Denial Code Hub

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.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The authorization number is missing, invalid, or does not apply to the billed services.

Authorization

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

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.

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Duplicate

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred prior to coverage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred after coverage terminated.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The time limit for filing has expired.

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient cannot be identified as our insured.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Our records indicate the patient is not an eligible dependent.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Duplicate

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Medical Necessity

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Indirect Medical Education Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Plan procedures not followed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Frequency

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Precertification/authorization/notification/pre-treatment absent.

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The date of death precedes the date of service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The date of birth follows the date of service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service(s) not valid for the provider type.

Provider

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

This injury/illness is covered by the liability carrier.

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The charges are a duplicate of a claim previously processed.

Duplicate

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

Coverage not in effect for the time period of this bill.

Eligibility

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

Services not provided by network/primary care providers.

Network

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service(s) not covered under this plan.

Not Covered

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

Submitting provider's NPI is not eligible to receive payment for this service.

Provider

This code is not in DenialPro’s current X12 public-code snapshot. It may appear on an older remittance or in payer-specific historical data. Verify the date of service, payer instructions, and applicable historical code set before taking action.

Precertification/notification/authorization/pre-treatment exceeded.

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Sequestration - reduction in federal payment

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Referral absent

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Deductible Amount

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coinsurance Amount

Coinsurance

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Co-payment Amount

Copay

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Insured has no dependent coverage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Insured has no coverage for newborns.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Lifetime benefit maximum has been reached.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prompt-pay discount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Adjusted for failure to obtain second surgical opinion

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Blood Deductible.

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Day outlier amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Cost outlier - Adjustment to compensate for additional costs.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Direct Medical Education Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Disproportionate Share Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Non-Covered days/Room charge adjustment.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient Interest Adjustment (Use Only Group code PR)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Professional fees removed from charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Dispensing fee adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Processed in Excess of charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to patient/insured/responsible party.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Major Medical Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Managed care withholding.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Tax withholding.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient payment option/election not in effect.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Billing date predates service date.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Not covered unless the provider accepts assignment.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure postponed, canceled, or delayed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

ESRD network support adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Indemnification adjustment - compensation for outstanding member responsibility.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Psychiatric reduction.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Claim submission fee.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Claim specific negotiated discount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prearranged demonstration project adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Technical fees removed from charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Interim bills cannot be processed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Monthly Medicaid patient liability amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Portion of payment deferred.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider contracted/negotiated rate expired or not on file.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Frequency

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payer deems the information submitted does not support this dosage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient refused the service/procedure.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/procedure was provided outside of the United States.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/procedure was provided as a result of terrorism.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider performance bonus

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Alternate benefit has been provided.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/equipment was not prescribed by a physician.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service was not prescribed prior to delivery.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prescription is incomplete.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prescription is not current.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required eligibility requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required spend down requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required residency requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure code was invalid on the date of service.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure modifier was invalid on the date of service.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Level of care change adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Revenue code and Procedure code do not match.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred during lapse in coverage

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Non-covered personal comfort or convenience services.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Discontinued or reduced service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Pharmacy discount card processing fee

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider Identifier - missing.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider identifier - Invalid format

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider Identifier - Not matched.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Administrative surcharges are not covered

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Based on subrogation of a third party settlement

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Sales Tax

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Low Income Subsidy (LIS) Co-payment Amount

Copay

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Services not provided by network/primary care providers.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Services not authorized by network/primary care providers.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider performance program withhold.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

This non-payable code is for required reporting only.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coinsurance

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service not payable per managed care contract.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Additional payment for Dental/Vision service utilization.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Processed under Medicaid ACA Enhanced Fee Schedule

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coverage/program guidelines were not met.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coverage/program guidelines were exceeded.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Fee/Service not payable per patient Care Coordination arrangement.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Attending provider is not eligible to provide direction of care.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Appeal procedures not followed

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Appeal time limits not met

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Referral exceeded

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to employer.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to attorney.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Pharmacy Direct/Indirect Remuneration (DIR)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Non-covered visits.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Late filing penalty.

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient is enrolled in a Hospice.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Services not documented in patient's medical records.

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Duplicate

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

'New Patient' qualifications were not met.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

This payment is adjusted based on the diagnosis.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Deductible Amount

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coinsurance Amount

Coinsurance

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Co-payment Amount

Copay

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The date of death precedes the date of service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The date of birth follows the date of service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Duplicate

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

This injury/illness is covered by the liability carrier.

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred prior to coverage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred after coverage terminated.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

The time limit for filing has expired.

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient cannot be identified as our insured.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Our records indicate the patient is not an eligible dependent.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Insured has no dependent coverage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Insured has no coverage for newborns.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Lifetime benefit maximum has been reached.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prompt-pay discount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Duplicate

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Medical Necessity

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Adjusted for failure to obtain second surgical opinion

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Blood Deductible.

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Day outlier amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Cost outlier - Adjustment to compensate for additional costs.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Indirect Medical Education Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Direct Medical Education Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Disproportionate Share Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Non-Covered days/Room charge adjustment.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient Interest Adjustment (Use Only Group code PR)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Professional fees removed from charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Dispensing fee adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Processed in Excess of charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Plan procedures not followed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to patient/insured/responsible party.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Major Medical Adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Managed care withholding.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Tax withholding.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient payment option/election not in effect.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Billing date predates service date.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Not covered unless the provider accepts assignment.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure postponed, canceled, or delayed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

ESRD network support adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Indemnification adjustment - compensation for outstanding member responsibility.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Psychiatric reduction.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Claim submission fee.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Claim specific negotiated discount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prearranged demonstration project adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Technical fees removed from charges.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Interim bills cannot be processed.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Monthly Medicaid patient liability amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Portion of payment deferred.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider contracted/negotiated rate expired or not on file.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Frequency

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Frequency

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payer deems the information submitted does not support this dosage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient refused the service/procedure.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/procedure was provided outside of the United States.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/procedure was provided as a result of terrorism.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider performance bonus

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Alternate benefit has been provided.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service/equipment was not prescribed by a physician.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service was not prescribed prior to delivery.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prescription is incomplete.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prescription is not current.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required eligibility requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required spend down requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient has not met the required residency requirements.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure code was invalid on the date of service.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Procedure modifier was invalid on the date of service.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Level of care change adjustment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Precertification/authorization/notification/pre-treatment absent.

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Precertification/notification/authorization/pre-treatment exceeded.

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Revenue code and Procedure code do not match.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred during lapse in coverage

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Non-covered personal comfort or convenience services.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Discontinued or reduced service.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Pharmacy discount card processing fee

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider Identifier - missing.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider identifier - Invalid format

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

National Provider Identifier - Not matched.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Administrative surcharges are not covered

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Based on subrogation of a third party settlement

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Timely Filing

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Sales Tax

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Modifier

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Diagnosis

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Low Income Subsidy (LIS) Co-payment Amount

Copay

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Services not provided by network/primary care providers.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Services not authorized by network/primary care providers.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Provider performance program withhold.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

This non-payable code is for required reporting only.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coinsurance

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Sequestration - reduction in federal payment

Regulatory

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Service not payable per managed care contract.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Additional payment for Dental/Vision service utilization.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Processed under Medicaid ACA Enhanced Fee Schedule

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coverage/program guidelines were not met.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coverage/program guidelines were exceeded.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Fee/Service not payable per patient Care Coordination arrangement.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Coordination

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Attending provider is not eligible to provide direction of care.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Appeal procedures not followed

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Appeal time limits not met

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Referral exceeded

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Referral absent

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to employer.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment made to attorney.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Pharmacy Direct/Indirect Remuneration (DIR)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Coding

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Patient refund amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Medicare Claim PPS Capital Cost Outlier Amount.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Prior hospitalization or 30 day transfer requirement not met.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Ungroupable DRG.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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)

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Authorization

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Contractual

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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).

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Provider

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Documentation

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Payment adjusted due to Apportionment.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Deductible Amount

Deductible

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Coinsurance Amount

Coinsurance

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Co-payment Amount

Copay

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred prior to coverage.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

Expenses incurred after coverage terminated.

X12 CARC

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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

Not Covered

Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.

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.