Appeal procedures not followed
Start: 11/01/2017
------------------------------------------------------------------
286
Appeal time limits not met
Start: 11/01/2017

287
Referral exceeded
Start: 11/01/2017

288
Referral absent
Start: 11/01/2017

289
Services considered under the dental and medical plans, benefits not available.
Start: 11/01/2017
Notes: Also see CARCs 254, 270 and 280.

290
Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 254 if the claim was not forwarded.
------------------------------------------------------------------
291
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 270 if the claim was not forwarded.

292
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 280 if the claim was not forwarded.

293
Payment made to employer.
Start: 05/01/2018

294
Payment made to attorney.
Start: 11/01/2017

295
Pharmacy Direct/Indirect Remuneration (DIR)
Start: 03/01/2018
------------------------------------------------------------------
296
Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.
Start: 07/01/2018

297
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.
Start: 03/01/2019

298
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.
Start: 03/01/2019

299
The billing provider is not eligible to receive payment for the service billed.
Start: 07/01/2019

300
Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.
Start: 07/01/2019
------------------------------------------------------------------
301
Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.
Start: 07/01/2019

302
Precertification/notification/authorization/pre-treatment time limit has expired.
Start: 11/01/2020

303
Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)
Start: 07/01/2021

304
Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.
Start: 03/01/2022

305
Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration.
Start: 03/01/2022
------------------------------------------------------------------
A0
Patient refund amount.
Start: 01/01/1995

A1
Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009

A2
Contractual adjustment.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.

A3
Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003

A4
Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008

A5
Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995

A6
Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995

A7
Presumptive Payment Adjustment
Start: 01/01/1995 | Stop: 07/01/2015

A8
Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
------------------------------------------------------------------
B1
Non-covered visits.
Start: 01/01/1995

B2
Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003

B3
Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003

B4
Late filing penalty.
Start: 01/01/1995

B5
Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 11/01/2015 | Stop: 05/01/2016
Notes: This code has been replaced by 272 and 273.

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 provider of this specialty.
Start: 01/01/1995 | Stop: 02/01/2006

B7
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

B8
Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

B9
Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007

B10
Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
Start: 01/01/1995

B11
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995

B12
Services not documented in patient's medical records.
Start: 01/01/1995 | Last Modified: 03/01/2018

B13
Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995

B14
Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
------------------------------------------------------------------
B15
This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017

B16
'New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007

B17
Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
Start: 01/01/1995 | Stop: 02/01/2006

B18
This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009

B19
Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003

B20
Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007

B21
The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003

B22
This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001

B23
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
------------------------------------------------------------------
D1
Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D2
Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D3
Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D4
Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D5
Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D6
Claim/service denied. Claim did not include patient's medical record for the service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D7
Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D8
Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.

D10
Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.

D11
Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.

D12
Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.

D13
Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
------------------------------------------------------------------
D14
Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.

D15
Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.

D16
Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].

D17
Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.

D18
Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.

D19
Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.

D20
Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.

D21
This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007

D22
Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
Start: 01/27/2008 | Stop: 01/01/2009

D23
This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2009 | Stop: 01/01/2012
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P1
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 162

P2
Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 191

P3
Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)
Start: 11/01/2013
Notes: This code replaces deactivated code 201

P4
Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 214

P5
Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 217

P6
Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 218

P7
The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 220

P8
Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 221

P9
No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 230

P10
Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 244

P11
The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)
Start: 11/01/2013
Notes: This code replaces deactivated code 255

P12
Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W1

P13
Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W2

P14
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W3

P15
Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code W4
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P16
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)
Start: 11/01/2013
Notes: This code replaces deactivated code W5

P17
Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W6

P18
Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W7

P19
Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W8

P20
Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W9

P21
Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 03/01/2018
Notes: This code replaces deactivated code Y1

P22
Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 03/01/2018
Notes: This code replaces deactivated code Y2

P23
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code Y3

P24
Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. Use only with Group Code CO.
Start: 11/01/2017

P25
Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).
Start: 11/01/2017

P26
Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).
Start: 11/01/2017

P27
Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017

P28
Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017

P29
Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017

P30
Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.
Start: 11/01/2020

P31
Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.
Start: 11/01/2020
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W1
Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.
Start: 02/29/2000 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P12

W2
Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use 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 the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 10/17/2010 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P13

W3
The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P14

W4
Workers' Compensation Medical Treatment Guideline Adjustment.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P15

W5
Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P16

W6
Referral not authorized by attending physician per regulatory requirement.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P17

W7
Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P18

W8
Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P19

W9
Service not paid under jurisdiction allowed outpatient facility fee schedule.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P20
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Y1
Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use 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 the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P21

Y2
Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use 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 the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P22

Y3
Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P23

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