Explanation Codes

These codes are descriptive codes that identify what was done to the claim line and the denial explanation.

codes in bold are considered most relevant for LA DPS&C

Code	Description	Explanation
04	Expense not covered by plan	Return to CCIH if Code # 04 is seen by itself. MCOB Code, sometimes left on in error, denied for another reason.
06	Inmate not eligible	Sent back on Eligibility spreadsheet by DPS&C
13	PPO Benefits applied	Populates on all paid claims
24	Duplicate charge	May be one line or entire claim
27	Claim adjustment	Additional payment on a previously paid claim. Possibly when the wrong contract rate was used for first payment.
32	Paid by previous carrier
36	Duplicate of a corrected claim	May be one line or entire claim
40	Additional payment	Used with Code 27 (e.g. Bill Type 137, or appeal received)
42	Inmate responsible for charges	Paroled inmate, CCIH does not send out EOB. Vendor must bill inmate.
44	Not covered, member responsible	Paroled inmate or charges for personal items
45	Re-file with physicians name	Physician's name is missing
46	Prior to effective date of group
47	Submit itemized statement	Additional data required for inpatient bill
48	Inclusive with per Diem rate	Facilities with per diem rate; charge amount may be more than allowed
50	Submit entire medical record	Additional data required
51	Amount previously billed	Duplicate- a second claim requested differently for same DOS
57	Not a state inmate
65	Late charges are not covered
67	Other coverage primary
82	Corrected EOB	EOB will not see; returned from DPS&C
95	Claim denial upheld	Vendor appeal- claim did not change
96	Inmate on medical furlough
107	Corrected claim received
108	Does not change amount paid	Used in conjunction with Denial Code # 95
114	Cannot bill assistant surgeon charges	surgery is not qualified for an assistant surgeon per Medicare
121	Inmate paroled	On Eligibility information returned from DPS&C
123	Invalid CPT code- resubmit	Use of an older or not eligible code; must refile claim
130	Diagnosis not valid for sex
131	Newborn care is not covered
137	Included in case rate	Same as a bundled charge for services- Replacing Code # 165
139	Included with DRG rate
146	No allowance for modifier 26	Charge is not allowed to be read usually for the 2nd time; Medicare guidelines
150	Convenience items not covered	Inpatient bill charges such as telephone or tv
151	After hours charges not covered	Used in conjunction with Medicare guidelines
153	Invalid age for CPT code	Used if billed incorrectly a CPT invalid for the age of patient
154	Invalid sex for CPT code
155	Invalid place of service
156	Invalid modifier code
157	Invalid diagnosis code
158	Invalid age for diagnosis
159	Unacceptable primary diagnosis
160	Incidental procedure	Part of bundled procedures; physician bill
161	Charge included in another code	Same as Code # 193 & 194
162	CPT not valid for service date	Billing error; provider billed originally with an invalid code
163	Included in global time period	Same as Code # 204 & 137
164	Possible catastrophe
165	Included in global allowance	Multi-lined claim and amount all-inclusive; cannot allow additional monies; rebill if no monies paid originally
166	Not medically necessary
167	Elective procedure not covered
168	Cosmetic procedure non covered
169	Secondary Diagnosis required
170	Non specific Primary Diagnosis
171	Invoice required for payment	Invoice required per contract for specific service (ex.blood, implant)
172	Claim paid by DPS&C	Duplicate; another claim received by CCIH that DPS&C has already paid
173	Resubmit Claim with DRG code	Missing DRG code
174	Not eligible
177	Page 1 of 2 missing, resubmit
178	Page 2 of 2 missing, resubmit
179	Submit additional documentation	e.g. Admin Dates
184	Resubmit claim by fiscal Year	Claim crossing two FYs
186	Claim returned to DPS&C	Regents, Alvarado Physician- any claims returned DPS&C
187	Multiple pages missing, re-bill
188	Resubmit with CPT code	Facility bills missing CPT codes with Revenue codes
190	No diagnosis code submitted
191	Please resubmit with diagnosis
192	Bill lacks required modifier/CPT code	Missing billing code, modifier or CPT for this line of service
193 & 194	Code is a component of another; not allowable	Used together, with 3M pricing
195 & 196	Code not recognized by OPPS; alternate code available; re-bill	Used together, with 3M pricing.
197	Resubmit Corrected Billing
202	CPT/Procedure code not allowable	3M pricing, not allowed by Medicare. (e.g. 99053)
203	Invalid bill type; resubmit	Using an invalid Bill Type
204	Inclusive with Base Rate	Same as Code # 163 & 165
205	Multiple surgery reduction	Claim line reduced due to Multiple Surgeries- Medicare Guidelines
206	Invalid use of modifier
207	Incidental charges reported, re-bill	Medicare no pay for incidental charges w/o complete hospital billing on UB04
208	Provide pick up address and zip	Ambulance billing
209	Submit anesthesia code
210	Units exceed medical necessity	3M MUE Edit
211	Not eligible per DPS&C contract
212	No RVP for this procedure
213	Inappropriate use of modifier
214	Covered inpatient service only	3M OCE EDIT
215	CPT does not match description
218	Invalid tax ID
219	Inappropriate specification of	3M OCE Edit/017
220	Bilateral procedure OCE	219 & 220 used as one denial
221	Claim lacks required device code
222	EDI-No tax ID submitted on claim
223	Re-bill on HCFA 1500 claim form
224	Service not billable to FI/MAC	Fiscan Intermediary / Medicare Administration
225	Provide service facility address
226	Requires HCPCS on same line	3M Edit 0048OCE 0048
227	No payee data record
228	Resubmit with height & weight	Dialysis claims only use # 228 & 229 together
229	of patient
230	Dental service not covered	by CCIH
231	Covered w/ condition code only	UB charges
232	Non allowed service for OPPS	3M Edit
233	Future service not payable
234	Registry charge returned to DPS&C
235	DME/Orthotics covered by DPS&C
236	Surgeon cannot bill as assistant	Surgeon billing as the Assistant's charges
237	Condition code required on bill	3M 00420CE
238	DPS&C refund received
239	Resubmit with only one base rate	Ambulance billing
240	No charges were submitted
241	Billable by hospital only	Contract based
242	EDI- No inmate Name submitted
243	EDI -No CDCR number submitted
244	Claim lacks required device code	3M edit 00710CE
245	Code not recognized by Medicare	Outpatient claims 3M edit 0028
246	Code only billable to DMERC(RTP)	3M edit 061 OCE
247	Verify Date of Service submitted
248	Previously paid as assistant	248 & 249 used together when assistant charge is billed by Surgeon
249	surgeon
250	Units > 1 is inappropriate	3M edit 0074 OCE
251	Invalid revenue code
253	Incorrect billing of blood
254	or blood products	3M edit 0074 OCE
255	Trauma response w/ critical care
256	Requires REV code with CPT code	3M edit
257	Re-bill using procedure(s) code(s)
258	as contracted	257 & 258 used as one denial
259	Please submit Medicare fiscal
260	intermediary letter	259 & 260 used as one denial
261	Statutory exclusion list and not
262	covered by Medicare outpatient	3M edit
263	Co-surgeon not permitted
264	ADJ-01 not completed/signed
265	Incorrectly billed address
266	in box 33, please resubmit	265 & 266 used as one denial
267	Admin Days denied by DPS&C
268	Mutually exclusive to another
269	CPT code billed	268 & 269 used as one denial
270	Submit supporting documentation
271	Per DPS&C UM inmate ineligible
272	Per DH at DPS&C
273	Additional paid to contracted
274	rate	Use 273 & 274 as one denial
275	NDC code required for payment
276	No inmate name submitted
277	Inmate not seen on
278	Date of Service	Use 277 & 278 as one denial
279	DRG submitted does not match CMS
280	group DRG code; submit
281	corrected DRG code	Use 279, 280, & 281 as one denial
282	Claims with handwritten
283	information are not accepted	Use 282 & 283 as one denial
284	Administrative fee included in
285	reimbursement	Use 284 & 285 as one denial
286	Re-bill Health Net, date of
287	service on new claim	Use 286 & 287 as one denial
288	Services packaged into PAC rate
289	Medicare non-covered item / service
290	Claim lacks required device code
291	radio labeled product; resubmit	Use 290 & 291 as one denial
292	Clinical diagnostic lab services
293	Claim service crosses contract with
294	PPO, please split and re-bill	Use 292 & 293 as one denial
295	Incidental services packaged
296	into APC rate	Use 295 & 296 as one denial
297	Adjustment / refund error
298	NDC submitted is invalid
299	Not approved per ADJ-01 form
300	Add on code not reimbursable
301	because valid primary CPT absent	Use 300 & 301 as one denial
302	Invalid age/gender for CPT code
303	Invalid age/gender for HCPCS
304	E&M service previously paid for
305	DOS, only one allowed per day	Use 304 & 305 as one denial
306	Patient seen within last 3 yrs
307	by physician, submit established
308	CPT code	Use 306, 307, & 308 as one denial
309	Patient seen within last 3 yrs
310	by physician, an established
311	code was reimbursed	Use 309, 310, & 311 as one denial
312	Included in global surgical
313	package for major surgery and is
314	not separately reimbursable	Use 312, 313, & 314 as one denial
315	Included in global surgical
316	package for minor surgery and is
317	not separately reimbursable	Use 315, 316, & 317 as one denial
318	This procedure is incidental to
319	another service on this Date of
320	Service and is not reimbursable	Use 318, 319, & 320 as one denial
321	This service is not reimbursable
322	based on the place of service	Use 321 & 322 as one denial
323	This service is not covered
324	An Assistant Surgeon, Co-Surgeon
325	or Team Surgeon for this CPT is
326	unnecessary and not reimbursed	Use 324, 325, & 326 as one denial
327	An Assistant Surgeon, Co-Surgeon
328	or Team Surgeon for this CPT
329	requires additional documentation	Use 327, 328, & 329 as one denial
330	Procedure submitted with more
331	than one multiple surgeon
332	modifier	Use 330, 331, & 332 as one denial
333	Invalid modifier for procedure
334	Duplicate charge
335	Exceeds the appropriate
336	number of units per day	Use 335 & 336 as one denial
337	Exceeds the appropriate
338	units for defined time frame	Use 337 & 338 as one denial
339	Component included with other
340	CPT billed for Date of Service	Use 339 & 340 as one denial
341	Mutually exclusive to another
342	procedure billed	Use 341 & 342 as one denial
343	Unlisted procedure requires
344	additional documentation	Use 343 & 344 as one denial
345	Not medically necessary based on
346	National Coverage Determination	Use 345 & 346 as one denial
347	Included in global
348	obstetric package	Use 347 & 348 as one denial
349	Procedure is part of a lab panel
350	and is not reimbursable	Use 349 & 350 as one denial
351	CPT is add on code and cannot be
352	billed as a standalone code	Use 351 & 352 as one denial
353	Included in global surgical
354	package for another CPT billed	Use 353 & 354 as one denial
355	Status B code payment included
356	in payment for other services on
357	same Date of Service	Use 355, 356, & 357 as one denial
358	Invalid diagnosis code
359	Status T code included in other
360	CPT payment for same DOS	Use 359 & 360 as one denial
361	Another E&M service billed for
362	same provider and same DOS
363	this CPT will not be reimbursed	Use 361, 362, & 363 as one denial
364	Global period applies, same
365	CPT billed with previous DOS	Use 364 & 365 as one denial
366	Refund received and applied
367	CPT code not valid for date of
368	service billed	Use 367 & 368 as one denial
369	Unlisted procedure or service
370	is not reimbursable	Use 369 & 370 as one denial
371	CPT submitted with multiple
372	units exceeding the CMS
373	Medically Unlikely Edit	Use 371, 372, & 373 as one denial
374	CPT/HCPCS is not valid for Date
375	of Service submitted on claim	Use 374 & 375 as one denial
376	Invalid diagnosis code submitted
377	Submit supporting medical
378	documentation	Use 377 & 378 as one denial
379	Invalid principle DX code
380	Service not separately payable
381	Code2 of a Code1/Code2
382	paid; needs modifier	Use 381 & 382 as one denial
383	Service units out of range
384	Invalid HCPCS code
385	Modifier required for payment
386	Diagnosis code requires ALS
387	HCPCS code.	use 386 & 387 as one denial
388	Not payable due to invalid base
389	rate HCPCS code	use 388 & 389 as one denial
391	Revenue code requires HCPCS code
392	Packaged / Incidental services
393	Invalid bill type
394	Invalid Place of Service
395	Excluded from negotiated rate
396	Provider compensation for this
397	service is zero per Coventry
398	Provider agreement	Use 396, 397, & 398 as one denial
399	Multiple medical visits, same
400	revenue code, same date without
401	condition code G0	Use 399, 400, & 401 as one denial
402	No additional payment due,
403	included with additional pricing	Use 402 & 403 as one denial
404	Claim lacks required device code
405	Claim lacks required
406	radio-labeled product	Use 405 & 406 as one denial
407	Invalid revenue code
408	Invalid principle procedure
409	Procedure/Sex conflict
410	Procedure may only be performed
411	in an inpatient setting	Use 410 & 411 as one denial
412	Place of Service not valid
413	for procedure billed	Use 412 & 413 as one denial
414	Invalid procedure to modifier
415	Lab test is component of a lab
416	panel and require being
417	billed using the panel code	Use 415, 416, & 417 as one denial
418	HSS ASC invalid Bill Type or
419	Place of Service	Use 418 & 419 as one denial
420	Provider is not contracted for
421	services submitted with this
422	Bill Type/POS	Use 420, 421, & 422 as one denial
423	Medical visit with procedure
424	without "25"	Use 423 & 424 as one denial
426	CMS rates not available	Health Net denial
427	Original bill required to price
428	late charges	Use 427 & 428 as one denial
429	Inpatient service not paid
430	under OPS	Use 429 & 430 as one denial
431	Packaged service/item; no
432	separate payment	Use 431 & 432 as one denial
433	Service not covered by Medicare
434	for free standing ASC	Use 433 & 434 as one denial
435	Component of comprehensive
436	procedure not allowed	Use 435 & 436 as one denial
437	Service not billable to the
438	fiscal intermediary	Use 437 & 438 as one denial
442	Invalid ICD procedure codes used
443	Additional charges added
444	Charges billed as non-covered
447	No allowance for Asst. Surgeon
448	NPI number does not match
449	Physician in box 31
450	Therapy service requires modifier
451	Invalid principle diagnosis
452	Present on Admission
453	POA codes are missing	Use 452 & 453 as one denial
454	Not medically necessary based on
455	local coverage determination	Bloodhound denial; use 454 & 455 as one denial
456	NDC# submitted has been
457	deactivated for this DOS	Use 456 & 457 as one denial
458	Status N code is non-covered	Bloodhound denial
463	Remit address does not match
464	BIS account information on file	Use 463 & 464 as one denial
466	Zip code point of pick up
467	is outside of supplier's contract	Use 466 & 467 as one denial
468	Invalid ADA code; resubmit
469	Please verify charges submitted
470	Incidental procedure not
471	separately reimbursed	OCE Edit 047-Use 470 & 471 as one denial
472	Resubmit claim with correct
473	NPI number	Use 472 & 473 as one denial
475	Discharge status is invalid	Use with code 197
481	Invalid or missing CMG code
484	G0379 only allowed with G0378	OCE Edit 0058
487	Service provided same day as
488	an inpatient procedure	OCE Edit 049-Use 487 & 488 as one denial
493	Vendor should re-bill through
494	the hospital/surgery ctr/phys	Use 493 & 494 as one denial
500	Packaged surgical procedures
501	include operation and
502	uncomplicated post-op care	Use 500, 501, & 502 as one denial
503	Non-covered - inmate is a donor
506	RUG values missing
507	DPS&C UM Audit required
511	Invalid DRG code
513	Line 1 does not match the
514	date of service billed in the
515	statement period submitted	Use 513, 514, & 515 as one denial
516	Line service date is invalid
517	in box 32 for Place of Service	Use 516 & 517 as one denial
518	Incorrect Bill Type
519	Admission Source Code, box 15
520	missing or invalid	Use 518, 519, & 520 as one denial

codes in bold are considered most relevant for DPS&C