Changes between Version 1 and Version 2 of ExplanationCodes


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Timestamp:
Jun 18, 2013, 9:54:55 AM (12 years ago)
Author:
Ray Richardson
Comment:

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  • ExplanationCodes

    v1 v2  
    33These codes are descriptive codes that identify what was done to the claim line and the denial explanation.
    44
    5 codes in '''bold''' are considered most relevant for CCHCS
     5codes in '''bold''' are considered most relevant for LA DPS&C
    66|| Code  || Description || Explanation ||
    77||  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. ||
    8 ||  06   || Inmate not eligible || Sent back on Eligibility spreadsheet by CCHCS ||
     8||  06   || Inmate not eligible || Sent back on Eligibility spreadsheet by DPS&C ||
    99||  13   || PPO Benefits applied || Populates on all paid claims ||
    1010||  24   || Duplicate charge || May be one line or entire claim ||
    … …  
    2424||  65   || Late charges are not covered ||  ||
    2525||  67   || Other coverage primary ||  ||
    26 ||  82   || Corrected EOB || EOB will not see; returned from CCHCS ||
     26||  82   || Corrected EOB || EOB will not see; returned from DPS&C ||
    2727|| '''95'''   || '''Claim denial upheld''' || Vendor appeal- claim did not change ||
    2828||  96   || Inmate on medical furlough ||  ||
    … …  
    3030||  108   || Does not change amount paid || Used in conjunction with Denial Code # 95 ||
    3131||  114   || Cannot bill assistant surgeon charges || surgery is not qualified for an assistant surgeon per Medicare ||
    32 ||  121   || Inmate paroled || On Eligibility information returned from CCHCS ||
     32||  121   || Inmate paroled || On Eligibility information returned from DPS&C ||
    3333||  123   || Invalid CPT code- resubmit || Use of an older or not eligible code; must refile claim ||
    3434||  130   || Diagnosis not valid for sex ||  ||
    … …  
    5555||  167   || Elective procedure not covered ||  ||
    5656||  168  || Cosmetic procedure non covered ||  ||       
    57 ||  169  || Secondary Diagnosis required        ||  ||
     57||  169  || Secondary Diagnosis required ||  ||
    5858||  170  || Non specific Primary Diagnosis ||  ||       
    5959|| '''171''' || '''Invoice required for payment''' || Invoice required per contract for specific service (ex.blood, implant) ||
    60 ||  172  || Claim paid by CCHCS || Duplicate; another claim received by CCIH that CCHCS has already paid ||
     60||  172  || Claim paid by DPS&C || Duplicate; another claim received by CCIH that DPS&C has already paid ||
    6161||  173  || Resubmit Claim with DRG code || Missing DRG code ||
    6262||  174  || Not eligible ||  || 
    … …  
    6565||  179  || Submit additional documentation || e.g. Admin Dates ||
    6666||  184  || Resubmit claim by fiscal Year || Claim crossing two FYs ||
    67 ||  186  || Claim returned to CCHCS || Regents, Alvarado Physician- any claims returned CCHCS ||
     67||  186  || Claim returned to DPS&C || Regents, Alvarado Physician- any claims returned DPS&C ||
    6868||  187  || Multiple pages missing, re-bill ||  ||       
    6969||  188  || Resubmit with CPT code || Facility bills missing CPT codes with Revenue codes ||
    … …  
    8383||  209  || Submit anesthesia code || ||
    8484||  210  || Units exceed medical necessity || 3M MUE Edit ||
    85 ||  211  || Not eligible per CCHCS contract || ||
     85||  211  || Not eligible per DPS&C contract || ||
    8686||  212  || No RVP for this procedure || ||
    8787||  213  || Inappropriate use of modifier || ||
    … …  
    104104||  232  || Non allowed service for OPPS || 3M Edit ||
    105105||  233  || Future service not payable || ||
    106 ||  234  || Registry charge returned to CCHCS || ||
    107 ||  235  || DME/Orthotics covered by CCHCS || ||
     106||  234  || Registry charge returned to DPS&C || ||
     107||  235  || DME/Orthotics covered by DPS&C || ||
    108108||  236  || Surgeon cannot bill as assistant || Surgeon billing as the Assistant's charges ||
    109109||  237  || Condition code required on bill || 3M 00420CE ||
    110 ||  238  || CCHCS refund received || ||
     110||  238  || DPS&C refund received || ||
    111111||  239  || Resubmit with only one base rate || Ambulance billing ||
    112112||  240  || No charges were submitted || ||
    … …  
    136136||  265  || Incorrectly billed address || ||
    137137||  266  || in box 33, please resubmit  || 265 & 266 used as one denial ||
    138 ||  267  || Admin Days denied by CCHCS || ||
     138||  267  || Admin Days denied by DPS&C || ||
    139139||  268  || Mutually exclusive to another || ||
    140140||  269  || CPT code billed || 268 & 269 used as one denial ||
    141141||  270  || Submit supporting documentation || ||
    142 ||  271  || Per CCHCS UM inmate ineligible || ||
    143 ||  272  || Per DH at CCHCS || ||
     142||  271  || Per DPS&C UM inmate ineligible || ||
     143||  272  || Per DH at DPS&C || ||
    144144||  273  || Additional paid to contracted || ||
    145145||  274  || rate || Use 273 & 274 as one denial ||
    … …  
    248248||  377  || Submit supporting medical || ||
    249249||  378  || documentation || Use 377 & 378 as one denial ||
    250 ||  379  || Invalid principle DX code || Health Net denial ||
    251 ||  380  || Service not separately payable || Health Net denial ||
     250||  379  || Invalid principle DX code || ||
     251||  380  || Service not separately payable || ||
    252252||  381  || Code2 of a Code1/Code2 || ||
    253 ||  382  || paid; needs modifier || Health Net denial; use 381 & 382 as one denial  ||
    254 ||  383  || Service units out of range || Health Net denial ||
    255 ||  384  || Invalid HCPCS code || Health Net denial ||
    256 ||  385  || Modifier required for payment || Health Net denial ||
     253||  382  || paid; needs modifier || Use 381 & 382 as one denial  ||
     254||  383  || Service units out of range || ||
     255||  384  || Invalid HCPCS code || ||
     256||  385  || Modifier required for payment || ||
    257257||  386  || Diagnosis code requires ALS || ||
    258258||  387  || HCPCS code. || use 386 & 387 as one denial ||
    259259||  388  || Not payable due to invalid base ||  ||
    260260||  389  || rate HCPCS code || use 388 & 389 as one denial ||
    261 ||  391  || Revenue code requires HCPCS code || Health Net denial ||
    262 ||  392  || Packaged / Incidental services || Health Net denial ||
    263 ||  393  || Invalid bill type || Health Net denial ||
    264 ||  394  || Invalid Place of Service || Health Net denial ||
    265 ||  395  || Excluded from negotiated rate || Health Net denial ||
     261||  391  || Revenue code requires HCPCS code || ||
     262||  392  || Packaged / Incidental services || ||
     263||  393  || Invalid bill type || ||
     264||  394  || Invalid Place of Service || ||
     265||  395  || Excluded from negotiated rate || ||
    266266||  396  || Provider compensation for this || ||
    267267||  397  || service is zero per Coventry || ||
    268 ||  398  || Provider agreement || Health Net denial; use 396, 397, & 398 as one denial ||
     268||  398  || Provider agreement || Use 396, 397, & 398 as one denial ||
    269269||  399  || Multiple medical visits, same || ||
    270270||  400  || revenue code, same date without || ||
    271 ||  401  || condition code G0 || Health Net denial; use 399, 400, & 401 as one denial ||
     271||  401  || condition code G0 || Use 399, 400, & 401 as one denial ||
    272272||  402  || No additional payment due, ||  ||
    273 ||  403  || included with additional pricing || Health Net denial; use 402 & 403 as one denial ||
     273||  403  || included with additional pricing || Use 402 & 403 as one denial ||
    274274||  404  || Claim lacks required device code || ||
    275275||  405  || Claim lacks required || ||
    276 ||  406  || radiolabeled product || Health Net denial; use 405 & 406 as one denial ||
    277 ||  407  || Invalid revenue code || Health Net denial ||
    278 ||  408  || Invalid principle procedure || Health Net denial ||
     276||  406  || radio-labeled product || Use 405 & 406 as one denial ||
     277||  407  || Invalid revenue code || ||
     278||  408  || Invalid principle procedure || ||
    279279||  409  || Procedure/Sex conflict || ||
    280280||  410  || Procedure may only be performed || ||
    281 ||  411  || in an inpatient setting || Health Net denial; use 410 & 411 as one denial ||
     281||  411  || in an inpatient setting || Use 410 & 411 as one denial ||
    282282||  412  || Place of Service not valid || ||
    283 ||  413  || for precedure billed || Use 412 & 413 as one denial ||
     283||  413  || for procedure billed || Use 412 & 413 as one denial ||
    284284||  414  || Invalid procedure to modifier || ||
    285285||  415  || Lab test is component of a lab || ||
    … …  
    290290||  420  || Provider is not contracted for || ||
    291291||  421  || services submitted with this || ||
    292 ||  422  || Bill Type/POS || Health Net denial; use 420, 421, & 422 as one denial ||
     292||  422  || Bill Type/POS || Use 420, 421, & 422 as one denial ||
    293293||  423  || Medical visit with procedure || ||
    294 ||  424  || without "25" || Health Net denial; use 423 & 424 as one denial ||
     294||  424  || without "25" || Use 423 & 424 as one denial ||
    295295||  426  || CMS rates not available || Health Net denial ||
    296296||  427  || Original bill required to price || ||
    297 ||  428  || late charges || Health Net denial; use 427 & 428 as one denial ||
     297||  428  || late charges || Use 427 & 428 as one denial ||
    298298||  429  || Inpatient service not paid || ||
    299 ||  430  || under OPS || Health Net denial; use 429 & 430 as one denial ||
     299||  430  || under OPS || Use 429 & 430 as one denial ||
    300300||  431  || Packaged service/item; no || ||
    301 ||  432  || separate payment || Health Net denial; use 431 & 432 as one denial ||
     301||  432  || separate payment || Use 431 & 432 as one denial ||
    302302||  433  || Service not covered by Medicare || ||
    303 ||  434  || for free standing ASC || Health Net denial; use 433 & 434 as one denial ||
     303||  434  || for free standing ASC || Use 433 & 434 as one denial ||
    304304||  435  || Component of comprehensive || ||
    305 ||  436  || procedure not allowed || Health Net denial; use 435 & 436 as one denial ||
     305||  436  || procedure not allowed || Use 435 & 436 as one denial ||
    306306||  437  || Service not billable to the || ||
    307 ||  438  || fiscal intermediary || Health Net denial; use 437 & 438 as one denial ||
     307||  438  || fiscal intermediary || Use 437 & 438 as one denial ||
    308308||  442  || Invalid ICD procedure codes used || ||
    309309||  443  || Additional charges added || ||
    … …  
    312312||  448  || NPI number does not match || ||
    313313||  449  || Physician in box 31 || ||
    314 ||  450  || Therapy service requires modifier || Health Net denial ||
    315 ||  451  || Invalid principle diagnosis || Health Net denial ||
     314||  450  || Therapy service requires modifier || ||
     315||  451  || Invalid principle diagnosis || ||
    316316||  452  || Present on Admission || ||
    317 ||  453  || POA codes are missing || Health Net denial; use 452 & 453 as one denial ||
     317||  453  || POA codes are missing || Use 452 & 453 as one denial ||
    318318||  454  || Not medically necessary based on || ||
    319319||  455  || local coverage determination || Bloodhound denial; use 454 & 455 as one denial ||
    … …  
    324324||  464  || BIS account information on file || Use 463 & 464 as one denial ||
    325325||  466  || Zip code point of pick up || ||
    326 ||  467  || is outside of supplier's contract || Health Net denial; use 466 & 467 as one denial ||
     326||  467  || is outside of supplier's contract || Use 466 & 467 as one denial ||
    327327||  468  || Invalid ADA code; resubmit || ||
    328328||  469  || Please verify charges submitted || ||
    … …  
    332332||  473  || NPI number || Use 472 & 473 as one denial ||
    333333||  475  || Discharge status is invalid || Use with code 197 ||
    334 ||  481  || Invalid or missing CMG code || Health Net denial ||
     334||  481  || Invalid or missing CMG code || ||
    335335||  484  || G0379 only allowed with G0378 || OCE Edit 0058 ||
    336336||  487  || Service provided same day as || ||
    337337||  488  || an inpatient procedure || OCE Edit 049-Use 487 & 488 as one denial ||
    338338||  493  || Vendor should re-bill through || ||
    339 ||  494  || the hospital/surgery ctr/phy || Use 493 & 494 as one denial ||
     339||  494  || the hospital/surgery ctr/phys || Use 493 & 494 as one denial ||
    340340||  500  || Packaged surgical procedures || ||
    341341||  501  || include operation and || ||
    … …  
    343343||  503  || Non-covered - inmate is a donor || ||
    344344||  506  || RUG values missing || ||
    345 || '''507''' || '''CCHCS UM Audit required''' || ||
     345|| '''507''' || '''DPS&C UM Audit required''' || ||
    346346||  511  || Invalid DRG code || ||
    347347||  513  || Line 1 does not match the || ||