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Explain the codes in ERA
Did you receive a code from a health plan, such as: PR32? The "PR" is a Claim Adjustment Group Code and the description for "32" is to the left. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and definitions are below:
CO | Contractual Obligation |
CR | Corrections and Reversal |
OA | Other Adjustment |
PI | Payer Initiated Reductions |
PR | Patient Responsibility |
Refer to the following links for latest codes for more details:
https://x12.org/codes/claim-adjustment-reason-codes
https://x12.org/index.php/codes/claim-adjustment-group-codes
1 | Deductible Amount |
2 | Coinsurance Amount |
3 | Co-payment Amount |
4 | 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. |
5 | 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. |
6 | 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. |
7 | 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. |
8 | 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. |
9 | 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. |
10 | 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. |
11 | The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
12 | 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. |
13 | The date of death precedes the date of service. |
14 | The date of birth follows the date of service. |
16 | 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. |
18 | Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) |
19 | This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. |
20 | This injury/illness is covered by the liability carrier. |
21 | This injury/illness is the liability of the no-fault carrier. |
22 | This care may be covered by another payer per coordination of benefits. |
23 | The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) |
24 | Charges are covered under a capitation agreement/managed care plan. |
26 | Expenses incurred prior to coverage. |
27 | Expenses incurred after coverage terminated. |
29 | The time limit for filing has expired. |
31 | Patient cannot be identified as our insured. |
32 | Our records indicate the patient is not an eligible dependent. |
33 | Insured has no dependent coverage. |
34 | Insured has no coverage for newborns. |
35 | Lifetime benefit maximum has been reached. |
39 | Services denied at the time authorization/pre-certification was requested. |
40 | 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. |
44 | Prompt-pay discount. |
45 | 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) |
49 | 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. |
50 | 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. |
51 | 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. |
53 | Services by an immediate relative or a member of the same household are not covered. |
54 | 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. |
55 | 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. |
56 | 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. |
58 | 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. |
59 | 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. |
60 | Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. |
61 | Adjusted for failure to obtain second surgical opinion |
66 | Blood Deductible. |
69 | Day outlier amount. |
70 | Cost outlier - Adjustment to compensate for additional costs. |
74 | Indirect Medical Education Adjustment. |
75 | Direct Medical Education Adjustment. |
76 | Disproportionate Share Adjustment. |
78 | Non-Covered days/Room charge adjustment. |
85 | Patient Interest Adjustment (Use Only Group code PR) |
89 | Professional fees removed from charges. |
90 | Ingredient cost adjustment. Usage: To be used for pharmaceuticals only. |
91 | Dispensing fee adjustment. |
94 | Processed in Excess of charges. |
95 | Plan procedures not followed. |
96 | 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. |
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. |
100 | Payment made to patient/insured/responsible party. |
101 | Predetermination: anticipated payment upon completion of services or claim adjudication. |
102 | Major Medical Adjustment. |
103 | Provider promotional discount (e.g., Senior citizen discount). |
104 | Managed care withholding. |
105 | Tax withholding. |
106 | Patient payment option/election not in effect. |
107 | 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. |
108 | Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. |
110 | Billing date predates service date. |
111 | Not covered unless the provider accepts assignment. |
112 | Service not furnished directly to the patient and/or not documented. |
114 | Procedure/product not approved by the Food and Drug Administration. |
115 | Procedure postponed, canceled, or delayed. |
116 | The advance indemnification notice signed by the patient did not comply with requirements. |
117 | Transportation is only covered to the closest facility that can provide the necessary care. |
118 | ESRD network support adjustment. |
119 | Benefit maximum for this time period or occurrence has been reached. |
121 | Indemnification adjustment - compensation for outstanding member responsibility. |
122 | Psychiatric reduction. |
128 | Newborn's services are covered in the mother's Allowance. |
129 | 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.) |
130 | Claim submission fee. |
131 | Claim specific negotiated discount. |
132 | Prearranged demonstration project adjustment. |
133 | 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). |
134 | Technical fees removed from charges. |
135 | Interim bills cannot be processed. |
136 | Failure to follow prior payer's coverage rules. (Use only with Group Code OA) |
137 | Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. |
139 | Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO. |
140 | Patient/Insured health identification number and name do not match. |
142 | Monthly Medicaid patient liability amount. |
143 | Portion of payment deferred. |
144 | Incentive adjustment, e.g. preferred product/service. |
146 | Diagnosis was invalid for the date(s) of service reported. |
147 | Provider contracted/negotiated rate expired or not on file. |
148 | 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.) |
149 | Lifetime benefit maximum has been reached for this service/benefit category. |
150 | Payer deems the information submitted does not support this level of service. |
151 | Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. |
152 | 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. |
153 | Payer deems the information submitted does not support this dosage. |
154 | Payer deems the information submitted does not support this day's supply. |
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