Medicare denial codes provide or describe the standard information to a patient or provider by an insurances about why a claim was denied. This is the standard format followed by all insurance companies for relieving the burden on the medical providers. MACs (Medicare Administrative Contractors) use appropriate group, claim adjustment reason, or remittance advice remark codes to communicate that why a claim or charges are not covered by Medicare and who is financially responsible for the charges.
A group code is a code identifying the general category of payment adjustment. Valid group codes for use on Medicare remittance advice are:
CO – Contractual Obligations: This group code is used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. These adjustments are considered a write off for the provider and are not billed to the patient in most of the cases.
OA – Other Adjustments: This group code is used when no other group code applies to the adjustment.
PR – Patient Responsibility: This group code is used when the adjustment represents an amount that may be billed to the patient or insured. This group would typically be used for deductible and co-pay adjustments.
Reason for Denial
|The procedure code is inconsistent with the modifier used, or a required modifier is missing.
|HCPCS code is inconsistent with modifier used or a required modifier is missing Item billed was processed under DMEPOS Competitive Bidding Program and requires an appropriate competitive bid modifier
|HCPCS code is inconsistent with modifier used or required modifier is missing
|The procedure code/bill type is inconsistent with the place of service.
|The procedure/revenue code is inconsistent with the patient’s age.
|The procedure/revenue code is inconsistent with the patient’s gender.
|The procedure code is inconsistent with the provider type/specialty (taxonomy).
|The diagnosis is inconsistent with the patient’s age.
|The diagnosis is inconsistent with the patient’s gender.
|The diagnosis is inconsistent with the procedure.
|The diagnosis is inconsistent with the provider type.
|The date of death precedes the date of service.
|The date of birth follows the date of service.
|Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
|Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate
|Item billed does not have base equipment on file. Main equipment is missing therefore Medicare will not pay for supplies
|MA13 N264 N575
|Item(s) billed did not have a valid ordering physician name
|MA13 N265 N276
|Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS)
|Claim/service lacks information or has submission/billing error(s) Missing/incomplete/invalid Information
|Claim/service lacks information or has submission/billing error(s). Did not indicate whether we are the primary or secondary payer.
|Payment adjusted because requested information was not provided or was
insufficient/incomplete. Additional information is supplied using remittance advice
remarks codes whenever appropriate.
|Claim denied because this is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.
|Claim denied because this injury/illness is covered by the liability carrier.
|Claim denied because this injury/illness is the liability of the no-fault carrier.
|Payment adjusted because this care may be covered by another payer per coordination of benefits.
|Payment adjusted because charges have been paid by another payer.
|Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
|Payment denied. Your stop loss deductible has not been met.
|Expenses incurred prior to coverage.
|Expenses incurred after coverage terminated.
|Coverage not in effect at the time the service was provided.
|The time limit for filing has expired. You may not appeal this decision.
|Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
|Claim denied as patient cannot be identified as our insured.
|Our records indicate that this dependent is not an eligible dependent as defined.
|Claim denied. Insured has no dependent coverage.
|Claim denied. Insured has no coverage for newborns.
|Benefit maximum has been reached.
|Balance does not exceed co-payment amount.
|Balance does not exceed deductible.
|Services not provided or authorized by designated (network) providers.
|Services denied at the time authorization/pre-certification was requested.
|Charges do not meet qualifications for emergent/urgent care.
|Discount agreed to in Preferred Provider contract.
|Charges exceed our fee schedule or maximum allowable amount.
|Charges exceed your contracted/legislated fee arrangement.
|This (these) service(s) is (are) not covered.
|This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
|This (these) procedure(s) is (are) not covered.
|These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
|These are non-covered services because this is not deemed a “medical necessity” by the payer.
|Documentation requested was not received or was not received timely
|Item billed may require a specific diagnosis or modifier code based on related Local Coverage Determination (LCD)
Development letter requesting additional documentation to support service billed was not received within provided timeline
Item being billed does not meet medical necessity
|Non covered services
|These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
This item or service does not meet the criteria for the category under which it was billed.
|These are non-covered services because this is a pre-existing condition. Item being billed does not meet medical necessity.
|The referring/prescribing provider is not eligible to refer/prescribe/order/perform the service billed.
|Services by an immediate relative or a member of the same household are not covered.
|Multiple physicians/assistants are not covered in this case.
|Claim/service denied because procedure/ treatment is deemed experimental/ investigational by the payer.
|Claim/service denied because procedure/ treatment has been deemed “proven to be effective” by the payer.
|Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day’s supply.
|Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
|Charges are reduced based on multiple surgery rules or concurrent anesthesia rules.
|Charges for outpatient services with this proximity to inpatient services are not covered.
|Charges adjusted as penalty for failure to obtain second surgical opinion.
|Payment denied/reduced for absence of, or exceeded, precertification/ authorization.
|Correction to a prior claim.
|Denial reversed per Medical Review.
|Procedure code was incorrect. This payment reflects the correct code.
|Lifetime reserve days.
|Day outlier amount.
|Cost outlier. Adjustment to compensate for additional costs.
|Primary payer amount.
|Indirect Medical Education Adjustment.
|Direct Medical Education Adjustment.
|Disproportionate Share Adjustment.
|Non-covered days/Room charge adjustment.
|Cost report days.
|Adjustment amount represents collection against receivable created in prior overpayment.
|Professional fees removed from charges.
|Ingredient cost adjustment.
|Dispensing fee adjustment.
|Claim paid in full.
|No claim level adjustments.
|Processed in excess of charges.
|Benefits adjusted. Plan procedures not followed.
|Payment is included in the allowance for another service/procedure.
|Beneficiary was inpatient on date of service billed
|HCPCS code billed is included in the payment/allowance for another service/procedure that has already been adjudicated
|The hospital must file the Medicare claim for this inpatient non-physician service.
|Medicare Secondary Payer Adjustment amount.
|Payment made to patient/insured/responsible party.
|Predetermination. Anticipated payment upon completion of services or claim adjudication.
|Major Medical Adjustment.
|Provider promotional discount (e.g., Senior citizen discount).
|Managed care withholding.
|Patient payment option/election not in effect.
|Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim.
|Payment adjusted because rent/purchase guidelines were not met.
|Rent/purchase guidelines were not met.
Consult plan benefit documents/guidelines for information about restrictions for this service.
|Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
|Claim was submitted to incorrect Jurisdiction
|Claim was submitted to incorrect contractor
|Claim was billed to the incorrect contractor
Beneficiary was enrolled in a Medicare Health Maintenance Organization (HMO) for date of service submitted
|Billing date predates service date.
|Not covered unless the provider accepts assignment.
|Payment adjusted as not furnished directly to the patient and/or not documented.
|Payment denied because service/procedure was provided outside the United States or as a result of war.
|Procedure/product not approved by the Food and Drug Administration.
|Payment adjusted as procedure postponed or cancelled.
|Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
|Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
|Charges reduced for ESRD network support.
|Benefit maximum for this time period has been reached.
|Patient is covered by a managed care plan.
|Payer refund due to overpayment.
|Payer refund amount – not our patient.
|Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
|Deductible – Major Medical.
|Coinsurance – Major Medical.
|Newborn’s services are covered in the mother’s allowance.
|Payment denied. Prior processing information appears incorrect.
|Claim submission fee.
|Claim specific negotiated discount.
|Prearranged demonstration project adjustment.
|The disposition of this claim/service is pending further review.
|Technical fees removed from charges.
|Claim denied. Interim bills cannot be processed.
|Claim adjusted. Plan procedures of a prior payer were not followed.
|Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
|Claim/Service denied. Appeal procedures not followed or time limits not met.
|Contracted funding agreement. Subscriber is employed by the provider of the services.
|Patient/Insured health identification number and name do not match.
|Claim adjustment because the claim spans eligible and ineligible periods of coverage.
|Claim adjusted by the monthly Medicaid patient liability amount.
|Portion of payment deferred.
|Incentive adjustment, e.g., preferred product/service.
|Premium payment withholding.
|Payment denied because the diagnosis was invalid for the date(s) of service reported.
|Provider contracted/negotiated rate expired or not on file.
|Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
|Patient refund amount.
|Claim denied charges.
|Oxygen equipment has exceeded the number of approved paid rentals
|Medicare Secondary Payer liability met.
|Medicare Claim PPS Capital Day Outlier Amount.
|Medicare Claim PPS Capital Cost Outlier Amount.
|Prior hospitalization or 30 day transfer requirement not met.
|Presumptive Payment Adjustment.
|Claim denied; ungroupable DRG.
|Late filing penalty.
|Payment adjusted because coverage/program guidelines were not met or were exceeded.
|This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
|This provider was not certified/eligible to be paid for this procedure/service on this date of service.
|This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Missing/incomplete/invalid credentialing data.
|Claim/service not covered/reduced because alternative services were available, and should not have been utilized.
|Services not covered because the patient is enrolled in a Hospice.
|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.
|The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
|Services not documented in patient’s medical records.
|Previously paid. Payment for this claim/service may have been provided in a previous payment.
|Payment denied because only one visit or consultation per physician per day is covered.
|Payment adjusted because this service/procedure is not paid separately.
|Payment adjusted because “new patient” qualifications were not met.
|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.
|Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
|Duplicate claim has already been submitted and processed
|Claim/service adjusted because of the finding of a Review Organization.
|Payment adjusted because procedure/service was partially or fully furnished by another provider.
|Procedure/service was partially or fully furnished by another provider. This item is denied when provided to this patient by a non-contract or non- demonstration supplier.
|The charges were reduced because the service/care was partially furnished by another physician.
|This payment is adjusted based on the diagnosis.
|Payment denied because this provider has failed an aspect of a proficiency testing program.
|Claim/service denied. Level of subluxation is missing or inadequate.
|Claim lacks the name, strength, or dosage of the drug furnished.
|Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
|Claim/service does not indicate the period of time for which this will be needed.
|Claim/service denied. Claim lacks individual lab codes included in the test.
|Claim/service denied. Claim did not include patient’s medical record for the service.
|Claim/service denied. Claim lacks date of patient’s most recent physician visit.
|Claim/service denied. Claim lacks indicator that “x-ray is available for review”.
|Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
|Claim/service denied. Completed physician financial relationship form not on file.
|Claim lacks completed pacemaker registration form.
|Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
|Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
|Claim lacks indication that plan of treatment is on file.
|Claim lacks indication that service was supervised or evaluated by a physician.
|Workers Compensation State Fee Schedule Adjustment.
Researching and resubmitting denied claims can lead to long, frustrating hours trying to figure out why the claim was denied in the first place. The good news is that on average, 60% of denied claims are recoverable and around 95% are preventable.
Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections.
We have more than 10 years experience in US Medical Billing and hand-on experience in Web Management, SEO, Content Marketing & Business Development with Research as a special forte.