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Complete Medicare Denial Codes List – Updated

June 13, 2022 by Aamir247 Leave a Comment

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.

Complete Medicare Denial Codes List

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.

Download Complete Denial Codes List

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