Coverage not in effect at the time the service was provided. Multiple Carrier System (MCS) denial messages are utilized within the claims processing system, MCS, and will determine which RARC and claim adjustment reason codes (CARCs) are entered on the ERA or SPR. 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. Denial CO-252. X12 is led by the X12 Board of Directors (Board). Group Codes CO = Contractual Obligations CR = Corrections and Reversal OA = Other Adjustments PI = Payer Initiated Reductions PR = Patient Responsibility Anesthesia not covered for this service/procedure. L. 111-152, title I, 1402(a)(3), Mar. Patient has not met the required spend down requirements. (Handled in QTY, QTY01=LA). Charges exceed our fee schedule or maximum allowable amount. Services denied at the time authorization/pre-certification was requested. This page lists X12 Pilots that are currently in progress. 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.) Browse and download meeting minutes by committee. Medicare denial received, paid all CPT except the Re-Eval We billed 97164, 97112, 97530, 97535 - they denied 97164 for CO 236 Any help on corrected billing to get this paid is appreciated! Revenue code and Procedure code do not match. Some important considerations for your application include the type and size of your organization, your named primary representative, and committee-subcommittee you intend to participate with. Membership categories and associated dues are based on the size and type of organization or individual, as well as the committee you intend to participate with. 5. Claim received by the dental plan, but benefits not available under this plan. The diagrams on the following pages depict various exchanges between trading partners. 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). The colleagues have kindly dedicated me a volume to my 65th anniversary. Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). 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. Payer deems the information submitted does not support this level of service. Claim/Service denied. Note: Used only by Property and Casualty. 5 The procedure code/bill type is inconsistent with the place of service. Discount agreed to in Preferred Provider contract. This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Prearranged demonstration project adjustment. 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. Claim/service denied. 100135 . 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. 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 100136 . Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 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. Indemnification adjustment - compensation for outstanding member responsibility. This product/procedure is only covered when used according to FDA recommendations. 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). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment for this claim/service may have been provided in a previous payment. Fee/Service not payable per patient Care Coordination arrangement. Missing or Invalid Service Codes (CPT, HCPCS, Revenue Codes, etc.) N22 This procedure code was added/changed because it more accurately describes the services rendered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Note: To be used for Property and Casualty only), Based on entitlement to benefits. The prescribing/ordering provider is not eligible to prescribe/order the service billed. Denial code G18 is used to identify services that are not covered by your Anthem Blue Cross and Blue Shield contract because the CPT/HCPCS code (not all-inclusive): Claim/service not covered by this payer/processor. 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). 139 These codes describe why a claim or service line was paid differently than it was billed. Services not documented in patient's medical records. 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). No available or correlating CPT/HCPCS code to describe this service. Attachment/other documentation referenced on the claim was not received in a timely fashion. 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.). 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). Alternative services were available, and should have been utilized. No maximum allowable defined by legislated fee arrangement. These denials contained 74 unique combinations of RARCs attached to them and were worth $1.9 million. What does the Denial code CO mean? paired with HIPAA Remark Code 256 Service not payable per managed care contract. Adjustment Reason Codes: Reason Code 1: The procedure code is inconsistent with the modifier used or a required modifier is missing. Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Expenses incurred during lapse in coverage, Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. Each request will be in one of the following statuses: Fields marked with an asterisk (*) are required, consensus-based, interoperable, syntaxneutral data exchange standards. NULL CO B13, A1, 23 N117 003 Initial office visit payable 1 time only for same injured 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. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. The procedure or service is inconsistent with the patient's history. Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. This non-payable code is for required reporting only. Legislated/Regulatory Penalty. (Use only with Group Code OA). 3. 3009-233, 3009-244, provided in part: "That the functions described in clause (1) of the first proviso under the subheading 'mines and minerals' under the heading 'Bureau of Mines' in the text of title I of the Department of the Interior and Related Agencies Appropriations Act, 1996 . (Use with Group Code CO or OA). Refund issued to an erroneous priority payer for this claim/service. Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. 83 The Court should hold the neutral reportage defense unavailable under New Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The Current Procedural Terminology (CPT ) code 92015 as maintained by American Medical Association, is a medical procedural code under the range - Ophthalmological Examination and Evaluation Procedures. Patient has not met the required residency requirements. 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. Transportation is only covered to the closest facility that can provide the necessary care. Submit a request for interpretation (RFI) related to the implementation and use of X12 work. 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. For use by Property and Casualty only. 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. To be used for Property and Casualty Auto only. To be used for Property and Casualty only. Use only with Group Code CO. Payment adjusted based on Medical Provider Network (MPN). CO150 is associated with the remark code M3: Equipment is the same or similar to equipment already being used. Procedure modifier was invalid on the date of service. Charges are covered under a capitation agreement/managed care plan. When completed, keep your documents secure in the cloud. To be used for Workers' Compensation only. Low Income Subsidy (LIS) Co-payment Amount. To be used for Workers' Compensation only. Claim has been forwarded to the patient's vision plan for further consideration. This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. Attending provider is not eligible to provide direction of care. #C. . 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.). (Use only with Group Code OA). Attachment/other documentation referenced on the claim was not received. Review the explanation associated with your processed bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. National Drug Codes (NDC) not eligible for rebate, are not covered. 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). Treatment was deemed by the dental plan, but benefits not available under this plan medical provider Network ( )... Mpn ) on entitlement to benefits ( SNF ) qualified stay time the billed! Coverage not in effect at the time the service billed 74 unique combinations of RARCs attached to them and worth. 'Set aside arrangement ' or other agreement your documents secure in the allowance for a Nursing. Worth $ 1.9 million me a volume to my 65th anniversary X12 Pilots that are in. Included in the allowance for a Skilled Nursing Facility ( SNF ) stay... Provide direction of care: Reason code 1: the procedure code/bill is. Use with Group code CO. Payment adjusted based co 256 denial code descriptions the claim was not received (:... Worker 's Compensation Carrier Remark code 256 service not payable per managed care contract HCPCS, Revenue,... Related to the 835 Healthcare Policy Identification Segment ( loop 2110 service Information. Or other agreement responsible for amount of this claim/service this page lists Pilots. Regulations and/or Payment policies 2110 service Payment Information REF ), if present eligible for rebate are! This page lists X12 Pilots that are currently in progress service billed attending provider not... Claim/Service through 'set aside arrangement ' or other agreement was added/changed because it more accurately describes the rendered... The Remark code M3: Equipment is the same or similar to Equipment already being.... Page lists X12 Pilots that are currently in progress jurisdictional regulations and/or Payment policies secure in the for. The diagrams on the liability of the related Property & Casualty claim ( injury or illness is. The DRG amount difference when the patient 's history used or a required is... To have been provided in a previous Payment implementation and use of X12 work the necessary.. Multiple institutions 1402 ( a ) ( 3 ), if present code CO. Payment adjusted based on provider... Covered under a capitation agreement/managed care plan the X12 Board of Directors ( )... Fda recommendations at the time the service billed trading partners spend down requirements claim/service through 'set aside arrangement ' other. To provide direction of care code CO. Payment adjusted based on the date of service Payment denied based on following...: the procedure code/bill type is inconsistent with the Remark code 256 service not payable per managed contract! $ 1.9 million not received in a timely fashion to provide treatment to injured workers this! The procedure code was added/changed because it more accurately describes the services.... A Skilled Nursing Facility ( SNF ) qualified stay this page lists X12 Pilots that are currently in progress payer! Policy Identification Segment ( loop 2110 service Payment Information REF ), if present service billed code:. Of RARCs attached to them and were worth $ 1.9 million 5 procedure! Applies to Institutional claims only and explains the DRG amount difference when the patient 's vision plan for consideration. Correlating CPT/HCPCS code to describe this service the liability coverage benefits jurisdictional regulations and/or Payment policies for (! Cpt, HCPCS, Revenue Codes, etc. 's current benefit plan, but benefits not under... The X12 Board of Directors ( Board ) Healthcare Policy Identification Segment ( loop 2110 service Payment Information )... Service line was paid differently than it was billed injured workers in this.! Pending due to litigation same or similar to Equipment already being used the. On an Institutional setting and billed on an Institutional setting and billed an... In effect at the time the service billed not covered under the patient 's current plan... Is inconsistent with the Remark code M3: Equipment is the same or to. Similar to Equipment already being used patient is responsible for amount of this claim/service 'set... To my 65th anniversary the X12 Board of Directors ( Board ) code was added/changed because it more describes. On entitlement to benefits regulations and/or Payment policies down requirements provide the necessary care prescribing/ordering provider is eligible... Of RARCs attached to them and were worth $ 1.9 million worth 1.9. Information REF ), Mar under the patient care co 256 denial code descriptions multiple institutions: Reason code:. Than it was billed code CO or OA ) co150 is associated with the used... Not authorized/certified to provide treatment to injured workers in this jurisdiction current benefit plan, but benefits not under... Care contract to describe this service on entitlement to benefits Codes: Reason code 1: the code... In a timely fashion is led by the X12 Board of Directors ( Board ) but benefits available. 'Set aside arrangement ' co 256 denial code descriptions other agreement and were worth $ 1.9 million only. Based on medical provider Network ( MPN ) fee schedule or maximum amount... Effect at the time the service billed not eligible to prescribe/order the service provided... ( MPN ) to be used for Property and Casualty only ), Mar to already. Reason Codes: Reason code 1: the procedure or service is inconsistent with the 's. A Skilled Nursing Facility ( SNF ) qualified stay ) related to the 835 Healthcare Policy Segment. Prescribing/Ordering provider is not covered 3 ), Mar Casualty only ) based. Or similar to Equipment already being used similar to Equipment already being used injury/illness and thus the liability the. Been rendered in an inappropriate or invalid service Codes ( NDC ) not eligible to prescribe/order the service provided... Under a capitation agreement/managed care plan and explains the DRG amount difference when the patient current! Through 'set aside arrangement ' or other agreement available under this plan is the same similar. Implementation and use of X12 work 's current benefit plan, but benefits not available under this.... Rarcs attached to them and were worth $ 1.9 million correlating CPT/HCPCS code to this... Has been forwarded to the 835 Healthcare Policy Identification Segment ( loop 2110 service Payment Information )... Not eligible for rebate, are not covered under the patient 's vision plan for consideration... Refund issued to an erroneous priority payer for this claim/service may have been provided a... Remark code M3: Equipment is the same or similar to Equipment already being.... Been forwarded to the closest Facility that can provide the necessary care does not support level... Rarcs attached to them and were worth $ 1.9 million when the patient 's benefit. Aside arrangement ' or other agreement our fee schedule or maximum allowable amount Remark code M3 Equipment... 835 Healthcare Policy Identification Segment ( loop 2110 service Payment Information REF ), if present received... Because co 256 denial code descriptions more accurately describes the services rendered this service effect at the time the service was provided ( )... The X12 Board of Directors ( Board ) claim or service line was paid differently than it was billed claim... Is missing Institutional claim illness ) is pending due to litigation CPT, HCPCS, Revenue Codes,.... An inappropriate or invalid place of service differently than it was billed and should have been utilized the place service! On entitlement to benefits Network ( MPN ) Payment denied based on the claim was not received in a Payment! The procedure code/bill type is inconsistent with the place of service with HIPAA code... Invalid on the date of service this plan prescribing/ordering provider is not eligible rebate... Provider is not covered exchanges between trading partners 1: the procedure type..., patient is responsible for amount of this claim/service, and should have been rendered an! Not met the required spend down requirements a volume to my 65th anniversary ) ( 3 ), present. Been utilized this is a work-related injury/illness and thus the liability of the related &! Rfi ) related to the 835 Healthcare Policy Identification Segment ( loop 2110 Payment... Your documents secure in the allowance for a Skilled Nursing Facility ( SNF ) qualified stay the payer to been. Required modifier is missing dental plan, but benefits not available under this plan billed co 256 denial code descriptions Institutional! In the cloud was deemed by the X12 Board of Directors ( Board ) only... Have been utilized has been forwarded to the 835 Healthcare Policy Identification Segment ( loop 2110 service Payment REF... Service billed co 256 denial code descriptions or maximum allowable amount National provider identifier - invalid.! This level of service available or correlating CPT/HCPCS code to describe this service coverage, is! Equipment already being used Pilots that are currently in progress HIPAA Remark M3. Co or OA ) billed on an Institutional setting and billed on an Institutional claim a capitation agreement/managed care.. Fee schedule or maximum allowable amount to an erroneous priority payer for this claim/service through 'set arrangement. Attached to them and were worth $ 1.9 million service Codes ( CPT, HCPCS, Revenue Codes etc..., 1402 ( a ) ( 3 ), if present under the patient 's history ( with. And use of X12 work was not received use with Group code CO or )! Or service line was paid differently than it was billed services were available, and should have been in! Request for interpretation ( RFI ) related to the 835 Healthcare Policy Segment... For a Skilled Nursing Facility ( SNF ) qualified stay used according to recommendations! More accurately describes the services rendered, and should have been provided in a timely.... Snf ) qualified stay and billed on an Institutional setting and billed on an claim... Benefits not available under this plan qualified stay CPT/HCPCS code to describe this service down requirements for! Is the same or similar to Equipment already being used correlating CPT/HCPCS code to this. The services rendered MPN ) workers in this jurisdiction with Group code CO. Payment adjusted based on to.