Claim Adjustment Reason Codes

Deductible Amount

The patient has a deductible that has not been met. This portion is the patient's responsibility before insurance starts paying.

Coinsurance Amount

The patient is responsible for a percentage of the allowed amount after the deductible is met. This is standard cost-sharing.

Co-payment Amount

A fixed amount the patient pays for a service, regardless of the total cost. Copays are typically collected at time of service.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The date of death precedes the date of service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The date of birth follows the date of service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This injury/illness is covered by the liability carrier.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This injury/illness is the liability of the no-fault carrier.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This care may be covered by another payer per coordination of benefits.

The payer believes another insurance plan should be billed first (or also). COB rules determine payer order.

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Charges are covered under a capitation agreement/managed care plan.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Expenses incurred prior to coverage.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Expenses incurred after coverage terminated.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The time limit for filing has expired.

The claim was submitted after the payer's filing deadline. Most payers will not pay claims submitted outside their filing window regardless of the clinical situation.

Patient cannot be identified as our insured.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Our records indicate the patient is not an eligible dependent.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Insured has no dependent coverage.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Insured has no coverage for newborns.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Lifetime benefit maximum has been reached.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prompt-pay discount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services by an immediate relative or a member of the same household are not covered.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjusted for failure to obtain second surgical opinion

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Blood Deductible.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Day outlier amount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Cost outlier - Adjustment to compensate for additional costs.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Indirect Medical Education Adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Direct Medical Education Adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Disproportionate Share Adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Non-Covered days/Room charge adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient Interest Adjustment (Use Only Group code PR)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Professional fees removed from charges.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Dispensing fee adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Processed in Excess of charges.

The payer paid more than the billed amount. This can occur due to system errors or rate calculation issues. The provider may receive a request to refund the overpayment.

Plan procedures not followed.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment made to patient/insured/responsible party.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Major Medical Adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Managed care withholding.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Tax withholding.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient payment option/election not in effect.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

The claim was submitted to the wrong payer. The payer has no jurisdiction over this claim. Resubmit to the correct carrier.

Billing date predates service date.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Not covered unless the provider accepts assignment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service not furnished directly to the patient and/or not documented.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Procedure postponed, canceled, or delayed.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The advance indemnification notice signed by the patient did not comply with requirements.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Transportation is only covered to the closest facility that can provide the necessary care.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

ESRD network support adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Indemnification adjustment - compensation for outstanding member responsibility.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Psychiatric reduction.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Newborn's services are covered in the mother's Allowance.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim submission fee.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim specific negotiated discount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prearranged demonstration project adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Technical fees removed from charges.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Interim bills cannot be processed.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient/Insured health identification number and name do not match.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Monthly Medicaid patient liability amount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Portion of payment deferred.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Incentive adjustment, e.g. preferred product/service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Diagnosis was invalid for the date(s) of service reported.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Provider contracted/negotiated rate expired or not on file.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Lifetime benefit maximum has been reached for this service/benefit category.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payer deems the information submitted does not support this level of service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payer deems the information submitted does not support this dosage.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payer deems the information submitted does not support this day's supply.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient refused the service/procedure.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service/procedure was provided as a result of an act of war.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service/procedure was provided outside of the United States.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service/procedure was provided as a result of terrorism.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Injury/illness was the result of an activity that is a benefit exclusion.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Provider performance bonus

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Attachment/other documentation referenced on the claim was not received.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Attachment/other documentation referenced on the claim was not received in a timely fashion.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Alternate benefit has been provided.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service/equipment was not prescribed by a physician.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service was not prescribed prior to delivery.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prescription is incomplete.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prescription is not current.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient has not met the required eligibility requirements.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient has not met the required spend down requirements.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient has not met the required residency requirements.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Procedure code was invalid on the date of service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Procedure modifier was invalid on the date of service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Level of care change adjustment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Refund issued to an erroneous priority payer for this claim/service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Precertification/authorization/notification/pre-treatment absent.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Precertification/notification/authorization/pre-treatment exceeded.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Revenue code and Procedure code do not match.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Expenses incurred during lapse in coverage

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Non-covered personal comfort or convenience services.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Discontinued or reduced service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This service/equipment/drug is not covered under the patient's current benefit plan

The specific service is excluded from the patient's insurance benefits. This is a patient responsibility code — the patient may owe the amount if properly notified.

Pharmacy discount card processing fee

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

National Provider Identifier - missing.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

National Provider identifier - Invalid format

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

National Provider Identifier - Not matched.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment adjusted because pre-certification/authorization not received in a timely fashion

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Administrative surcharges are not covered

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Non-compliance with the physician self referral prohibition legislation or payer policy.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Based on subrogation of a third party settlement

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Based on the findings of a review organization or the payer's findings.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient identification compromised by identity theft. Identity verification required for processing this and future claims.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Sales Tax

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim spans eligible and ineligible periods of coverage. Rebill separate claims.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Low Income Subsidy (LIS) Co-payment Amount

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services not provided by network/primary care providers.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services not authorized by network/primary care providers.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Provider performance program withhold.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This non-payable code is for required reporting only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

This claim has been identified as a readmission. (Use only with Group Code CO)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Sequestration - reduction in federal payment

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service not payable per managed care contract.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Additional payment for Dental/Vision service utilization.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Processed under Medicaid ACA Enhanced Fee Schedule

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The procedure or service is inconsistent with the patient's history.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjustment for postage cost. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The Claim spans two calendar years. Please resubmit one claim per calendar year.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Coverage/program guidelines were not met.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Coverage/program guidelines were exceeded.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Fee/Service not payable per patient Care Coordination arrangement.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services denied by the prior payer(s) are not covered by this payer.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Deductible waived per contractual agreement. Use only with Group Code CO.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Attending provider is not eligible to provide direction of care.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Appeal procedures not followed

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Appeal time limits not met

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Referral exceeded

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Referral absent

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Services considered under the dental and medical plans, benefits not available.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment made to employer.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment made to attorney.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Pharmacy Direct/Indirect Remuneration (DIR)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The billing provider is not eligible to receive payment for the service billed.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Precertification/notification/authorization/pre-treatment time limit has expired.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Type of bill is inconsistent with the patient status. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Medicare Maximum Fair Price Standard Default Refund Amount Adjustment. 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: To be used only for the Medicare Drug Price Negotiation Program.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment is adjusted due to contracted funding agreement between the payer and provider.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient refund amount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.) Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Medicare Claim PPS Capital Cost Outlier Amount.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Prior hospitalization or 30 day transfer requirement not met.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Ungroupable DRG.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Non-covered visits.

The payer is identifying visits that are not covered under the applicable benefit or payment rules.

Late filing penalty.

The payer applied a penalty because the claim or required filing was received late.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Patient is enrolled in a Hospice.

The payer indicates the patient was enrolled in hospice, which may change who is responsible for payment for services related to the terminal condition.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

Think WRONG PAYER / PAYER TRANSFER. The payer that received the claim says it is not responsible and has transferred the claim or service to the proper payer or processor.

Services not documented in patient's medical records.

The payer could not find documentation in the medical record supporting that the billed service was performed.

Previously paid. Payment for this claim/service may have been provided in a previous payment.

The payer believes this claim or service was already paid.

Only one visit or consultation per physician per day is covered.

The payer allows only one covered visit or consultation by the physician on the same day.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

'New Patient' qualifications were not met.

The payer says the patient does not meet the definition required for a new-patient service.

Procedure/service was partially or fully furnished by another provider.

The payer believes another provider furnished some or all of the billed service.

This payment is adjusted based on the diagnosis.

The payer adjusted payment because of the diagnosis information submitted on the claim.

Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.

The laboratory procedure billed is not authorized under the provider or laboratory CLIA proficiency testing status.

State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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)

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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).

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

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.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.

Payment adjusted due to Apportionment.

Current X12 Claim Adjustment Reason Code. Read this reason together with the actual group code shown on the ERA/EOB and any accompanying RARCs before deciding who is responsible or what action to take.