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 Code |
Remark Code |
Reason for Denial |
| Code 01 | Deductible amount. | |
| Code 02 | Coinsurance amount. | |
| Code 03 | Co-payment amount. | |
| Code 04 | The procedure code is inconsistent with the modifier used, or a required modifier is missing. | |
| Code 04 | M114 N565 | 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 |
| Code 04 | N519 | HCPCS code is inconsistent with modifier used or required modifier is missing |
| Code 05 | The procedure code/bill type is inconsistent with the place of service. | |
| Code 06 | The procedure/revenue code is inconsistent with the patient’s age. | |
| Code 07 | The procedure/revenue code is inconsistent with the patient’s gender. | |
| Code 08 | The procedure code is inconsistent with the provider type/specialty (taxonomy). | |
| Code 09 | The diagnosis is inconsistent with the patient’s age. | |
| Code 10 | The diagnosis is inconsistent with the patient’s gender. | |
| Code 11 | The diagnosis is inconsistent with the procedure. | |
| Code 12 | The diagnosis is inconsistent with the provider type. | |
| Code 13 | The date of death precedes the date of service. | |
| Code 14 | The date of birth follows the date of service. | |
| Code 15 | Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. | |
| Code 16 | Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate | |
| Code 16 | M124 | Item billed does not have base equipment on file. Main equipment is missing therefore Medicare will not pay for supplies |
| Code 16 | MA13 N264 N575 | Item(s) billed did not have a valid ordering physician name |
| Code 16 | 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) |
| Code 16 | MA27 N382 | Claim/service lacks information or has submission/billing error(s) Missing/incomplete/invalid Information |
| Code 16 | MA83 | Claim/service lacks information or has submission/billing error(s). Did not indicate whether we are the primary or secondary payer. |
| Code 17 | Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using remittance advice remarks codes whenever appropriate. |
|
| Code 18 | Duplicate claim/service. | |
| Code 19 | Claim denied because this is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier. | |
| Code 20 | Claim denied because this injury/illness is covered by the liability carrier. | |
| Code 21 | Claim denied because this injury/illness is the liability of the no-fault carrier. | |
| Code 22 | Payment adjusted because this care may be covered by another payer per coordination of benefits. | |
| Code 23 | Payment adjusted because charges have been paid by another payer. | |
| Code 24 | Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. | |
| Code 25 | Payment denied. Your stop loss deductible has not been met. | |
| Code 26 | Expenses incurred prior to coverage. | |
| Code 27 | Expenses incurred after coverage terminated. | |
| Code 28 | Coverage not in effect at the time the service was provided. | |
| Code 29 | N211 | The time limit for filing has expired. You may not appeal this decision. |
| Code 30 | Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. | |
| Code 31 | Claim denied as patient cannot be identified as our insured. | |
| Code 32 | Our records indicate that this dependent is not an eligible dependent as defined. | |
| Code 33 | Claim denied. Insured has no dependent coverage. | |
| Code 34 | Claim denied. Insured has no coverage for newborns. | |
| Code 35 | Benefit maximum has been reached. | |
| Code 36 | Balance does not exceed co-payment amount. | |
| Code 37 | Balance does not exceed deductible. | |
| Code 38 | Services not provided or authorized by designated (network) providers. | |
| Code 39 | Services denied at the time authorization/pre-certification was requested. | |
| Code 40 | Charges do not meet qualifications for emergent/urgent care. | |
| Code 41 | Discount agreed to in Preferred Provider contract. | |
| Code 42 | Charges exceed our fee schedule or maximum allowable amount. | |
| Code 43 | Gramm-Rudman reduction. | |
| Code 44 | Prompt-pay discount. | |
| Code 45 | Charges exceed your contracted/legislated fee arrangement. | |
| Code 46 | This (these) service(s) is (are) not covered. | |
| Code 47 | This (these) diagnosis(es) is (are) not covered, missing, or are invalid. | |
| Code 48 | This (these) procedure(s) is (are) not covered. | |
| Code 49 | These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. | |
| Code 50 | These are non-covered services because this is not deemed a “medical necessity” by the payer. | |
| Code 50 | M127 | Documentation requested was not received or was not received timely |
| Code 50 | N115 | 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 |
| Code 50 | N130 | Non covered services |
| Code 50 | N180 | 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. |
| Code 51 | These are non-covered services because this is a pre-existing condition. Item being billed does not meet medical necessity. | |
| Code 52 | The referring/prescribing provider is not eligible to refer/prescribe/order/perform the service billed. | |
| Code 53 | Services by an immediate relative or a member of the same household are not covered. | |
| Code 54 | Multiple physicians/assistants are not covered in this case. | |
| Code 55 | Claim/service denied because procedure/ treatment is deemed experimental/ investigational by the payer. | |
| Code 56 | Claim/service denied because procedure/ treatment has been deemed “proven to be effective” by the payer. | |
| Code 57 | 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. | |
| Code 58 | Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. | |
| Code 59 | Charges are reduced based on multiple surgery rules or concurrent anesthesia rules. | |
| Code 60 | Charges for outpatient services with this proximity to inpatient services are not covered. | |
| Code 61 | Charges adjusted as penalty for failure to obtain second surgical opinion. | |
| Code 62 | Payment denied/reduced for absence of, or exceeded, precertification/ authorization. | |
| Code 63 | Correction to a prior claim. | |
| Code 64 | Denial reversed per Medical Review. | |
| Code 65 | Procedure code was incorrect. This payment reflects the correct code. | |
| Code 66 | Blood deductible. | |
| Code 67 | Lifetime reserve days. | |
| Code 68 | DRG weight. | |
| Code 69 | Day outlier amount. | |
| Code 70 | Cost outlier. Adjustment to compensate for additional costs. | |
| Code 71 | Primary payer amount. | |
| Code 72 | Coinsurance day. | |
| Code 73 | Administrative days. | |
| Code 74 | Indirect Medical Education Adjustment. | |
| Code 75 | Direct Medical Education Adjustment. | |
| Code 76 | Disproportionate Share Adjustment. | |
| Code 77 | Covered days. | |
| Code 78 | Non-covered days/Room charge adjustment. | |
| Code 79 | Cost report days. | |
| Code 80 | Outlier days. | |
| Code 81 | Discharges. | |
| Code 82 | PIP days. | |
| Code 83 | Total visits. | |
| Code 84 | Capital Adjustment. | |
| Code 85 | Interest amount. | |
| Code 86 | Statutory Adjustment. | |
| Code 87 | Transfer amount. | |
| Code 88 | Adjustment amount represents collection against receivable created in prior overpayment. | |
| Code 89 | Professional fees removed from charges. | |
| Code 90 | Ingredient cost adjustment. | |
| Code 91 | Dispensing fee adjustment. | |
| Code 92 | Claim paid in full. | |
| Code 93 | No claim level adjustments. | |
| Code 94 | Processed in excess of charges. | |
| Code 95 | Benefits adjusted. Plan procedures not followed. | |
| Code 96 | Non-covered charges. | |
| Code 97 | Payment is included in the allowance for another service/procedure. | |
| Code 97 | M2 | Beneficiary was inpatient on date of service billed |
| Code 97 | N390 | HCPCS code billed is included in the payment/allowance for another service/procedure that has already been adjudicated |
| Code 98 | The hospital must file the Medicare claim for this inpatient non-physician service. | |
| Code 99 | Medicare Secondary Payer Adjustment amount. | |
| Code 100 | Payment made to patient/insured/responsible party. | |
| Code 101 | Predetermination. Anticipated payment upon completion of services or claim adjudication. | |
| Code 102 | Major Medical Adjustment. | |
| Code 103 | Provider promotional discount (e.g., Senior citizen discount). | |
| Code 104 | Managed care withholding. | |
| Code 105 | Tax withholding. | |
| Code 106 | Patient payment option/election not in effect. | |
| Code 107 | Claim/service denied because the related or qualifying claim/service was not paid or identified on the claim. | |
| Code 108 | Payment adjusted because rent/purchase guidelines were not met. | |
| Code 108 | N130 | Rent/purchase guidelines were not met. Consult plan benefit documents/guidelines for information about restrictions for this service. |
| Code 109 | Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. | |
| Code 109 | N104 | Claim was submitted to incorrect Jurisdiction |
| Code 109 | N130 | Claim was submitted to incorrect contractor |
| Code 109 | N418 | Claim was billed to the incorrect contractor Beneficiary was enrolled in a Medicare Health Maintenance Organization (HMO) for date of service submitted |
| Code 110 | Billing date predates service date. | |
| Code 111 | Not covered unless the provider accepts assignment. | |
| Code 112 | Payment adjusted as not furnished directly to the patient and/or not documented. | |
| Code 113 | Payment denied because service/procedure was provided outside the United States or as a result of war. | |
| Code 114 | Procedure/product not approved by the Food and Drug Administration. | |
| Code 115 | Payment adjusted as procedure postponed or cancelled. | |
| Code 116 | Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. | |
| Code 117 | Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. | |
| Code 118 | Charges reduced for ESRD network support. | |
| Code 119 | Benefit maximum for this time period has been reached. | |
| Code 120 | Patient is covered by a managed care plan. | |
| Code 121 | Indemnification adjustment. | |
| Code 122 | Psychiatric reduction. | |
| Code 123 | Payer refund due to overpayment. | |
| Code 124 | Payer refund amount – not our patient. | |
| Code 125 | Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. | |
| Code 126 | Deductible – Major Medical. | |
| Code 127 | Coinsurance – Major Medical. | |
| Code 128 | Newborn’s services are covered in the mother’s allowance. | |
| Code 129 | Payment denied. Prior processing information appears incorrect. | |
| Code 130 | Claim submission fee. | |
| Code 131 | Claim specific negotiated discount. | |
| Code 132 | Prearranged demonstration project adjustment. | |
| Code 133 | The disposition of this claim/service is pending further review. | |
| Code 134 | Technical fees removed from charges. | |
| Code 135 | Claim denied. Interim bills cannot be processed. | |
| Code 136 | Claim adjusted. Plan procedures of a prior payer were not followed. | |
| Code 137 | Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. | |
| Code 138 | Claim/Service denied. Appeal procedures not followed or time limits not met. | |
| Code 139 | Contracted funding agreement. Subscriber is employed by the provider of the services. | |
| Code 140 | Patient/Insured health identification number and name do not match. | |
| Code 141 | Claim adjustment because the claim spans eligible and ineligible periods of coverage. | |
| Code 142 | Claim adjusted by the monthly Medicaid patient liability amount. | |
| Code 143 | Portion of payment deferred. | |
| Code 144 | Incentive adjustment, e.g., preferred product/service. | |
| Code 145 | Premium payment withholding. | |
| Code 146 | Payment denied because the diagnosis was invalid for the date(s) of service reported. | |
| Code 147 | Provider contracted/negotiated rate expired or not on file. | |
| Code 148 | Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. | |
| Code A0 | Patient refund amount. | |
| Code A1 | Claim denied charges. | |
| Code A1 | N370 | Oxygen equipment has exceeded the number of approved paid rentals |
| Code A2 | Contractual adjustment. | |
| Code A3 | Medicare Secondary Payer liability met. | |
| Code A4 | Medicare Claim PPS Capital Day Outlier Amount. | |
| Code A5 | Medicare Claim PPS Capital Cost Outlier Amount. | |
| Code A6 | Prior hospitalization or 30 day transfer requirement not met. | |
| Code A7 | Presumptive Payment Adjustment. | |
| Code A8 | Claim denied; ungroupable DRG. | |
| Code B1 | Non-covered visits. | |
| Code B2 | Covered visits. | |
| Code B3 | Covered charges. | |
| Code B4 | Late filing penalty. | |
| Code B5 | Payment adjusted because coverage/program guidelines were not met or were exceeded. | |
| Code B6 | 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. | |
| Code B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. | |
| Code B7 | N570 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. Missing/incomplete/invalid credentialing data. |
| Code B8 | Claim/service not covered/reduced because alternative services were available, and should not have been utilized. | |
| Code B9 | Services not covered because the patient is enrolled in a Hospice. | |
| Code B10 | 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. | |
| Code B11 | The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. | |
| Code B12 | Services not documented in patient’s medical records. | |
| Code B13 | Previously paid. Payment for this claim/service may have been provided in a previous payment. | |
| Code B14 | Payment denied because only one visit or consultation per physician per day is covered. | |
| Code B15 | Payment adjusted because this service/procedure is not paid separately. | |
| Code B16 | Payment adjusted because “new patient” qualifications were not met. | |
| Code 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. | |
| Code B18 | Payment denied because this procedure code/modifier was invalid on the date of service or claim submission. | |
| Code B18 | N522 | Duplicate claim has already been submitted and processed |
| Code B19 | Claim/service adjusted because of the finding of a Review Organization. | |
| Code B20 | Payment adjusted because procedure/service was partially or fully furnished by another provider. | |
| Code B20 | M115 N211 | 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. |
| Code B21 | The charges were reduced because the service/care was partially furnished by another physician. | |
| Code B22 | This payment is adjusted based on the diagnosis. | |
| Code B23 | Payment denied because this provider has failed an aspect of a proficiency testing program. | |
| Code D1 | Claim/service denied. Level of subluxation is missing or inadequate. | |
| Code D2 | Claim lacks the name, strength, or dosage of the drug furnished. | |
| Code D3 | Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. | |
| Code D4 | Claim/service does not indicate the period of time for which this will be needed. | |
| Code D5 | Claim/service denied. Claim lacks individual lab codes included in the test. | |
| Code D6 | Claim/service denied. Claim did not include patient’s medical record for the service. | |
| Code D7 | Claim/service denied. Claim lacks date of patient’s most recent physician visit. | |
| Code D8 | Claim/service denied. Claim lacks indicator that “x-ray is available for review”. | |
| Code D9 | Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. | |
| Code D10 | Claim/service denied. Completed physician financial relationship form not on file. | |
| Code D11 | Claim lacks completed pacemaker registration form. | |
| Code D12 | Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. | |
| Code D13 | Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. | |
| Code D14 | Claim lacks indication that plan of treatment is on file. | |
| Code D15 | Claim lacks indication that service was supervised or evaluated by a physician. | |
| Code W1 | 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.
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