The system should contain all of the possible remarks codes supported by the 835 process and are used in the Negative Balance Report to provide a hover over description.  Many of the codes are currently Inactive.  Should you need to either add a new code or make an existing code active, this is where you would manage it.

ERA - Remarks Codes

Existing Remarks Codes

Edit: N301

Missing/incomplete/invalid procedure date(s).

Edit: N302

Missing/incomplete/invalid other procedure date(s).

Edit: N303

Missing/incomplete/invalid principal procedure date.

Edit: N304

Missing/incomplete/invalid dispensed date.

Edit: N305

Missing/incomplete/invalid injury/accident date.

Edit: N306

Missing/incomplete/invalid acute manifestation date.

Edit: N307

Missing/incomplete/invalid adjudication or payment date.

Edit: N308

Missing/incomplete/invalid appliance placement date.

Edit: N309

Missing/incomplete/invalid assessment date.

Edit: N31

Missing/incomplete/invalid prescribing provider identifier.

Edit: N310

Missing/incomplete/invalid assumed or relinquished care date.

Edit: N311

Missing/incomplete/invalid authorized to return to work date.

Edit: N312

Missing/incomplete/invalid begin therapy date.

Edit: N313

Missing/incomplete/invalid certification revision date.

Edit: N314

Missing/incomplete/invalid diagnosis date.

Edit: N315

Missing/incomplete/invalid disability from date.

Edit: N316

Missing/incomplete/invalid disability to date.

Edit: N317

Missing/incomplete/invalid discharge hour.

Edit: N318

Missing/incomplete/invalid discharge or end of care date.

Edit: N319

Missing/incomplete/invalid hearing or vision prescription date.

Edit: N32

Claim must be submitted by the provider who rendered the service.

Edit: N320

Missing/incomplete/invalid Home Health Certification Period.

Edit: N321

Missing/incomplete/invalid last admission period.

Edit: N322

Missing/incomplete/invalid last certification date.

Edit: N323

Missing/incomplete/invalid last contact date.

Edit: N324

Missing/incomplete/invalid last seen/visit date.

Edit: N325

Missing/incomplete/invalid last worked date.

Edit: N326

Missing/incomplete/invalid last x-ray date.

Edit: N327

Missing/incomplete/invalid other insured birth date.

Edit: N328

Missing/incomplete/invalid Oxygen Saturation Test date.

Edit: N329

Missing/incomplete/invalid patient birth date.

Edit: N33

No record of health check prior to initiation of treatment.

Edit: N330

Missing/incomplete/invalid patient death date.

Edit: N331

Missing/incomplete/invalid physician order date.

Edit: N332

Missing/incomplete/invalid prior hospital discharge date.

Edit: N333

Missing/incomplete/invalid prior placement date.

Edit: N334

Missing/incomplete/invalid re-evaluation date.

Edit: N335

Missing/incomplete/invalid referral date.

Edit: N336

Missing/incomplete/invalid replacement date.

Edit: N337

Missing/incomplete/invalid secondary diagnosis date.

Edit: N338

Missing/incomplete/invalid shipped date.

Edit: N339

Missing/incomplete/invalid similar illness or symptom date.

Edit: N34

Incorrect claim form/format for this service.

Edit: N340

Missing/incomplete/invalid subscriber birth date.

Edit: N341

Missing/incomplete/invalid surgery date.

Edit: N342

Missing/incomplete/invalid test performed date.

Edit: N343

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.

Edit: N344

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.

Edit: N345

Date range not valid with units submitted.

Edit: N346

Missing/incomplete/invalid oral cavity designation code.

Edit: N347

Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

Edit: N348

You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.

Edit: N349

The administration method and drug must be reported to adjudicate this service.

Edit: N35

Program integrity/utilization review decision.

Edit: N350

Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.

Edit: N351

Service date outside of the approved treatment plan service dates.

Edit: N352
Edit: N353
Edit: N354

Incomplete/invalid invoice.

Edit: N355
Edit: N356

Not covered when performed with, or subsequent to, a non-covered service.

Edit: N357

Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.

Edit: N358
Edit: N359

Missing/incomplete/invalid height.

Edit: N36
Edit: N360
Edit: N362

The number of Days or Units of Service exceeds our acceptable maximum.

Edit: N363
Edit: N364
Edit: N366

Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.

Edit: N367
Edit: N368

You must appeal the determination of the previously adjudicated claim.

Edit: N369
Edit: N37

Missing/incomplete/invalid tooth number/letter.

Edit: N370

Billing exceeds the rental months covered/approved by the payer.

Edit: N371
Edit: N372

Only reasonable and necessary maintenance/service charges are covered.

Edit: N373

It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.

Edit: N374

Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.

Edit: N375

Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.

Edit: N376

Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.

Edit: N377

Payment based on a processed replacement claim.

Edit: N378

Missing/incomplete/invalid prescription quantity.

Edit: N379

Claim level information does not match line level information.

Edit: N380

The original claim has been processed, submit a corrected claim.

Edit: N381
Edit: N382

Missing/incomplete/invalid patient identifier.

Edit: N383

Not covered when deemed cosmetic.

Edit: N384

Records indicate that the referenced body part/tooth has been removed in a previous procedure.

Edit: N385

Notification of admission was not timely according to published plan procedures.

Edit: N386

This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

Edit: N387
Edit: N388

Missing/incomplete/invalid prescription number.

Edit: N389

Duplicate prescription number submitted.

Edit: N39

Procedure code is not compatible with tooth number/letter.

Edit: N390

This service/report cannot be billed separately.

Edit: N391

Missing emergency department records.

Edit: N392

Incomplete/invalid emergency department records.

Edit: N393

Missing progress notes/report.

Edit: N394

Incomplete/invalid progress notes/report.

Edit: N395

Missing laboratory report.

Edit: N396

Incomplete/invalid laboratory report.

Edit: N397

Benefits are not available for incomplete service(s)/undelivered item(s).

Edit: N398

Missing elective consent form.

Edit: N399

Incomplete/invalid elective consent form.

Edit: N4

Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.

Edit: N40

Missing radiology film(s)/image(s).

Edit: N400
Edit: N401

Missing periodontal charting.

Edit: N402

Incomplete/invalid periodontal charting.

Edit: N403

Missing facility certification.

Edit: N404

Incomplete/invalid facility certification.

Edit: N405

This service is only covered when the donor’s insurer(s) do not provide coverage for the service.

Edit: N406

This service is only covered when the recipient’s insurer(s) do not provide coverage for the service.

Edit: N407

You are not an approved submitter for this transmission format.

Edit: N408

This payer does not cover deductibles assessed by a previous payer.

Edit: N409

This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.

Edit: N410

Not covered unless the prescription changes.

Edit: N411

This service is allowed one time in a 6-month period.

Edit: N412

This service is allowed 2 times in a 12-month period.

Edit: N413

This service is allowed 2 times in a benefit year.

Edit: N414

This service is allowed 4 times in a 12-month period.

Edit: N415

This service is allowed 1 time in an 18-month period.

Edit: N416

This service is allowed 1 time in a 3-year period.

Edit: N417

This service is allowed 1 time in a 5-year period.

Edit: N418

Misrouted claim. See the payer’s claim submission instructions.

Edit: N419

Claim payment was the result of a payer’s retroactive adjustment due to a retroactive rate change.

Edit: N42

Missing mental health assessment.

Edit: N420

Claim payment was the result of a payer’s retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.

Edit: N421

Claim payment was the result of a payer’s retroactive adjustment due to a review organization decision.

Edit: N422

Claim payment was the result of a payer’s retroactive adjustment due to a payer’s contract incentive program.

Edit: N423

Claim payment was the result of a payer’s retroactive adjustment due to a non standard program.

Edit: N424

Patient does not reside in the geographic area required for this type of payment.

Edit: N425

Statutorily excluded service(s).

Edit: N426

No coverage when self-administered.

Edit: N427

Payment for eyeglasses or contact lenses can be made only after cataract surgery.

Edit: N428

Not covered when performed in this place of service.

Edit: N429

Not covered when considered routine.

Edit: N43

Bed hold or leave days exceeded.

Edit: N430

Procedure code is inconsistent with the units billed.

Edit: N431

Not covered with this procedure.

Edit: N432
Edit: N433

Resubmit this claim using only your National Provider Identifier (NPI).

Edit: N434

Missing/Incomplete/Invalid Present on Admission indicator.

Edit: N435

Exceeds number/frequency approved /allowed within time period without support documentation.

Edit: N436

The injury claim has not been accepted and a mandatory medical reimbursement has been made.

Edit: N437
Edit: N438

This jurisdiction only accepts paper claims.

Edit: N439

Missing anesthesia physical status report/indicators.

Edit: N440

Incomplete/invalid anesthesia physical status report/indicators.

Edit: N441

This missed/cancelled appointment is not covered.

Edit: N442

Payment based on an alternate fee schedule.

Edit: N443

Missing/incomplete/invalid total time or begin/end time.

Edit: N444
Edit: N445

Missing document for actual cost or paid amount.

Edit: N446

Incomplete/invalid document for actual cost or paid amount.

Edit: N447

Payment is based on a generic equivalent as required documentation was not provided.

Edit: N448

This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.

Edit: N449

Payment based on a comparable drug/service/supply.

Edit: N45

Payment based on authorized amount.

Edit: N450

Covered only when performed by the primary treating physician or the designee.

Edit: N451

Missing Admission Summary Report.

Edit: N452

Incomplete/invalid Admission Summary Report.

Edit: N453

Missing Consultation Report.

Edit: N454

Incomplete/invalid Consultation Report.

Edit: N455

Missing Physician Order.

Edit: N456

Incomplete/invalid Physician Order.

Edit: N457

Missing Diagnostic Report.

Edit: N458

Incomplete/invalid Diagnostic Report.

Edit: N459

Missing Discharge Summary.

Edit: N46

Missing/incomplete/invalid admission hour.

Edit: N460

Incomplete/invalid Discharge Summary.

Edit: N461

Missing Nursing Notes.

Edit: N462

Incomplete/invalid Nursing Notes.

Edit: N463

Missing support data for claim.

Edit: N464

Incomplete/invalid support data for claim.

Edit: N465

Missing Physical Therapy Notes/Report.

Edit: N466

Incomplete/invalid Physical Therapy Notes/Report.

Edit: N467

Missing Tests and Analysis Report.

Edit: N468

Incomplete/invalid Report of Tests and Analysis Report.

Edit: N469
Edit: N47

Claim conflicts with another inpatient stay.

Edit: N470

This payment will complete the mandatory medical reimbursement limit.

Edit: N471

Missing/incomplete/invalid HIPPS Rate Code.

Edit: N472

Payment for this service has been issued to another provider.

Edit: N473

Missing certification.

Edit: N474

Incomplete/invalid certification.

Edit: N475

Missing completed referral form.

Edit: N476

Incomplete/invalid completed referral form.

Edit: N477

Missing Dental Models.

Edit: N478

Incomplete/invalid Dental Models.

Edit: N479

Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: N48

Claim information does not agree with information received from other insurance carrier.

Edit: N480

Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: N481

Missing Models.

Edit: N482

Incomplete/invalid Models.

Edit: N485

Missing Physical Therapy Certification.

Edit: N486

Incomplete/invalid Physical Therapy Certification.

Edit: N487

Missing Prosthetics or Orthotics Certification.

Edit: N488

Incomplete/invalid Prosthetics or Orthotics Certification.

Edit: N489

Missing referral form.

Edit: N49

Court ordered coverage information needs validation.

Edit: N490

Incomplete/invalid referral form.

Edit: N491

Missing/Incomplete/Invalid Exclusionary Rider Condition.

Edit: N492
Edit: N493

Missing Doctor First Report of Injury.

Edit: N494

Incomplete/invalid Doctor First Report of Injury.

Edit: N495

Missing Supplemental Medical Report.

Edit: N496

Incomplete/invalid Supplemental Medical Report.

Edit: N497

Missing Medical Permanent Impairment or Disability Report.

Edit: N498

Incomplete/invalid Medical Permanent Impairment or Disability Report.

Edit: N499

Missing Medical Legal Report.

Edit: N5

EOB received from previous payer. Claim not on file.

Edit: N50

Missing/incomplete/invalid discharge information.

Edit: N500

Incomplete/invalid Medical Legal Report.

Edit: N501

Missing Vocational Report.

Edit: N502

Incomplete/invalid Vocational Report.

Edit: N503

Missing Work Status Report.

Edit: N504

Incomplete/invalid Work Status Report.

Edit: N505
Edit: N506
Edit: N507

Plan distance requirements have not been met.

Edit: N508
Edit: N509
Edit: N51

Electronic interchange agreement not on file for provider/submitter.

Edit: N510
Edit: N511
Edit: N512
Edit: N513
Edit: N516

Records indicate a mismatch between the submitted NPI and EIN.

Edit: N517

Resubmit a new claim with the requested information.

Edit: N518

No separate payment for accessories when furnished for use with oxygen equipment.

Edit: N519

Invalid combination of HCPCS modifiers.

Edit: N52

Patient not enrolled in the billing provider’s managed care plan on the date of service.

Edit: N520
Edit: N521

Mismatch between the submitted provider information and the provider information stored in our system.

Edit: N522

Duplicate of a claim processed, or to be processed, as a crossover claim.

Edit: N523

The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.

Edit: N524

Based on policy this payment constitutes payment in full.

Edit: N525

These services are not covered when performed within the global period of another service.

Edit: N526

Not qualified for recovery based on employer size.

Edit: N527

We processed this claim as the primary payer prior to receiving the recovery demand.

Edit: N528

Patient is entitled to benefits for Institutional Services only.

Edit: N529

Patient is entitled to benefits for Professional Services only.

Edit: N53

Missing/incomplete/invalid point of pick-up address.

Edit: N530

Not Qualified for Recovery based on enrollment information.

Edit: N531

Not qualified for recovery based on direct payment of premium.

Edit: N532

Not qualified for recovery based on disability and working status.

Edit: N533

Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.

Edit: N534

This is an individual policy, the employer does not participate in plan sponsorship.

Edit: N535

Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.

Edit: N536

We are not changing the prior payer’s determination of patient responsibility, which you may collect, as this service is not covered by us.

Edit: N537

We have examined claims history and no records of the services have been found.

Edit: N538

A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.

Edit: N539
Edit: N54

Claim information is inconsistent with pre-certified/authorized services.

Edit: N540

Payment adjusted based on the interrupted stay policy.

Edit: N541

Mismatch between the submitted insurance type code and the information stored in our system.

Edit: N542

Missing income verification.

Edit: N543

Incomplete/invalid income verification.

Edit: N544
Edit: N545

Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.

Edit: N546

Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.

Edit: N547

A refund request (Frequency Type Code 8) was processed previously.

Edit: N548
Edit: N549
Edit: N55

Procedures for billing with group/referring/performing providers were not followed.

Edit: N550
Edit: N551

Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.

Edit: N552

Payment adjusted to reverse a previous withhold/bonus amount.

Edit: N554

Missing/Incomplete/Invalid Family Planning Indicator.

Edit: N555

Missing medication list.

Edit: N556

Incomplete/invalid medication list.

Edit: N557

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.

Edit: N558

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.

Edit: N559

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.

Edit: N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.

Edit: N560

The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.

Edit: N561

The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.

Edit: N562

The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.

Edit: N563
Edit: N564

Patient did not meet the inclusion criteria for the demonstration project or pilot program.

Edit: N565
Edit: N566
Edit: N567

Not covered when considered preventative.

Edit: N568
Edit: N569

Not covered when performed for the reported diagnosis.

Edit: N57

Missing/incomplete/invalid prescribing date.

Edit: N570

Missing/incomplete/invalid credentialing data.

Edit: N571
Edit: N572

This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.

Edit: N573
Edit: N574

Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

Edit: N575

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

Edit: N576

Services not related to the specific incident/claim/accident/loss being reported.

Edit: N577

Personal Injury Protection (PIP) Coverage.

Edit: N578

Coverages do not apply to this loss.

Edit: N579

Medical Payments Coverage (MPC).

Edit: N58

Missing/incomplete/invalid patient liability amount.

Edit: N580

Determination based on the provisions of the insurance policy.

Edit: N581

Investigation of coverage eligibility is pending.

Edit: N582

Benefits suspended pending the patient’s cooperation.

Edit: N583

Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.

Edit: N584

Not covered based on the insured’s noncompliance with policy or statutory conditions.

Edit: N585

Benefits are no longer available based on a final injury settlement.

Edit: N586

The injured party does not qualify for benefits.

Edit: N587

Policy benefits have been exhausted.

Edit: N588

The patient has instructed that medical claims/bills are not to be paid.

Edit: N589

Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.

Edit: N59
Edit: N590

Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.

Edit: N591

Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).

Edit: N592

Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.

Edit: N593

Not covered based on failure to attend a scheduled Independent Medical Exam (IME).

Edit: N594

Records reflect the injured party did not complete an Application for Benefits for this loss.

Edit: N595

Records reflect the injured party did not complete an Assignment of Benefits for this loss.

Edit: N596

Records reflect the injured party did not complete a Medical Authorization for this loss.

Edit: N597

Adjusted based on a medical/dental provider’s apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.

Edit: N598

Health care policy coverage is primary.

Edit: N599

Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered.

Edit: N6

Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.

Edit: N600

Adjusted based on the applicable fee schedule for the region in which the service was rendered.

Edit: N601

In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.

Edit: N602

Adjusted based on the Redbook maximum allowance.

Edit: N603

This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.

Edit: N604

In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers’ Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.

Edit: N605

This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.

Edit: N606

The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

Edit: N607

Service provided for non-compensable condition(s).

Edit: N608

The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.

Edit: N609

80% of the provider’s billed amount is being recommended for payment according to Act 6.

Edit: N61

Rebill services on separate claims.

Edit: N610
Edit: N611

Claim in litigation. Contact insurer for more information.

Edit: N612

Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.

Edit: N613
Edit: N614
Edit: N615
Edit: N616
Edit: N617

This enrollee is in the second or third month of the advance premium tax credit grace period.

Edit: N618
Edit: N619

Coverage terminated for non-payment of premium.

Edit: N62

Dates of service span multiple rate periods. Resubmit separate claims.

Edit: N620
Edit: N621

Charges for Jurisdiction required forms, reports, or chart notes are not payable.

Edit: N622

Not covered based on the date of injury/accident.

Edit: N623

Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.

Edit: N624

The associated Workers’ Compensation claim has been withdrawn.

Edit: N625

Missing/Incomplete/Invalid Workers’ Compensation Claim Number.

Edit: N626

New or established patient E/M codes are not payable with chiropractic care codes.

Edit: N628

Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.

Edit: N629

Reviews/documentation/notes/summaries/reports/charts not requested.

Edit: N63

Rebill services on separate claim lines.

Edit: N630

Referral not authorized by attending physician.

Edit: N631

Medical Fee Schedule does not list this code. An allowance was made for a comparable service.

Edit: N633

Additional anesthesia time units are not allowed.

Edit: N634

The allowance is calculated based on anesthesia time units.

Edit: N635

The Allowance is calculated based on the anesthesia base units plus time.

Edit: N636

Adjusted because this is reimbursable only once per injury.

Edit: N637

Consultations are not allowed once treatment has been rendered by the same provider.

Edit: N638

Reimbursement has been made according to the home health fee schedule.

Edit: N639

Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.

Edit: N64
Edit: N640

Exceeds number/frequency approved/allowed within time period.

Edit: N641

Reimbursement has been based on the number of body areas rated.

Edit: N642

Adjusted when billed as individual tests instead of as a panel.

Edit: N643

The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.

Edit: N644

Reimbursement has been made according to the bilateral procedure rule.

Edit: N645

Mark-up allowance.

Edit: N646

Reimbursement has been adjusted based on the guidelines for an assistant.

Edit: N647

Adjusted based on diagnosis-related group (DRG).

Edit: N648

Adjusted based on Stop Loss.

Edit: N649

Payment based on invoice.

Edit: N65

Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.

Edit: N650

This policy was not in effect for this date of loss. No coverage is available.

Edit: N651

No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.

Edit: N652

The date of service is before the date of loss.

Edit: N653

The date of injury does not match the reported date of loss.

Edit: N654

Adjusted based on achievement of maximum medical improvement (MMI).

Edit: N655

Payment based on provider’s geographic region.

Edit: N656

An interest payment is being made because benefits are being paid outside the statutory requirement.

Edit: N657

This should be billed with the appropriate code for these services.

Edit: N658

The billed service(s) are not considered medical expenses.

Edit: N659

This item is exempt from sales tax.

Edit: N660

Sales tax has been included in the reimbursement.

Edit: N661

Documentation does not support that the services rendered were medically necessary.

Edit: N662
Edit: N663

Adjusted based on an agreed amount.

Edit: N664

Adjusted based on a legal settlement.

Edit: N665

Services by an unlicensed provider are not reimbursable.

Edit: N666

Only one evaluation and management code at this service level is covered during the course of care.

Edit: N667

Missing prescription.

Edit: N668

Incomplete/invalid prescription.

Edit: N669

Adjusted based on the Medicare fee schedule.

Edit: N67
Edit: N670

This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

Edit: N671

Payment based on a jurisdiction cost-charge ratio.

Edit: N672
Edit: N673

Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.

Edit: N674

Not covered unless a pre-requisite procedure/service has been provided.

Edit: N675

Additional information is required from the injured party.

Edit: N676

Service does not qualify for payment under the Outpatient Facility Fee Schedule.

Edit: N677
Edit: N678

Missing post-operative images/visual field results.

Edit: N679

Incomplete/Invalid post-operative images/visual field results.

Edit: N68

Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.

Edit: N680

Missing/Incomplete/Invalid date of previous dental extractions.

Edit: N681

Missing/Incomplete/Invalid full arch series.

Edit: N682

Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.

Edit: N683

Missing/Incomplete/Invalid prior treatment documentation.

Edit: N684

Payment denied as this is a specialty claim submitted as a general claim.

Edit: N685

Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.

Edit: N686

Missing/incomplete/Invalid questionnaire needed to complete payment determination.

Edit: N687
Edit: N688
Edit: N689
Edit: N69
Edit: N690
Edit: N691
Edit: N692
Edit: N693
Edit: N694
Edit: N695
Edit: N696
Edit: N697
Edit: N698
Edit: N699

Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.

Edit: N7
Edit: N70

Consolidated billing and payment applies.

Edit: N700

Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.

Edit: N701

Payment adjusted based on the Value-based Payment Modifier.

Edit: N702

Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.

Edit: N703

This service is incompatible with previously adjudicated claims or claims in process.

Edit: N704
Edit: N705

Incomplete/invalid documentation.

Edit: N706

Missing documentation.

Edit: N707

Incomplete/invalid orders.

Edit: N708

Missing orders.

Edit: N709

Incomplete/invalid notes.

Edit: N71

Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.

Edit: N710

Missing notes.

Edit: N711

Incomplete/invalid summary.

Edit: N712

Missing summary.

Edit: N713

Incomplete/invalid report.

Edit: N714

Missing report.

Edit: N715

Incomplete/invalid chart.

Edit: N716

Missing chart.

Edit: N717

Incomplete/Invalid documentation of face-to-face examination.

Edit: N718

Missing documentation of face-to-face examination.

Edit: N719

Penalty applied based on plan requirements not being met.

Edit: N72

PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.

Edit: N720
Edit: N721

This service is only covered when performed as part of a clinical trial.

Edit: N722

Patient must use Workers’ Compensation Set-Aside (WCSA) funds to pay for the medical service or item.

Edit: N723

Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.

Edit: N724

Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.

Edit: N725

A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: N726

A conditional payment is not allowed.

Edit: N727

A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: N728

A workers’ compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: N729

Missing patient medical/dental record for this service.

Edit: N730

Incomplete/invalid patient medical/dental record for this service.

Edit: N731

Incomplete/Invalid mental health assessment.

Edit: N732

Services performed at an unlicensed facility are not reimbursable.

Edit: N733

Regulatory surcharges are paid directly to the state.

Edit: N734

The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.

Edit: N736

Incomplete/invalid Sleep Study Report.

Edit: N737

Missing Sleep Study Report.

Edit: N738

Incomplete/invalid Vein Study Report.

Edit: N739

Missing Vein Study Report.

Edit: N74

Resubmit with multiple claims, each claim covering services provided in only one calendar month.

Edit: N740

The member’s Consumer Spending Account does not contain sufficient funds to cover the member’s liability for this claim/service.

Edit: N741

This is a site neutral payment.

Edit: N743

Adjusted because the services may be related to an employment accident.

Edit: N744

Adjusted because the services may be related to an auto/other accident.

Edit: N745

Missing Ambulance Report.

Edit: N746

Incomplete/invalid Ambulance Report.

Edit: N747

This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.

Edit: N748

Adjusted because the related hospital charges have not been received.

Edit: N749

Missing Blood Gas Report.

Edit: N75

Missing/incomplete/invalid tooth surface information.

Edit: N750

Incomplete/invalid Blood Gas Report.

Edit: N751

Adjusted because the patient is covered under a Medicare Part D plan.

Edit: N752

Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).

Edit: N753

Missing/incomplete/invalid Attachment Control Number.

Edit: N754

Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.

Edit: N755

Missing/incomplete/invalid ICD Indicator.

Edit: N756

Missing/incomplete/invalid point of drop-off address.

Edit: N757

Adjusted based on the Federal Indian Fees schedule (MLR).

Edit: N758

Adjusted based on the prior authorization decision.

Edit: N759

Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.

Edit: N76

Missing/incomplete/invalid number of riders.

Edit: N760

This facility is not authorized to receive payment for the service(s).

Edit: N761

This provider is not authorized to receive payment for the service(s).

Edit: N762

This facility is not certified for Tomosynthesis (3-D) mammography.

Edit: N763

The demonstration code is not appropriate for this claim; resubmit without a demonstration code.

Edit: N764

Missing/incomplete/invalid Hematocrit (HCT) value.

Edit: N765

This payer does not cover co-insurance assessed by a previous payer.

Edit: N766

This payer does not cover co-payment assessed by a previous payer.

Edit: N767
Edit: N768

Incomplete/invalid initial evaluation report.

Edit: N769

A lateral diagnosis is required.

Edit: N77

Missing/incomplete/invalid designated provider number.

Edit: N770

The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the information received.

Edit: N771
Edit: N772
Edit: N773

Drug supplied not obtained from specialty vendor.

Edit: N774
Edit: N775

Payment adjusted based on x-ray radiograph on film.

Edit: N776

This service is not a covered Telehealth service.

Edit: N777

Missing Assignment of Benefits Indicator.

Edit: N778

Missing Primary Care Physician Information.

Edit: N779

Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is received.

Edit: N78

The necessary components of the child and teen checkup (EPSDT) were not completed.

Edit: N780

Missing/incomplete/invalid end therapy date.

Edit: N781
Edit: N782
Edit: N783
Edit: N784

Missing comprehensive procedure code.

Edit: N785

Missing current radiology film/images.

Edit: N786

Benefit limitation for the orthodontic active and/or retention phase of treatment.

Edit: N787
Edit: N788

The third party administrator/review organization did not receive the requested information.

Edit: N789

Clinical Trial is not a covered benefit.

Edit: N79

Service billed is not compatible with patient location information.

Edit: N790

Provider/supplier not accredited for product/service.

Edit: N791

Missing history & physical report.

Edit: N792

Incomplete/invalid history & physical report.

Edit: N793
Edit: N794

Payment adjusted based on type of technology used.

Edit: N8

Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.

Edit: N80

Missing/incomplete/invalid prenatal screening information.

Edit: N81

Procedure billed is not compatible with tooth surface code.

Edit: N82

Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.

Edit: N83

No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

Edit: N84
Edit: N85
Edit: N86

A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.

Edit: N87

Home use of biofeedback therapy is not covered.

Edit: N88
Edit: N89
Edit: N9

Adjustment represents the estimated amount a previous payer may pay.

Edit: N90

Covered only when performed by the attending physician.

Edit: N91

Services not included in the appeal review.

Edit: N92

This facility is not certified for digital mammography.

Edit: N93

A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.

Edit: N94

Claim/Service denied because a more specific taxonomy code is required for adjudication.

Edit: N95

This provider type/provider specialty may not bill this service.

Edit: N96

Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.

Edit: N97

Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.

Edit: N98

Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.

Edit: N99

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Edit: HE-M10

Equipment purchases are limited to the first or the tenth month of medical necessity.

Edit: HE-M100

We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.

Edit: HE-M102

Service not performed on equipment approved by the FDA for this purpose.

Edit: HE-M103

Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.

Edit: HE-M104

Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.

Edit: HE-M105

Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.

Edit: HE-M107

Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.

Edit: HE-M109

We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.

Edit: HE-M11

DME, orthotics and prosthetics must be billed to the DME carrier who services the patient’s zip code.

Edit: HE-M111

We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.

Edit: HE-M112

Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.

Edit: HE-M113

Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.

Edit: HE-M114

This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.

Edit: HE-M115

This item is denied when provided to this patient by a non-contract or non-demonstration supplier.

Edit: HE-M116

Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program.

Edit: HE-M117

Not covered unless submitted via electronic claim.

Edit: HE-M119

Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).

Edit: HE-M12

Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.

Edit: HE-M121

We pay for this service only when performed with a covered cryosurgical ablation.

Edit: HE-M122

Missing/incomplete/invalid level of subluxation.

Edit: HE-M123

Missing/incomplete/invalid name, strength, or dosage of the drug furnished.

Edit: HE-M124

Missing indication of whether the patient owns the equipment that requires the part or supply.

Edit: HE-M125

Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.

Edit: HE-M126

Missing/incomplete/invalid individual lab codes included in the test.

Edit: HE-M127

Missing patient medical record for this service.

Edit: HE-M129

Missing/incomplete/invalid indicator of x-ray availability for review.

Edit: HE-M13

Only one initial visit is covered per specialty per medical group.

Edit: HE-M130

Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Edit: HE-M131

Missing physician financial relationship form.

Edit: HE-M132

Missing pacemaker registration form.

Edit: HE-M133

Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.

Edit: HE-M134

Performed by a facility/supplier in which the provider has a financial interest.

Edit: HE-M135

Missing/incomplete/invalid plan of treatment.

Edit: HE-M136

Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.

Edit: HE-M137

Part B coinsurance under a demonstration project or pilot program.

Edit: HE-M138

Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.

Edit: HE-M139

Denied services exceed the coverage limit for the demonstration.

Edit: HE-M14

No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.

Edit: HE-M141

Missing physician certified plan of care.

Edit: HE-M142

Missing American Diabetes Association Certificate of Recognition.

Edit: HE-M143

The provider must update license information with the payer.

Edit: HE-M144

Pre-/post-operative care payment is included in the allowance for the surgery/procedure.

Edit: HE-M15

Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

Edit: HE-M16
Edit: HE-M17
Edit: HE-M18

Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient’s home.

Edit: HE-M19

Missing oxygen certification/re-certification.

Edit: HE-M2

Not paid separately when the patient is an inpatient.

Edit: HE-M20

Missing/incomplete/invalid HCPCS.

Edit: HE-M21

Missing/incomplete/invalid place of residence for this service/item provided in a home.

Edit: HE-M22

Missing/incomplete/invalid number of miles traveled.

Edit: HE-M23

Missing invoice.

Edit: HE-M24

Missing/incomplete/invalid number of doses per vial.

Edit: HE-M25

The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.

Edit: HE-M26
Edit: HE-M27
Edit: HE-M28

This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.

Edit: HE-M29

Missing operative note/report.

Edit: HE-M3

Equipment is the same or similar to equipment already being used.

Edit: HE-M30

Missing pathology report.

Edit: HE-M31

Missing radiology report.

Edit: HE-M32
Edit: HE-M36

This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.

Edit: HE-M37

Not covered when the patient is under age 35.

Edit: HE-M38
Edit: HE-M39
Edit: HE-M4
Edit: HE-M40

Claim must be assigned and must be filed by the practitioner’s employer.

Edit: HE-M41

We do not pay for this as the patient has no legal obligation to pay for this.

Edit: HE-M42

The medical necessity form must be personally signed by the attending physician.

Edit: HE-M44

Missing/incomplete/invalid condition code.

Edit: HE-M45

Missing/incomplete/invalid occurrence code(s).

Edit: HE-M46

Missing/incomplete/invalid occurrence span code(s).

Edit: HE-M47

Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN).

Edit: HE-M49

Missing/incomplete/invalid value code(s) or amount(s).

Edit: HE-M5

Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.

Edit: HE-M50

Missing/incomplete/invalid revenue code(s).

Edit: HE-M51

Missing/incomplete/invalid procedure code(s).

Edit: HE-M52
Edit: HE-M53

Missing/incomplete/invalid days or units of service.

Edit: HE-M54

Missing/incomplete/invalid total charges.

Edit: HE-M55

We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.

Edit: HE-M56

Missing/incomplete/invalid payer identifier.

Edit: HE-M59
Edit: HE-M6
Edit: HE-M60

Missing Certificate of Medical Necessity.

Edit: HE-M61

We cannot pay for this as the approval period for the FDA clinical trial has expired.

Edit: HE-M62

Missing/incomplete/invalid treatment authorization code.

Edit: HE-M64

Missing/incomplete/invalid other diagnosis.

Edit: HE-M65

One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.

Edit: HE-M66

Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.

Edit: HE-M67

Missing/incomplete/invalid other procedure code(s).

Edit: HE-M69

Paid at the regular rate as you did not submit documentation to justify the modified procedure code.

Edit: HE-M7

No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price.

Edit: HE-M70
Edit: HE-M71

Total payment reduced due to overlap of tests billed.

Edit: HE-M73

The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.

Edit: HE-M74

This service does not qualify for a HPSA/Physician Scarcity bonus payment.

Edit: HE-M75

Multiple automated multichannel tests performed on the same day combined for payment.

Edit: HE-M76

Missing/incomplete/invalid diagnosis or condition.

Edit: HE-M77

Missing/incomplete/invalid/inappropriate place of service.

Edit: HE-M79

Missing/incomplete/invalid charge.

Edit: HE-M8

We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.

Edit: HE-M80

Not covered when performed during the same session/date as a previously processed service for the patient.

Edit: HE-M81

You are required to code to the highest level of specificity.

Edit: HE-M82

Service is not covered when patient is under age 50.

Edit: HE-M83

Service is not covered unless the patient is classified as at high risk.

Edit: HE-M84

Medical code sets used must be the codes in effect at the time of service.

Edit: HE-M85

Subjected to review of physician evaluation and management services.

Edit: HE-M86

Service denied because payment already made for same/similar procedure within set time frame.

Edit: HE-M87

Claim/service(s) subjected to CFO-CAP prepayment review.

Edit: HE-M89

Not covered more than once under age 40.

Edit: HE-M9
Edit: HE-M90

Not covered more than once in a 12 month period.

Edit: HE-M91

Lab procedures with different CLIA certification numbers must be billed on separate claims.

Edit: HE-M93

Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.

Edit: HE-M94

Information supplied does not support a break in therapy. A new capped rental period will not begin.

Edit: HE-M95

Services subjected to Home Health Initiative medical review/cost report audit.

Edit: HE-M96

The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.

Edit: HE-M97

Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.

Edit: HE-M99

Missing/incomplete/invalid Universal Product Number/Serial Number.

Edit: HE-MA01
Edit: HE-MA02
Edit: HE-MA04

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

Edit: HE-MA07
Edit: HE-MA08
Edit: HE-MA09
Edit: HE-MA10
Edit: HE-MA100

Missing/incomplete/invalid date of current illness or symptoms.

Edit: HE-MA103

Hemophilia Add On.

Edit: HE-MA106

PIP (Periodic Interim Payment) claim.

Edit: HE-MA107

Paper claim contains more than three separate data items in field 19.

Edit: HE-MA108

Paper claim contains more than one data item in field 23.

Edit: HE-MA109

Claim processed in accordance with ambulatory surgical guidelines.

Edit: HE-MA110

Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.

Edit: HE-MA111

Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory’s name and address.

Edit: HE-MA112

Missing/incomplete/invalid group practice information.

Edit: HE-MA113

Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.

Edit: HE-MA114

Missing/incomplete/invalid information on where the services were furnished.

Edit: HE-MA115

Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).

Edit: HE-MA116

Did not complete the statement ‘Homebound’ on the claim to validate whether laboratory services were performed at home or in an institution.

Edit: HE-MA117

This claim has been assessed a $1.00 user fee.

Edit: HE-MA118
Edit: HE-MA12

You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).

Edit: HE-MA120

Missing/incomplete/invalid CLIA certification number.

Edit: HE-MA121

Missing/incomplete/invalid x-ray date.

Edit: HE-MA122

Missing/incomplete/invalid initial treatment date.

Edit: HE-MA123

Your center was not selected to participate in this study, therefore, we cannot pay for these services.

Edit: HE-MA125

Per legislation governing this program, payment constitutes payment in full.

Edit: HE-MA126

Pancreas transplant not covered unless kidney transplant performed.

Edit: HE-MA128

Missing/incomplete/invalid FDA approval number.

Edit: HE-MA13
Edit: HE-MA130

Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Edit: HE-MA131

Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.

Edit: HE-MA132

Adjustment to the pre-demonstration rate.

Edit: HE-MA133

Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.

Edit: HE-MA134

Missing/incomplete/invalid provider number of the facility where the patient resides.

Edit: HE-MA14
Edit: HE-MA15
Edit: HE-MA16

The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.

Edit: HE-MA17

We are the primary payer and have paid at the primary rate. You must contact the patient’s other insurer to refund any excess it may have paid due to its erroneous primary payment.

Edit: HE-MA18
Edit: HE-MA19
Edit: HE-MA20

Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.

Edit: HE-MA21

SSA records indicate mismatch with name and sex.

Edit: HE-MA22

Payment of less than $1.00 suppressed.

Edit: HE-MA23

Demand bill approved as result of medical review.

Edit: HE-MA24

Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.

Edit: HE-MA25

A patient may not elect to change a hospice provider more than once in a benefit period.

Edit: HE-MA26
Edit: HE-MA27

Missing/incomplete/invalid entitlement number or name shown on the claim.

Edit: HE-MA28
Edit: HE-MA30

Missing/incomplete/invalid type of bill.

Edit: HE-MA31

Missing/incomplete/invalid beginning and ending dates of the period billed.

Edit: HE-MA32

Missing/incomplete/invalid number of covered days during the billing period.

Edit: HE-MA33

Missing/incomplete/invalid noncovered days during the billing period.

Edit: HE-MA34

Missing/incomplete/invalid number of coinsurance days during the billing period.

Edit: HE-MA35

Missing/incomplete/invalid number of lifetime reserve days.

Edit: HE-MA36

Missing/incomplete/invalid patient name.

Edit: HE-MA37

Missing/incomplete/invalid patient’s address.

Edit: HE-MA39

Missing/incomplete/invalid gender.

Edit: HE-MA40

Missing/incomplete/invalid admission date.

Edit: HE-MA41

Missing/incomplete/invalid admission type.

Edit: HE-MA42

Missing/incomplete/invalid admission source.

Edit: HE-MA43

Missing/incomplete/invalid patient status.

Edit: HE-MA44
Edit: HE-MA45
Edit: HE-MA46
Edit: HE-MA47

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.

Edit: HE-MA48

Missing/incomplete/invalid name or address of responsible party or primary payer.

Edit: HE-MA50

Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.

Edit: HE-MA53

Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.

Edit: HE-MA54

Physician certification or election consent for hospice care not received timely.

Edit: HE-MA55

Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.

Edit: HE-MA56

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.

Edit: HE-MA57

Patient submitted written request to revoke his/her election for religious non-medical health care services.

Edit: HE-MA58

Missing/incomplete/invalid release of information indicator.

Edit: HE-MA59
Edit: HE-MA60

Missing/incomplete/invalid patient relationship to insured.

Edit: HE-MA61

Missing/incomplete/invalid social security number or health insurance claim number.

Edit: HE-MA62
Edit: HE-MA63

Missing/incomplete/invalid principal diagnosis.

Edit: HE-MA64

Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.

Edit: HE-MA65

Missing/incomplete/invalid admitting diagnosis.

Edit: HE-MA66

Missing/incomplete/invalid principal procedure code.

Edit: HE-MA67
Edit: HE-MA68
Edit: HE-MA69

Missing/incomplete/invalid remarks.

Edit: HE-MA70

Missing/incomplete/invalid provider representative signature.

Edit: HE-MA71

Missing/incomplete/invalid provider representative signature date.

Edit: HE-MA72
Edit: HE-MA73

Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.

Edit: HE-MA74
Edit: HE-MA75

Missing/incomplete/invalid patient or authorized representative signature.

Edit: HE-MA76

Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.

Edit: HE-MA77
Edit: HE-MA79

Billed in excess of interim rate.

Edit: HE-MA80

Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.

Edit: HE-MA81

Missing/incomplete/invalid provider/supplier signature.

Edit: HE-MA83

Did not indicate whether we are the primary or secondary payer.

Edit: HE-MA84

Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.

Edit: HE-MA88

Missing/incomplete/invalid insured’s address and/or telephone number for the primary payer.

Edit: HE-MA89

Missing/incomplete/invalid patient’s relationship to the insured for the primary payer.

Edit: HE-MA90

Missing/incomplete/invalid employment status code for the primary insured.

Edit: HE-MA91
Edit: HE-MA92

Missing plan information for other insurance.

Edit: HE-MA93

Non-PIP (Periodic Interim Payment) claim.

Edit: HE-MA94
Edit: HE-MA96

Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.

Edit: HE-MA97

Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.

Edit: HE-MA99

Missing/incomplete/invalid Medigap information.

Edit: HE-N1
Edit: HE-N10

Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.

Edit: HE-N103

Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.

Edit: HE-N104

This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.

Edit: HE-N105

This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claims processing.

Edit: HE-N106

Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.

Edit: HE-N107

Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.

Edit: HE-N108

Missing/incomplete/invalid upgrade information.

Edit: HE-N109
Edit: HE-N11

Denial reversed because of medical review.

Edit: HE-N110

This facility is not certified for film mammography.

Edit: HE-N111

No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.

Edit: HE-N112

This claim is excluded from your electronic remittance advice.

Edit: HE-N113

Only one initial visit is covered per physician, group practice or provider.

Edit: HE-N114

During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.

Edit: HE-N115

This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.

Edit: HE-N116
Edit: HE-N117
Edit: HE-N118

This service is not paid if billed more than once every 28 days.

Edit: HE-N119

This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.

Edit: HE-N12

Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.

Edit: HE-N120

Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.

Edit: HE-N121

Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.

Edit: HE-N122

Add-on code cannot be billed by itself.

Edit: HE-N123
Edit: HE-N124

Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.

Edit: HE-N125

Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice.

Edit: HE-N126

Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.

Edit: HE-N127

This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.

Edit: HE-N128

This amount represents the prior to coverage portion of the allowance.

Edit: HE-N129

Not eligible due to the patient’s age.

Edit: HE-N13

Payment based on professional/technical component modifier(s).

Edit: HE-N130

Consult plan benefit documents/guidelines for information about restrictions for this service.

Edit: HE-N131

Total payments under multiple contracts cannot exceed the allowance for this service.

Edit: HE-N132
Edit: HE-N133
Edit: HE-N134
Edit: HE-N135

Record fees are the patient’s responsibility and limited to the specified co-payment.

Edit: HE-N136
Edit: HE-N137
Edit: HE-N138
Edit: HE-N139
Edit: HE-N140
Edit: HE-N141

The patient was not residing in a long-term care facility during all or part of the service dates billed.

Edit: HE-N142

The original claim was denied. Resubmit a new claim, not a replacement claim.

Edit: HE-N143

The patient was not in a hospice program during all or part of the service dates billed.

Edit: HE-N144

The rate changed during the dates of service billed.

Edit: HE-N146

Missing screening document.

Edit: HE-N147

Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.

Edit: HE-N148

Missing/incomplete/invalid date of last menstrual period.

Edit: HE-N149

Rebill all applicable services on a single claim.

Edit: HE-N15

Services for a newborn must be billed separately.

Edit: HE-N150

Missing/incomplete/invalid model number.

Edit: HE-N151

Telephone contact services will not be paid until the face-to-face contact requirement has been met.

Edit: HE-N152

Missing/incomplete/invalid replacement claim information.

Edit: HE-N153

Missing/incomplete/invalid room and board rate.

Edit: HE-N154
Edit: HE-N155
Edit: HE-N156
Edit: HE-N157

Transportation to/from this destination is not covered.

Edit: HE-N158

Transportation in a vehicle other than an ambulance is not covered.

Edit: HE-N159

Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.

Edit: HE-N16

Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.

Edit: HE-N160

The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.

Edit: HE-N161

This drug/service/supply is covered only when the associated service is covered.

Edit: HE-N162
Edit: HE-N163

Medical record does not support code billed per the code definition.

Edit: HE-N167

Charges exceed the post-transplant coverage limit.

Edit: HE-N170

A new/revised/renewed certificate of medical necessity is needed.

Edit: HE-N171

Payment for repair or replacement is not covered or has exceeded the purchase price.

Edit: HE-N172

The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.

Edit: HE-N173

No qualifying hospital stay dates were provided for this episode of care.

Edit: HE-N174

This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group ‘PR’.

Edit: HE-N175

Missing review organization approval.

Edit: HE-N176

Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.

Edit: HE-N177
Edit: HE-N178

Missing pre-operative images/visual field results.

Edit: HE-N179

Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.

Edit: HE-N180

This item or service does not meet the criteria for the category under which it was billed.

Edit: HE-N181

Additional information is required from another provider involved in this service.

Edit: HE-N182

This claim/service must be billed according to the schedule for this plan.

Edit: HE-N183
Edit: HE-N184

Rebill technical and professional components separately.

Edit: HE-N185
Edit: HE-N186

Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.

Edit: HE-N187
Edit: HE-N188

The approved level of care does not match the procedure code submitted.

Edit: HE-N189
Edit: HE-N19

Procedure code incidental to primary procedure.

Edit: HE-N190

Missing contract indicator.

Edit: HE-N191

The provider must update insurance information directly with payer.

Edit: HE-N192

Patient is a Medicaid/Qualified Medicare Beneficiary.

Edit: HE-N193
Edit: HE-N194

Technical component not paid if provider does not own the equipment used.

Edit: HE-N195

The technical component must be billed separately.

Edit: HE-N196
Edit: HE-N197

The subscriber must update insurance information directly with payer.

Edit: HE-N198

Rendering provider must be affiliated with the pay-to provider.

Edit: HE-N199

Additional payment/recoupment approved based on payer-initiated review/audit.

Edit: HE-N2

This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.

Edit: HE-N20

Service not payable with other service rendered on the same date.

Edit: HE-N200

The professional component must be billed separately.

Edit: HE-N202
Edit: HE-N203

Missing/incomplete/invalid anesthesia time/units.

Edit: HE-N204

Services under review for possible pre-existing condition. Send medical records for prior 12 months

Edit: HE-N205

Information provided was illegible.

Edit: HE-N206

The supporting documentation does not match the information sent on the claim.

Edit: HE-N207

Missing/incomplete/invalid weight.

Edit: HE-N208

Missing/incomplete/invalid DRG code.

Edit: HE-N209

Missing/incomplete/invalid taxpayer identification number (TIN).

Edit: HE-N21
Edit: HE-N210
Edit: HE-N211
Edit: HE-N212

Charges processed under a Point of Service benefit .

Edit: HE-N213

Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information.

Edit: HE-N214

Missing/incomplete/invalid history of the related initial surgical procedure(s).

Edit: HE-N215
Edit: HE-N216

We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.

Edit: HE-N217

We pay only one site of service per provider per claim.

Edit: HE-N218

You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.

Edit: HE-N219

Payment based on previous payer’s allowed amount.

Edit: HE-N22
Edit: HE-N220
Edit: HE-N221

Missing Admitting History and Physical report.

Edit: HE-N222

Incomplete/invalid Admitting History and Physical report.

Edit: HE-N223

Missing documentation of benefit to the patient during initial treatment period.

Edit: HE-N224

Incomplete/invalid documentation of benefit to the patient during initial treatment period.

Edit: HE-N226

Incomplete/invalid American Diabetes Association Certificate of Recognition.

Edit: HE-N227

Incomplete/invalid Certificate of Medical Necessity.

Edit: HE-N228

Incomplete/invalid consent form.

Edit: HE-N229

Incomplete/invalid contract indicator.

Edit: HE-N23
Edit: HE-N230

Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.

Edit: HE-N231

Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Edit: HE-N232

Incomplete/invalid itemized bill/statement.

Edit: HE-N233

Incomplete/invalid operative note/report.

Edit: HE-N234

Incomplete/invalid oxygen certification/re-certification.

Edit: HE-N235

Incomplete/invalid pacemaker registration form.

Edit: HE-N236

Incomplete/invalid pathology report.

Edit: HE-N237

Incomplete/invalid patient medical record for this service.

Edit: HE-N238

Incomplete/invalid physician certified plan of care.

Edit: HE-N239

Incomplete/invalid physician financial relationship form.

Edit: HE-N24

Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.

Edit: HE-N240

Incomplete/invalid radiology report.

Edit: HE-N241

Incomplete/invalid review organization approval.

Edit: HE-N242

Incomplete/invalid radiology film(s)/image(s).

Edit: HE-N243

Incomplete/invalid/not approved screening document.

Edit: HE-N244

Incomplete/Invalid pre-operative images/visual field results.

Edit: HE-N245

Incomplete/invalid plan information for other insurance .

Edit: HE-N246

State regulated patient payment limitations apply to this service.

Edit: HE-N247

Missing/incomplete/invalid assistant surgeon taxonomy.

Edit: HE-N248

Missing/incomplete/invalid assistant surgeon name.

Edit: HE-N249

Missing/incomplete/invalid assistant surgeon primary identifier.

Edit: HE-N25

This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.

Edit: HE-N250

Missing/incomplete/invalid assistant surgeon secondary identifier.

Edit: HE-N251

Missing/incomplete/invalid attending provider taxonomy.

Edit: HE-N252

Missing/incomplete/invalid attending provider name.

Edit: HE-N253

Missing/incomplete/invalid attending provider primary identifier.

Edit: HE-N254

Missing/incomplete/invalid attending provider secondary identifier.

Edit: HE-N255

Missing/incomplete/invalid billing provider taxonomy.

Edit: HE-N256

Missing/incomplete/invalid billing provider/supplier name.

Edit: HE-N257

Missing/incomplete/invalid billing provider/supplier primary identifier.

Edit: HE-N258

Missing/incomplete/invalid billing provider/supplier address.

Edit: HE-N259

Missing/incomplete/invalid billing provider/supplier secondary identifier.

Edit: HE-N26

Missing itemized bill/statement.

Edit: HE-N260

Missing/incomplete/invalid billing provider/supplier contact information.

Edit: HE-N261

Missing/incomplete/invalid operating provider name.

Edit: HE-N262

Missing/incomplete/invalid operating provider primary identifier.

Edit: HE-N263

Missing/incomplete/invalid operating provider secondary identifier.

Edit: HE-N264

Missing/incomplete/invalid ordering provider name.

Edit: HE-N265

Missing/incomplete/invalid ordering provider primary identifier.

Edit: HE-N266

Missing/incomplete/invalid ordering provider address.

Edit: HE-N267

Missing/incomplete/invalid ordering provider secondary identifier.

Edit: HE-N268

Missing/incomplete/invalid ordering provider contact information.

Edit: HE-N269

Missing/incomplete/invalid other provider name.

Edit: HE-N27

Missing/incomplete/invalid treatment number.

Edit: HE-N270

Missing/incomplete/invalid other provider primary identifier.

Edit: HE-N271

Missing/incomplete/invalid other provider secondary identifier.

Edit: HE-N272

Missing/incomplete/invalid other payer attending provider identifier.

Edit: HE-N273

Missing/incomplete/invalid other payer operating provider identifier.

Edit: HE-N274

Missing/incomplete/invalid other payer other provider identifier.

Edit: HE-N275

Missing/incomplete/invalid other payer purchased service provider identifier.

Edit: HE-N276

Missing/incomplete/invalid other payer referring provider identifier.

Edit: HE-N277

Missing/incomplete/invalid other payer rendering provider identifier.

Edit: HE-N278

Missing/incomplete/invalid other payer service facility provider identifier.

Edit: HE-N279

Missing/incomplete/invalid pay-to provider name.

Edit: HE-N28

Consent form requirements not fulfilled.

Edit: HE-N280

Missing/incomplete/invalid pay-to provider primary identifier.

Edit: HE-N281

Missing/incomplete/invalid pay-to provider address.

Edit: HE-N282

Missing/incomplete/invalid pay-to provider secondary identifier.

Edit: HE-N283

Missing/incomplete/invalid purchased service provider identifier.

Edit: HE-N284

Missing/incomplete/invalid referring provider taxonomy.

Edit: HE-N285

Missing/incomplete/invalid referring provider name.

Edit: HE-N286

Missing/incomplete/invalid referring provider primary identifier.

Edit: HE-N287

Missing/incomplete/invalid referring provider secondary identifier.

Edit: HE-N288

Missing/incomplete/invalid rendering provider taxonomy.

Edit: HE-N289

Missing/incomplete/invalid rendering provider name.

Edit: HE-N290

Missing/incomplete/invalid rendering provider primary identifier.

Edit: HE-N291

Missing/incomplete/invalid rendering provider secondary identifier.

Edit: HE-N292

Missing/incomplete/invalid service facility name.

Edit: HE-N293

Missing/incomplete/invalid service facility primary identifier.

Edit: HE-N294

Missing/incomplete/invalid service facility primary address.

Edit: HE-N295

Missing/incomplete/invalid service facility secondary identifier.

Edit: HE-N296

Missing/incomplete/invalid supervising provider name.

Edit: HE-N297

Missing/incomplete/invalid supervising provider primary identifier.

Edit: HE-N298

Missing/incomplete/invalid supervising provider secondary identifier.

Edit: HE-N299

Missing/incomplete/invalid occurrence date(s).

Edit: HE-N3

Missing consent form.

Edit: HE-N30

Patient ineligible for this service.

Edit: HE-N300

Missing/incomplete/invalid occurrence span date(s).

Edit: HE-N301

Missing/incomplete/invalid procedure date(s).

Edit: HE-N302

Missing/incomplete/invalid other procedure date(s).

Edit: HE-N303

Missing/incomplete/invalid principal procedure date.

Edit: HE-N304

Missing/incomplete/invalid dispensed date.

Edit: HE-N305

Missing/incomplete/invalid injury/accident date.

Edit: HE-N306

Missing/incomplete/invalid acute manifestation date.

Edit: HE-N307

Missing/incomplete/invalid adjudication or payment date.

Edit: HE-N308

Missing/incomplete/invalid appliance placement date.

Edit: HE-N309

Missing/incomplete/invalid assessment date.

Edit: HE-N31

Missing/incomplete/invalid prescribing provider identifier.

Edit: HE-N310

Missing/incomplete/invalid assumed or relinquished care date.

Edit: HE-N311

Missing/incomplete/invalid authorized to return to work date.

Edit: HE-N312

Missing/incomplete/invalid begin therapy date.

Edit: HE-N313

Missing/incomplete/invalid certification revision date.

Edit: HE-N314

Missing/incomplete/invalid diagnosis date.

Edit: HE-N315

Missing/incomplete/invalid disability from date.

Edit: HE-N316

Missing/incomplete/invalid disability to date.

Edit: HE-N317

Missing/incomplete/invalid discharge hour.

Edit: HE-N318

Missing/incomplete/invalid discharge or end of care date.

Edit: HE-N319

Missing/incomplete/invalid hearing or vision prescription date.

Edit: HE-N32

Claim must be submitted by the provider who rendered the service.

Edit: HE-N320

Missing/incomplete/invalid Home Health Certification Period.

Edit: HE-N321

Missing/incomplete/invalid last admission period.

Edit: HE-N322

Missing/incomplete/invalid last certification date.

Edit: HE-N323

Missing/incomplete/invalid last contact date.

Edit: HE-N324

Missing/incomplete/invalid last seen/visit date.

Edit: HE-N325

Missing/incomplete/invalid last worked date.

Edit: HE-N326

Missing/incomplete/invalid last x-ray date.

Edit: HE-N327

Missing/incomplete/invalid other insured birth date.

Edit: HE-N328

Missing/incomplete/invalid Oxygen Saturation Test date.

Edit: HE-N329

Missing/incomplete/invalid patient birth date.

Edit: HE-N33

No record of health check prior to initiation of treatment.

Edit: HE-N330

Missing/incomplete/invalid patient death date.

Edit: HE-N331

Missing/incomplete/invalid physician order date.

Edit: HE-N332

Missing/incomplete/invalid prior hospital discharge date.

Edit: HE-N333

Missing/incomplete/invalid prior placement date.

Edit: HE-N334

Missing/incomplete/invalid re-evaluation date.

Edit: HE-N335

Missing/incomplete/invalid referral date.

Edit: HE-N336

Missing/incomplete/invalid replacement date.

Edit: HE-N337

Missing/incomplete/invalid secondary diagnosis date.

Edit: HE-N338

Missing/incomplete/invalid shipped date.

Edit: HE-N339

Missing/incomplete/invalid similar illness or symptom date.

Edit: HE-N34

Incorrect claim form/format for this service.

Edit: HE-N340

Missing/incomplete/invalid subscriber birth date.

Edit: HE-N341

Missing/incomplete/invalid surgery date.

Edit: HE-N342

Missing/incomplete/invalid test performed date.

Edit: HE-N343

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.

Edit: HE-N344

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.

Edit: HE-N345

Date range not valid with units submitted.

Edit: HE-N346

Missing/incomplete/invalid oral cavity designation code.

Edit: HE-N347

Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

Edit: HE-N348

You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.

Edit: HE-N349

The administration method and drug must be reported to adjudicate this service.

Edit: HE-N35

Program integrity/utilization review decision.

Edit: HE-N350

Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.

Edit: HE-N351

Service date outside of the approved treatment plan service dates.

Edit: HE-N352
Edit: HE-N353
Edit: HE-N354

Incomplete/invalid invoice.

Edit: HE-N355
Edit: HE-N356

Not covered when performed with, or subsequent to, a non-covered service.

Edit: HE-N357

Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.

Edit: HE-N358
Edit: HE-N359

Missing/incomplete/invalid height.

Edit: HE-N36
Edit: HE-N360
Edit: HE-N362

The number of Days or Units of Service exceeds our acceptable maximum.

Edit: HE-N363
Edit: HE-N364
Edit: HE-N366

Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.

Edit: HE-N367
Edit: HE-N368

You must appeal the determination of the previously adjudicated claim.

Edit: HE-N369
Edit: HE-N37

Missing/incomplete/invalid tooth number/letter.

Edit: HE-N370

Billing exceeds the rental months covered/approved by the payer.

Edit: HE-N371
Edit: HE-N372

Only reasonable and necessary maintenance/service charges are covered.

Edit: HE-N373

It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.

Edit: HE-N374

Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.

Edit: HE-N375

Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.

Edit: HE-N376

Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.

Edit: HE-N377

Payment based on a processed replacement claim.

Edit: HE-N378

Missing/incomplete/invalid prescription quantity.

Edit: HE-N379

Claim level information does not match line level information.

Edit: HE-N380

The original claim has been processed, submit a corrected claim.

Edit: HE-N381
Edit: HE-N382

Missing/incomplete/invalid patient identifier.

Edit: HE-N383

Not covered when deemed cosmetic.

Edit: HE-N384

Records indicate that the referenced body part/tooth has been removed in a previous procedure.

Edit: HE-N385

Notification of admission was not timely according to published plan procedures.

Edit: HE-N386

This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

Edit: HE-N387
Edit: HE-N388

Missing/incomplete/invalid prescription number.

Edit: HE-N389

Duplicate prescription number submitted.

Edit: HE-N39

Procedure code is not compatible with tooth number/letter.

Edit: HE-N390

This service/report cannot be billed separately.

Edit: HE-N391

Missing emergency department records.

Edit: HE-N392

Incomplete/invalid emergency department records.

Edit: HE-N393

Missing progress notes/report.

Edit: HE-N394

Incomplete/invalid progress notes/report.

Edit: HE-N395

Missing laboratory report.

Edit: HE-N396

Incomplete/invalid laboratory report.

Edit: HE-N397

Benefits are not available for incomplete service(s)/undelivered item(s).

Edit: HE-N398

Missing elective consent form.

Edit: HE-N399

Incomplete/invalid elective consent form.

Edit: HE-N4

Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.

Edit: HE-N40

Missing radiology film(s)/image(s).

Edit: HE-N400
Edit: HE-N401

Missing periodontal charting.

Edit: HE-N402

Incomplete/invalid periodontal charting.

Edit: HE-N403

Missing facility certification.

Edit: HE-N404

Incomplete/invalid facility certification.

Edit: HE-N405

This service is only covered when the donor’s insurer(s) do not provide coverage for the service.

Edit: HE-N406

This service is only covered when the recipient’s insurer(s) do not provide coverage for the service.

Edit: HE-N407

You are not an approved submitter for this transmission format.

Edit: HE-N408

This payer does not cover deductibles assessed by a previous payer.

Edit: HE-N409

This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.

Edit: HE-N410

Not covered unless the prescription changes.

Edit: HE-N411

This service is allowed one time in a 6-month period.

Edit: HE-N412

This service is allowed 2 times in a 12-month period.

Edit: HE-N413

This service is allowed 2 times in a benefit year.

Edit: HE-N414

This service is allowed 4 times in a 12-month period.

Edit: HE-N415

This service is allowed 1 time in an 18-month period.

Edit: HE-N416

This service is allowed 1 time in a 3-year period.

Edit: HE-N417

This service is allowed 1 time in a 5-year period.

Edit: HE-N418

Misrouted claim. See the payer’s claim submission instructions.

Edit: HE-N419

Claim payment was the result of a payer’s retroactive adjustment due to a retroactive rate change.

Edit: HE-N42

Missing mental health assessment.

Edit: HE-N420

Claim payment was the result of a payer’s retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.

Edit: HE-N421

Claim payment was the result of a payer’s retroactive adjustment due to a review organization decision.

Edit: HE-N422

Claim payment was the result of a payer’s retroactive adjustment due to a payer’s contract incentive program.

Edit: HE-N423

Claim payment was the result of a payer’s retroactive adjustment due to a non standard program.

Edit: HE-N424

Patient does not reside in the geographic area required for this type of payment.

Edit: HE-N425

Statutorily excluded service(s).

Edit: HE-N426

No coverage when self-administered.

Edit: HE-N427

Payment for eyeglasses or contact lenses can be made only after cataract surgery.

Edit: HE-N428

Not covered when performed in this place of service.

Edit: HE-N429

Not covered when considered routine.

Edit: HE-N43

Bed hold or leave days exceeded.

Edit: HE-N430

Procedure code is inconsistent with the units billed.

Edit: HE-N431

Not covered with this procedure.

Edit: HE-N432
Edit: HE-N433

Resubmit this claim using only your National Provider Identifier (NPI).

Edit: HE-N434

Missing/Incomplete/Invalid Present on Admission indicator.

Edit: HE-N435

Exceeds number/frequency approved /allowed within time period without support documentation.

Edit: HE-N436

The injury claim has not been accepted and a mandatory medical reimbursement has been made.

Edit: HE-N437
Edit: HE-N438

This jurisdiction only accepts paper claims.

Edit: HE-N439

Missing anesthesia physical status report/indicators.

Edit: HE-N440

Incomplete/invalid anesthesia physical status report/indicators.

Edit: HE-N441

This missed/cancelled appointment is not covered.

Edit: HE-N442

Payment based on an alternate fee schedule.

Edit: HE-N443

Missing/incomplete/invalid total time or begin/end time.

Edit: HE-N444
Edit: HE-N445

Missing document for actual cost or paid amount.

Edit: HE-N446

Incomplete/invalid document for actual cost or paid amount.

Edit: HE-N447

Payment is based on a generic equivalent as required documentation was not provided.

Edit: HE-N448

This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.

Edit: HE-N449

Payment based on a comparable drug/service/supply.

Edit: HE-N45

Payment based on authorized amount.

Edit: HE-N450

Covered only when performed by the primary treating physician or the designee.

Edit: HE-N451

Missing Admission Summary Report.

Edit: HE-N452

Incomplete/invalid Admission Summary Report.

Edit: HE-N453

Missing Consultation Report.

Edit: HE-N454

Incomplete/invalid Consultation Report.

Edit: HE-N455

Missing Physician Order.

Edit: HE-N456

Incomplete/invalid Physician Order.

Edit: HE-N457

Missing Diagnostic Report.

Edit: HE-N458

Incomplete/invalid Diagnostic Report.

Edit: HE-N459

Missing Discharge Summary.

Edit: HE-N46

Missing/incomplete/invalid admission hour.

Edit: HE-N460

Incomplete/invalid Discharge Summary.

Edit: HE-N461

Missing Nursing Notes.

Edit: HE-N462

Incomplete/invalid Nursing Notes.

Edit: HE-N463

Missing support data for claim.

Edit: HE-N464

Incomplete/invalid support data for claim.

Edit: HE-N465

Missing Physical Therapy Notes/Report.

Edit: HE-N466

Incomplete/invalid Physical Therapy Notes/Report.

Edit: HE-N467

Missing Tests and Analysis Report.

Edit: HE-N468

Incomplete/invalid Report of Tests and Analysis Report.

Edit: HE-N469
Edit: HE-N47

Claim conflicts with another inpatient stay.

Edit: HE-N470

This payment will complete the mandatory medical reimbursement limit.

Edit: HE-N471

Missing/incomplete/invalid HIPPS Rate Code.

Edit: HE-N472

Payment for this service has been issued to another provider.

Edit: HE-N473

Missing certification.

Edit: HE-N474

Incomplete/invalid certification.

Edit: HE-N475

Missing completed referral form.

Edit: HE-N476

Incomplete/invalid completed referral form.

Edit: HE-N477

Missing Dental Models.

Edit: HE-N478

Incomplete/invalid Dental Models.

Edit: HE-N479

Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: HE-N48

Claim information does not agree with information received from other insurance carrier.

Edit: HE-N480

Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: HE-N481

Missing Models.

Edit: HE-N482

Incomplete/invalid Models.

Edit: HE-N485

Missing Physical Therapy Certification.

Edit: HE-N486

Incomplete/invalid Physical Therapy Certification.

Edit: HE-N487

Missing Prosthetics or Orthotics Certification.

Edit: HE-N488

Incomplete/invalid Prosthetics or Orthotics Certification.

Edit: HE-N489

Missing referral form.

Edit: HE-N49

Court ordered coverage information needs validation.

Edit: HE-N490

Incomplete/invalid referral form.

Edit: HE-N491

Missing/Incomplete/Invalid Exclusionary Rider Condition.

Edit: HE-N492
Edit: HE-N493

Missing Doctor First Report of Injury.

Edit: HE-N494

Incomplete/invalid Doctor First Report of Injury.

Edit: HE-N495

Missing Supplemental Medical Report.

Edit: HE-N496

Incomplete/invalid Supplemental Medical Report.

Edit: HE-N497

Missing Medical Permanent Impairment or Disability Report.

Edit: HE-N498

Incomplete/invalid Medical Permanent Impairment or Disability Report.

Edit: HE-N499

Missing Medical Legal Report.

Edit: HE-N5

EOB received from previous payer. Claim not on file.

Edit: HE-N50

Missing/incomplete/invalid discharge information.

Edit: HE-N500

Incomplete/invalid Medical Legal Report.

Edit: HE-N501

Missing Vocational Report.

Edit: HE-N502

Incomplete/invalid Vocational Report.

Edit: HE-N503

Missing Work Status Report.

Edit: HE-N504

Incomplete/invalid Work Status Report.

Edit: HE-N505
Edit: HE-N506
Edit: HE-N507

Plan distance requirements have not been met.

Edit: HE-N508
Edit: HE-N509
Edit: HE-N51

Electronic interchange agreement not on file for provider/submitter.

Edit: HE-N510
Edit: HE-N511
Edit: HE-N512
Edit: HE-N513
Edit: HE-N516

Records indicate a mismatch between the submitted NPI and EIN.

Edit: HE-N517

Resubmit a new claim with the requested information.

Edit: HE-N518

No separate payment for accessories when furnished for use with oxygen equipment.

Edit: HE-N519

Invalid combination of HCPCS modifiers.

Edit: HE-N52

Patient not enrolled in the billing provider’s managed care plan on the date of service.

Edit: HE-N520
Edit: HE-N521

Mismatch between the submitted provider information and the provider information stored in our system.

Edit: HE-N522

Duplicate of a claim processed, or to be processed, as a crossover claim.

Edit: HE-N523

The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.

Edit: HE-N524

Based on policy this payment constitutes payment in full.

Edit: HE-N525

These services are not covered when performed within the global period of another service.

Edit: HE-N526

Not qualified for recovery based on employer size.

Edit: HE-N527

We processed this claim as the primary payer prior to receiving the recovery demand.

Edit: HE-N528

Patient is entitled to benefits for Institutional Services only.

Edit: HE-N529

Patient is entitled to benefits for Professional Services only.

Edit: HE-N53

Missing/incomplete/invalid point of pick-up address.

Edit: HE-N530

Not Qualified for Recovery based on enrollment information.

Edit: HE-N531

Not qualified for recovery based on direct payment of premium.

Edit: HE-N532

Not qualified for recovery based on disability and working status.

Edit: HE-N533

Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.

Edit: HE-N534

This is an individual policy, the employer does not participate in plan sponsorship.

Edit: HE-N535

Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.

Edit: HE-N536

We are not changing the prior payer’s determination of patient responsibility, which you may collect, as this service is not covered by us.

Edit: HE-N537

We have examined claims history and no records of the services have been found.

Edit: HE-N538

A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.

Edit: HE-N539
Edit: HE-N54

Claim information is inconsistent with pre-certified/authorized services.

Edit: HE-N540

Payment adjusted based on the interrupted stay policy.

Edit: HE-N541

Mismatch between the submitted insurance type code and the information stored in our system.

Edit: HE-N542

Missing income verification.

Edit: HE-N543

Incomplete/invalid income verification.

Edit: HE-N544
Edit: HE-N545

Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.

Edit: HE-N546

Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.

Edit: HE-N547

A refund request (Frequency Type Code 8) was processed previously.

Edit: HE-N548
Edit: HE-N549
Edit: HE-N55

Procedures for billing with group/referring/performing providers were not followed.

Edit: HE-N550
Edit: HE-N551

Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.

Edit: HE-N552

Payment adjusted to reverse a previous withhold/bonus amount.

Edit: HE-N554

Missing/Incomplete/Invalid Family Planning Indicator.

Edit: HE-N555

Missing medication list.

Edit: HE-N556

Incomplete/invalid medication list.

Edit: HE-N557

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.

Edit: HE-N558

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.

Edit: HE-N559

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.

Edit: HE-N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.

Edit: HE-N560

The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.

Edit: HE-N561

The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.

Edit: HE-N562

The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.

Edit: HE-N563
Edit: HE-N564

Patient did not meet the inclusion criteria for the demonstration project or pilot program.

Edit: HE-N565
Edit: HE-N566
Edit: HE-N567

Not covered when considered preventative.

Edit: HE-N568
Edit: HE-N569

Not covered when performed for the reported diagnosis.

Edit: HE-N57

Missing/incomplete/invalid prescribing date.

Edit: HE-N570

Missing/incomplete/invalid credentialing data.

Edit: HE-N571
Edit: HE-N572

This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.

Edit: HE-N573
Edit: HE-N574

Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

Edit: HE-N575

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

Edit: HE-N576

Services not related to the specific incident/claim/accident/loss being reported.

Edit: HE-N577

Personal Injury Protection (PIP) Coverage.

Edit: HE-N578

Coverages do not apply to this loss.

Edit: HE-N579

Medical Payments Coverage (MPC).

Edit: HE-N58

Missing/incomplete/invalid patient liability amount.

Edit: HE-N580

Determination based on the provisions of the insurance policy.

Edit: HE-N581

Investigation of coverage eligibility is pending.

Edit: HE-N582

Benefits suspended pending the patient’s cooperation.

Edit: HE-N583

Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.

Edit: HE-N584

Not covered based on the insured’s noncompliance with policy or statutory conditions.

Edit: HE-N585

Benefits are no longer available based on a final injury settlement.

Edit: HE-N586

The injured party does not qualify for benefits.

Edit: HE-N587

Policy benefits have been exhausted.

Edit: HE-N588

The patient has instructed that medical claims/bills are not to be paid.

Edit: HE-N589

Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.

Edit: HE-N59
Edit: HE-N590

Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.

Edit: HE-N591

Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).

Edit: HE-N592

Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.

Edit: HE-N593

Not covered based on failure to attend a scheduled Independent Medical Exam (IME).

Edit: HE-N594

Records reflect the injured party did not complete an Application for Benefits for this loss.

Edit: HE-N595

Records reflect the injured party did not complete an Assignment of Benefits for this loss.

Edit: HE-N596

Records reflect the injured party did not complete a Medical Authorization for this loss.

Edit: HE-N597

Adjusted based on a medical/dental provider’s apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.

Edit: HE-N598

Health care policy coverage is primary.

Edit: HE-N599

Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered.

Edit: HE-N6

Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.

Edit: HE-N600

Adjusted based on the applicable fee schedule for the region in which the service was rendered.

Edit: HE-N601

In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.

Edit: HE-N602

Adjusted based on the Redbook maximum allowance.

Edit: HE-N603

This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.

Edit: HE-N604

In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers’ Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.

Edit: HE-N605

This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.

Edit: HE-N606

The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

Edit: HE-N607

Service provided for non-compensable condition(s).

Edit: HE-N608

The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.

Edit: HE-N609

80% of the provider’s billed amount is being recommended for payment according to Act 6.

Edit: HE-N61

Rebill services on separate claims.

Edit: HE-N610
Edit: HE-N611

Claim in litigation. Contact insurer for more information.

Edit: HE-N612

Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.

Edit: HE-N613
Edit: HE-N614
Edit: HE-N615
Edit: HE-N616
Edit: HE-N617

This enrollee is in the second or third month of the advance premium tax credit grace period.

Edit: HE-N618
Edit: HE-N619

Coverage terminated for non-payment of premium.

Edit: HE-N62

Dates of service span multiple rate periods. Resubmit separate claims.

Edit: HE-N620
Edit: HE-N621

Charges for Jurisdiction required forms, reports, or chart notes are not payable.

Edit: HE-N622

Not covered based on the date of injury/accident.

Edit: HE-N623

Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.

Edit: HE-N624

The associated Workers’ Compensation claim has been withdrawn.

Edit: HE-N625

Missing/Incomplete/Invalid Workers’ Compensation Claim Number.

Edit: HE-N626

New or established patient E/M codes are not payable with chiropractic care codes.

Edit: HE-N628

Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.

Edit: HE-N629

Reviews/documentation/notes/summaries/reports/charts not requested.

Edit: HE-N63

Rebill services on separate claim lines.

Edit: HE-N630

Referral not authorized by attending physician.

Edit: HE-N631

Medical Fee Schedule does not list this code. An allowance was made for a comparable service.

Edit: HE-N633

Additional anesthesia time units are not allowed.

Edit: HE-N634

The allowance is calculated based on anesthesia time units.

Edit: HE-N635

The Allowance is calculated based on the anesthesia base units plus time.

Edit: HE-N636

Adjusted because this is reimbursable only once per injury.

Edit: HE-N637

Consultations are not allowed once treatment has been rendered by the same provider.

Edit: HE-N638

Reimbursement has been made according to the home health fee schedule.

Edit: HE-N639

Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.

Edit: HE-N64
Edit: HE-N640

Exceeds number/frequency approved/allowed within time period.

Edit: HE-N641

Reimbursement has been based on the number of body areas rated.

Edit: HE-N642

Adjusted when billed as individual tests instead of as a panel.

Edit: HE-N643

The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.

Edit: HE-N644

Reimbursement has been made according to the bilateral procedure rule.

Edit: HE-N645

Mark-up allowance.

Edit: HE-N646

Reimbursement has been adjusted based on the guidelines for an assistant.

Edit: HE-N647

Adjusted based on diagnosis-related group (DRG).

Edit: HE-N648

Adjusted based on Stop Loss.

Edit: HE-N649

Payment based on invoice.

Edit: HE-N65

Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.

Edit: HE-N650

This policy was not in effect for this date of loss. No coverage is available.

Edit: HE-N651

No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.

Edit: HE-N652

The date of service is before the date of loss.

Edit: HE-N653

The date of injury does not match the reported date of loss.

Edit: HE-N654

Adjusted based on achievement of maximum medical improvement (MMI).

Edit: HE-N655

Payment based on provider’s geographic region.

Edit: HE-N656

An interest payment is being made because benefits are being paid outside the statutory requirement.

Edit: HE-N657

This should be billed with the appropriate code for these services.

Edit: HE-N658

The billed service(s) are not considered medical expenses.

Edit: HE-N659

This item is exempt from sales tax.

Edit: HE-N660

Sales tax has been included in the reimbursement.

Edit: HE-N661

Documentation does not support that the services rendered were medically necessary.

Edit: HE-N662
Edit: HE-N663

Adjusted based on an agreed amount.

Edit: HE-N664

Adjusted based on a legal settlement.

Edit: HE-N665

Services by an unlicensed provider are not reimbursable.

Edit: HE-N666

Only one evaluation and management code at this service level is covered during the course of care.

Edit: HE-N667

Missing prescription.

Edit: HE-N668

Incomplete/invalid prescription.

Edit: HE-N669

Adjusted based on the Medicare fee schedule.

Edit: HE-N67
Edit: HE-N670

This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

Edit: HE-N671

Payment based on a jurisdiction cost-charge ratio.

Edit: HE-N672
Edit: HE-N673

Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.

Edit: HE-N674

Not covered unless a pre-requisite procedure/service has been provided.

Edit: HE-N675

Additional information is required from the injured party.

Edit: HE-N676

Service does not qualify for payment under the Outpatient Facility Fee Schedule.

Edit: HE-N677
Edit: HE-N678

Missing post-operative images/visual field results.

Edit: HE-N679

Incomplete/Invalid post-operative images/visual field results.

Edit: HE-N68

Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.

Edit: HE-N680

Missing/Incomplete/Invalid date of previous dental extractions.

Edit: HE-N681

Missing/Incomplete/Invalid full arch series.

Edit: HE-N682

Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.

Edit: HE-N683

Missing/Incomplete/Invalid prior treatment documentation.

Edit: HE-N684

Payment denied as this is a specialty claim submitted as a general claim.

Edit: HE-N685

Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.

Edit: HE-N686

Missing/incomplete/Invalid questionnaire needed to complete payment determination.

Edit: HE-N687
Edit: HE-N688
Edit: HE-N689
Edit: HE-N69
Edit: HE-N690
Edit: HE-N691
Edit: HE-N692
Edit: HE-N693
Edit: HE-N694
Edit: HE-N695
Edit: HE-N696
Edit: HE-N697
Edit: HE-N698
Edit: HE-N699

Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.

Edit: HE-N7
Edit: HE-N70

Consolidated billing and payment applies.

Edit: HE-N700

Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.

Edit: HE-N701

Payment adjusted based on the Value-based Payment Modifier.

Edit: HE-N702

Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.

Edit: HE-N703

This service is incompatible with previously adjudicated claims or claims in process.

Edit: HE-N704
Edit: HE-N705

Incomplete/invalid documentation.

Edit: HE-N706

Missing documentation.

Edit: HE-N707

Incomplete/invalid orders.

Edit: HE-N708

Missing orders.

Edit: HE-N709

Incomplete/invalid notes.

Edit: HE-N71

Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.

Edit: HE-N710

Missing notes.

Edit: HE-N711

Incomplete/invalid summary.

Edit: HE-N712

Missing summary.

Edit: HE-N713

Incomplete/invalid report.

Edit: HE-N714

Missing report.

Edit: HE-N715

Incomplete/invalid chart.

Edit: HE-N716

Missing chart.

Edit: HE-N717

Incomplete/Invalid documentation of face-to-face examination.

Edit: HE-N718

Missing documentation of face-to-face examination.

Edit: HE-N719

Penalty applied based on plan requirements not being met.

Edit: HE-N72

PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.

Edit: HE-N720
Edit: HE-N721

This service is only covered when performed as part of a clinical trial.

Edit: HE-N722

Patient must use Workers’ Compensation Set-Aside (WCSA) funds to pay for the medical service or item.

Edit: HE-N723

Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.

Edit: HE-N724

Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.

Edit: HE-N725

A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: HE-N726

A conditional payment is not allowed.

Edit: HE-N727

A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: HE-N728

A workers’ compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: HE-N729

Missing patient medical/dental record for this service.

Edit: HE-N730

Incomplete/invalid patient medical/dental record for this service.

Edit: HE-N731

Incomplete/Invalid mental health assessment.

Edit: HE-N732

Services performed at an unlicensed facility are not reimbursable.

Edit: HE-N733

Regulatory surcharges are paid directly to the state.

Edit: HE-N734

The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.

Edit: HE-N736

Incomplete/invalid Sleep Study Report.

Edit: HE-N737

Missing Sleep Study Report.

Edit: HE-N738

Incomplete/invalid Vein Study Report.

Edit: HE-N739

Missing Vein Study Report.

Edit: HE-N74

Resubmit with multiple claims, each claim covering services provided in only one calendar month.

Edit: HE-N740

The member’s Consumer Spending Account does not contain sufficient funds to cover the member’s liability for this claim/service.

Edit: HE-N741

This is a site neutral payment.

Edit: HE-N743

Adjusted because the services may be related to an employment accident.

Edit: HE-N744

Adjusted because the services may be related to an auto/other accident.

Edit: HE-N745

Missing Ambulance Report.

Edit: HE-N746

Incomplete/invalid Ambulance Report.

Edit: HE-N747

This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.

Edit: HE-N748

Adjusted because the related hospital charges have not been received.

Edit: HE-N749

Missing Blood Gas Report.

Edit: HE-N75

Missing/incomplete/invalid tooth surface information.

Edit: HE-N750

Incomplete/invalid Blood Gas Report.

Edit: HE-N751

Adjusted because the patient is covered under a Medicare Part D plan.

Edit: HE-N752

Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).

Edit: HE-N753

Missing/incomplete/invalid Attachment Control Number.

Edit: HE-N754

Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.

Edit: HE-N755

Missing/incomplete/invalid ICD Indicator.

Edit: HE-N756

Missing/incomplete/invalid point of drop-off address.

Edit: HE-N757

Adjusted based on the Federal Indian Fees schedule (MLR).

Edit: HE-N758

Adjusted based on the prior authorization decision.

Edit: HE-N759

Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.

Edit: HE-N76

Missing/incomplete/invalid number of riders.

Edit: HE-N760

This facility is not authorized to receive payment for the service(s).

Edit: HE-N761

This provider is not authorized to receive payment for the service(s).

Edit: HE-N762

This facility is not certified for Tomosynthesis (3-D) mammography.

Edit: HE-N763

The demonstration code is not appropriate for this claim; resubmit without a demonstration code.

Edit: HE-N764

Missing/incomplete/invalid Hematocrit (HCT) value.

Edit: HE-N765

This payer does not cover co-insurance assessed by a previous payer.

Edit: HE-N766

This payer does not cover co-payment assessed by a previous payer.

Edit: HE-N767
Edit: HE-N768

Incomplete/invalid initial evaluation report.

Edit: HE-N769

A lateral diagnosis is required.

Edit: HE-N77

Missing/incomplete/invalid designated provider number.

Edit: HE-N770

The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the information received.

Edit: HE-N771
Edit: HE-N772
Edit: HE-N773

Drug supplied not obtained from specialty vendor.

Edit: HE-N774
Edit: HE-N775

Payment adjusted based on x-ray radiograph on film.

Edit: HE-N776

This service is not a covered Telehealth service.

Edit: HE-N777

Missing Assignment of Benefits Indicator.

Edit: HE-N778

Missing Primary Care Physician Information.

Edit: HE-N779

Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is received.

Edit: HE-N78

The necessary components of the child and teen checkup (EPSDT) were not completed.

Edit: HE-N780

Missing/incomplete/invalid end therapy date.

Edit: HE-N781
Edit: HE-N782
Edit: HE-N783
Edit: HE-N784

Missing comprehensive procedure code.

Edit: HE-N785

Missing current radiology film/images.

Edit: HE-N786

Benefit limitation for the orthodontic active and/or retention phase of treatment.

Edit: HE-N787
Edit: HE-N788

The third party administrator/review organization did not receive the requested information.

Edit: HE-N789

Clinical Trial is not a covered benefit.

Edit: HE-N79

Service billed is not compatible with patient location information.

Edit: HE-N790

Provider/supplier not accredited for product/service.

Edit: HE-N791

Missing history & physical report.

Edit: HE-N792

Incomplete/invalid history & physical report.

Edit: HE-N793
Edit: HE-N794

Payment adjusted based on type of technology used.

Edit: HE-N8

Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.

Edit: HE-N80

Missing/incomplete/invalid prenatal screening information.

Edit: HE-N81

Procedure billed is not compatible with tooth surface code.

Edit: HE-N82

Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.

Edit: HE-N83

No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

Edit: HE-N84
Edit: HE-N85
Edit: HE-N86

A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.

Edit: HE-N87

Home use of biofeedback therapy is not covered.

Edit: HE-N88
Edit: HE-N89
Edit: HE-N9

Adjustment represents the estimated amount a previous payer may pay.

Edit: HE-N90

Covered only when performed by the attending physician.

Edit: HE-N91

Services not included in the appeal review.

Edit: HE-N92

This facility is not certified for digital mammography.

Edit: HE-N93

A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.

Edit: HE-N94

Claim/Service denied because a more specific taxonomy code is required for adjudication.

Edit: HE-N95

This provider type/provider specialty may not bill this service.

Edit: HE-N96

Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.

Edit: HE-N97

Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.

Edit: HE-N98

Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.

Edit: HE-N99

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Edit: RX-M10

Equipment purchases are limited to the first or the tenth month of medical necessity.

Edit: RX-M100

We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.

Edit: RX-M102

Service not performed on equipment approved by the FDA for this purpose.

Edit: RX-M103

Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.

Edit: RX-M104

Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.

Edit: RX-M105

Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.

Edit: RX-M107

Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.

Edit: RX-M109

We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.

Edit: RX-M11

DME, orthotics and prosthetics must be billed to the DME carrier who services the patient’s zip code.

Edit: RX-M111

We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.

Edit: RX-M112

Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.

Edit: RX-M113

Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.

Edit: RX-M114

This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.

Edit: RX-M115

This item is denied when provided to this patient by a non-contract or non-demonstration supplier.

Edit: RX-M116

Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program.

Edit: RX-M117

Not covered unless submitted via electronic claim.

Edit: RX-M119

Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).

Edit: RX-M12

Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.

Edit: RX-M121

We pay for this service only when performed with a covered cryosurgical ablation.

Edit: RX-M122

Missing/incomplete/invalid level of subluxation.

Edit: RX-M123

Missing/incomplete/invalid name, strength, or dosage of the drug furnished.

Edit: RX-M124

Missing indication of whether the patient owns the equipment that requires the part or supply.

Edit: RX-M125

Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.

Edit: RX-M126

Missing/incomplete/invalid individual lab codes included in the test.

Edit: RX-M127

Missing patient medical record for this service.

Edit: RX-M129

Missing/incomplete/invalid indicator of x-ray availability for review.

Edit: RX-M13

Only one initial visit is covered per specialty per medical group.

Edit: RX-M130

Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Edit: RX-M131

Missing physician financial relationship form.

Edit: RX-M132

Missing pacemaker registration form.

Edit: RX-M133

Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.

Edit: RX-M134

Performed by a facility/supplier in which the provider has a financial interest.

Edit: RX-M135

Missing/incomplete/invalid plan of treatment.

Edit: RX-M136

Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.

Edit: RX-M137

Part B coinsurance under a demonstration project or pilot program.

Edit: RX-M138

Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.

Edit: RX-M139

Denied services exceed the coverage limit for the demonstration.

Edit: RX-M14

No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.

Edit: RX-M141

Missing physician certified plan of care.

Edit: RX-M142

Missing American Diabetes Association Certificate of Recognition.

Edit: RX-M143

The provider must update license information with the payer.

Edit: RX-M144

Pre-/post-operative care payment is included in the allowance for the surgery/procedure.

Edit: RX-M15

Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

Edit: RX-M16
Edit: RX-M17
Edit: RX-M18

Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient’s home.

Edit: RX-M19

Missing oxygen certification/re-certification.

Edit: RX-M2

Not paid separately when the patient is an inpatient.

Edit: RX-M20

Missing/incomplete/invalid HCPCS.

Edit: RX-M21

Missing/incomplete/invalid place of residence for this service/item provided in a home.

Edit: RX-M22

Missing/incomplete/invalid number of miles traveled.

Edit: RX-M23

Missing invoice.

Edit: RX-M24

Missing/incomplete/invalid number of doses per vial.

Edit: RX-M25

The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.

Edit: RX-M26
Edit: RX-M27
Edit: RX-M28

This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.

Edit: RX-M29

Missing operative note/report.

Edit: RX-M3

Equipment is the same or similar to equipment already being used.

Edit: RX-M30

Missing pathology report.

Edit: RX-M31

Missing radiology report.

Edit: RX-M32
Edit: RX-M36

This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.

Edit: RX-M37

Not covered when the patient is under age 35.

Edit: RX-M38
Edit: RX-M39
Edit: RX-M4
Edit: RX-M40

Claim must be assigned and must be filed by the practitioner’s employer.

Edit: RX-M41

We do not pay for this as the patient has no legal obligation to pay for this.

Edit: RX-M42

The medical necessity form must be personally signed by the attending physician.

Edit: RX-M44

Missing/incomplete/invalid condition code.

Edit: RX-M45

Missing/incomplete/invalid occurrence code(s).

Edit: RX-M46

Missing/incomplete/invalid occurrence span code(s).

Edit: RX-M47

Missing/incomplete/invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN).

Edit: RX-M49

Missing/incomplete/invalid value code(s) or amount(s).

Edit: RX-M5

Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.

Edit: RX-M50

Missing/incomplete/invalid revenue code(s).

Edit: RX-M51

Missing/incomplete/invalid procedure code(s).

Edit: RX-M52
Edit: RX-M53

Missing/incomplete/invalid days or units of service.

Edit: RX-M54

Missing/incomplete/invalid total charges.

Edit: RX-M55

We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.

Edit: RX-M56

Missing/incomplete/invalid payer identifier.

Edit: RX-M59
Edit: RX-M6
Edit: RX-M60

Missing Certificate of Medical Necessity.

Edit: RX-M61

We cannot pay for this as the approval period for the FDA clinical trial has expired.

Edit: RX-M62

Missing/incomplete/invalid treatment authorization code.

Edit: RX-M64

Missing/incomplete/invalid other diagnosis.

Edit: RX-M65

One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.

Edit: RX-M66

Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.

Edit: RX-M67

Missing/incomplete/invalid other procedure code(s).

Edit: RX-M69

Paid at the regular rate as you did not submit documentation to justify the modified procedure code.

Edit: RX-M7

No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price.

Edit: RX-M70
Edit: RX-M71

Total payment reduced due to overlap of tests billed.

Edit: RX-M73

The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.

Edit: RX-M74

This service does not qualify for a HPSA/Physician Scarcity bonus payment.

Edit: RX-M75

Multiple automated multichannel tests performed on the same day combined for payment.

Edit: RX-M76

Missing/incomplete/invalid diagnosis or condition.

Edit: RX-M77

Missing/incomplete/invalid/inappropriate place of service.

Edit: RX-M79

Missing/incomplete/invalid charge.

Edit: RX-M8

We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.

Edit: RX-M80

Not covered when performed during the same session/date as a previously processed service for the patient.

Edit: RX-M81

You are required to code to the highest level of specificity.

Edit: RX-M82

Service is not covered when patient is under age 50.

Edit: RX-M83

Service is not covered unless the patient is classified as at high risk.

Edit: RX-M84

Medical code sets used must be the codes in effect at the time of service.

Edit: RX-M85

Subjected to review of physician evaluation and management services.

Edit: RX-M86

Service denied because payment already made for same/similar procedure within set time frame.

Edit: RX-M87

Claim/service(s) subjected to CFO-CAP prepayment review.

Edit: RX-M89

Not covered more than once under age 40.

Edit: RX-M9
Edit: RX-M90

Not covered more than once in a 12 month period.

Edit: RX-M91

Lab procedures with different CLIA certification numbers must be billed on separate claims.

Edit: RX-M93

Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.

Edit: RX-M94

Information supplied does not support a break in therapy. A new capped rental period will not begin.

Edit: RX-M95

Services subjected to Home Health Initiative medical review/cost report audit.

Edit: RX-M96

The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.

Edit: RX-M97

Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.

Edit: RX-M99

Missing/incomplete/invalid Universal Product Number/Serial Number.

Edit: RX-MA01
Edit: RX-MA02
Edit: RX-MA04

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

Edit: RX-MA07
Edit: RX-MA08
Edit: RX-MA09
Edit: RX-MA10
Edit: RX-MA100

Missing/incomplete/invalid date of current illness or symptoms.

Edit: RX-MA103

Hemophilia Add On.

Edit: RX-MA106

PIP (Periodic Interim Payment) claim.

Edit: RX-MA107

Paper claim contains more than three separate data items in field 19.

Edit: RX-MA108

Paper claim contains more than one data item in field 23.

Edit: RX-MA109

Claim processed in accordance with ambulatory surgical guidelines.

Edit: RX-MA110

Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.

Edit: RX-MA111

Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory’s name and address.

Edit: RX-MA112

Missing/incomplete/invalid group practice information.

Edit: RX-MA113

Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.

Edit: RX-MA114

Missing/incomplete/invalid information on where the services were furnished.

Edit: RX-MA115

Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).

Edit: RX-MA116

Did not complete the statement ‘Homebound’ on the claim to validate whether laboratory services were performed at home or in an institution.

Edit: RX-MA117

This claim has been assessed a $1.00 user fee.

Edit: RX-MA118
Edit: RX-MA12

You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).

Edit: RX-MA120

Missing/incomplete/invalid CLIA certification number.

Edit: RX-MA121

Missing/incomplete/invalid x-ray date.

Edit: RX-MA122

Missing/incomplete/invalid initial treatment date.

Edit: RX-MA123

Your center was not selected to participate in this study, therefore, we cannot pay for these services.

Edit: RX-MA125

Per legislation governing this program, payment constitutes payment in full.

Edit: RX-MA126

Pancreas transplant not covered unless kidney transplant performed.

Edit: RX-MA128

Missing/incomplete/invalid FDA approval number.

Edit: RX-MA13
Edit: RX-MA130

Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Edit: RX-MA131

Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.

Edit: RX-MA132

Adjustment to the pre-demonstration rate.

Edit: RX-MA133

Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.

Edit: RX-MA134

Missing/incomplete/invalid provider number of the facility where the patient resides.

Edit: RX-MA14
Edit: RX-MA15
Edit: RX-MA16

The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.

Edit: RX-MA17

We are the primary payer and have paid at the primary rate. You must contact the patient’s other insurer to refund any excess it may have paid due to its erroneous primary payment.

Edit: RX-MA18
Edit: RX-MA19
Edit: RX-MA20

Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.

Edit: RX-MA21

SSA records indicate mismatch with name and sex.

Edit: RX-MA22

Payment of less than $1.00 suppressed.

Edit: RX-MA23

Demand bill approved as result of medical review.

Edit: RX-MA24

Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.

Edit: RX-MA25

A patient may not elect to change a hospice provider more than once in a benefit period.

Edit: RX-MA26
Edit: RX-MA27

Missing/incomplete/invalid entitlement number or name shown on the claim.

Edit: RX-MA28
Edit: RX-MA30

Missing/incomplete/invalid type of bill.

Edit: RX-MA31

Missing/incomplete/invalid beginning and ending dates of the period billed.

Edit: RX-MA32

Missing/incomplete/invalid number of covered days during the billing period.

Edit: RX-MA33

Missing/incomplete/invalid noncovered days during the billing period.

Edit: RX-MA34

Missing/incomplete/invalid number of coinsurance days during the billing period.

Edit: RX-MA35

Missing/incomplete/invalid number of lifetime reserve days.

Edit: RX-MA36

Missing/incomplete/invalid patient name.

Edit: RX-MA37

Missing/incomplete/invalid patient’s address.

Edit: RX-MA39

Missing/incomplete/invalid gender.

Edit: RX-MA40

Missing/incomplete/invalid admission date.

Edit: RX-MA41

Missing/incomplete/invalid admission type.

Edit: RX-MA42

Missing/incomplete/invalid admission source.

Edit: RX-MA43

Missing/incomplete/invalid patient status.

Edit: RX-MA44
Edit: RX-MA45
Edit: RX-MA46
Edit: RX-MA47

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.

Edit: RX-MA48

Missing/incomplete/invalid name or address of responsible party or primary payer.

Edit: RX-MA50

Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.

Edit: RX-MA53

Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.

Edit: RX-MA54

Physician certification or election consent for hospice care not received timely.

Edit: RX-MA55

Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.

Edit: RX-MA56

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.

Edit: RX-MA57

Patient submitted written request to revoke his/her election for religious non-medical health care services.

Edit: RX-MA58

Missing/incomplete/invalid release of information indicator.

Edit: RX-MA59
Edit: RX-MA60

Missing/incomplete/invalid patient relationship to insured.

Edit: RX-MA61

Missing/incomplete/invalid social security number or health insurance claim number.

Edit: RX-MA62
Edit: RX-MA63

Missing/incomplete/invalid principal diagnosis.

Edit: RX-MA64

Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.

Edit: RX-MA65

Missing/incomplete/invalid admitting diagnosis.

Edit: RX-MA66

Missing/incomplete/invalid principal procedure code.

Edit: RX-MA67
Edit: RX-MA68
Edit: RX-MA69

Missing/incomplete/invalid remarks.

Edit: RX-MA70

Missing/incomplete/invalid provider representative signature.

Edit: RX-MA71

Missing/incomplete/invalid provider representative signature date.

Edit: RX-MA72
Edit: RX-MA73

Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.

Edit: RX-MA74
Edit: RX-MA75

Missing/incomplete/invalid patient or authorized representative signature.

Edit: RX-MA76

Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.

Edit: RX-MA77
Edit: RX-MA79

Billed in excess of interim rate.

Edit: RX-MA80

Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.

Edit: RX-MA81

Missing/incomplete/invalid provider/supplier signature.

Edit: RX-MA83

Did not indicate whether we are the primary or secondary payer.

Edit: RX-MA84

Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.

Edit: RX-MA88

Missing/incomplete/invalid insured’s address and/or telephone number for the primary payer.

Edit: RX-MA89

Missing/incomplete/invalid patient’s relationship to the insured for the primary payer.

Edit: RX-MA90

Missing/incomplete/invalid employment status code for the primary insured.

Edit: RX-MA91
Edit: RX-MA92

Missing plan information for other insurance.

Edit: RX-MA93

Non-PIP (Periodic Interim Payment) claim.

Edit: RX-MA94
Edit: RX-MA96

Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.

Edit: RX-MA97

Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.

Edit: RX-MA99

Missing/incomplete/invalid Medigap information.

Edit: RX-N1
Edit: RX-N10

Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.

Edit: RX-N103

Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.

Edit: RX-N104

This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.

Edit: RX-N105

This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claims processing.

Edit: RX-N106

Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.

Edit: RX-N107

Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.

Edit: RX-N108

Missing/incomplete/invalid upgrade information.

Edit: RX-N109
Edit: RX-N11

Denial reversed because of medical review.

Edit: RX-N110

This facility is not certified for film mammography.

Edit: RX-N111

No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.

Edit: RX-N112

This claim is excluded from your electronic remittance advice.

Edit: RX-N113

Only one initial visit is covered per physician, group practice or provider.

Edit: RX-N114

During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.

Edit: RX-N115

This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD.

Edit: RX-N116
Edit: RX-N117
Edit: RX-N118

This service is not paid if billed more than once every 28 days.

Edit: RX-N119

This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.

Edit: RX-N12

Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.

Edit: RX-N120

Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.

Edit: RX-N121

Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.

Edit: RX-N122

Add-on code cannot be billed by itself.

Edit: RX-N123
Edit: RX-N124

Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.

Edit: RX-N125

Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice.

Edit: RX-N126

Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.

Edit: RX-N127

This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.

Edit: RX-N128

This amount represents the prior to coverage portion of the allowance.

Edit: RX-N129

Not eligible due to the patient’s age.

Edit: RX-N13

Payment based on professional/technical component modifier(s).

Edit: RX-N130

Consult plan benefit documents/guidelines for information about restrictions for this service.

Edit: RX-N131

Total payments under multiple contracts cannot exceed the allowance for this service.

Edit: RX-N132
Edit: RX-N133
Edit: RX-N134
Edit: RX-N135

Record fees are the patient’s responsibility and limited to the specified co-payment.

Edit: RX-N136
Edit: RX-N137
Edit: RX-N138
Edit: RX-N139
Edit: RX-N140
Edit: RX-N141

The patient was not residing in a long-term care facility during all or part of the service dates billed.

Edit: RX-N142

The original claim was denied. Resubmit a new claim, not a replacement claim.

Edit: RX-N143

The patient was not in a hospice program during all or part of the service dates billed.

Edit: RX-N144

The rate changed during the dates of service billed.

Edit: RX-N146

Missing screening document.

Edit: RX-N147

Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.

Edit: RX-N148

Missing/incomplete/invalid date of last menstrual period.

Edit: RX-N149

Rebill all applicable services on a single claim.

Edit: RX-N15

Services for a newborn must be billed separately.

Edit: RX-N150

Missing/incomplete/invalid model number.

Edit: RX-N151

Telephone contact services will not be paid until the face-to-face contact requirement has been met.

Edit: RX-N152

Missing/incomplete/invalid replacement claim information.

Edit: RX-N153

Missing/incomplete/invalid room and board rate.

Edit: RX-N154
Edit: RX-N155
Edit: RX-N156
Edit: RX-N157

Transportation to/from this destination is not covered.

Edit: RX-N158

Transportation in a vehicle other than an ambulance is not covered.

Edit: RX-N159

Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.

Edit: RX-N16

Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.

Edit: RX-N160

The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.

Edit: RX-N161

This drug/service/supply is covered only when the associated service is covered.

Edit: RX-N162
Edit: RX-N163

Medical record does not support code billed per the code definition.

Edit: RX-N167

Charges exceed the post-transplant coverage limit.

Edit: RX-N170

A new/revised/renewed certificate of medical necessity is needed.

Edit: RX-N171

Payment for repair or replacement is not covered or has exceeded the purchase price.

Edit: RX-N172

The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.

Edit: RX-N173

No qualifying hospital stay dates were provided for this episode of care.

Edit: RX-N174

This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group ‘PR’.

Edit: RX-N175

Missing review organization approval.

Edit: RX-N176

Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.

Edit: RX-N177
Edit: RX-N178

Missing pre-operative images/visual field results.

Edit: RX-N179

Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.

Edit: RX-N180

This item or service does not meet the criteria for the category under which it was billed.

Edit: RX-N181

Additional information is required from another provider involved in this service.

Edit: RX-N182

This claim/service must be billed according to the schedule for this plan.

Edit: RX-N183
Edit: RX-N184

Rebill technical and professional components separately.

Edit: RX-N185
Edit: RX-N186

Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.

Edit: RX-N187
Edit: RX-N188

The approved level of care does not match the procedure code submitted.

Edit: RX-N189
Edit: RX-N19

Procedure code incidental to primary procedure.

Edit: RX-N190

Missing contract indicator.

Edit: RX-N191

The provider must update insurance information directly with payer.

Edit: RX-N192

Patient is a Medicaid/Qualified Medicare Beneficiary.

Edit: RX-N193
Edit: RX-N194

Technical component not paid if provider does not own the equipment used.

Edit: RX-N195

The technical component must be billed separately.

Edit: RX-N196
Edit: RX-N197

The subscriber must update insurance information directly with payer.

Edit: RX-N198

Rendering provider must be affiliated with the pay-to provider.

Edit: RX-N199

Additional payment/recoupment approved based on payer-initiated review/audit.

Edit: RX-N2

This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.

Edit: RX-N20

Service not payable with other service rendered on the same date.

Edit: RX-N200

The professional component must be billed separately.

Edit: RX-N202
Edit: RX-N203

Missing/incomplete/invalid anesthesia time/units.

Edit: RX-N204

Services under review for possible pre-existing condition. Send medical records for prior 12 months

Edit: RX-N205

Information provided was illegible.

Edit: RX-N206

The supporting documentation does not match the information sent on the claim.

Edit: RX-N207

Missing/incomplete/invalid weight.

Edit: RX-N208

Missing/incomplete/invalid DRG code.

Edit: RX-N209

Missing/incomplete/invalid taxpayer identification number (TIN).

Edit: RX-N21
Edit: RX-N210
Edit: RX-N211
Edit: RX-N212

Charges processed under a Point of Service benefit .

Edit: RX-N213

Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information.

Edit: RX-N214

Missing/incomplete/invalid history of the related initial surgical procedure(s).

Edit: RX-N215
Edit: RX-N216

We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.

Edit: RX-N217

We pay only one site of service per provider per claim.

Edit: RX-N218

You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.

Edit: RX-N219

Payment based on previous payer’s allowed amount.

Edit: RX-N22
Edit: RX-N220
Edit: RX-N221

Missing Admitting History and Physical report.

Edit: RX-N222

Incomplete/invalid Admitting History and Physical report.

Edit: RX-N223

Missing documentation of benefit to the patient during initial treatment period.

Edit: RX-N224

Incomplete/invalid documentation of benefit to the patient during initial treatment period.

Edit: RX-N226

Incomplete/invalid American Diabetes Association Certificate of Recognition.

Edit: RX-N227

Incomplete/invalid Certificate of Medical Necessity.

Edit: RX-N228

Incomplete/invalid consent form.

Edit: RX-N229

Incomplete/invalid contract indicator.

Edit: RX-N23
Edit: RX-N230

Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.

Edit: RX-N231

Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.

Edit: RX-N232

Incomplete/invalid itemized bill/statement.

Edit: RX-N233

Incomplete/invalid operative note/report.

Edit: RX-N234

Incomplete/invalid oxygen certification/re-certification.

Edit: RX-N235

Incomplete/invalid pacemaker registration form.

Edit: RX-N236

Incomplete/invalid pathology report.

Edit: RX-N237

Incomplete/invalid patient medical record for this service.

Edit: RX-N238

Incomplete/invalid physician certified plan of care.

Edit: RX-N239

Incomplete/invalid physician financial relationship form.

Edit: RX-N24

Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.

Edit: RX-N240

Incomplete/invalid radiology report.

Edit: RX-N241

Incomplete/invalid review organization approval.

Edit: RX-N242

Incomplete/invalid radiology film(s)/image(s).

Edit: RX-N243

Incomplete/invalid/not approved screening document.

Edit: RX-N244

Incomplete/Invalid pre-operative images/visual field results.

Edit: RX-N245

Incomplete/invalid plan information for other insurance .

Edit: RX-N246

State regulated patient payment limitations apply to this service.

Edit: RX-N247

Missing/incomplete/invalid assistant surgeon taxonomy.

Edit: RX-N248

Missing/incomplete/invalid assistant surgeon name.

Edit: RX-N249

Missing/incomplete/invalid assistant surgeon primary identifier.

Edit: RX-N25

This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.

Edit: RX-N250

Missing/incomplete/invalid assistant surgeon secondary identifier.

Edit: RX-N251

Missing/incomplete/invalid attending provider taxonomy.

Edit: RX-N252

Missing/incomplete/invalid attending provider name.

Edit: RX-N253

Missing/incomplete/invalid attending provider primary identifier.

Edit: RX-N254

Missing/incomplete/invalid attending provider secondary identifier.

Edit: RX-N255

Missing/incomplete/invalid billing provider taxonomy.

Edit: RX-N256

Missing/incomplete/invalid billing provider/supplier name.

Edit: RX-N257

Missing/incomplete/invalid billing provider/supplier primary identifier.

Edit: RX-N258

Missing/incomplete/invalid billing provider/supplier address.

Edit: RX-N259

Missing/incomplete/invalid billing provider/supplier secondary identifier.

Edit: RX-N26

Missing itemized bill/statement.

Edit: RX-N260

Missing/incomplete/invalid billing provider/supplier contact information.

Edit: RX-N261

Missing/incomplete/invalid operating provider name.

Edit: RX-N262

Missing/incomplete/invalid operating provider primary identifier.

Edit: RX-N263

Missing/incomplete/invalid operating provider secondary identifier.

Edit: RX-N264

Missing/incomplete/invalid ordering provider name.

Edit: RX-N265

Missing/incomplete/invalid ordering provider primary identifier.

Edit: RX-N266

Missing/incomplete/invalid ordering provider address.

Edit: RX-N267

Missing/incomplete/invalid ordering provider secondary identifier.

Edit: RX-N268

Missing/incomplete/invalid ordering provider contact information.

Edit: RX-N269

Missing/incomplete/invalid other provider name.

Edit: RX-N27

Missing/incomplete/invalid treatment number.

Edit: RX-N270

Missing/incomplete/invalid other provider primary identifier.

Edit: RX-N271

Missing/incomplete/invalid other provider secondary identifier.

Edit: RX-N272

Missing/incomplete/invalid other payer attending provider identifier.

Edit: RX-N273

Missing/incomplete/invalid other payer operating provider identifier.

Edit: RX-N274

Missing/incomplete/invalid other payer other provider identifier.

Edit: RX-N275

Missing/incomplete/invalid other payer purchased service provider identifier.

Edit: RX-N276

Missing/incomplete/invalid other payer referring provider identifier.

Edit: RX-N277

Missing/incomplete/invalid other payer rendering provider identifier.

Edit: RX-N278

Missing/incomplete/invalid other payer service facility provider identifier.

Edit: RX-N279

Missing/incomplete/invalid pay-to provider name.

Edit: RX-N28

Consent form requirements not fulfilled.

Edit: RX-N280

Missing/incomplete/invalid pay-to provider primary identifier.

Edit: RX-N281

Missing/incomplete/invalid pay-to provider address.

Edit: RX-N282

Missing/incomplete/invalid pay-to provider secondary identifier.

Edit: RX-N283

Missing/incomplete/invalid purchased service provider identifier.

Edit: RX-N284

Missing/incomplete/invalid referring provider taxonomy.

Edit: RX-N285

Missing/incomplete/invalid referring provider name.

Edit: RX-N286

Missing/incomplete/invalid referring provider primary identifier.

Edit: RX-N287

Missing/incomplete/invalid referring provider secondary identifier.

Edit: RX-N288

Missing/incomplete/invalid rendering provider taxonomy.

Edit: RX-N289

Missing/incomplete/invalid rendering provider name.

Edit: RX-N290

Missing/incomplete/invalid rendering provider primary identifier.

Edit: RX-N291

Missing/incomplete/invalid rendering provider secondary identifier.

Edit: RX-N292

Missing/incomplete/invalid service facility name.

Edit: RX-N293

Missing/incomplete/invalid service facility primary identifier.

Edit: RX-N294

Missing/incomplete/invalid service facility primary address.

Edit: RX-N295

Missing/incomplete/invalid service facility secondary identifier.

Edit: RX-N296

Missing/incomplete/invalid supervising provider name.

Edit: RX-N297

Missing/incomplete/invalid supervising provider primary identifier.

Edit: RX-N298

Missing/incomplete/invalid supervising provider secondary identifier.

Edit: RX-N299

Missing/incomplete/invalid occurrence date(s).

Edit: RX-N3

Missing consent form.

Edit: RX-N30

Patient ineligible for this service.

Edit: RX-N300

Missing/incomplete/invalid occurrence span date(s).

Edit: RX-N301

Missing/incomplete/invalid procedure date(s).

Edit: RX-N302

Missing/incomplete/invalid other procedure date(s).

Edit: RX-N303

Missing/incomplete/invalid principal procedure date.

Edit: RX-N304

Missing/incomplete/invalid dispensed date.

Edit: RX-N305

Missing/incomplete/invalid injury/accident date.

Edit: RX-N306

Missing/incomplete/invalid acute manifestation date.

Edit: RX-N307

Missing/incomplete/invalid adjudication or payment date.

Edit: RX-N308

Missing/incomplete/invalid appliance placement date.

Edit: RX-N309

Missing/incomplete/invalid assessment date.

Edit: RX-N31

Missing/incomplete/invalid prescribing provider identifier.

Edit: RX-N310

Missing/incomplete/invalid assumed or relinquished care date.

Edit: RX-N311

Missing/incomplete/invalid authorized to return to work date.

Edit: RX-N312

Missing/incomplete/invalid begin therapy date.

Edit: RX-N313

Missing/incomplete/invalid certification revision date.

Edit: RX-N314

Missing/incomplete/invalid diagnosis date.

Edit: RX-N315

Missing/incomplete/invalid disability from date.

Edit: RX-N316

Missing/incomplete/invalid disability to date.

Edit: RX-N317

Missing/incomplete/invalid discharge hour.

Edit: RX-N318

Missing/incomplete/invalid discharge or end of care date.

Edit: RX-N319

Missing/incomplete/invalid hearing or vision prescription date.

Edit: RX-N32

Claim must be submitted by the provider who rendered the service.

Edit: RX-N320

Missing/incomplete/invalid Home Health Certification Period.

Edit: RX-N321

Missing/incomplete/invalid last admission period.

Edit: RX-N322

Missing/incomplete/invalid last certification date.

Edit: RX-N323

Missing/incomplete/invalid last contact date.

Edit: RX-N324

Missing/incomplete/invalid last seen/visit date.

Edit: RX-N325

Missing/incomplete/invalid last worked date.

Edit: RX-N326

Missing/incomplete/invalid last x-ray date.

Edit: RX-N327

Missing/incomplete/invalid other insured birth date.

Edit: RX-N328

Missing/incomplete/invalid Oxygen Saturation Test date.

Edit: RX-N329

Missing/incomplete/invalid patient birth date.

Edit: RX-N33

No record of health check prior to initiation of treatment.

Edit: RX-N330

Missing/incomplete/invalid patient death date.

Edit: RX-N331

Missing/incomplete/invalid physician order date.

Edit: RX-N332

Missing/incomplete/invalid prior hospital discharge date.

Edit: RX-N333

Missing/incomplete/invalid prior placement date.

Edit: RX-N334

Missing/incomplete/invalid re-evaluation date.

Edit: RX-N335

Missing/incomplete/invalid referral date.

Edit: RX-N336

Missing/incomplete/invalid replacement date.

Edit: RX-N337

Missing/incomplete/invalid secondary diagnosis date.

Edit: RX-N338

Missing/incomplete/invalid shipped date.

Edit: RX-N339

Missing/incomplete/invalid similar illness or symptom date.

Edit: RX-N34

Incorrect claim form/format for this service.

Edit: RX-N340

Missing/incomplete/invalid subscriber birth date.

Edit: RX-N341

Missing/incomplete/invalid surgery date.

Edit: RX-N342

Missing/incomplete/invalid test performed date.

Edit: RX-N343

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.

Edit: RX-N344

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.

Edit: RX-N345

Date range not valid with units submitted.

Edit: RX-N346

Missing/incomplete/invalid oral cavity designation code.

Edit: RX-N347

Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

Edit: RX-N348

You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.

Edit: RX-N349

The administration method and drug must be reported to adjudicate this service.

Edit: RX-N35

Program integrity/utilization review decision.

Edit: RX-N350

Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.

Edit: RX-N351

Service date outside of the approved treatment plan service dates.

Edit: RX-N352
Edit: RX-N353
Edit: RX-N354

Incomplete/invalid invoice.

Edit: RX-N355
Edit: RX-N356

Not covered when performed with, or subsequent to, a non-covered service.

Edit: RX-N357

Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.

Edit: RX-N358
Edit: RX-N359

Missing/incomplete/invalid height.

Edit: RX-N36
Edit: RX-N360
Edit: RX-N362

The number of Days or Units of Service exceeds our acceptable maximum.

Edit: RX-N363
Edit: RX-N364
Edit: RX-N366

Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.

Edit: RX-N367
Edit: RX-N368

You must appeal the determination of the previously adjudicated claim.

Edit: RX-N369
Edit: RX-N37

Missing/incomplete/invalid tooth number/letter.

Edit: RX-N370

Billing exceeds the rental months covered/approved by the payer.

Edit: RX-N371
Edit: RX-N372

Only reasonable and necessary maintenance/service charges are covered.

Edit: RX-N373

It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.

Edit: RX-N374

Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.

Edit: RX-N375

Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.

Edit: RX-N376

Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.

Edit: RX-N377

Payment based on a processed replacement claim.

Edit: RX-N378

Missing/incomplete/invalid prescription quantity.

Edit: RX-N379

Claim level information does not match line level information.

Edit: RX-N380

The original claim has been processed, submit a corrected claim.

Edit: RX-N381
Edit: RX-N382

Missing/incomplete/invalid patient identifier.

Edit: RX-N383

Not covered when deemed cosmetic.

Edit: RX-N384

Records indicate that the referenced body part/tooth has been removed in a previous procedure.

Edit: RX-N385

Notification of admission was not timely according to published plan procedures.

Edit: RX-N386

This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.

Edit: RX-N387
Edit: RX-N388

Missing/incomplete/invalid prescription number.

Edit: RX-N389

Duplicate prescription number submitted.

Edit: RX-N39

Procedure code is not compatible with tooth number/letter.

Edit: RX-N390

This service/report cannot be billed separately.

Edit: RX-N391

Missing emergency department records.

Edit: RX-N392

Incomplete/invalid emergency department records.

Edit: RX-N393

Missing progress notes/report.

Edit: RX-N394

Incomplete/invalid progress notes/report.

Edit: RX-N395

Missing laboratory report.

Edit: RX-N396

Incomplete/invalid laboratory report.

Edit: RX-N397

Benefits are not available for incomplete service(s)/undelivered item(s).

Edit: RX-N398

Missing elective consent form.

Edit: RX-N399

Incomplete/invalid elective consent form.

Edit: RX-N4

Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB.

Edit: RX-N40

Missing radiology film(s)/image(s).

Edit: RX-N400
Edit: RX-N401

Missing periodontal charting.

Edit: RX-N402

Incomplete/invalid periodontal charting.

Edit: RX-N403

Missing facility certification.

Edit: RX-N404

Incomplete/invalid facility certification.

Edit: RX-N405

This service is only covered when the donor’s insurer(s) do not provide coverage for the service.

Edit: RX-N406

This service is only covered when the recipient’s insurer(s) do not provide coverage for the service.

Edit: RX-N407

You are not an approved submitter for this transmission format.

Edit: RX-N408

This payer does not cover deductibles assessed by a previous payer.

Edit: RX-N409

This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.

Edit: RX-N410

Not covered unless the prescription changes.

Edit: RX-N411

This service is allowed one time in a 6-month period.

Edit: RX-N412

This service is allowed 2 times in a 12-month period.

Edit: RX-N413

This service is allowed 2 times in a benefit year.

Edit: RX-N414

This service is allowed 4 times in a 12-month period.

Edit: RX-N415

This service is allowed 1 time in an 18-month period.

Edit: RX-N416

This service is allowed 1 time in a 3-year period.

Edit: RX-N417

This service is allowed 1 time in a 5-year period.

Edit: RX-N418

Misrouted claim. See the payer’s claim submission instructions.

Edit: RX-N419

Claim payment was the result of a payer’s retroactive adjustment due to a retroactive rate change.

Edit: RX-N42

Missing mental health assessment.

Edit: RX-N420

Claim payment was the result of a payer’s retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.

Edit: RX-N421

Claim payment was the result of a payer’s retroactive adjustment due to a review organization decision.

Edit: RX-N422

Claim payment was the result of a payer’s retroactive adjustment due to a payer’s contract incentive program.

Edit: RX-N423

Claim payment was the result of a payer’s retroactive adjustment due to a non standard program.

Edit: RX-N424

Patient does not reside in the geographic area required for this type of payment.

Edit: RX-N425

Statutorily excluded service(s).

Edit: RX-N426

No coverage when self-administered.

Edit: RX-N427

Payment for eyeglasses or contact lenses can be made only after cataract surgery.

Edit: RX-N428

Not covered when performed in this place of service.

Edit: RX-N429

Not covered when considered routine.

Edit: RX-N43

Bed hold or leave days exceeded.

Edit: RX-N430

Procedure code is inconsistent with the units billed.

Edit: RX-N431

Not covered with this procedure.

Edit: RX-N432
Edit: RX-N433

Resubmit this claim using only your National Provider Identifier (NPI).

Edit: RX-N434

Missing/Incomplete/Invalid Present on Admission indicator.

Edit: RX-N435

Exceeds number/frequency approved /allowed within time period without support documentation.

Edit: RX-N436

The injury claim has not been accepted and a mandatory medical reimbursement has been made.

Edit: RX-N437
Edit: RX-N438

This jurisdiction only accepts paper claims.

Edit: RX-N439

Missing anesthesia physical status report/indicators.

Edit: RX-N440

Incomplete/invalid anesthesia physical status report/indicators.

Edit: RX-N441

This missed/cancelled appointment is not covered.

Edit: RX-N442

Payment based on an alternate fee schedule.

Edit: RX-N443

Missing/incomplete/invalid total time or begin/end time.

Edit: RX-N444
Edit: RX-N445

Missing document for actual cost or paid amount.

Edit: RX-N446

Incomplete/invalid document for actual cost or paid amount.

Edit: RX-N447

Payment is based on a generic equivalent as required documentation was not provided.

Edit: RX-N448

This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.

Edit: RX-N449

Payment based on a comparable drug/service/supply.

Edit: RX-N45

Payment based on authorized amount.

Edit: RX-N450

Covered only when performed by the primary treating physician or the designee.

Edit: RX-N451

Missing Admission Summary Report.

Edit: RX-N452

Incomplete/invalid Admission Summary Report.

Edit: RX-N453

Missing Consultation Report.

Edit: RX-N454

Incomplete/invalid Consultation Report.

Edit: RX-N455

Missing Physician Order.

Edit: RX-N456

Incomplete/invalid Physician Order.

Edit: RX-N457

Missing Diagnostic Report.

Edit: RX-N458

Incomplete/invalid Diagnostic Report.

Edit: RX-N459

Missing Discharge Summary.

Edit: RX-N46

Missing/incomplete/invalid admission hour.

Edit: RX-N460

Incomplete/invalid Discharge Summary.

Edit: RX-N461

Missing Nursing Notes.

Edit: RX-N462

Incomplete/invalid Nursing Notes.

Edit: RX-N463

Missing support data for claim.

Edit: RX-N464

Incomplete/invalid support data for claim.

Edit: RX-N465

Missing Physical Therapy Notes/Report.

Edit: RX-N466

Incomplete/invalid Physical Therapy Notes/Report.

Edit: RX-N467

Missing Tests and Analysis Report.

Edit: RX-N468

Incomplete/invalid Report of Tests and Analysis Report.

Edit: RX-N469
Edit: RX-N47

Claim conflicts with another inpatient stay.

Edit: RX-N470

This payment will complete the mandatory medical reimbursement limit.

Edit: RX-N471

Missing/incomplete/invalid HIPPS Rate Code.

Edit: RX-N472

Payment for this service has been issued to another provider.

Edit: RX-N473

Missing certification.

Edit: RX-N474

Incomplete/invalid certification.

Edit: RX-N475

Missing completed referral form.

Edit: RX-N476

Incomplete/invalid completed referral form.

Edit: RX-N477

Missing Dental Models.

Edit: RX-N478

Incomplete/invalid Dental Models.

Edit: RX-N479

Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: RX-N48

Claim information does not agree with information received from other insurance carrier.

Edit: RX-N480

Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

Edit: RX-N481

Missing Models.

Edit: RX-N482

Incomplete/invalid Models.

Edit: RX-N485

Missing Physical Therapy Certification.

Edit: RX-N486

Incomplete/invalid Physical Therapy Certification.

Edit: RX-N487

Missing Prosthetics or Orthotics Certification.

Edit: RX-N488

Incomplete/invalid Prosthetics or Orthotics Certification.

Edit: RX-N489

Missing referral form.

Edit: RX-N49

Court ordered coverage information needs validation.

Edit: RX-N490

Incomplete/invalid referral form.

Edit: RX-N491

Missing/Incomplete/Invalid Exclusionary Rider Condition.

Edit: RX-N492
Edit: RX-N493

Missing Doctor First Report of Injury.

Edit: RX-N494

Incomplete/invalid Doctor First Report of Injury.

Edit: RX-N495

Missing Supplemental Medical Report.

Edit: RX-N496

Incomplete/invalid Supplemental Medical Report.

Edit: RX-N497

Missing Medical Permanent Impairment or Disability Report.

Edit: RX-N498

Incomplete/invalid Medical Permanent Impairment or Disability Report.

Edit: RX-N499

Missing Medical Legal Report.

Edit: RX-N5

EOB received from previous payer. Claim not on file.

Edit: RX-N50

Missing/incomplete/invalid discharge information.

Edit: RX-N500

Incomplete/invalid Medical Legal Report.

Edit: RX-N501

Missing Vocational Report.

Edit: RX-N502

Incomplete/invalid Vocational Report.

Edit: RX-N503

Missing Work Status Report.

Edit: RX-N504

Incomplete/invalid Work Status Report.

Edit: RX-N505
Edit: RX-N506
Edit: RX-N507

Plan distance requirements have not been met.

Edit: RX-N508
Edit: RX-N509
Edit: RX-N51

Electronic interchange agreement not on file for provider/submitter.

Edit: RX-N510
Edit: RX-N511
Edit: RX-N512
Edit: RX-N513
Edit: RX-N516

Records indicate a mismatch between the submitted NPI and EIN.

Edit: RX-N517

Resubmit a new claim with the requested information.

Edit: RX-N518

No separate payment for accessories when furnished for use with oxygen equipment.

Edit: RX-N519

Invalid combination of HCPCS modifiers.

Edit: RX-N52

Patient not enrolled in the billing provider’s managed care plan on the date of service.

Edit: RX-N520
Edit: RX-N521

Mismatch between the submitted provider information and the provider information stored in our system.

Edit: RX-N522

Duplicate of a claim processed, or to be processed, as a crossover claim.

Edit: RX-N523

The limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.

Edit: RX-N524

Based on policy this payment constitutes payment in full.

Edit: RX-N525

These services are not covered when performed within the global period of another service.

Edit: RX-N526

Not qualified for recovery based on employer size.

Edit: RX-N527

We processed this claim as the primary payer prior to receiving the recovery demand.

Edit: RX-N528

Patient is entitled to benefits for Institutional Services only.

Edit: RX-N529

Patient is entitled to benefits for Professional Services only.

Edit: RX-N53

Missing/incomplete/invalid point of pick-up address.

Edit: RX-N530

Not Qualified for Recovery based on enrollment information.

Edit: RX-N531

Not qualified for recovery based on direct payment of premium.

Edit: RX-N532

Not qualified for recovery based on disability and working status.

Edit: RX-N533

Services performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.

Edit: RX-N534

This is an individual policy, the employer does not participate in plan sponsorship.

Edit: RX-N535

Payment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.

Edit: RX-N536

We are not changing the prior payer’s determination of patient responsibility, which you may collect, as this service is not covered by us.

Edit: RX-N537

We have examined claims history and no records of the services have been found.

Edit: RX-N538

A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.

Edit: RX-N539
Edit: RX-N54

Claim information is inconsistent with pre-certified/authorized services.

Edit: RX-N540

Payment adjusted based on the interrupted stay policy.

Edit: RX-N541

Mismatch between the submitted insurance type code and the information stored in our system.

Edit: RX-N542

Missing income verification.

Edit: RX-N543

Incomplete/invalid income verification.

Edit: RX-N544
Edit: RX-N545

Payment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.

Edit: RX-N546

Payment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.

Edit: RX-N547

A refund request (Frequency Type Code 8) was processed previously.

Edit: RX-N548
Edit: RX-N549
Edit: RX-N55

Procedures for billing with group/referring/performing providers were not followed.

Edit: RX-N550
Edit: RX-N551

Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.

Edit: RX-N552

Payment adjusted to reverse a previous withhold/bonus amount.

Edit: RX-N554

Missing/Incomplete/Invalid Family Planning Indicator.

Edit: RX-N555

Missing medication list.

Edit: RX-N556

Incomplete/invalid medication list.

Edit: RX-N557

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.

Edit: RX-N558

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.

Edit: RX-N559

This claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.

Edit: RX-N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.

Edit: RX-N560

The pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.

Edit: RX-N561

The bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission.

Edit: RX-N562

The provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.

Edit: RX-N563
Edit: RX-N564

Patient did not meet the inclusion criteria for the demonstration project or pilot program.

Edit: RX-N565
Edit: RX-N566
Edit: RX-N567

Not covered when considered preventative.

Edit: RX-N568
Edit: RX-N569

Not covered when performed for the reported diagnosis.

Edit: RX-N57

Missing/incomplete/invalid prescribing date.

Edit: RX-N570

Missing/incomplete/invalid credentialing data.

Edit: RX-N571
Edit: RX-N572

This procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.

Edit: RX-N573
Edit: RX-N574

Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

Edit: RX-N575

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.

Edit: RX-N576

Services not related to the specific incident/claim/accident/loss being reported.

Edit: RX-N577

Personal Injury Protection (PIP) Coverage.

Edit: RX-N578

Coverages do not apply to this loss.

Edit: RX-N579

Medical Payments Coverage (MPC).

Edit: RX-N58

Missing/incomplete/invalid patient liability amount.

Edit: RX-N580

Determination based on the provisions of the insurance policy.

Edit: RX-N581

Investigation of coverage eligibility is pending.

Edit: RX-N582

Benefits suspended pending the patient’s cooperation.

Edit: RX-N583

Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.

Edit: RX-N584

Not covered based on the insured’s noncompliance with policy or statutory conditions.

Edit: RX-N585

Benefits are no longer available based on a final injury settlement.

Edit: RX-N586

The injured party does not qualify for benefits.

Edit: RX-N587

Policy benefits have been exhausted.

Edit: RX-N588

The patient has instructed that medical claims/bills are not to be paid.

Edit: RX-N589

Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.

Edit: RX-N59
Edit: RX-N590

Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.

Edit: RX-N591

Payment based on an Independent Medical Examination (IME) or Utilization Review (UR).

Edit: RX-N592

Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.

Edit: RX-N593

Not covered based on failure to attend a scheduled Independent Medical Exam (IME).

Edit: RX-N594

Records reflect the injured party did not complete an Application for Benefits for this loss.

Edit: RX-N595

Records reflect the injured party did not complete an Assignment of Benefits for this loss.

Edit: RX-N596

Records reflect the injured party did not complete a Medical Authorization for this loss.

Edit: RX-N597

Adjusted based on a medical/dental provider’s apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.

Edit: RX-N598

Health care policy coverage is primary.

Edit: RX-N599

Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits, when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider, reimbursement levels in the community and various federal and state fee schedules applicable to automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursement for the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for the locale in which the services were rendered.

Edit: RX-N6

Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.

Edit: RX-N600

Adjusted based on the applicable fee schedule for the region in which the service was rendered.

Edit: RX-N601

In accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.

Edit: RX-N602

Adjusted based on the Redbook maximum allowance.

Edit: RX-N603

This fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.

Edit: RX-N604

In accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers’ Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.

Edit: RX-N605

This fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.

Edit: RX-N606

The Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.

Edit: RX-N607

Service provided for non-compensable condition(s).

Edit: RX-N608

The fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.

Edit: RX-N609

80% of the provider’s billed amount is being recommended for payment according to Act 6.

Edit: RX-N61

Rebill services on separate claims.

Edit: RX-N610
Edit: RX-N611

Claim in litigation. Contact insurer for more information.

Edit: RX-N612

Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.

Edit: RX-N613
Edit: RX-N614
Edit: RX-N615
Edit: RX-N616
Edit: RX-N617

This enrollee is in the second or third month of the advance premium tax credit grace period.

Edit: RX-N618
Edit: RX-N619

Coverage terminated for non-payment of premium.

Edit: RX-N62

Dates of service span multiple rate periods. Resubmit separate claims.

Edit: RX-N620
Edit: RX-N621

Charges for Jurisdiction required forms, reports, or chart notes are not payable.

Edit: RX-N622

Not covered based on the date of injury/accident.

Edit: RX-N623

Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.

Edit: RX-N624

The associated Workers’ Compensation claim has been withdrawn.

Edit: RX-N625

Missing/Incomplete/Invalid Workers’ Compensation Claim Number.

Edit: RX-N626

New or established patient E/M codes are not payable with chiropractic care codes.

Edit: RX-N628

Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.

Edit: RX-N629

Reviews/documentation/notes/summaries/reports/charts not requested.

Edit: RX-N63

Rebill services on separate claim lines.

Edit: RX-N630

Referral not authorized by attending physician.

Edit: RX-N631

Medical Fee Schedule does not list this code. An allowance was made for a comparable service.

Edit: RX-N633

Additional anesthesia time units are not allowed.

Edit: RX-N634

The allowance is calculated based on anesthesia time units.

Edit: RX-N635

The Allowance is calculated based on the anesthesia base units plus time.

Edit: RX-N636

Adjusted because this is reimbursable only once per injury.

Edit: RX-N637

Consultations are not allowed once treatment has been rendered by the same provider.

Edit: RX-N638

Reimbursement has been made according to the home health fee schedule.

Edit: RX-N639

Reimbursement has been made according to the inpatient rehabilitation facilities fee schedule.

Edit: RX-N64
Edit: RX-N640

Exceeds number/frequency approved/allowed within time period.

Edit: RX-N641

Reimbursement has been based on the number of body areas rated.

Edit: RX-N642

Adjusted when billed as individual tests instead of as a panel.

Edit: RX-N643

The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.

Edit: RX-N644

Reimbursement has been made according to the bilateral procedure rule.

Edit: RX-N645

Mark-up allowance.

Edit: RX-N646

Reimbursement has been adjusted based on the guidelines for an assistant.

Edit: RX-N647

Adjusted based on diagnosis-related group (DRG).

Edit: RX-N648

Adjusted based on Stop Loss.

Edit: RX-N649

Payment based on invoice.

Edit: RX-N65

Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.

Edit: RX-N650

This policy was not in effect for this date of loss. No coverage is available.

Edit: RX-N651

No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.

Edit: RX-N652

The date of service is before the date of loss.

Edit: RX-N653

The date of injury does not match the reported date of loss.

Edit: RX-N654

Adjusted based on achievement of maximum medical improvement (MMI).

Edit: RX-N655

Payment based on provider’s geographic region.

Edit: RX-N656

An interest payment is being made because benefits are being paid outside the statutory requirement.

Edit: RX-N657

This should be billed with the appropriate code for these services.

Edit: RX-N658

The billed service(s) are not considered medical expenses.

Edit: RX-N659

This item is exempt from sales tax.

Edit: RX-N660

Sales tax has been included in the reimbursement.

Edit: RX-N661

Documentation does not support that the services rendered were medically necessary.

Edit: RX-N662
Edit: RX-N663

Adjusted based on an agreed amount.

Edit: RX-N664

Adjusted based on a legal settlement.

Edit: RX-N665

Services by an unlicensed provider are not reimbursable.

Edit: RX-N666

Only one evaluation and management code at this service level is covered during the course of care.

Edit: RX-N667

Missing prescription.

Edit: RX-N668

Incomplete/invalid prescription.

Edit: RX-N669

Adjusted based on the Medicare fee schedule.

Edit: RX-N67
Edit: RX-N670

This service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.

Edit: RX-N671

Payment based on a jurisdiction cost-charge ratio.

Edit: RX-N672
Edit: RX-N673

Reimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.

Edit: RX-N674

Not covered unless a pre-requisite procedure/service has been provided.

Edit: RX-N675

Additional information is required from the injured party.

Edit: RX-N676

Service does not qualify for payment under the Outpatient Facility Fee Schedule.

Edit: RX-N677
Edit: RX-N678

Missing post-operative images/visual field results.

Edit: RX-N679

Incomplete/Invalid post-operative images/visual field results.

Edit: RX-N68

Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.

Edit: RX-N680

Missing/Incomplete/Invalid date of previous dental extractions.

Edit: RX-N681

Missing/Incomplete/Invalid full arch series.

Edit: RX-N682

Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance.

Edit: RX-N683

Missing/Incomplete/Invalid prior treatment documentation.

Edit: RX-N684

Payment denied as this is a specialty claim submitted as a general claim.

Edit: RX-N685

Missing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.

Edit: RX-N686

Missing/incomplete/Invalid questionnaire needed to complete payment determination.

Edit: RX-N687
Edit: RX-N688
Edit: RX-N689
Edit: RX-N69
Edit: RX-N690
Edit: RX-N691
Edit: RX-N692
Edit: RX-N693
Edit: RX-N694
Edit: RX-N695
Edit: RX-N696
Edit: RX-N697
Edit: RX-N698
Edit: RX-N699

Payment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.

Edit: RX-N7
Edit: RX-N70

Consolidated billing and payment applies.

Edit: RX-N700

Payment adjusted based on the Electronic Health Records (EHR) Incentive Program.

Edit: RX-N701

Payment adjusted based on the Value-based Payment Modifier.

Edit: RX-N702

Decision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.

Edit: RX-N703

This service is incompatible with previously adjudicated claims or claims in process.

Edit: RX-N704
Edit: RX-N705

Incomplete/invalid documentation.

Edit: RX-N706

Missing documentation.

Edit: RX-N707

Incomplete/invalid orders.

Edit: RX-N708

Missing orders.

Edit: RX-N709

Incomplete/invalid notes.

Edit: RX-N71

Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.

Edit: RX-N710

Missing notes.

Edit: RX-N711

Incomplete/invalid summary.

Edit: RX-N712

Missing summary.

Edit: RX-N713

Incomplete/invalid report.

Edit: RX-N714

Missing report.

Edit: RX-N715

Incomplete/invalid chart.

Edit: RX-N716

Missing chart.

Edit: RX-N717

Incomplete/Invalid documentation of face-to-face examination.

Edit: RX-N718

Missing documentation of face-to-face examination.

Edit: RX-N719

Penalty applied based on plan requirements not being met.

Edit: RX-N72

PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.

Edit: RX-N720
Edit: RX-N721

This service is only covered when performed as part of a clinical trial.

Edit: RX-N722

Patient must use Workers’ Compensation Set-Aside (WCSA) funds to pay for the medical service or item.

Edit: RX-N723

Patient must use Liability set-aside (LSA) funds to pay for the medical service or item.

Edit: RX-N724

Patient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.

Edit: RX-N725

A liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: RX-N726

A conditional payment is not allowed.

Edit: RX-N727

A no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: RX-N728

A workers’ compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.

Edit: RX-N729

Missing patient medical/dental record for this service.

Edit: RX-N730

Incomplete/invalid patient medical/dental record for this service.

Edit: RX-N731

Incomplete/Invalid mental health assessment.

Edit: RX-N732

Services performed at an unlicensed facility are not reimbursable.

Edit: RX-N733

Regulatory surcharges are paid directly to the state.

Edit: RX-N734

The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.

Edit: RX-N736

Incomplete/invalid Sleep Study Report.

Edit: RX-N737

Missing Sleep Study Report.

Edit: RX-N738

Incomplete/invalid Vein Study Report.

Edit: RX-N739

Missing Vein Study Report.

Edit: RX-N74

Resubmit with multiple claims, each claim covering services provided in only one calendar month.

Edit: RX-N740

The member’s Consumer Spending Account does not contain sufficient funds to cover the member’s liability for this claim/service.

Edit: RX-N741

This is a site neutral payment.

Edit: RX-N743

Adjusted because the services may be related to an employment accident.

Edit: RX-N744

Adjusted because the services may be related to an auto/other accident.

Edit: RX-N745

Missing Ambulance Report.

Edit: RX-N746

Incomplete/invalid Ambulance Report.

Edit: RX-N747

This is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.

Edit: RX-N748

Adjusted because the related hospital charges have not been received.

Edit: RX-N749

Missing Blood Gas Report.

Edit: RX-N75

Missing/incomplete/invalid tooth surface information.

Edit: RX-N750

Incomplete/invalid Blood Gas Report.

Edit: RX-N751

Adjusted because the patient is covered under a Medicare Part D plan.

Edit: RX-N752

Missing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).

Edit: RX-N753

Missing/incomplete/invalid Attachment Control Number.

Edit: RX-N754

Missing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.

Edit: RX-N755

Missing/incomplete/invalid ICD Indicator.

Edit: RX-N756

Missing/incomplete/invalid point of drop-off address.

Edit: RX-N757

Adjusted based on the Federal Indian Fees schedule (MLR).

Edit: RX-N758

Adjusted based on the prior authorization decision.

Edit: RX-N759

Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.

Edit: RX-N76

Missing/incomplete/invalid number of riders.

Edit: RX-N760

This facility is not authorized to receive payment for the service(s).

Edit: RX-N761

This provider is not authorized to receive payment for the service(s).

Edit: RX-N762

This facility is not certified for Tomosynthesis (3-D) mammography.

Edit: RX-N763

The demonstration code is not appropriate for this claim; resubmit without a demonstration code.

Edit: RX-N764

Missing/incomplete/invalid Hematocrit (HCT) value.

Edit: RX-N765

This payer does not cover co-insurance assessed by a previous payer.

Edit: RX-N766

This payer does not cover co-payment assessed by a previous payer.

Edit: RX-N767
Edit: RX-N768

Incomplete/invalid initial evaluation report.

Edit: RX-N769

A lateral diagnosis is required.

Edit: RX-N77

Missing/incomplete/invalid designated provider number.

Edit: RX-N770

The adjustment request received from the provider has been processed. Your original claim has been adjusted based on the information received.

Edit: RX-N771
Edit: RX-N772
Edit: RX-N773

Drug supplied not obtained from specialty vendor.

Edit: RX-N774
Edit: RX-N775

Payment adjusted based on x-ray radiograph on film.

Edit: RX-N776

This service is not a covered Telehealth service.

Edit: RX-N777

Missing Assignment of Benefits Indicator.

Edit: RX-N778

Missing Primary Care Physician Information.

Edit: RX-N779

Replacement/Void claims cannot be submitted until the original claim has finalized. Please resubmit once payment or denial is received.

Edit: RX-N78

The necessary components of the child and teen checkup (EPSDT) were not completed.

Edit: RX-N780

Missing/incomplete/invalid end therapy date.

Edit: RX-N781
Edit: RX-N782
Edit: RX-N783
Edit: RX-N784

Missing comprehensive procedure code.

Edit: RX-N785

Missing current radiology film/images.

Edit: RX-N786

Benefit limitation for the orthodontic active and/or retention phase of treatment.

Edit: RX-N787
Edit: RX-N788

The third party administrator/review organization did not receive the requested information.

Edit: RX-N789

Clinical Trial is not a covered benefit.

Edit: RX-N79

Service billed is not compatible with patient location information.

Edit: RX-N790

Provider/supplier not accredited for product/service.

Edit: RX-N791

Missing history & physical report.

Edit: RX-N792

Incomplete/invalid history & physical report.

Edit: RX-N793
Edit: RX-N794

Payment adjusted based on type of technology used.

Edit: RX-N8

Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.

Edit: RX-N80

Missing/incomplete/invalid prenatal screening information.

Edit: RX-N81

Procedure billed is not compatible with tooth surface code.

Edit: RX-N82

Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.

Edit: RX-N83

No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

Edit: RX-N84
Edit: RX-N85
Edit: RX-N86

A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.

Edit: RX-N87

Home use of biofeedback therapy is not covered.

Edit: RX-N88
Edit: RX-N89
Edit: RX-N9

Adjustment represents the estimated amount a previous payer may pay.

Edit: RX-N90

Covered only when performed by the attending physician.

Edit: RX-N91

Services not included in the appeal review.

Edit: RX-N92

This facility is not certified for digital mammography.

Edit: RX-N93

A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.

Edit: RX-N94

Claim/Service denied because a more specific taxonomy code is required for adjudication.

Edit: RX-N95

This provider type/provider specialty may not bill this service.

Edit: RX-N96

Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.

Edit: RX-N97

Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.

Edit: RX-N98

Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.

Edit: RX-N99

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.