CLAIM ADJUDICATION CODES AND ACTIONS REASON ID HIPAA ID REASON DESCRIPTION RECOMMENDED ACTION STEPS

CLAIM ADJUDICATION CODES AND ACTIONS REASON ID 1 2 3 HIPAA ID 45 92 198 REASON DESCRIPTION Adjusted - Above contract rate Approved Authed units exce...
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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.

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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.

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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.

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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.

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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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