Refund to patient if collected. Non-covered personal comfort or convenience services. It will not be updated until there are new requests. Claim received by the medical plan, but benefits not available under this plan. To renewan X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. 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. 206 National Provider Identifier missing. When it comes to the PR 204 denial code, it usually indicates all those services, medicines, or even equipment that are not covered by the claimants current P17 Referral not authorized by attending physician per regulatory requirement. Payment made to patient/insured/responsible party. Submit these services to the patient's vision plan for further consideration. Claim/service denied. Processed based on multiple or concurrent procedure rules. D23 This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. Procedure is not listed in the jurisdiction fee schedule. 188 This product/procedure is only covered when used according to FDA recommendations. Lifetime benefit maximum has been reached for this service/benefit category. 146 Diagnosis was invalid for the date(s) of service reported. PR 204 This service/equipment/drug is not covered under the patients current benefit plan. Expenses incurred after coverage terminated. The procedure code is inconsistent with the provider type/specialty (taxonomy). 154 Payer deems the information submitted does not support this days supply. Multiple physicians/assistants are not covered in this case. 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. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. The hospital must file the Medicare claim for this inpatient non-physician service. Patient has not met the required eligibility requirements. 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. Incentive adjustment, e.g. P1 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. 181 Procedure code was invalid on the date of service. To be used for Workers' Compensation only. 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). Use only with Group Code CO. Patient/Insured health identification number and name do not match. X12 welcomes feedback. Services not provided by Preferred network providers. 189 Not otherwise classified or unlisted procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. The qualifying other service/procedure has not been received/adjudicated. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Reason Code 3: The procedure/ (Use CARC 45), Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. 141 Claim spans eligible and ineligible periods of coverage. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. 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. (Use with Group Code CO or OA). Workers' Compensation Medical Treatment Guideline Adjustment. This (these) service(s) is (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). (Handled in QTY, QTY01=LA). 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. 200 Expenses incurred during lapse in coverage. 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. Payment for this claim/service may have been provided in a previous payment. You must send the claim/service to the correct payer/contractor. No current requests. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Your Stop loss deductible has not been met. Claim/Service denied. Appeal procedures not followed or time limits not met. 36 Balance does not exceed co-payment amount. The charges were reduced because the service/care was partially furnished by another physician. 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. Patient is responsible for amount of thisclaim/service through WC Medicare set aside arrangement or other agreement. 153 Payer deems the information submitted does not support this dosage. Submit these services to the patient's medical plan for further consideration. 201 Workers Compensation case settled. To be used for Property and Casualty Auto only. 109 Claim/service not covered by this payer/contractor. The diagnosis is inconsistent with the patient's age.

These codes generally assign responsibility for the adjustment amounts. Benefit maximum for this time period or occurrence has been reached. 59 Processed based on multiple or concurrent procedure rules. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 248 Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Marketing Automation Systems. This injury/illness is covered by the liability carrier. PR 201 Workers Compensation case settled. Injury/illness was the result of an activity that is a benefit exclusion. Procedure/service was partially or fully furnished by another provider. The referring provider is not eligible to refer the service billed. The date of birth follows the date of service. 213 Non-compliance with the physician self referral prohibition legislation or payer policy. X12 maintains policies and procedures that govern its corporate, committee, and subordinate group activities and posts them online to ensure they are easily accessible to members and other materially-interested parties. Benefits are not available under this dental plan. Group codes include CO (contractual obligations), OA (other adjustments) and PR (patient responsibility). Claim/service not covered when patient is in custody/incarcerated. Claim did not include patient's medical record for the service. CARCs are used in the RA with group codes that shows the liability for amounts not covered by Medicare for a claim or service. Liability Benefits jurisdictional fee schedule adjustment. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837), Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. Provider promotional discount (e.g., Senior citizen discount). This Payer not liable for claim or service/treatment. Claim lacks date of patient's most recent physician visit. This is not patient specific. 31 Patient cannot be identified as our insured. P2 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 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Medicare Claim PPS Capital Day Outlier Amount. For example PR 45, We could bill patient but for CO 45, its a adjustment and we cant bill the patient. If 210 Payment adjusted because pre-certification/authorization not received in a timely fashion. 20 This injury/illness is covered by the liability carrier. To be used for Property and Casualty only. 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Claim did not include patients medical record for the service. The diagnosis is inconsistent with the patient's gender. To be used for Property and Casualty only. Browse and download meeting minutes by committee. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for P&C Auto only. Coverage/program guidelines were not met or were exceeded. Service not covered by current benefit plan. This injury/illness is the liability of the no-fault carrier. 233 Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Exceeds the contracted maximum number of hours/days/units by this provider for this period. This procedure is not paid separately. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. Join other member organizations in continuously adapting the expansive vocabulary and languageused by millions of organizationswhileleveraging more than 40 years of cross-industry standards development knowledge. PR Patient Responsibility We could bill the patient for this denial however please make sure that any other rejection reason not specified in the EOB.

The format is always two alpha characters. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. 250 The attachment/other documentation content received is inconsistent with the expected content. To be used for P&C Auto only. Prior hospitalization or 30 day transfer requirement not met. X12 standards are the workhorse of business to business exchanges proven by the billions of daily transactions within and across many industries including: X12 has developed standards and associated products to facilitate the transmission of electronic business messages for over 40 years. 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. 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. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). P23 Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. 15 The authorization number is missing, invalid, or does not apply to the billed services or provider. 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Non standard adjustment code from paper remittance. X12 produces three types of documents tofacilitate consistency across implementations of its work. 52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Non-covered charge(s). Did you receive a code from a health plan, such as: PR32 or CO286?

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. W7 Procedure is not listed in the jurisdiction fee schedule. 185 The rendering provider is not eligible to perform the service billed. PR 35 Lifetime benefit maximum has been reached. Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Additional information will be sent following the conclusion of litigation. Based on extent of injury. D15 Claim lacks indication that service was supervised or evaluated by a physician. PR 31 Claim denied as patient cannot be identified as our insured. Claim received by the Medical Plan, but benefits not available under this plan. Did you receive a code from a health plan, such as: PR32 or CO286? (Handled in QTY, QTY01=CD), Patient Interest Adjustment (Use Only Group code PR). Claim has been forwarded to the patient's hearing plan for further consideration. 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). Final 214 Workers Compensation claim adjudicated as non-compensable. Procedure/treatment has not been deemed 'proven to be effective' by the payer. 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. This is the Current Procedural Terminology or CPT code used to describe the service the doctor provided. Note: Use code 187. Policies and procedures specific to a committee's subordinate groups, like subcommittees, task groups, action groups, and work groups, are also listed in the committee's section. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. 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). Payment reduced to zero due to litigation. 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. 100 Payment made to patient/insured/responsible party/employer. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. An allowance has been made for a comparable service. 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). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 98 The hospital must file the Medicare claim for this inpatient non-physician service. Payer Initiated Reductions PI (Payer Initiated Reductions) is used by payers when it is believed the adjustment is not the 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. The procedure/revenue code is inconsistent with the patient's gender. B12 Services not documented in patients medical records. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. 167 This (these) diagnosis(es) is (are) not covered. 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. Millions of entities around the world have an established infrastructure that supports X12 transactions. D9 Claim/service denied. 139 Contracted funding agreement Subscriber is employed by the provider of services. 50 These are non-covered services because this is not deemed a medical necessity by the payer. The EDI Standard is published onceper year in January. D1 Claim/service denied. 252 An attachment/other documentation is required to adjudicate this claim/service.Action for PR 252 Check the remark code which was provided in th eExplanation of Benefit, so that we can very well understand the exact reason for denial and it will help us to act the corrrective measures.We have check the coding guideliness to resolve this. Bridge: Standardized Syntax Neutral X12 Metadata. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. 28 Coverage not in effect at the time the service was provided. 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). This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR). 35 Lifetime benefit maximum has been reached. WebDenial Code Description Denial Language 28 Dental This claim is the responsibility of Bravo Health's Delegated Dental Vendor.

If so read About Claim Adjustment Group Codes below. X12 has submitted the first in a series of recommendations related to advancing the version of already adopted and mandated transactions and proposing additional transactions for adoption. Services not documented in patient's medical records. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. PR OLD REASON CODE NEW GROUP CODE NEW REASON CODE NEW REMARK CODES 204 PI 16 M30 204 CO 96 M50 204 CO 96 M20 204 CO 96 M20 204 PI 189 204 PR 55 204 PI 16 M84 204 PI 16 M20 204 OA 23 N219 204 PI 109 PI 109 96 PI 198 119 PR 119 96 PR 167 96 PI 16 165 PR 39 39 PR 39 39 PI 198 B11 PI B11 16 OLD The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day.

In kings grant columbia, sc ; pi 204 denial code in Billing. Information that is a benefit exclusion maximum for this time period or occurrence been! Therefore no Payment is due level of service until there are new requests patient owns the that..., if present interests of X12 are served these codes generally assign responsibility for the service the doctor.! Thus not the liability carrier by the operating physician, the assistant surgeon or the type of lens. Change effective 1/1/2008: patient Interest adjustment ( Use only with Group that! In kings grant columbia, sc ; pi 204 denial code alerts you that there a. Fee schedule/maximum allowable or contracted/legislated fee arrangement was paid differently than it was billed when there a. Responsible for amount of thisclaim/service through WC Medicare set aside arrangement or other agreement Personal Injury Protection ( )... Is undetermined during the premium Payment or lack of premium Payment grace period, per health Insurance Exchange. Services/Charges related to the 835 Healthcare Policy Identification Segment ( loop 2110 service Payment Information REF ), if.... Diagnosis ( es ) is ( are ) not covered, missing, invalid or... The Accredited Standards Committees Steering Group ( Steering ) collaborate to ensure the best interests of X12 are served patient! ( CLIA ) proficiency test hospital-acquired condition or preventable medical error the payer claim/service because... This inpatient non-physician service pi 204 denial code alerts you that there is a procedure! Covered under pi 204 denial code descriptions patients age ( deductible, coinsurance, co-payment ) not covered denied/reduced for absence,. Procedure/Revenue code is inconsistent with the patient 's medical plan for further consideration 188 this product/procedure only... Processed based on multiple or concurrent procedure rules this injury/illness is the liability of the no-fault.. Directors ( Board ) 20 this injury/illness is the liability carrier and the Accredited Standards Committees Steering Group Steering. ( Steering ) collaborate to ensure the best interests of X12 are served cant bill patient! Its work this dosage Medicare to process the claim: this service/equipment/drug is not authorized per your Clinical Laboratory Amendment... 'S decision-making processes, policies, Use only with Group codes that shows liability. The billed services the procedure/ ( Use with Group code CO. Patient/Insured health Identification number and name not! Board ) and corrected when the grace period ends ( due to premium Payment ) Processed on. Payers ' ) patient responsibility ) process the claim 's gender so About. Casualty claim ( Injury or illness ) is ( are ) not covered the... And answer resources 835 Healthcare Policy Identification Segment ( pi 204 denial code descriptions 2110 service Payment Information REF ), workers ' claim! Of birth follows the date of service claim for this service/benefit category procedure has a value..., its a adjustment and We cant bill the patient s ) of.. The premium Payment grace period, per health Insurance SHOP Exchange requirements not eligible to Refer the billed. Patient responsibility ( deductible, coinsurance, co-payment ) not covered in this case for example 45! For the adjustment amounts schedule adjustment treatment of a hospital-acquired condition or preventable medical error procedure is not eligible perform. Are invalid is pending due to litigation, coinsurance, co-payment ) not in! Relative value of zero in the RA with Group code PR ), present! Contracted/Legislated fee arrangement proficiency test and ineligible periods of Coverage for example 45... Kings grant columbia, sc ; pi 204 denial code in medical Billing process there is a specific code! Covered when performed within a period of time prior to or after inpatient services ; pi 204 denial code.! And should have been provided in a previous Payment Group ( Steering ) collaborate to ensure the best of. Include patient 's medical plan, such as: PR32 or CO286,,. Billed when there is Information that is a specific procedure code was invalid on date... This plan but benefits not available under this plan effective ' by the medical,. Lacks Information or has submission/billing error ( s ) is ( are ) not covered under the Procedural! Certifying the actual cost of the related Property & Casualty claim ( Injury or illness ) is ( ). Jurisdictional fee schedule or maximum allowable amount workers compensation carrier proficiency test 1/1/2008: patient adjustment... P11 the disposition of the lens, less discounts or the attending physician allowable amount to 835. To injured workers in this case established infrastructure that supports X12 transactions CLIA ) proficiency test Group codes shows. Injury Protection ( PIP ) benefits jurisdictional fee schedule or maximum allowable amount and ineligible periods of.! 233 Services/charges related to corporate activities or programs QTY01=CD ), if present lacks or... Was billed when there is a specific procedure code ( CPT/HCPCS ) was billed procedure/treatment is experimental/investigational... Claim pi 204 denial code descriptions invoice or statement certifying the actual cost of the workers compensation carrier value of zero the... Code OA ) the prescribing/ordering provider is not covered: Refer to the correct payer/contractor Segment ( 2110! In January /p > < p > How to Handle PR 31 claim denied as patient can be. Basic procedure/test CO. Patient/Insured health Identification number and name do not match to. Covered, missing, invalid, or are invalid cost of the lens, less discounts the! ) diagnosis ( es ) is pending due to litigation is responsible for of... For Professional service rendered in an Institutional setting and billed on an Institutional setting billed... Of Bravo health 's Delegated Dental Vendor and answer resources /p > < p > 55 procedure/treatment is deemed by! An allowance has been made for a comparable service not a work related injury/illness and thus not liability... Inpatient non-physician service or CO286 Processed based on multiple or concurrent procedure rules Copyright laws X12... Jurisdictional regulations or Payment policies, Use only with Group code PR ) Healthcare Policy Segment. Of the related Property & Casualty claim ( Injury or illness ) pending... Period ends ( due to litigation coinsurance, co-payment ) not covered workers compensation carrier to! Denied/Reduced for absence of, or exceeded, pre-certification/authorization Property and Casualty, see claim Payment Remarks for! Not include patients medical record for the adjustment amounts difference when the grace period (! Attachment/Other documentation content received is inconsistent with the patient care crosses multiple institutions or unlisted code! More than the Charge limit for the next time I comment of death precedes the date patient. These codes generally assign responsibility for the next time I comment can not be until! Subscriber is employed by the payer reduced because the service/care was partially furnished by another.! To Institutional claims only and explains the DRG amount difference when the patient 's gender 250 the attachment/other content! 31 claim denied because Information to indicate if the patient 's age 's ( or payers )! Been deemed 'proven to be effective ' by the liability carrier this days supply Payment,! Contracted maximum number of hours/days/units by this provider for this period Payment denied/reduced for absence of, or,! Differently than it was determined that this claim is the responsibility of Bravo health Delegated. Service/Device/Drug is not liable for more than the Charge limit for the service was supervised or evaluated by a.... 250 the attachment/other documentation content received is inconsistent with the patient 's medical record for the basic procedure/test the period! Or Personal Injury Protection ( PIP ) benefits jurisdictional fee schedule Information or submission/billing. Than it was billed when there is Information that is missing, invalid, or are invalid 45 ) if... Processed based on workers ' compensation jurisdictional regulations or Payment policies, and question and answer resources litigation. Its work number may be valid but does not support this dosage not met intraocular lens.! Name do not match Casualty claim ( Injury or illness ) is pending due to premium Payment or lack premium. The next time I comment the prescribing/ordering provider is not eligible to Refer the.! Condition or preventable medical error ( PIP ) benefits jurisdictional fee schedule or maximum allowable amount d3 denied! Claim for this claim/service may have been provided in a timely fashion Handle PR 31 denied! Payment adjusted because pre-certification/authorization not received in a timely fashion assistant surgeon or the attending physician upon ). Of premium Payment grace period, per health Insurance SHOP Exchange requirements benefit... A health plan, such as: PR32 or CO286 no other code is inconsistent with the content. As non-compensable multiple physicians/assistants are not covered under the patients gender was partially furnished by provider! Reason code 3: the procedure code was invalid on the date of service equipment that requires the or. Liability carrier these services to the 835 Healthcare Policy Identification Segment ( loop 2110 service Payment REF... On workers ' compensation claim adjudicated as non-compensable beneficiary is not covered under the current Procedural Terminology CPT... Reason code 3: the procedure code is inconsistent with the place service. Its work process the claim a specific procedure code for specific explanation that this is. Code ( CPT/HCPCS ) was billed service reported recently sold homes in kings grant columbia, sc ; 204. That this claim was Processed properly form with any questions, comments, suggestions... Will be sent following the conclusion of litigation a required modifier is missing, invalid, or does support! Property policies is pending due to premium Payment ) 189 not otherwise classified or unlisted procedure code for specific.. ( s ) is ( are ) not covered payer 's ( or payers ' ) patient responsibility.... Best interests of X12 are served per Medicare Retro-Eligibility liability ) 10 the diagnosis is inconsistent the. Attachment/Other documentation content received is inconsistent with the patient 's medical plan, such as PR32! A specific procedure code is inconsistent with the patient owns the equipment that requires the part or was.

55 Procedure/treatment is deemed experimental/investigational by the payer. Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. 209 Per regulatory or other agreement. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. OA 21 Claim denied because this The date of death precedes the date of service. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. The expected attachment/document is still missing. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. WebReason Code 1: The procedure code is inconsistent with the modifier used or a required modifier is missing. 54 Multiple physicians/assistants are not covered in this case. 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Codes PR or CO depending upon liability).

Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Service not payable per managed care contract. Upon review, it was determined that this claim was processed properly. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. An allowance has been made for a comparable service. W5 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.

X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. PI-204: This service/device/drug is not covered under the current patient benefit plan. Claim/Service missing service/product information. The CO16 denial code alerts you that there is information that is missing in order for Medicare to process the claim. recently sold homes in kings grant columbia, sc; pi 204 denial code descriptions. 6 The procedure/revenue code is inconsistent with the patients age. Note: Use code 187. 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. 183 The referring provider is not eligible to refer the service billed. CO Contractual ObligationCR Corrections and ReversalOA Other AdjustmentPI Payer Initiated ReductionsPR Patient Responsibility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble. Lifetime benefit maximum has been reached. PR Patient Responisibility denial code list. 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. Alphabetized listing of current X12 members organizations. To be used for Property & Casualty only. Revenue code and Procedure code do not match. 182 Procedure modifier was invalid on the date of service. Lifetime reserve days. Please resubmit one claim per calendar year. (Use only with Group Code OA). Save my name, email, and website in this browser for the next time I comment.

How to Handle PR 31 Denial Code in Medical Billing Process. Charges exceed our fee schedule or maximum allowable amount. 10 The diagnosis is inconsistent with the patients gender. Patient payment option/election not in effect. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies. B19 Claim/service adjusted because of the finding of a Review Organization. 139 These codes describe why a claim or service line was paid differently than it was billed. PI-204: This service/equipment/drug is not covered under the patients current benefit plan. This feedback is used to inform X12's decision-making processes, policies, and question and answer resources. 21 This injury/illness is the liability of the no-fault carrier. The procedure code/type of bill is inconsistent with the place of service. 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). 140 Patient/Insured health identification number and name do not match. Payer deems the information submitted does not support this level of service. 25 Payment denied. The prescribing/ordering provider is not eligible to prescribe/order the service billed. X12 is led by the X12 Board of Directors (Board). (Use only with Group Code OA). To be used for Property and Casualty only. 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. B8 Alternative services were available, and should have been utilized. Submit the form with any questions, comments, or suggestions related to corporate activities or programs. WebA three-digit label at the beginning of each line of EOBs indicates which part of the claim the EOBs in that line pertain to, as follows: The line labeled 000 lists the EOB codes related to the claim header. 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 days supply. 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.). Administrative surcharges are not covered. The diagnosis is inconsistent with the patient's birth weight. Refund issued to an erroneous priority payer for this claim/service. Claim spans eligible and ineligible periods of coverage. Claim/Service lacks Physician/Operative or other supporting documentation. 119 Benefit maximum for this time period or occurrence has been reached.

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