Table of Contents

Claim Adjustment Group Codes

In the healthcare industry, Claim Adjustment Group (CAG) codes serve as a standardized system of categorizing and identifying the various reasons why insurance claims have been denied or adjusted. These codes are used by insurance companies and providers to communicate the reasoning behind the adjustments made to a claim. There are several different types of CAG codes, each with its own unique purpose.

The most commonly used CAG codes are CO, PR, and OA.

CO – Contractual Obligation
Start: 05/20/2018
OA – Other Adjustment
Start: 05/20/2018
PI – Payor Initiated Reduction
Start: 05/20/2018
PR – Patient Responsibility
Start: 05/20/2018

Claim Adjustment Reason Codes

Claim Adjustment Reason Codes, also known as CARCs, are standard codes used by healthcare providers and insurance companies to indicate why a particular claim was either paid or denied. These codes provide a clear and concise explanation of why a claim was processed in a particular way, and they help to streamline the claims process by reducing the need for lengthy and complex explanations.

1 – Deductible Amount
Start: 01/01/1995
2 – Coinsurance Amount
Start: 01/01/1995
3 – Co-payment Amount
Start: 01/01/1995
4 – The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2020
5 – The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2018
6 – The procedure/revenue code is inconsistent with the patient’s age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
7 – The procedure/revenue code is inconsistent with the patient’s gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
8 – The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
9 – The diagnosis is inconsistent with the patient’s age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
10 – The diagnosis is inconsistent with the patient’s gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
11 – The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
12 – The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
13 – The date of death precedes the date of service.
Start: 01/01/1995
14 – The date of birth follows the date of service.
Start: 01/01/1995
16 – Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 03/01/2018
18 – Exact duplicate claim/service (Use only with Group Code OA except where state workers’ compensation regulations requires CO)
Start: 01/01/1995 | Last Modified: 06/02/2013
19 – This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
20 – This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21 – This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22 – This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23 – The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
Start: 01/01/1995 | Last Modified: 09/30/2012
24 – Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
26 – Expenses incurred prior to coverage.
Start: 01/01/1995
27 – Expenses incurred after coverage terminated.
Start: 01/01/1995
29 – The time limit for filing has expired.
Start: 01/01/1995
31 – Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32 – Our records indicate the patient is not an eligible dependent.
Start: 01/01/1995 | Last Modified: 03/01/2018
33 – Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34 – Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007
35 – Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
39 – Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995
40 – Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
44 – Prompt-pay discount.
Start: 01/01/1995
45 – Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)
Start: 01/01/1995 | Last Modified: 07/01/2017
49 – This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
51 – These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
53 – Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995
54 – Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
55 – Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
56 – Procedure/treatment has not been deemed ‘proven to be effective’ by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
58 – Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
59 – Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
60 – Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
61 – Adjusted for failure to obtain second surgical opinion
Start: 01/01/1995 | Last Modified: 03/01/2017
Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.
66 – Blood Deductible.
Start: 01/01/1995
69 – Day outlier amount.
Start: 01/01/1995
70 – Cost outlier – Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
74 – Indirect Medical Education Adjustment.
Start: 01/01/1995
75 – Direct Medical Education Adjustment.
Start: 01/01/1995
76 – Disproportionate Share Adjustment.
Start: 01/01/1995
78 – Non-Covered days/Room charge adjustment.
Start: 01/01/1995
85 – Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient.
89 – Professional fees removed from charges.
Start: 01/01/1995
90 – Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2017
91 – Dispensing fee adjustment.
Start: 01/01/1995
94 – Processed in Excess of charges.
Start: 01/01/1995
95 – Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96 – Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
100 – Payment made to patient/insured/responsible party.
Start: 01/01/1995 | Last Modified: 05/01/2018
101 – Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999
102 – Major Medical Adjustment.
Start: 01/01/1995
103 – Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001
104 – Managed care withholding.
Start: 01/01/1995
105 – Tax withholding.
Start: 01/01/1995
106 – Patient payment option/election not in effect.
Start: 01/01/1995
107 – The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
108 – Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
109 – Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Start: 01/01/1995 | Last Modified: 01/29/2012
110 – Billing date predates service date.
Start: 01/01/1995
111 – Not covered unless the provider accepts assignment.
Start: 01/01/1995
112 – Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
114 – Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995
115 – Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116 – The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117 – Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118 – ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119 – Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004
121 – Indemnification adjustment – compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122 – Psychiatric reduction.
Start: 01/01/1995
128 – Newborn’s services are covered in the mother’s Allowance.
Start: 02/28/1997
129 – Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 02/28/1997 | Last Modified: 01/30/2011
130 – Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
131 – Claim specific negotiated discount.
Start: 02/28/1997
132 – Prearranged demonstration project adjustment.
Start: 02/28/1997
133 – The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).
Start: 07/01/2014 | Last Modified: 07/01/2017
134 – Technical fees removed from charges.
Start: 10/31/1998
135 – Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136 – Failure to follow prior payer’s coverage rules. (Use only with Group Code OA)
Start: 10/31/1998 | Last Modified: 07/01/2013
137 – Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
139 – Contracted funding agreement – Subscriber is employed by the provider of services. Use only with Group Code CO.
Start: 06/30/1999 | Last Modified: 05/01/2018
140 – Patient/Insured health identification number and name do not match.
Start: 06/30/1999
142 – Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143 – Portion of payment deferred.
Start: 02/28/2001
144 – Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001
146 – Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147 – Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002
148 – Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/30/2002 | Last Modified: 09/20/2009
149 – Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150 – Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151 – Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008
152 – Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 10/31/2002 | Last Modified: 07/01/2017
153 – Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154 – Payer deems the information submitted does not support this day’s supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155 – Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
157 – Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158 – Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159 – Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160 – Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161 – Provider performance bonus
Start: 02/29/2004
163 – Attachment/other documentation referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 06/02/2013
164 – Attachment/other documentation referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 06/02/2013
166 – These services were submitted after this payers responsibility for processing claims under this plan ended.
Start: 02/28/2005
167 – This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
169 – Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170 – Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
171 – Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
172 – Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
173 – Service/equipment was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 07/01/2013
174 – Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175 – Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176 – Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177 – Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178 – Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179 – Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 03/01/2017
180 – Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
181 – Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
182 – Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183 – The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
184 – The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
185 – The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 07/01/2017
186 – Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187 – Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009
188 – This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005
189 – ‘Not otherwise classified’ or ‘unlisted’ procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
Start: 06/30/2005
190 – Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
192 – Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 07/01/2017
193 – Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008
194 – Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195 – Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
197 – Precertification/authorization/notification/pre-treatment absent.
Start: 10/31/2006 | Last Modified: 05/01/2018
198 – Precertification/notification/authorization/pre-treatment exceeded.
Start: 10/31/2006 | Last Modified: 05/01/2018
199 – Revenue code and Procedure code do not match.
Start: 10/31/2006
200 – Expenses incurred during lapse in coverage
Start: 10/31/2006
201 – Patient is responsible for amount of this claim/service through ‘set aside arrangement’ or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 10/31/2006 | Last Modified: 09/28/2014
Notes: Not for use by Workers’ Compensation payers; use code P3 instead.
202 – Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203 – Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204 – This service/equipment/drug is not covered under the patient’s current benefit plan
Start: 02/28/2007
205 – Pharmacy discount card processing fee
Start: 07/09/2007
206 – National Provider Identifier – missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207 – National Provider identifier – Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008
208 – National Provider Identifier – Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209 – Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)
Start: 07/09/2007 | Last Modified: 07/01/2013
210 – Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
211 – National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007
212 – Administrative surcharges are not covered
Start: 11/05/2007
213 – Non-compliance with the physician self referral prohibition legislation or payer policy.
Start: 01/27/2008
215 – Based on subrogation of a third party settlement
Start: 01/27/2008
216 – Based on the findings of a review organization
Start: 01/27/2008
219 – Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 01/27/2008 | Last Modified: 07/01/2017
222 – Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/01/2008 | Last Modified: 07/01/2017
223 – Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
Start: 06/01/2008
224 – Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
Start: 06/01/2008
225 – Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
Start: 06/01/2008
226 – Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 07/01/2013
227 – Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/20/2009
228 – Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008
229 – Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer’s cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)
Start: 01/25/2009 | Last Modified: 07/01/2017
231 – Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2009 | Last Modified: 07/01/2017
232 – Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009 | Last Modified: 07/01/2017
233 – Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
Start: 01/24/2010
234 – This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/24/2010
235 – Sales Tax
Start: 06/06/2010
236 – This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
Start: 01/30/2011 | Last Modified: 07/01/2013
237 – Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/05/2011
238 – Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
Start: 03/01/2012 | Last Modified: 07/01/2013
239 – Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
Start: 03/01/2012 | Last Modified: 01/29/2012
240 – The diagnosis is inconsistent with the patient’s birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/03/2012 | Last Modified: 07/01/2017
241 – Low Income Subsidy (LIS) Co-payment Amount
Start: 06/03/2012
242 – Services not provided by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38
243 – Services not authorized by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38
245 – Provider performance program withhold.
Start: 09/30/2012
246 – This non-payable code is for required reporting only.
Start: 09/30/2012
247 – Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
248 – Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
249 – This claim has been identified as a readmission. (Use only with Group Code CO)
Start: 09/30/2012
250 – The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014
251 – The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014
252 – An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/02/2013
253 – Sequestration – reduction in federal payment
Start: 06/02/2013 | Last Modified: 11/01/2013
254 – Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient’s medical plan for further consideration.
Start: 06/02/2013 | Last Modified: 11/01/2017
Notes: Use CARC 290 if the claim was forwarded.
256 – Service not payable per managed care contract.
Start: 06/02/2013
257 – The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
Start: 11/01/2013 | Last Modified: 06/01/2014
Notes: To be used after the first month of the grace period.
258 – Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
Start: 11/01/2013
259 – Additional payment for Dental/Vision service utilization.
Start: 01/26/2014
260 – Processed under Medicaid ACA Enhanced Fee Schedule
Start: 01/26/2014
261 – The procedure or service is inconsistent with the patient’s history.
Start: 06/01/2014
262 – Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
263 – Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
264 – Adjustment for postage cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
265 – Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
266 – Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.
Start: 11/01/2014 | Last Modified: 07/01/2017
267 – Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2014 | Last Modified: 04/01/2015
268 – The Claim spans two calendar years. Please resubmit one claim per calendar year.
Start: 11/01/2014
269 – Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 03/01/2015 | Last Modified: 07/01/2017
270 – Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration.
Start: 07/01/2015 | Last Modified: 11/01/2017
Notes: Use CARC 291 if the claim was forwarded.
271 – Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)
Start: 11/01/2015 | Last Modified: 03/01/2018
272 – Coverage/program guidelines were not met.
Start: 11/01/2015
273 – Coverage/program guidelines were exceeded.
Start: 11/01/2015
274 – Fee/Service not payable per patient Care Coordination arrangement.
Start: 11/01/2015
275 – Prior payer’s (or payers’) patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)
Start: 11/01/2015
276 – Services denied by the prior payer(s) are not covered by this payer.
Start: 11/01/2015
277 – The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
Start: 11/01/2015
Notes: To be used during 31 day SHOP grace period.
278 – Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2016 | Last Modified: 07/01/2017
279 – Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member’s ‘narrow’ network.
Start: 11/01/2016 | Last Modified: 07/01/2017
280 – Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s Pharmacy plan for further consideration.
Start: 03/01/2017 | Last Modified: 11/01/2017
Notes: Use CARC 292 if the claim was forwarded.
281 – Deductible waived per contractual agreement. Use only with Group Code CO.
Start: 07/01/2017
282 – The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2017
283 – Attending provider is not eligible to provide direction of care.
Start: 11/01/2017
284 – Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.
Start: 11/01/2017
285 – Appeal procedures not followed
Start: 11/01/2017
286 – Appeal time limits not met
Start: 11/01/2017
287 – Referral exceeded
Start: 11/01/2017
288 – Referral absent
Start: 11/01/2017
289 – Services considered under the dental and medical plans, benefits not available.
Start: 11/01/2017
Notes: Also see CARCs 254, 270 and 280.
290 – Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient’s medical plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 254 if the claim was not forwarded.
291 – Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient’s dental plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 270 if the claim was not forwarded.
292 – Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient’s pharmacy plan for further consideration.
Start: 11/01/2017
Notes: Use CARC 280 if the claim was not forwarded.
293 – Payment made to employer.
Start: 05/01/2018
294 – Payment made to attorney.
Start: 11/01/2017
295 – Pharmacy Direct/Indirect Remuneration (DIR)
Start: 03/01/2018
296 – Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.
Start: 07/01/2018
297 – Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s vision plan for further consideration.
Start: 03/01/2019
298 – Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient’s vision plan for further consideration.
Start: 03/01/2019
299 – The billing provider is not eligible to receive payment for the service billed.
Start: 07/01/2019
300 – Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient’s Behavioral Health Plan for further consideration.
Start: 07/01/2019
301 – Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient’s Behavioral Health Plan for further consideration.
Start: 07/01/2019
302 – Precertification/notification/authorization/pre-treatment time limit has expired.
Start: 11/01/2020
303 – Prior payer’s (or payers’) patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)
Start: 07/01/2021
304 – Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s hearing plan for further consideration.
Start: 03/01/2022
305 – Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient’s hearing plan for further consideration.
Start: 03/01/2022
A0 – Patient refund amount.
Start: 01/01/1995
A1 – Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) The following will be added to this definition on 7/1/2023, Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available.
Start: 01/01/1995 | Last Modified: 11/16/2022
A5 – Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995
A6 – Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995
A8 – Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
B1 – Non-covered visits.
Start: 01/01/1995
B4 – Late filing penalty.
Start: 01/01/1995
B7 – This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
B8 – Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
B9 – Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10 – Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
Start: 01/01/1995
B11 – The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995
B12 – Services not documented in patient’s medical records.
Start: 01/01/1995 | Last Modified: 03/01/2018
B13 – Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995
B14 – Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15 – This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 07/01/2017
B16 – ‘New Patient’ qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B20 – Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B22 – This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001
B23 – Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
P1 – State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 162
P2 – Not a work related injury/illness and thus not the liability of the workers’ compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers’ Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 191
P3 – Workers’ Compensation case settled. Patient is responsible for amount of this claim/service through WC ‘Medicare set aside arrangement’ or other agreement. To be used for Workers’ Compensation only. (Use only with Group Code PR)
Start: 11/01/2013
Notes: This code replaces deactivated code 201
P4 – Workers’ Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers’ Compensation only
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 214
P5 – Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 217
P6 – Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 218
P7 – The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 220
P8 – Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code 221
P9 – No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 230
P10 – Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 244
P11 – The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)
Start: 11/01/2013
Notes: This code replaces deactivated code 255
P12 – Workers’ compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers’ Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W1
P13 – Payment reduced or denied based on workers’ compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers’ Compensation only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W2
P14 – The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code W3
P15 – Workers’ Compensation Medical Treatment Guideline Adjustment. To be used for Workers’ Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code W4
P16 – Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers’ Compensation only. (Use with Group Code CO or OA)
Start: 11/01/2013
Notes: This code replaces deactivated code W5
P17 – Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W6
P18 – Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W7
P19 – Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W8
P20 – Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W9
P21 – Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 03/01/2018
Notes: This code replaces deactivated code Y1
P22 – Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 03/01/2018
Notes: This code replaces deactivated code Y2
P23 – Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013 | Last Modified: 07/01/2017
Notes: This code replaces deactivated code Y3
P24 – Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. Use only with Group Code CO.
Start: 11/01/2017
P25 – Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).
Start: 11/01/2017
P26 – Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).
Start: 11/01/2017
P27 – Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017
P28 – Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier ‘IG’) if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017
P29 – Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2017
P30 – Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.
Start: 11/01/2020
P31 – Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.
Start: 11/01/2020
P32 – Payment adjusted due to Apportionment.
Start: 08/01/2022