CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 1 2 3
HIPAA ID 45 92 198
REASON DESCRIPTION Adjusted - Above contract rate Approved Authed units exceeded
4 5 6 7
96 29 110 22
8
181
Basic units Claim received after billable period Claim submitted before service date Patient has other insurance which covers the service Patient not covered by contract
9
52
Clinician not licensed to provide the service
10 11
2 59
12 13
63 198
Coinsurance Amount Concurrent service has already been approved. Cannot bill another one. Correction to prior claim Daily limit exceeded
14
204
Discontinued Service
15 16
18 11
Duplicate Claim DX code is invalid for service/insurance combo
17 18
96 31
FFS claim pended for 14 days wait Incorrect Member -- Patient not enrolled on DOS
19
140
Incorrect Member -- Patient not enrolled on DOS
20
181
Incorrect Service -- Service not in database
21
6
Invalid Age Group & PC combo
22 23
96 9
Invalid Amount Invalid diagnosis/Age combo
RECOMMENDED ACTION STEPS Post payment and any adjustment to charges. Do not refile. Post payment and any adjustment to charges. Do not refile. Verify units authorized and provided. Follow Eastpointe UM procedure for requesting Authorization if applicable. Do not refile if authorized units are truly exceeded. No action needed. Package exceeded unit limit. Requires a new authorization. Write off charges as non-billable. Do not refile. Check DOS for accuracy. Refile only if incorrect. Do not bill service prior to service date. Submit claim to primary insurance before submitting remainder due in Alpha. Check criteria listed in provider contract for patient eligibility. Confirm patient eligibility. Check claim for accuracy and if no errors exist, claim cannot be billed. No action needed. If billed in error, correct and refile claim. Amount due from patient or responsible party. Do not refile claim. Review all services provided to consumer on that date. Adjust off as non-billable. Refile only if incorrect. Post payment and any adjustment. Do not refile. Only one occurrence of service is billable per day. Adjust off charges and do not refile. Only if service is billed as daily summary of units, file adjusted claim. Service has been lapsed/removed from benefit plan and is no longer billable. Review Medicaid or State Funded contract. Contact Eastpointe if needed. Claim has previously been submitted and adjudicated. Do not refile. Verify that all diagnosis information is correct on claim and that primary diagnosis is in the correct position on the claim. No action needed. Await adjudication of claim. Do not refile. Verify that all patient information is correct on claim. If no errors exist, contact Eastpointe. Verify that all patient information is correct on claim. If no errors exist, contact Eastpointe Verify that all service information is correct on claim. If no errors exist, contact Eastpointe. Verify that consumer age corresponds with procedure code billed and that all information is submitted correctly. Refile only if incorrect. Enter charge information for service. Refile Claim. Verify that consumer Dx corresponds with consumer age and that all information is submitted correctly. Refile only if incorrect.
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CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 24
HIPAA ID 11
REASON DESCRIPTION Invalid PC / DX Combo
25
5
26
208
Invalid Provider
27
206
Invalid provider NPI #
28
206
Invalid Rendering NPI
29 30
96 96
Invalid Units Monthly case rate already paid (TCM)
31 32 33
198 147 46
Monthly limit exceeded No rates available Non billable Service
34 35
96 62
Re-submission already processed Service is not authorized
36
181
Service not in contract
37
181
Service not in provider profile
38 39
24 8
40
198
Sub capitated Provider/Service The procedure code is inconsistent with the provider type/specialty (taxonomy). Weekly limit exceeded
41 42 43
123 123 125
Readju - Audit Payback Readju - Audit Payback Readju - Audit Recoup
44
62
Readju - Authorization/Treatment Revisions
Verify that service is included in provider profile in Alpha. Confirm through Eastpointe prior to refiling claim. Claim is reimbursed through monthly payment and not fee for service. Do not refile. Verify the Taxonomy code filed for the claim. If incorrectly submitted, correct and refile. Contact Eastpointe to add taxonomy code. Limit to occurrence of service billable per week. Adjust off charges and do not refile. Only if service is billed in error, file adjusted claim. Claim readjudicated by Eastpointe to affect payback due to audit of services. No action needed. Claim readjudicated by Eastpointe to affect payback due to audit of services. No action needed. Claim readjudicated by Eastpointe to effect recoupment of funds due to audit of services. No action needed. Bill any corrected service, if applicable. Claim readjudicated by Eastpointe due to changes in authorization or treatment plan. No action needed.
45
125
Readju - Billing Days Extended
Claim readjudicated by Eastpointe due to extension of claims filing period.
Invalid POS & Service combo
RECOMMENDED ACTION STEPS Verify that Procedure code corresponds with Dx and that all information is submitted correctly. Refile only if incorrect. Verify place of service used for billing and that it is appropriate for the service billed. If incorrect, refile under a valid place of service. Verify that provider information is correct on claim and is valid for the service billed. Contact Eastpointe to update, and then refile. Verify that provider NPI is correct on claim and is valid NPI for the service billed. Contact Eastpointe to update, and then refile. Verify that rendering NPI is correct on claim and is valid NPI for the service billed. Contact Eastpointe to update, and then refile. Verify that the units are correct for service billed, and refile claim. Service is generally no longer billable after 12/31/2012, but may be for EPSDT consumers. Contact Eastpointe Provider Network if disputing denial. Units for monthly service were exceeded. Do not refile claim. Rate not established in rate schedule. Contact Eastpointe. Service is not covered under Eastpointe Benefit Plan. Confirm correct service billed, and contact Eastpointe if disputing denial. Duplicate claim. Do not refile claim. Contact Eastpointe. Verify Service Authorization for consumer. Follow Eastpointe UM procedure for prior approval if no authorization is on file. Review Medicaid or State services contract, and confirm through Eastpointe.
Page 2 of 7
CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 46
HIPAA ID 125
REASON DESCRIPTION Readju - Billing Terms Revised
47
125
Readju - Client Manually Matched
48 49 50 51
125 63 18 22
Readju - Contract Terminated Readju - Corrected Claim Readju - Duplicate Claims Readju - EOB Required
52
125
Readju - Other
53
22
Readju - Other Primary Insurance
54
2
Readju - Patient Liability
55
125
Readju - Provider Billing Error
56
125
Readju - Provider ID Incorrect
57
125
Readju - Rate Change
58 59 60
123 123 125
Overid - Audit Payback Overid - Audit Payback Overid - Audit Recoup
61
62
Overid - Authorization/Treatment Revisions
62
125
Overid - Billing Terms Revised
63 64 65 66
125 63 18 22
Overid - Contract Terminated Overid - Corrected Claim Overid - Duplicate Claims Overid - EOB Required
RECOMMENDED ACTION STEPS Claim readjudicated by Eastpointe due to change in billing terms. Consult Contract documents or Eastpointe website. Claim submitted without complete consumer information. Manually matched and readjudicated by Eastpointe. No action needed. Claim readjudicated by Eastpointe to reflect end of contract and provider status. Claim corrected and readjudicated by Eastpointe. Do not refile. Claim readjudicated by Eastpointe has already been billed and processed. Do not refile. Claim readjudicated by Eastpointe. Provider must document primary payer and payment status when refiling claim. Claim readjudicated by Eastpointe for unspecified reason. Contact Eastpointe with questions. Claim readjudicated by Eastpointe for other insurance eligibility. Provider must bill to primary insurance. Contact Eastpointe with questions. Claim readjudicated by Eastpointe to reflect consumer responsibility. Provider should seek payment from consumer or responsible party. Contact Eastpointe with questions. Claim readjudicated by Eastpointe to correct billing error. Review adjudication results. Contact Eastpointe with questions. Claim readjudicated by Eastpointe to correct provider of service. Review adjudication results. Contact Eastpointe with questions. Claim readjudicated by Eastpointe to process under correct billing rate. Review adjudication results. Contact Eastpointe with questions. Claim override done by Eastpointe to affect payback due to audit of services. No action needed. Claim override done by Eastpointe to affect payback due to audit of services. No action needed. Claim override done by Eastpointe to effect recoupment of funds due to audit of services. No action needed. Bill any corrected service, if applicable. Claim override done by Eastpointe due to changes in authorization or treatment plan. No action needed. Claim override done by Eastpointe due to change in billing terms. Consult contract documents or Eastpointe website. Claim override done by Eastpointe to reflect end of contract and provider status. Claim corrected and override done by Eastpointe. Do not refile. Claim override done by Eastpointe has already been billed and processed. Do not refile. Claim override done by Eastpointe. Provider must document primary payer and payment status when refiling claim.
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CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 67
HIPAA ID 62
RECOMMENDED ACTION STEPS Claim override done by Eastpointe due to changes in authorization or treatment plan. No action needed.
125
REASON DESCRIPTION Overid - Missing/incomplete/invalid treatment authorization code Overid - Other
68 69
22
Overid - Other Primary Insurance
70
2
Overid - Patient Liability
Claim override done by Eastpointe for other insurance eligibility. Provider must bill to primary insurance. Contact Eastpointe with questions. Claim override done by Eastpointe to reflect consumer responsibility. Provider should seek payment from consumer or responsible party. Contact Eastpointe with questions.
71
125
Overid - Provider Billing Error
72
125
Overid - Rate Change
73 74 75
123 123 125
Revert - Audit Payback Revert - Audit Payback Revert - Audit Recoup
76
62
Revert - Authorization/Treatment Revisions
77
125
Revert - Billing Terms Revised
78 79 80 81
125 63 18 22
Revert - Contract Terminated Revert - Corrected Claim Revert - Duplicate Claims Revert - EOB Required
82
125
Revert - Other
83
22
Revert - Other Primary Insurance
84 85
2 125
Revert - Patient Liability Revert - Provider Billing Error
86
63
Revert - Reverted because reversal/replacement claim has been submitted
Claim override done by Eastpointe for unspecified reason. Contact Eastpointe with questions.
Claim override done by Eastpointe to correct billing error. Review adjudication results. Contact Eastpointe with questions. Claim override done by Eastpointe to process under correct billing rate. Review adjudication results. Contact Eastpointe with questions. Claim reverted by Eastpointe to effect payback due to audit of services. No action needed. Claim reverted by Eastpointe to effect payback due to audit of services. No action needed. Claim reverted by Eastpointe to effect recoupment of funds due to audit of services. No action needed. Bill any corrected service, if applicable. Claim reverted by Eastpointe due to changes in authorization or treatment plan. No action needed. Claim reverted by Eastpointe due to change in billing terms. Consult contract documents or Eastpointe website. Claim reverted by Eastpointe to reflect end of contract and provider status. Claim corrected and reverted by Eastpointe. Do not refile. Claim reverted by Eastpointe has already been billed and processed. Do not refile. Claim reverted by Eastpointe. Provider must document primary payer and payment status when refiling claim. Claim reverted by Eastpointe for unspecified reason. Contact Eastpointe with questions. Claim reverted by Eastpointe for other insurance eligibility. Provider must bill to primary insurance. Contact Eastpointe with questions. Amount denied is the responsibility of the consumer. No action needed. Claim reverted by Eastpointe to reflect consumer responsibility. Provider should seek payment from consumer or responsible party. Contact Eastpointe with questions. Claim reverted by Eastpointe to correct billing error. Review adjudication results. Contact Eastpointe with questions.
Page 4 of 7
CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 87
HIPAA ID 2
REASON DESCRIPTION Adjusted Against Co-Insurance
88 89
11 147
Invalid DRG DX Code No DRG exists or rate is not set up yet
RECOMMENDED ACTION STEPS Claim adjudication reflects consumer responsibility. Provider should seek payment from consumer or responsible party. Contact Eastpointe with questions. Verify DRG diagnosis code and resubmit if billed in error. Verify all DRG information from claim and if billed correctly, contact Eastpointe.
90 91 92
48 199 99
Non-Covered DRG Services Invalid Revenue Code Excess amount over allowed Medicare copayment
Services billed under this DRG are not reimbursable. No action needed. Verify revenue code and resubmit if billed in error. Claim adjudication reflects coordination of benefits with Medicare and consumer. Provider should seek payment from consumer or responsible party. Contact Eastpointe with questions.
93
125
Verify DCN or resubmission ref # from original claim. Resubmit as replacement/void.
94
125
Invalid DCN (Document Ctrl #) or resubmission ref # Resubmitted claim DOS is after original claim submission date
95
125
96
125
97 98 99 100 101
42 63 63 125 125
Exceeded budgeted amount Readju - Denial Rebilling Overid - Denial Rebilling Invalid date span for discharge claims Patient does not have a valid Target Pop. on DOS
Post payment and adjustment. Do not refile. Duplicate of previously submitted claim. Duplicate of previously submitted claim. Verify dates and resubmit claim. Verify that consumer has a valid and current IPRS target population for the date of service billed. Contact Eastpointe for assistance. If no errors exist, do not refile.
102
125
Patient does not have a valid Target Pop. for DX submitted in claim
Verify that consumer has a valid IPRS target population that corresponds with the diagnosis information on claim. Contact Eastpointe for assistance. If no errors exist, do not refile.
103
125
104
125
Verify that consumer has a valid IPRS target population for the service billed. Contact Eastpointe Patient does not have a valid Target Pop. for service submitted in claim for assistance. If no errors exist, do not refile. Loaded from legacy system - no reason available Request MCO look into claim issue further.
105
125
Pended for manual review
Resubmit original claim as replacement claim with original DOS.
Verify DCN or resubmission ref # from original claim. Resubmit. Resubmitted claim does not match with the referenced claim Referenced claims have already been resubmitted. No action needed. Contact Eastpointe if claim still requires attention. Multiple resubmissions not allowed
Claims staff to manually review claim. Provider can ask for update on manual review status.
Page 5 of 7
CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 106
HIPAA ID 125
REASON DESCRIPTION Pended for COB since patient has no COB record
107
5
108
31
109 110
197 22
The procedure code/bill type is inconsistent with the place of service. N o c o ve r a g e a v a i l a b l e fo r patient/service/provider combo Service is not authorized for supplied site Revert - Retroactive Medicaid
111
22
Revert - Medicaid coverage
112 113
A1 B6
114
B6
115
47
116
23
117 118 119
22 22 133
Add-on code cannot be billed by itself The taxonomy code for the billing provider is missing. Missing/Incomplete/Invalid attending/rendering taxonomy code The diagnosis submitted on the claim is no longer billable or accepted by NC Tracks and will deny at that level. Adjustment represents the estimated amount the primary payer may have paid. Override Medicaid Coverage Override Retroactive Medicaid The disposition of the claim/service is pending further review. (Use only with Group Code OA)
120
45
Amount exceeded allowable COB amount
121
185
The rendering provider is not eligible to perform the service billed
122
MA130
125
119
A specific site could not be determined Annual frequency exceed
RECOMMENDED ACTION STEPS Provider to update patient, COB tile as claim was submitted with COB information. Notify Claims staff once COB information has been updated. If submitting COB information was a mistake, notify Claims staff so the claim can be denied and provider can resubmit. Provider to contact Eastpointe for resolution. Eastpointe shall verify service and to place of service mapping. Provider check consumers eligibility and service provided Provider check the site on the SARS - it must match the site on the claim being billed. Ensure that the primary insurance for the patient has been billed and is indicated on the claim being submitted to the MCO. Ensure that the primary insurance for the patient has been billed and is indicated on the claim being submitted to the MCO. Contact your MCO for further assistance. Check and confirm that the taxonomy submitted on the claim is associated with the NPI submitted. If so, contact your MCO for assistance. Check and confirm that the taxonomy submitted on the claim is associated with the attending/rendering NPI submitted. If so, contact your MCO for assistance. Rebill the claim with a 5 digit diagnosis code.
Contact your MCO for further assistance. Confirm patient eligibility by contacting Eastpointe. Confirm patient eligibility by contacting Eastpointe. Contact your MCO for further assistance.
Post payment and any adjustment to charges. Do not refile. Contact Eastpointe with questions. If service is marked as clinician based, rebill with the correct clinician NPI as the rendering. If not marked as clinician based, update the rendering NPI to the site’s NPI where the service was performed. Verify that site NPI is included in provider profile in Alpha. Confirm through Eastpointe prior to refiling claim. Limit to occurrence of service billable per year. Adjust off charges and do not refile. Only if service is billed in error, file adjusted claim. Contact Eastpointe with questions.
Page 6 of 7
CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 127
HIPAA ID 23
128
23
REASON DESCRIPTION The impact of prior payer(s) adjudication including payments and/or adjustments Amount in excess of prior payer(s) coinsurance
RECOMMENDED ACTION STEPS Post payment and any adjustment to charges. Do not refile. Contact Eastpointe with questions. Post payment and any adjustment to charges. Do not refile. Contact Eastpointe with questions.
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