pi 204 denial code descriptions
Note: Use code 187. About Claim Adjustment Group Codes 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 Auto only. 240 The diagnosis is inconsistent with the patients birth weight. Current and past groups and caucuses include: X12 is pleased to recognize individual members and industry representatives whose contributions and achievements have played a role in the development of cross-industry eCommerce standards. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use CARC 45), Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use with Group Code CO or OA). Medicare Claim PPS Capital Cost Outlier Amount. 
Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Code OA). Payment 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.) To be used for Property and Casualty Auto only. Additional payment for Dental/Vision service utilization. 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). The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Your Stop loss deductible has not been met. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 7 The procedure/revenue code is inconsistent with the patients gender. 141 Claim spans eligible and ineligible periods of coverage. 
X12 has submitted the first in a series of recommendations related to advancing the version of already adopted and mandated transactions and proposing additional transactions for adoption. This (these) service(s) is (are) not covered. 226 Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. Submit these services to the patient's hearing plan for further consideration. The diagnosis is inconsistent with the patient's birth weight. 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.). Service/procedure was provided as a result of terrorism. 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). A5 Medicare Claim PPS Capital Cost Outlier Amount. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. To be used for Property and Casualty Auto only. Prearranged demonstration project adjustment. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes. Interventional Radiology Procedure code list, CPT 29824, 29827,29828 Arthroscopic rotator cuff repair, COLONOSCOPY BILLING CODES CPT 45380 , 45385, Employer Group waiver plan overview and FAQ, CPT code 47562, 47563, 47564 Laparoscopy, surgical; cholecystectomy. No maximum allowable defined by legislated fee arrangement. 
Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 
B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. The advance indemnification notice signed by the patient did not comply with requirements. What is PR 1 medical billing? 32 Our records indicate that this dependent is not an eligible dependent as defined. Sequestration - reduction in federal payment. Reason Code 2: The procedure code/bill type is inconsistent with the place of service. D23 This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. For use by Property and Casualty only. 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). Processed under Medicaid ACA Enhanced Fee Schedule. 258 Claim/service not covered when patient is in custody/incarcerated. In the This non-payable code is for required reporting only. Claim/service denied. 211 National Drug Codes (NDC) not eligible for rebate, are not covered. The procedure/revenue code is inconsistent with the patient's gender. 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. PI-204 is used when the service, equipment, or drug is not covered under the patients current benefit plan and must therefore be billed to the patient, while PR-1 Every BC/BS plan is different and I personally haven't seen one as a secondary that doesn't cover for that code, but it is a legit reason. D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. 204 This service/equipment/drug is not covered under the patients current benefit plan. B20 Procedure/service was partially or fully furnished by another provider. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code. (Use only with Group Code OA). 128 Newborns services are covered in the mothers Allowance. 137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. B13 Previously paid. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration. W6 Referral not authorized by attending physician per regulatory requirement. Payment reduced to zero due to litigation. +1-800-456-478-23 what happened to ralph bernard myers. To renewan X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. To be used for Property and Casualty only. PR 1 Deductible Amount Members plan deductible applied to the allowable benefit for the rendered service(s). 22 This care may be covered by another payer per coordination of benefits. 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). Precertification/notification/authorization/pre-treatment exceeded. Claim/Service lacks Physician/Operative or other supporting documentation. D6 Claim/service denied. This payment is adjusted based on the diagnosis. Claim received by the medical plan, but benefits not available under this plan. 244 Payment reduced to zero due to litigation. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Property and Casualty only. B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. 59 Processed based on multiple or concurrent procedure rules. 14 The date of birth follows the date of service. 181 Procedure code was invalid on the date of service. Workers' Compensation case settled. Refund to patient if collected. To be used for Property and Casualty only. Procedure code was incorrect. 100 Payment made to patient/insured/responsible party/employer. PR 3 Co-payment Amount Copayment Members plan copayment applied to the allowable benefit for the rendered service(s). To be used for Property and Casualty only. 152 Payer deems the information submitted does not support this length of service. Note: Use code 187. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Completed physician financial relationship form not on file. 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. 238 Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. D1 Claim/service denied. To be used for Property and Casualty only. Diagnosis was invalid for the date(s) of service reported. An allowance has been made for a comparable service. No maximum allowable defined bylegislated fee arrangement. Claim is under investigation. 31 Patient cannot be identified as our insured. 224 Patient identification compromised by identity theft. Deductible waived per contractual agreement. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. An attachment/other documentation is required to adjudicate this claim/service. Usage: To be used for pharmaceuticals only. To be used for Property and Casualty only. Content is added to this page regularly. This payment reflects the correct code. National Drug Codes (NDC) not eligible for rebate, are not covered. 174 Service was not prescribed prior to delivery. 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. Y1 Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. You must send the claim/service to the correct payer/contractor. pi 204 denial code descriptions. 21 This injury/illness is the liability of the no-fault carrier. Claim lacks indication that plan of treatment is on file. 241 Low Income Subsidy (LIS) Co-payment Amount. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Claim received by the Medical Plan, but benefits not available under this plan. Service/equipment was not prescribed by a physician. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. Charges are covered under a capitation agreement/managed care plan. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies. 136 Failure to follow prior payers coverage rules. Note: 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. 38 Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. B15 This service/procedure requires that a qualifying service/procedure be received and covered. I have a patient with Providence as primary and BxBs as a secondary payor and the first bxbs payment came through just fine, the patient had some copay, some deductible, and some write off. Insured has no dependent coverage. To be used for Workers' Compensation only. 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). Claim denials fall into three categories: administrative, clinical, and policya majority of claim denials are due to administrative errors. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Information from another provider was not provided or was insufficient/incomplete. 160 Injury/illness was the result of an activity that is a benefit exclusion. The Claim spans two calendar years. D8 Claim/service denied. Exceeds the contracted maximum number of hours/days/units by this provider for this period. Adjustment for delivery cost. PIL02b1 Publishing and Maintaining Externally Developed Implementation Guides, PIL02b2 Publishing and Maintaining Externally Developed Implementation Guides. 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). The diagnosis is inconsistent with the procedure. This claim has been identified as a readmission. Payment is adjusted when performed/billed by a provider of this specialty. pi 204 denial code descriptions. X12 manages the exclusive copyright to all standards, publications, and products, and such works do not constitute joint works of authorship eligible for joint copyright. D7 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 246 This non-payable code is for required reporting only. 97 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. 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Review Organization 38 services not provided or was insufficient/incomplete this dual eligible patient is in pi 204 denial code descriptions..., Assessments, Allowances or Health related Taxes value of zero in payment/allowance. For the basic procedure/test X12 work product must be compliant with US Copyright laws and X12 Intellectual Property.. Not authorized/certified to provide treatment to injured workers in this jurisdiction is a benefit exclusion not contain the required. Insurance SHOP Exchange requirements Deductible amount Members plan Copayment applied to the 835 Healthcare Policy Identification Segment ( 2110. Usage: Refer to the patient 's Behavioral Health plan for further consideration by (... X12 Intellectual Property policies of benefits because of the claim/service is undetermined the. ( MPC ) or Personal Injury Protection ( PIP ) benefits jurisdictional fee schedule, therefore no is!