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30131134136142170171174200201202203204207DETAIL DESCRIPTIONMissing service provider zip code (box 32)Missing pickup zip code on the claimBilled charges should be zero for home health claimHospital based ASC claim can't be submitted on UB formService dates are not in the same calendar yearInvalid place of serviceInvalid type of billSubscriber not actively enrolled on service dateMember not actively enrolled on service dateNo coverage during service periodCoverage change during service periodBenefit not covered for spouseBenefit not covered for dependentCOB ClaimThis is COB claim for a member who does not have double coverageOut of network provider: submit the claim to Cofinity for pricing. P.O. Box 2720Farmington Hills, MI 48333Allowed amount is ZeroMultiple primary coverageSubmitted Allowed amount present on a Complete Process (CP) claimType of Bill - Deny ActionService date after receive dateDate of service before date of birthInterim billingMissing Diagnosis pointer OR Invalid ICD Diagnosis codeAdditional digit is required for the ICD Diagnosis codeUnknown CPT code - Please resubmit with a HIPAA valid CPT codeInactive CPT code - Please resubmit with a HIPAA valid CPT codeUnknown Modifier - Please resubmit with a HIPAA valid ModifierUnknown ICD Procedure code - Please resubmit with a valid codeEDI 47

215Missing Admission source for the Revenue code submitted, for NONPPO provider -216217223231232233243244245270Invalid Value Codes for the Revenue codes submitted, for NONPPO providerHOST claim cannot be submitted with zero total chargesReferring provider NPI is missing in Ancillary claim.Current claim falls within the history claim date rangeCurrent claim falls outside the history claim date rangeUnknown Secondary ICD Diagnosis CodeInvalid Diagnosis CodeInvalid Secondary Diagnosis CodeInvalid Procedure codeAuthorization is required for this serviceNo proper auth has been obtain by provider or member, copayment amount incase oApplied benefit per authorized network-Applied benefits per authorized network. Missing auth network on line(s)Not enough money in the COB Savings to pay member obligationClaim submitted with ICD9 Diagnosis codes. Please re-submit claim with ICD10Diagnosis codes.Claim submitted with ICD10 Diagnosis codes. Please re-submit claim with ICD9Diagnosis codesUnlisted code - Please resubmit using a more specific code and/or a description ofcodePayment Reduced by Deductible AmountA copayment has been applied to this serviceA coinsurance has been applied to this serviceMember in HospiceReduced paid by percent allowed after out of pocket is metPayment adjusted based on modifier submittedAdditional digit is required for the Secondary ICD Diagnosis 35:CO*45-

8339340342343344345346348350351352357361362Family Deductible limit is metReduced paid by provider withholdReduced allowed by Subro amountNumber of visit per year exceed max, reduced visitsNumber of visits exceeded max, reduced visitsApplied copay balanceUnable to take balance copayThere is no paid amount after applied copay balanceRecalculated allowed amountReduced Amount BY MAX AllowedIndividual out of pocket limit for benefit year is metCopay has already been taken for this visit.Family lifetime max limit is metFamily out of pocket limit for benefit year is metIndividual lifetime out of pocket limit is metFamily lifetime out of pocket limit is metNumber of copayment met.Reduced number of copaysAlternate HHRG Code and anticipate payment is available. Check Report fordetailsIndividual Deductible limit is metExceeded max allowed amount for claimMember annual allowed amount exceeded maxAnnual allowed amount for ben cat exceeds max.Member lifetime allowed amount exceeded maxFamily annual allowed amount exceeded maxIndividual life max for benefit category exceeded maxFamily life max for benefit category exceededFamily annual allowed amount for benefit category exceeded maxMember age excludes benefit coverageStudent age limitation in this planMissing COBRA 5835:CO*B5-

364Performed service is not part of contract which will be paid under global fee co-365366This service is still within days after from range in this global fee contract,Global fee accumulator has been updated with a new event 394395396397398399406407410411414Remaining portion will not be paid, since this is max amount which can be coveredSubscriber enrolled in Cobra, will keep his or her ID.Billed charges paid by MemberPaid amount on the replacement claim is less than the backed-out claimSubmitted DRG not same as the Calculated DRGVoid ClaimStandard Medicaid Fee ScheduleFee schedule is not activePossible COBPossible COB - Multiple CoverageHCFA / Outpatient per case contract with providerUB per line item contract with providerPayment is fee schedule basedPercent billed contract with providerCapitation contract with providerGlobal fee contract with providerPayment Based on Per Diem RateInpatient Per admit contract with providerGrouper contract with providerDRG contract with provider requires DRG code be present on UB92 formHCFA payment by service code per day/claimAdd NDC AWP paymentCode not in Fee Schedule.Not paid because of capitation contractLower allowed amount by Rebundler percentageAllowed amount reduced because of multiple ASC surgery 5:CO*47835:CO*45835:CO*45835:CO*24835:CO*45

1512528529530531533538539540600601602604Additional charges have been applied.Paid by additional charges.Schedule amount exceed Billed amount; Pay billed amount.Additional charges charges will not be paid since the total allowable amount isgreater than bill amount.Zip code requires carrier and localityApplied Combined Par Network benefitsPreexisting conditionsAuthorization not foundAuthorization given to different memberAuthorization has been deniedDenied by RebundlerNew Line ItemDuplicate Line ItemAssistant Surgeon limit exceeded for this procedurereduced paid according to rebundler ruleRider Option selectedRider Option - Number of visits exceeds allowableReduced paid by discount amountAge is out of range for the given Primary DiagnosisGender is invalid for the given Primary Diagnosis.Age is out of range for the given codeGender code is invalid for the given CPTMODIFIER NOT CONSIDERED ELIGIBLE BY SIGNATURE CARE - PROV W/OStop Loss amount reachedClaim being denied over filing limitTotal charges not equal to total charges of line itemsManual overwriteManual PaymentManual DeniedInjectable/infusion/Pathology/Lab code requires prior approval by the *45835:OA*216835:CO*197

621623624Inappropriate Coding or Claim FormPrimary Carrier EOB Required or proof of termination of Primary carrierNot A Covered BenefitDenied - No Medical CoverageDenied - No Dental CoverageDenied - No Vision CoverageDuplicate ClaimEligibility Documentation Required (i.e., Birth Certificate, Marriage License,Divorce Decree)Exceeds filing limit - Can Not Bill PatientInvestigating Other Insurance For COB or MVA.Denied Incidental ProcedureInvalid/Deleted Diagnosis CodeInvalid/Deleted Procedure CodeMedical Records Must Be Submitted.Other Insurance Information RequiredPart of global code or Procedure is within the global period or procedureperformed by the same providerPrior/After UR Authorized DatesDenied - Over Plan Filing Limit625626627628629630631632633634Unlisted Procedure - Submit specific CPT/HCPCS or detailed description of servicerequired in comment field and Documentation of Medical NecessityNot A Billable Service By This ProviderAn established patient E/M code should have been used.Denied-Service Exceeds Plan LimitCharges Incurred After Term DateDuplicate Line ItemClaim Exceeds Authorized VisitsDenied -No UR Authorization/Authorization not approvedDiagnosis Does Not Match Authorized DiagnosisPenalty - No Out Of Network CO*197835:CO*197835:CO*197

1652653654655656657658659660661662Inappropriate Place Of Service BilledItemized Statement RequiredDenied Related To Workmans CompProvider Not Properly CredentialedPaid or Processed as SecondaryCharges Incurred Prior To Effective DateRequested Information ReceivedRequire Copy Of Operative ReportPending For Medicare Effective DateAge Is Out Of Range For Given CPTIncorrect Patient DemographicsRequire Attending Physicians Name-field 31 and/or NPI in field 24JDenied Requested Information Not ReceivedRequired Description of Primary's Remark CodesDenied-Exceeds allowed quantity or frequencyDenied-Submit to Community Mental Health. Inpatient behavioral services are acarve out for Medicaid beneficiaries.Allowable Applied to the DeductibleThis Is A PredeterminationDual eligible enrollee-Eligible for, not enrolled in d - Subsequent PT/OT/ST visits must be authorized by Navant 734/995-1969Submit Original Primary EOBMaximum Pay Amount. Patient Owes BalanceResubmit With Anesthesia Code/ModifierDenied-Present on Admission Indicator Required, information may be missing orinvalid.Exceeds Yearly Dental MaximumPrimary diagnosis code not recognized by this DRG Grouper. Please map diagnosisto the prev. versioDenied-Missing Multiple Surgical ModifierServices not provided by a designated or contracted :CO*4835:CO*164

663664665666No Secondary Consideration Until Primary's Request SatisfiedRequire Primary Carrier's EOBAdditional PaymentSplit Claim Needed for Non Covered Charges667668Denied-Require facility name and address where services were rendered, box 32 835:OA*16EOB and Claim Do Not Match835:CO*22Denied - The immunization must be billed with the immunization administrationcode.835:CO*234Forward claim to Psychcare 1-800-221-5487835:CO*16Denied-Submit claim to Beacon Health Options - PO Box 1854 Hicksville, NY 118021854835:CO*24Not Included In Case Rate835:CO*45Resubmit- illegible EOB835:CO*22Split Payment Due To Benefits835:CO*16Denied - Replacement/void claim received835:CO*18Require Copy of Birth Certificate835:CO*177Require eligibility verification form835:CO*177Send medical records to: PO Box 27476, Salt Lake City, UT 84127-0476, fax866/503-8239835:OA*133Submit Claim to Occupational Eyewear Network at 3824 Thirteen Mile Rd, Warren,MI 48092- ATTN:Total835:CO*24Claim not submitted with contracted TIN/ NPI/ payee information835:CO*16Paid per settlement835:CO*177Service line pending fee schedule/pricer update. Payment to be adjusted when feeavailable.835:CO*16Non-Network/InActive Provider/Non-contracted Physician835:OA*242Denied by Medical Director after Review835:CO*45Covered In Contracted Case Rate835:CO*45Per primary carrier EOB, This is a provider write-off835:CO*45Denied-Exceeds annual maximum benefit 35:CO*16

ssion of a claim under review or previously denied by TC3/CHANGEHEALTH CARESubmit Claim to Cofinity for PricingDx code not listed in the Emergency Transport Diagnosis Code DatabaseNot a THC Enrollee/Incorrect Member/ClaimantResubmit with a THC referralResubmit with Prenatal DatesINVALID PLACE OF SERVICENot covered by Medicaid/ MedicareService includedPreviously paidCharges are covered under a capitation agreementService is not authorized on the referral or authorizationPayment applied to plan deductibleNumber of visit exceeds annual allowableAdjust Allowed amount to amount per visit max.Claim exceeds days since accident (EOB)Claim exceed EOB max pay amountPayment is according EOB formulaBenefit reduced by plan deductibleMissing accident date for accident related claimClaim had been paid at header levelThis visit has been paid.Minimum % OF billed applied.Exceed maximum allowed time for pended claim - DeniedApplied Header level Add-on AmountApplied iCES editsDenied based on iCES editsApplied percent reduction as per ICESDenied based on pricing reductionBenefit Payment Copay Order (Deductible/Copay)Benefit Payment Copay Order CO*18835:CO*216-