Claim Adjustment Group Codes

CO Contractual Obligation

Contract obligations are those duties that each party is legally responsible for in acontract agreement. In a contract, each party exchanges something of value, whether it be a product, services, money, etc. On both sides of the agreement, each party has various obligations in connected with this exchange

CR Corrections and ReversalNote: This value is not to be used with 005010 and up.

OA Other Adjustment

It is used when no other group code applies to the adjustment.

PI Payer Initiated Reductions

It is used by payers when it is believed the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and payer.

PR Patient Responsibility

It is used for deductible, coinsurance and copay when the adjustments represent an amount that should be billed to the patient or the secondary insurance.

List of Claim denail codes for Contractual Obligation

CO 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.

CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits.

CO 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.

CO 29 The time limit for filing has expired.

CO 38 Services not provided or authorized by designated (network/primary care) providers.

CO 39 Services denied at the time authorization/pre-certification was requested.

CO 45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).

CO 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO 50 These are non-covered services because this is not deemed a `medical necessity’ by the payer.

CO 51 These are non-covered services because this is a pre-existing condition

CO 54 Multiple physicians/assistants are not covered in this case .

CO 55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.

CO 56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective’ by the payer.

CO 58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

CO 60 Charges for outpatient services with this proximity to inpatient services are not covered.

CO 66 Blood Deductible.

CO 69 Day outlier amount.

CO 70 Cost outlier – Adjustment to compensate for additional costs.

CO 76 Disproportionate Share Adjustment.

CO 78 Non-Covered days/Room charge adjustment.

CO 89 Professional fees removed from charges.

CO 91 Dispensing fee adjustment.

CO 94 Processed in Excess of charges.

CO 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

CO 101 Predetermination: anticipated payment upon completion of services or claim adjudication.

CO 102 Major Medical Adjustment.

CO 103 Provider promotional discount (e.g., Senior citizen discount).

CO 107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.

CO 110 Billing date predates service date.

CO 111 Not covered unless the provider accepts assignment.

CO 114 Procedure/product not approved by the Food and Drug Administration.

CO 117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.

CO 119 Benefit maximum for this time period or occurrence has been reached.

CO 125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

CO 128 Newborn’s services are covered in the mother’s Allowance.

CO 135 Claim denied. Interim bills cannot be processed.

CO 138 Claim/service denied. Appeal procedures not followed or time limits not met.

CO 139 Contracted funding agreement – Subscriber is employed by the provider of services.

CO 146 Payment denied because the diagnosis was invalid for the date(s) of service reported.

CO 157 Payment denied/reduced because service/procedure was provided as a result of an act of war.

CO 158 Payment denied/reduced because the service/procedure was provided outside of the United States.

CO 159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.

CO 160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.

CO 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.

CO 165 Payment denied /reduced for absence of, or exceeded referral

CO 167 This (these) diagnosis(es) is (are) not covered.

CO 170 Payment is denied when performed/billed by this type of provider.

CO 171 Payment is denied when performed/billed by this type of provider in this type of facility.

CO 172 Payment is adjusted when performed/billed by a provider of this specialty

CO 174 Payment denied because this service was not prescribed prior to delivery

CO 175 Payment denied because the prescription is incomplete

CO 176 Payment denied because the prescription is not current

CO 183 The referring provider is not eligible to refer the service billed.

CO 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.

CO 185 The rendering provider is not eligible to perform the service billed.

CO 188 This product/procedure is only covered when used according to FDA recommendations.

CO 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

CO 191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier.

CO 193 Original payment decision is being maintained. This claim was processed properly the first time.

CO 205 Pharmacy discount card processing fee

CO 211 National Drug Codes (NDC) not eligible for rebate, are not covered.

CO A4 Medicare Claim PPS Capital Day Outlier Amount.

CO A5 Medicare Claim PPS Capital Cost Outlier Amount.

CO A7 Presumptive Payment Adjustment

CO 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.

CO B14 Payment denied because only one visit or consultation per physician per day is covered.

CO B16 Payment adjusted because `New Patient’ qualifications were not met.

CO B23 Payment denied because this provider has failed an aspect of a proficiency testing program.

CO B4 Late filing penalty.

CO B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.

CO B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.

PR – Patient Responsibility denial code list

PR 1 Deductible Amount Member’s plan deductible applied to the allowable benefit for the rendered service(s).

PR 2 Coinsurance Amount  Member’s plan coinsurance rate applied to allowable benefit for the rendered service(s).

PR 3 Co-payment Amount Copayment Member’s plan copayment applied to the allowable benefit for the rendered service(s).

PR 25 Payment denied. Your Stop loss deductible has not been met.

PR 26 Expenses incurred prior to coverage.

PR 27 Expenses incurred after coverage terminated.

PR 31 Claim denied as patient cannot be identified as our insured.

PR 32 Our records indicate that this dependent is not an eligible dependent as defined.

PR 33 Claim denied. Insured has no dependent coverage.

PR 34 Claim denied. Insured has no coverage for newborns.

PR 35 Lifetime benefit maximum has been reached.

PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)

PR 126 Deductible — Major Medical

PR 127 Coinsurance — Major Medical

PR 140 Patient/Insured health identification number and name do not match
.PR 149 Lifetime benefit maximum has been reached for this service/benefit category.

PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.

PR 168 Payment denied as Service(s) have been considered under the patient’s medical plan. Benefits are not available under this dental plan

PR 177 Payment denied because the patient has not met the required eligibility requirements

PR 200 Expenses incurred during lapse in coverage

PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).

PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan

PR B1 Non-covered visits.

PR B9 Services not covered because the patient is enrolled in a Hospice.