Claim Adjustment Reason Codes - X12

Maybe your like

Skip to main navigation Skip to content Menu

Membership
- X12 Members List
- Membership Benefits
- Membership Categories
- Membership Application
X12 Members List

Alphabetized listing of current X12 members organizations.

Membership Benefits

Join other member organizations in continuously adapting the expansive vocabulary and language used by millions of organizations while leveraging more than 40 years of cross-industry standards development knowledge.

Membership Categories

Membership categories and associated dues are based on the size and type of organization or individual, as well as the committee you intend to participate with.

Membership Application

To apply for an X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. Some important considerations for your application include the type and size of your organization, your named primary representative, and committee-subcommittee you intend to participate with.

Renew Membership

To renew an X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. Some important considerations for your application include the type and size of your organization, your named primary representative, and committee-subcommittee you intend to participate with.
Products
- Glass
- Licensing Program
- External Code Lists
- Technical Reports
- X12 Transaction Sets
- By Industry
- Intellectual Property Use
Glass

Online access to all available versions of X12 products, including The EDI Standard, Code Source Directory, Control Standards, EDI Standard Figures, Guidelines and Technical Reports.

Licensing Program

Multi-tier licensing categories are based on how licensees benefit from X12's work, replacing traditional one-size-fits-all approaches. Categories include Commercial, Internal, Developer and more.

External Code Lists
Claim Adjustment Group Codes Claim Adjustment Reason Codes Claim Status Category Codes Claim Status Codes Error Reason Codes Industry Specific Remark Codes Insurance Business Process Application Error Codes Insurance Descriptor Codes Payment Type Codes Property & Casualty Code Lists Provider Adjustment Reason Codes Provider Taxonomy Codes Remittance Advice Remark Codes Report Type Codes Service Review Decision Reason Codes Service Type Codes Service Type Descriptor Codes See All Code Lists
Technical Reports

X12 produces three types of documents to facilitate consistency across implementations of its work.
- Type 2: Reference Model
- Type 3: Implementation Guide
- Type 4: Clarification Paper
All X12 Transaction Sets

X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes. Each transaction set is maintained by a subcommittee operating within X12’s Accredited Standards Committee.

By Industry

X12 standards are the workhorse of business to business exchanges proven by the billions of daily transactions within and across many industries including:
- Finance
- Health Care
- Insurance
- Supply Chain
- Transportation
- Aerospace
Intellectual Property Use

X12 has developed standards and associated products to facilitate the transmission of electronic business messages for over 40 years. X12 manages the exclusive copyright to all standards, publications, and products, and such works do not constitute joint works of authorship eligible for joint copyright.

All X12 work products are copyrighted. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies.
About
- About X12
- neX12
- Officers
- Committees
- Liaisons
- Industry Groups and Caucuses
- Awards
- Terms, Policies and Licenses
About X12

Chartered by the American National Standards Institute for more than 40 years, X12 develops and maintains EDI standards and XML schemas which drive business processes globally. X12's diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

Overview

Corporate Mission and Principles

neX12

X12 standards are the workhorse of business to business exchanges proven by the billions of transactions based on X12 standards that are used daily in various industries including supply chain, transportation, government, finance, and health care. Millions of entities around the world have an established infrastructure that supports X12 transactions.

Introducing neX12...

X12 is well-positioned to continue to serve its members and the large install base by continuing to support the existing metadata, standards, and implementation tools while also focusing on several key collaborative initiatives.
- Glass: X12's Online Viewer
- Bridge: Standardized Syntax Neutral X12 Metadata
- ARC: Annual Release Cycle
Officers

X12 is led by the X12 Board of Directors (Board). The X12 Board and the Accredited Standards Committee’s Steering group (Steering) collaborate to ensure the best interests of X12 are served. Each group has specific responsibilities and the groups cooperatively handle items or issues that span the responsibilities of both groups.

Committees
- Accredited Standards Committee (ASC)
  - Steering Committee
  - Procedures Review Board (PRB)
  - Policies and Procedures (P&P)
  - ASC Subcommittees
    - X12C – Communications and Controls
    - X12I – Transportation
    - X12J – Technical Assessment
    - X12M – Supply Chain
    - X12N – Insurance
- Registered Standards Committee (RSC)
  - RSC Subcommittees
    - X12-03 – External Code List Oversight (ECO)
    - X12-04 – Business to Everything (B2X)
Liaisons

X12 appoints various types of liaisons, including external and internal liaisons. Internal liaisons coordinate between two X12 groups. External liaisons represent X12's interests to another organization as defined in a formal agreement between the two organizations. More information is available in X12 Liaisons (CAP17).

Industry Groups and Caucuses

X12 welcomes the assembling of members with common interests as industry groups and caucuses.

Current and past groups and caucuses include:
- Clearinghouse Caucus
- Connectivity Caucus
- Dental Caucus
- Medicaid Caucus
- Provider Caucus
- Tricare Caucus
- Innovation Taskforce
Awards

X12 is pleased to recognize individual members and industry representatives whose contributions and achievements have played a role in the development of cross-industry eCommerce standards.

Edward A. Guilbert Lifetime Achievement Award

Earl “Buddy” Bass Achievement Award

Distinguished Service Award

Terms, Policies, and Licenses

X12’s website terms of use, privacy policy, and license agreements, which you have agreed to based on your use of X12 resources and content.

View Terms, Policies and Licenses
News + Events
- News
- X12 Blog
- Meetings
- Important Dates
- Release Schedule
- X12 Recommendations to NCVHS
News
January 7, 2026 X12 Board of Directors Election December 22, 2025 X12 Member Announcement - Recommendation to NCVHS December 16, 2025 X12’s JSON Survey Validates Consensus-driven Transaction Standards are Critical December 8, 2025 X12 Board Elections Scheduled for January 2026 – Application Period Open November 21, 2025 New Case Study: Illinois HFS Engages X12 Data with Optum to Re-Invent Claims Management September 22, 2025 X12 Publishes 008060 Versions of all HIPAA-Mandated Implementation Guides See All News
X12 Blog
February 22, 2024 Funding Sources Vary Widely Among Standards Associations July 21, 2023 One Size Does Not Fit All for Standards Funding Models November 28, 2022 X12’s Annual Release Cycle Keeps Implementation Guides Up to Date November 17, 2022 B2X Supports “Business to Everything” for X12 Stakeholders September 22, 2022 Saddened by the loss of a long-time X12 contributor September 15, 2022 Evolving X12’s Licensing Model for the Greater Good See All Blog Posts
Meetings

Upcoming meetings:
Summer 2026 StandingSunday, June 7, 2026 – Wednesday, June 17, 2026 Meeting Details Fall 2026 StandingSunday, September 27, 2026 – Wednesday, October 7, 2026 Meeting Details See All Meetings
Important Dates
February 16 – ASC Ballot: Maintenance Request Package begins March 6 – Deadline for submitting code maintenance requests for member review of Batch 137 March 13 – Batch 137 member review begins March 18 – ASC Ballot: Maintenance Request Package ends April 3 – Batch 137 member review ends April 13 – April Technical Assessment Meeting 1:30-3:30 PM ET Monday & Tuesday - 1:30-2:30 PM ET Wednesday See All Important Dates
Release Schedule

The EDI Standard is published once per year in January.

Proposed modifications to the current EDI Standard proceed through a series of ballots and must be approved by impacted subcommittees, the Technical Assessment Subcommittee (TAS), and the Accredited Standards Committee stakeholders in order to be included in the next publication.

The tables on this page depict the key dates for various steps in a normal modification/publication cycle.

X12 Recommendations to NCVHS

X12 has submitted the first two in a series of recommendations related to advancing the version of already adopted and mandated transactions and proposing additional transactions for adoption.

Based on industry feedback, X12 is using a phased approach for the recommendations rather than presenting the entire catalog of adopted and mandated transactions at once. Each recommendation will cover a set of logically grouped transactions and will include supporting information that will assist reviewers as they look at the functionality enhancements and other revisions.
Resources
- Feedback
- Policies and Procedures
- Forms
- Meeting Minutes
- Requests for Interpretation
- Info Center
- X12 EDI Examples
- Transaction Flow
- Membership & Licensing Help
- Contact Us
Feedback

X12 welcomes feedback. Submit the form with any questions, comments, or suggestions related to corporate activities or programs. This feedback is used to inform X12's decision-making processes, policies, and question and answer resources. This form is not used to request maintenance (revisions) to X12 products or to submit comments related to an internal or public review period.

Policies and Procedures

X12 maintains policies and procedures that govern its corporate, committee, and subordinate group activities and posts them online to ensure they are easily accessible to members and other materially-interested parties.

Forms

Frequently Used Forms
Code Maintenance Request Request for Interpretation Maintenance Requests Member Representative Request for Workspace Access See All Forms
Meeting Minutes

Browse and download meeting minutes by committee.

Requests for Interpretation

Review X12's official interpretations based on submitted RFIs related to the meaning and use of X12 Standards, Guidelines, and Technical Reports, including Technical Report Type 3 (TR3) implementation guidelines. Submit a request for interpretation (RFI) related to the implementation and use of X12 work.

Info Center

Information about the X12 organization, its activities, committees & subcommittees, tools, products, and processes. Information is presented as a PowerPoint deck, informational paper, educational material, or checklist. Content is added to this page regularly.

Information related to the X12 corporation is listed in the Corporate section below. Committee-level information is listed in each committee's separate section. Policies and procedures specific to a committee's subordinate groups, like subcommittees, task groups, action groups, and work groups, are also listed in the committee's section.

X12 EDI Standard Examples
270/271 — Health Care Eligibility Benefit Inquiry and Response 276/277 — Health Care Claim Status Request and Response 276/277 — Health Care Claim Status Request and Response 276/277 — Health Care Claim Status Request and Response 277 — Health Care Information Status Notification 277 — Data Reporting Acknowledgment 278 — Health Care Services Review - Request for Review and Response 278 — Health Care Services Review - Inquiry and Response 278 — Health Care Services Review Notification and Acknowledgment 278 — Health Care Services Review Notification and Acknowledgment 278 — Request for Review and Response Examples 278 — Health Care Services Review - Request for Review and Response See All Examples
Transaction Flow

X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. The diagrams on the following pages depict various exchanges between trading partners.

Supply Chain Transaction Flow

Health Care Transaction Flow

Membership & Licensing Help
For help on how to purchase, manage, or renew your X12 membership, license, or code list subscription, review these FAQs.
Contact Us

Contact us through email, mail, or over the phone. All of our contact information is here.

Reference
For Members

Follow @x12standards

Home
Products
External Code Lists

Section title: External Code Lists back to code lists Claim Adjustment Reason Codes 139

These codes describe why a claim or service line was paid differently than it was billed.

Did you receive a code from a health plan, such as: PR32 or CO286? If so read About Claim Adjustment Group Codes below.

About Claim Adjustment Group Codes Did you receive a code from a health plan, such as: PR32 or CO286? The "PR" is a Claim Adjustment Group Code and the description for "32" is below. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and definitions are below:

CO	Contractual Obligation
CR	Corrections and Reversal Note: This value is not to be used with 005010 and up.
OA	Other Adjustment
PI	Payer Initiated Reductions
PR	Patient Responsibility

Maintenance Request Status

The list below shows the status of change requests which are in process.

Each request will be in one of the following statuses:

Received The request has been submitted but is not yet under review.
Pending Staff has looked at the request to ensure it's a legitimate request (not spam), that it is assigned to the correct CMG, and that all required information is present.
In Process The CMG has initiated their decision process.
On Hold The CMG has initiated their decision process but cannot complete it at this time.
CMG Approved The CMG has considered and approved the request, this does not mean it was approved exactly as submitted, it means maintenance related to the request was approved. Requests in this status will be applied to the next version.
CMG Disapproved The CMG has considered and disapproved the request, no maintenance action will occur. Requests in this status are complete/final.

Status Last Reviewed: 1/1/2026

Num.	Date	Requested Description	Type	Code	Status
No current requests. This list has been stable since the last update. It will not be updated until there are new requests.

Maintenance Request Form

Fields marked with an asterisk (*) are required

Name Email Request Type - Select -Revise the description of an existing codeAdd a new codeDeactivate a code Current Code Value *The description you are suggesting for a new code or to replace the description for a current code. Brief description *Explain the business scenario or use case when the requested new code would be used, the reason an existing code is no longer appropriate for the code list’s business purpose, or reason the current description needs to be revised. Business justification 11/1/2025 Filter by code:Reset Filter codes by status:Show AllCurrentTo Be DeactivatedDeactivated

1	Deductible AmountStart: 01/01/1995
2	Coinsurance AmountStart: 01/01/1995
3	Co-payment AmountStart: 01/01/1995
4	The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 03/01/2020
5	The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 03/01/2018
6	The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
7	The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
8	The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
9	The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
10	The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
11	The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
12	The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
13	The date of death precedes the date of service.Start: 01/01/1995
14	The date of birth follows the date of service.Start: 01/01/1995
15	The authorization number is missing, invalid, or does not apply to the billed services or provider.Start: 01/01/1995 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
16	Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 03/01/2018
17	Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 07/01/2009
18	Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)Start: 01/01/1995 \| Last Modified: 06/02/2013
19	This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.Start: 01/01/1995 \| Last Modified: 09/30/2007
20	This injury/illness is covered by the liability carrier.Start: 01/01/1995 \| Last Modified: 09/30/2007
21	This injury/illness is the liability of the no-fault carrier.Start: 01/01/1995 \| Last Modified: 09/30/2007
22	This care may be covered by another payer per coordination of benefits.Start: 01/01/1995 \| Last Modified: 09/30/2007
23	The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)Start: 01/01/1995 \| Last Modified: 09/30/2012
24	Charges are covered under a capitation agreement/managed care plan.Start: 01/01/1995 \| Last Modified: 09/30/2007
25	Payment denied. Your Stop loss deductible has not been met.Start: 01/01/1995 \| Stop: 04/01/2008
26	Expenses incurred prior to coverage.Start: 01/01/1995
27	Expenses incurred after coverage terminated.Start: 01/01/1995
28	Coverage not in effect at the time the service was provided.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Redundant to codes 26&27.
29	The time limit for filing has expired.Start: 01/01/1995
30	Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.Start: 01/01/1995 \| Stop: 02/01/2006
31	Patient cannot be identified as our insured.Start: 01/01/1995 \| Last Modified: 09/30/2007
32	Our records indicate the patient is not an eligible dependent.Start: 01/01/1995 \| Last Modified: 03/01/2018
33	Insured has no dependent coverage.Start: 01/01/1995 \| Last Modified: 09/30/2007
34	Insured has no coverage for newborns.Start: 01/01/1995 \| Last Modified: 09/30/2007
35	Lifetime benefit maximum has been reached.Start: 01/01/1995 \| Last Modified: 10/31/2002
36	Balance does not exceed co-payment amount.Start: 01/01/1995 \| Stop: 10/16/2003
37	Balance does not exceed deductible.Start: 01/01/1995 \| Stop: 10/16/2003
38	Services not provided or authorized by designated (network/primary care) providers.Start: 01/01/1995 \| Last Modified: 06/02/2013 \| Stop: 01/01/2013Notes: CARC codes 242 and 243 are replacements for this deactivated code
39	Services denied at the time authorization/pre-certification was requested.Start: 01/01/1995
40	Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
41	Discount agreed to in Preferred Provider contract.Start: 01/01/1995 \| Stop: 10/16/2003
42	Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 06/01/2007
43	Gramm-Rudman reduction.Start: 01/01/1995 \| Stop: 07/01/2006
44	Prompt-pay discount.Start: 01/01/1995
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)Start: 01/01/1995 \| Last Modified: 07/01/2017
46	This (these) service(s) is (are) not covered.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 96.
47	This (these) diagnosis(es) is (are) not covered, missing, or are invalid.Start: 01/01/1995 \| Stop: 02/01/2006
48	This (these) procedure(s) is (are) not covered.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 96.
49	This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
50	These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
51	These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
52	The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.Start: 01/01/1995 \| Stop: 02/01/2006
53	Services by an immediate relative or a member of the same household are not covered.Start: 01/01/1995
54	Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
55	Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
56	Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
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.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Split into codes 150, 151, 152, 153 and 154.
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
60	Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.Start: 01/01/1995 \| Last Modified: 06/01/2008
61	Adjusted for failure to obtain second surgical opinionStart: 01/01/1995 \| Last Modified: 03/01/2017Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.
62	Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 04/01/2007
63	Correction to a prior claim.Start: 01/01/1995 \| Stop: 10/16/2003
64	Denial reversed per Medical Review.Start: 01/01/1995 \| Stop: 10/16/2003
65	Procedure code was incorrect. This payment reflects the correct code.Start: 01/01/1995 \| Stop: 10/16/2003
66	Blood Deductible.Start: 01/01/1995
67	Lifetime reserve days. (Handled in QTY, QTY01=LA)Start: 01/01/1995 \| Stop: 10/16/2003
68	DRG weight. (Handled in CLP12)Start: 01/01/1995 \| Stop: 10/16/2003
69	Day outlier amount.Start: 01/01/1995
70	Cost outlier - Adjustment to compensate for additional costs.Start: 01/01/1995 \| Last Modified: 06/30/2001
71	Primary Payer amount.Start: 01/01/1995 \| Stop: 06/30/2000Notes: Use code 23.
72	Coinsurance day. (Handled in QTY, QTY01=CD)Start: 01/01/1995 \| Stop: 10/16/2003
73	Administrative days.Start: 01/01/1995 \| Stop: 10/16/2003
74	Indirect Medical Education Adjustment.Start: 01/01/1995
75	Direct Medical Education Adjustment.Start: 01/01/1995
76	Disproportionate Share Adjustment.Start: 01/01/1995
77	Covered days. (Handled in QTY, QTY01=CA)Start: 01/01/1995 \| Stop: 10/16/2003
78	Non-Covered days/Room charge adjustment.Start: 01/01/1995
79	Cost Report days. (Handled in MIA15)Start: 01/01/1995 \| Stop: 10/16/2003
80	Outlier days. (Handled in QTY, QTY01=OU)Start: 01/01/1995 \| Stop: 10/16/2003
81	Discharges.Start: 01/01/1995 \| Stop: 10/16/2003
82	PIP days.Start: 01/01/1995 \| Stop: 10/16/2003
83	Total visits.Start: 01/01/1995 \| Stop: 10/16/2003
84	Capital Adjustment. (Handled in MIA)Start: 01/01/1995 \| Stop: 10/16/2003
85	Patient Interest Adjustment (Use Only Group code PR)Start: 01/01/1995 \| Last Modified: 07/09/2007Notes: Only use when the payment of interest is the responsibility of the patient.
86	Statutory Adjustment.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Duplicative of code 45.
87	Transfer amount.Start: 01/01/1995 \| Last Modified: 09/20/2009 \| Stop: 01/01/2012
88	Adjustment amount represents collection against receivable created in prior overpayment.Start: 01/01/1995 \| Stop: 06/30/2007
89	Professional fees removed from charges.Start: 01/01/1995
90	Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.Start: 01/01/1995 \| Last Modified: 07/01/2017
91	Dispensing fee adjustment.Start: 01/01/1995
92	Claim Paid in full.Start: 01/01/1995 \| Stop: 10/16/2003
93	No Claim level Adjustments.Start: 01/01/1995 \| Stop: 10/16/2003Notes: As of 004010, CAS at the claim level is optional.
94	Processed in Excess of charges.Start: 01/01/1995
95	Plan procedures not followed.Start: 01/01/1995 \| Last Modified: 09/30/2007
96	Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
98	The hospital must file the Medicare claim for this inpatient non-physician service.Start: 01/01/1995 \| Stop: 10/16/2003
99	Medicare Secondary Payer Adjustment Amount.Start: 01/01/1995 \| Stop: 10/16/2003
100	Payment made to patient/insured/responsible party.Start: 01/01/1995 \| Last Modified: 05/01/2018
101	Predetermination: anticipated payment upon completion of services or claim adjudication.Start: 01/01/1995 \| Last Modified: 02/28/1999
102	Major Medical Adjustment.Start: 01/01/1995
103	Provider promotional discount (e.g., Senior citizen discount).Start: 01/01/1995 \| Last Modified: 06/30/2001
104	Managed care withholding.Start: 01/01/1995
105	Tax withholding.Start: 01/01/1995
106	Patient payment option/election not in effect.Start: 01/01/1995
107	The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
108	Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
109	Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.Start: 01/01/1995 \| Last Modified: 01/29/2012
110	Billing date predates service date.Start: 01/01/1995
111	Not covered unless the provider accepts assignment.Start: 01/01/1995
112	Service not furnished directly to the patient and/or not documented.Start: 01/01/1995 \| Last Modified: 09/30/2007
113	Payment denied because service/procedure was provided outside the United States or as a result of war.Start: 01/01/1995 \| Last Modified: 02/28/2001 \| Stop: 06/30/2007Notes: Use Codes 157, 158 or 159.
114	Procedure/product not approved by the Food and Drug Administration.Start: 01/01/1995
115	Procedure postponed, canceled, or delayed.Start: 01/01/1995 \| Last Modified: 09/30/2007
116	The advance indemnification notice signed by the patient did not comply with requirements.Start: 01/01/1995 \| Last Modified: 09/30/2007
117	Transportation is only covered to the closest facility that can provide the necessary care.Start: 01/01/1995 \| Last Modified: 09/30/2007
118	ESRD network support adjustment.Start: 01/01/1995 \| Last Modified: 09/30/2007
119	Benefit maximum for this time period or occurrence has been reached.Start: 01/01/1995 \| Last Modified: 02/29/2004
120	Patient is covered by a managed care plan.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 24.
121	Indemnification adjustment - compensation for outstanding member responsibility.Start: 01/01/1995 \| Last Modified: 09/30/2007
122	Psychiatric reduction.Start: 01/01/1995
123	Payer refund due to overpayment.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Refer to implementation guide for proper handling of reversals.
124	Payer refund amount - not our patient.Start: 01/01/1995 \| Last Modified: 06/30/1999 \| Stop: 06/30/2007Notes: Refer to implementation guide for proper handling of reversals.
125	Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 01/01/1995 \| Last Modified: 09/20/2009 \| Stop: 11/01/2013
126	Deductible -- Major MedicalStart: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008Notes: Use Group Code PR and code 1.
127	Coinsurance -- Major MedicalStart: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008Notes: Use Group Code PR and code 2.
128	Newborn's services are covered in the mother's Allowance.Start: 02/28/1997
129	Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 02/28/1997 \| Last Modified: 01/30/2011
130	Claim submission fee.Start: 02/28/1997 \| Last Modified: 06/30/2001
131	Claim specific negotiated discount.Start: 02/28/1997
132	Prearranged demonstration project adjustment.Start: 02/28/1997
133	The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).Start: 07/01/2014 \| Last Modified: 07/01/2017
134	Technical fees removed from charges.Start: 10/31/1998
135	Interim bills cannot be processed.Start: 10/31/1998 \| Last Modified: 09/30/2007
136	Failure to follow prior payer's coverage rules. (Use only with Group Code OA)Start: 10/31/1998 \| Last Modified: 07/01/2013
137	Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.Start: 02/28/1999 \| Last Modified: 09/30/2007
138	Appeal procedures not followed or time limits not met.Start: 06/30/1999 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
139	Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.Start: 06/30/1999 \| Last Modified: 05/01/2018
140	Patient/Insured health identification number and name do not match.Start: 06/30/1999
141	Claim spans eligible and ineligible periods of coverage.Start: 06/30/1999 \| Last Modified: 09/30/2007 \| Stop: 07/01/2012
142	Monthly Medicaid patient liability amount.Start: 06/30/2000 \| Last Modified: 09/30/2007
143	Portion of payment deferred.Start: 02/28/2001
144	Incentive adjustment, e.g. preferred product/service.Start: 06/30/2001
145	Premium payment withholdingStart: 06/30/2002 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008Notes: Use Group Code CO and code 45.
146	Diagnosis was invalid for the date(s) of service reported.Start: 06/30/2002 \| Last Modified: 09/30/2007
147	Provider contracted/negotiated rate expired or not on file.Start: 06/30/2002
148	Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 06/30/2002 \| Last Modified: 09/20/2009
149	Lifetime benefit maximum has been reached for this service/benefit category.Start: 10/31/2002
150	Payer deems the information submitted does not support this level of service.Start: 10/31/2002 \| Last Modified: 09/30/2007
151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.Start: 10/31/2002 \| Last Modified: 01/27/2008
152	Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 10/31/2002 \| Last Modified: 07/01/2017
153	Payer deems the information submitted does not support this dosage.Start: 10/31/2002 \| Last Modified: 09/30/2007
154	Payer deems the information submitted does not support this day's supply.Start: 10/31/2002 \| Last Modified: 09/30/2007
155	Patient refused the service/procedure.Start: 06/30/2003 \| Last Modified: 09/30/2007
156	Flexible spending account payments. Note: Use code 187.Start: 09/30/2003 \| Last Modified: 01/25/2009 \| Stop: 10/01/2009
157	Service/procedure was provided as a result of an act of war.Start: 09/30/2003 \| Last Modified: 09/30/2007
158	Service/procedure was provided outside of the United States.Start: 09/30/2003 \| Last Modified: 09/30/2007
159	Service/procedure was provided as a result of terrorism.Start: 09/30/2003 \| Last Modified: 09/30/2007
160	Injury/illness was the result of an activity that is a benefit exclusion.Start: 09/30/2003 \| Last Modified: 09/30/2007
161	Provider performance bonusStart: 02/29/2004
162	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.Start: 02/29/2004 \| Stop: 07/01/2014Notes: Use code P1
163	Attachment/other documentation referenced on the claim was not received.Start: 06/30/2004 \| Last Modified: 06/02/2013
164	Attachment/other documentation referenced on the claim was not received in a timely fashion.Start: 06/30/2004 \| Last Modified: 06/02/2013
165	Referral absent or exceeded.Start: 10/31/2004 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
166	These services were submitted after this payers responsibility for processing claims under this plan ended.Start: 02/28/2005
167	This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
168	Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.Start: 06/30/2005 \| Last Modified: 11/01/2017 \| Stop: 05/01/2018
169	Alternate benefit has been provided.Start: 06/30/2005 \| Last Modified: 09/30/2007
170	Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
171	Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
172	Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
173	Service/equipment was not prescribed by a physician.Start: 06/30/2005 \| Last Modified: 07/01/2013
174	Service was not prescribed prior to delivery.Start: 06/30/2005 \| Last Modified: 09/30/2007
175	Prescription is incomplete.Start: 06/30/2005 \| Last Modified: 09/30/2007
176	Prescription is not current.Start: 06/30/2005 \| Last Modified: 09/30/2007
177	Patient has not met the required eligibility requirements.Start: 06/30/2005 \| Last Modified: 09/30/2007
178	Patient has not met the required spend down requirements.Start: 06/30/2005 \| Last Modified: 09/30/2007
179	Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 03/01/2017
180	Patient has not met the required residency requirements.Start: 06/30/2005 \| Last Modified: 09/30/2007
181	Procedure code was invalid on the date of service.Start: 06/30/2005 \| Last Modified: 09/30/2007
182	Procedure modifier was invalid on the date of service.Start: 06/30/2005 \| Last Modified: 09/30/2007
183	The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
184	The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
185	The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/30/2005 \| Last Modified: 07/01/2017
186	Level of care change adjustment.Start: 06/30/2005 \| Last Modified: 09/30/2007
187	Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)Start: 06/30/2005 \| Last Modified: 01/25/2009
188	This product/procedure is only covered when used according to FDA recommendations.Start: 06/30/2005
189	'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/serviceStart: 06/30/2005
190	Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.Start: 10/31/2005
191	Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)Start: 10/31/2005 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014Notes: Use code P2
192	Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.Start: 10/31/2005 \| Last Modified: 07/01/2017
193	Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.Start: 02/28/2006 \| Last Modified: 01/27/2008
194	Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.Start: 02/28/2006 \| Last Modified: 09/30/2007
195	Refund issued to an erroneous priority payer for this claim/service.Start: 02/28/2006 \| Last Modified: 09/30/2007
196	Claim/service denied based on prior payer's coverage determination.Start: 06/30/2006 \| Stop: 02/01/2007Notes: Use code 136.
197	Precertification/authorization/notification/pre-treatment absent.Start: 10/31/2006 \| Last Modified: 05/01/2018
198	Precertification/notification/authorization/pre-treatment exceeded.Start: 10/31/2006 \| Last Modified: 05/01/2018
199	Revenue code and Procedure code do not match.Start: 10/31/2006
200	Expenses incurred during lapse in coverageStart: 10/31/2006
201	Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 10/31/2006 \| Last Modified: 09/28/2014Notes: Not for use by Workers' Compensation payers; use code P3 instead.
202	Non-covered personal comfort or convenience services.Start: 02/28/2007 \| Last Modified: 09/30/2007
203	Discontinued or reduced service.Start: 02/28/2007 \| Last Modified: 09/30/2007
204	This service/equipment/drug is not covered under the patient's current benefit planStart: 02/28/2007
205	Pharmacy discount card processing feeStart: 07/09/2007
206	National Provider Identifier - missing.Start: 07/09/2007 \| Last Modified: 09/30/2007
207	National Provider identifier - Invalid formatStart: 07/09/2007 \| Last Modified: 06/01/2008
208	National Provider Identifier - Not matched.Start: 07/09/2007 \| Last Modified: 09/30/2007
209	Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)Start: 07/09/2007 \| Last Modified: 07/01/2013
210	Payment adjusted because pre-certification/authorization not received in a timely fashionStart: 07/09/2007
211	National Drug Codes (NDC) not eligible for rebate, are not covered.Start: 07/09/2007
212	Administrative surcharges are not coveredStart: 11/05/2007
213	Non-compliance with the physician self referral prohibition legislation or payer policy.Start: 01/27/2008
214	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyStart: 01/27/2008 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014Notes: Use code P4
215	Based on subrogation of a third party settlementStart: 01/27/2008
216	Based on the findings of a review organization or the payer's findings.Start: 01/27/2008 \| Last Modified: 03/01/2025
217	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)Start: 01/27/2008 \| Last Modified: 09/30/2012 \| Stop: 07/01/2014Notes: Use code P5
218	Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyStart: 01/27/2008 \| Last Modified: 10/17/2010 \| Stop: 07/01/2014Notes: Use code P6
219	Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).Start: 01/27/2008 \| Last Modified: 07/01/2017
220	The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)Start: 01/27/2008 \| Last Modified: 09/30/2012 \| Stop: 07/01/2014Notes: Use code P7
221	Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)Start: 01/27/2008 \| Last Modified: 07/01/2013 \| Stop: 07/01/2014Notes: Use code P8
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/01/2008 \| Last Modified: 07/01/2017
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.Start: 06/01/2008
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims.Start: 06/01/2008
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)Start: 06/01/2008
226	Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 09/21/2008 \| Last Modified: 07/01/2013
227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 09/21/2008 \| Last Modified: 09/20/2009
228	Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudicationStart: 09/21/2008
229	Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)Start: 01/25/2009 \| Last Modified: 07/01/2017
230	No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.Start: 01/25/2009 \| Stop: 07/01/2014Notes: Use code P9
231	Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 07/01/2009 \| Last Modified: 07/01/2017
232	Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.Start: 11/01/2009 \| Last Modified: 07/01/2017
233	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.Start: 01/24/2010
234	This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 01/24/2010
235	Sales TaxStart: 06/06/2010
236	This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.Start: 01/30/2011 \| Last Modified: 07/01/2013
237	Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 06/05/2011
238	Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)Start: 03/01/2012 \| Last Modified: 07/01/2013
239	Claim spans eligible and ineligible periods of coverage. Rebill separate claims.Start: 03/01/2012 \| Last Modified: 01/29/2012
240	The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 06/03/2012 \| Last Modified: 07/01/2017
241	Low Income Subsidy (LIS) Co-payment AmountStart: 06/03/2012
242	Services not provided by network/primary care providers.Start: 06/03/2012 \| Last Modified: 06/02/2013Notes: This code replaces deactivated code 38
243	Services not authorized by network/primary care providers.Start: 06/03/2012 \| Last Modified: 06/02/2013Notes: This code replaces deactivated code 38
244	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.Start: 09/30/2012 \| Stop: 07/01/2014Notes: Use code P10
245	Provider performance program withhold.Start: 09/30/2012
246	This non-payable code is for required reporting only.Start: 09/30/2012
247	Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.Start: 09/30/2012Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
248	Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.Start: 09/30/2012Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
249	This claim has been identified as a readmission. (Use only with Group Code CO)Start: 09/30/2012
250	The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Start: 09/30/2012 \| Last Modified: 06/01/2014
251	The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Start: 09/30/2012 \| Last Modified: 06/01/2014
252	An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Start: 09/30/2012 \| Last Modified: 06/02/2013
253	Sequestration - reduction in federal paymentStart: 06/02/2013 \| Last Modified: 11/01/2013
254	Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.Start: 06/02/2013 \| Last Modified: 11/01/2017Notes: Use CARC 290 if the claim was forwarded.
255	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P11
256	Service not payable per managed care contract.Start: 06/02/2013
257	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)Start: 11/01/2013 \| Last Modified: 06/01/2014Notes: To be used after the first month of the grace period.
258	Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.Start: 11/01/2013
259	Additional payment for Dental/Vision service utilization.Start: 01/26/2014
260	Processed under Medicaid ACA Enhanced Fee ScheduleStart: 01/26/2014
261	The procedure or service is inconsistent with the patient's history.Start: 06/01/2014
262	Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.Start: 11/01/2014 \| Last Modified: 07/01/2017
263	Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.Start: 11/01/2014 \| Last Modified: 07/01/2017
264	Adjustment for postage cost. Usage: To be used for pharmaceuticals only.Start: 11/01/2014 \| Last Modified: 07/01/2017
265	Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.Start: 11/01/2014 \| Last Modified: 07/01/2017
266	Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.Start: 11/01/2014 \| Last Modified: 07/01/2017
267	Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 11/01/2014 \| Last Modified: 04/01/2015
268	The Claim spans two calendar years. Please resubmit one claim per calendar year.Start: 11/01/2014
269	Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 03/01/2015 \| Last Modified: 07/01/2017
270	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration.Start: 07/01/2015 \| Last Modified: 11/01/2017Notes: Use CARC 291 if the claim was forwarded.
271	Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)Start: 11/01/2015 \| Last Modified: 03/01/2018
272	Coverage/program guidelines were not met.Start: 11/01/2015
273	Coverage/program guidelines were exceeded.Start: 11/01/2015
274	Fee/Service not payable per patient Care Coordination arrangement.Start: 11/01/2015
275	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)Start: 11/01/2015
276	Services denied by the prior payer(s) are not covered by this payer.Start: 11/01/2015
277	The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)Start: 11/01/2015Notes: To be used during 31 day SHOP grace period.
278	Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 07/01/2016 \| Last Modified: 07/01/2017
279	Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network.Start: 11/01/2016 \| Last Modified: 07/01/2017
280	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.Start: 03/01/2017 \| Last Modified: 11/01/2017Notes: Use CARC 292 if the claim was forwarded.
281	Deductible waived per contractual agreement. Use only with Group Code CO.Start: 07/01/2017
282	The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 07/01/2017
283	Attending provider is not eligible to provide direction of care.Start: 11/01/2017
284	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.Start: 11/01/2017
285	Appeal procedures not followedStart: 11/01/2017
286	Appeal time limits not metStart: 11/01/2017
287	Referral exceededStart: 11/01/2017
288	Referral absentStart: 11/01/2017
289	Services considered under the dental and medical plans, benefits not available.Start: 11/01/2017Notes: Also see CARCs 254, 270 and 280.
290	Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.Start: 11/01/2017Notes: Use CARC 254 if the claim was not forwarded.
291	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.Start: 11/01/2017Notes: Use CARC 270 if the claim was not forwarded.
292	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.Start: 11/01/2017Notes: Use CARC 280 if the claim was not forwarded.
293	Payment made to employer.Start: 05/01/2018
294	Payment made to attorney.Start: 11/01/2017
295	Pharmacy Direct/Indirect Remuneration (DIR)Start: 03/01/2018
296	Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.Start: 07/01/2018
297	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.Start: 03/01/2019
298	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.Start: 03/01/2019
299	The billing provider is not eligible to receive payment for the service billed.Start: 07/01/2019
300	Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.Start: 07/01/2019
301	Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.Start: 07/01/2019
302	Precertification/notification/authorization/pre-treatment time limit has expired.Start: 11/01/2020
303	Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)Start: 07/01/2021
304	Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.Start: 03/01/2022
305	Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration.Start: 03/01/2022
306	Type of bill is inconsistent with the patient status. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 11/01/2023
307	Medicare Maximum Fair Price Standard Default Refund Amount Adjustment. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: To be used only for the Medicare Drug Price Negotiation Program.Start: 03/01/2025
308	Payment is adjusted due to contracted funding agreement between the payer and provider.Start: 11/01/2025
A0	Patient refund amount.Start: 01/01/1995
A1	Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available.Start: 01/01/1995 \| Last Modified: 11/16/2022
A2	Contractual adjustment.Start: 01/01/1995 \| Last Modified: 02/28/2007 \| Stop: 01/01/2008Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3	Medicare Secondary Payer liability met.Start: 01/01/1995 \| Stop: 10/16/2003
A4	Medicare Claim PPS Capital Day Outlier Amount.Start: 01/01/1995 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008
A5	Medicare Claim PPS Capital Cost Outlier Amount.Start: 01/01/1995
A6	Prior hospitalization or 30 day transfer requirement not met.Start: 01/01/1995
A7	Presumptive Payment AdjustmentStart: 01/01/1995 \| Stop: 07/01/2015
A8	Ungroupable DRG.Start: 01/01/1995 \| Last Modified: 09/30/2007
B1	Non-covered visits.Start: 01/01/1995
B2	Covered visits.Start: 01/01/1995 \| Stop: 10/16/2003
B3	Covered charges.Start: 01/01/1995 \| Stop: 10/16/2003
B4	Late filing penalty.Start: 01/01/1995
B5	Coverage/program guidelines were not met or were exceeded.Start: 01/01/1995 \| Last Modified: 11/01/2015 \| Stop: 05/01/2016Notes: This code has been replaced by 272 and 273.
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.Start: 01/01/1995 \| Stop: 02/01/2006
B7	This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
B8	Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
B9	Patient is enrolled in a Hospice.Start: 01/01/1995 \| Last Modified: 09/30/2007
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.Start: 01/01/1995
B11	The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.Start: 01/01/1995
B12	Services not documented in patient's medical records.Start: 01/01/1995 \| Last Modified: 03/01/2018
B13	Previously paid. Payment for this claim/service may have been provided in a previous payment.Start: 01/01/1995
B14	Only one visit or consultation per physician per day is covered.Start: 01/01/1995 \| Last Modified: 09/30/2007
B15	This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Start: 01/01/1995 \| Last Modified: 07/01/2017
B16	'New Patient' qualifications were not met.Start: 01/01/1995 \| Last Modified: 09/30/2007
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.Start: 01/01/1995 \| Stop: 02/01/2006
B18	This procedure code and modifier were invalid on the date of service.Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 03/01/2009
B19	Claim/service adjusted because of the finding of a Review Organization.Start: 01/01/1995 \| Stop: 10/16/2003
B20	Procedure/service was partially or fully furnished by another provider.Start: 01/01/1995 \| Last Modified: 09/30/2007
B21	The charges were reduced because the service/care was partially furnished by another physician.Start: 01/01/1995 \| Stop: 10/16/2003
B22	This payment is adjusted based on the diagnosis.Start: 01/01/1995 \| Last Modified: 02/28/2001
B23	Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.Start: 01/01/1995 \| Last Modified: 09/30/2007
D1	Claim/service denied. Level of subluxation is missing or inadequate.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D2	Claim lacks the name, strength, or dosage of the drug furnished.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D3	Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D4	Claim/service does not indicate the period of time for which this will be needed.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D5	Claim/service denied. Claim lacks individual lab codes included in the test.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D6	Claim/service denied. Claim did not include patient's medical record for the service.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D7	Claim/service denied. Claim lacks date of patient's most recent physician visit.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D8	Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
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.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 16 and remark codes if necessary.
D10	Claim/service denied. Completed physician financial relationship form not on file.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D11	Claim lacks completed pacemaker registration form.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D12	Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D13	Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D14	Claim lacks indication that plan of treatment is on file.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D15	Claim lacks indication that service was supervised or evaluated by a physician.Start: 01/01/1995 \| Stop: 10/16/2003Notes: Use code 17.
D16	Claim lacks prior payer payment information.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code [N4].
D17	Claim/Service has invalid non-covered days.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.
D18	Claim/Service has missing diagnosis information.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.
D19	Claim/Service lacks Physician/Operative or other supporting documentationStart: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.
D20	Claim/Service missing service/product information.Start: 01/01/1995 \| Stop: 06/30/2007Notes: Use code 16 with appropriate claim payment remark code.
D21	This (these) diagnosis(es) is (are) missing or are invalidStart: 01/01/1995 \| Stop: 06/30/2007
D22	Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing codeStart: 01/27/2008 \| Stop: 01/01/2009
D23	This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Start: 11/01/2009 \| Stop: 01/01/2012
P1	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code 162
P2	Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code 191
P3	Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)Start: 11/01/2013Notes: This code replaces deactivated code 201
P4	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyStart: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code 214
P5	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code 217
P6	Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code 218
P7	The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code 220
P8	Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code 221
P9	No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code 230
P10	Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code 244
P11	The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)Start: 11/01/2013Notes: This code replaces deactivated code 255
P12	Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code W1
P13	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code W2
P14	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code W3
P15	Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.Start: 11/01/2013Notes: This code replaces deactivated code W4
P16	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)Start: 11/01/2013Notes: This code replaces deactivated code W5
P17	Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code W6
P18	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code W7
P19	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code W8
P20	Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.Start: 11/01/2013Notes: This code replaces deactivated code W9
P21	Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2013 \| Last Modified: 03/01/2018Notes: This code replaces deactivated code Y1
P22	Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2013 \| Last Modified: 03/01/2018Notes: This code replaces deactivated code Y2
P23	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2013 \| Last Modified: 07/01/2017Notes: This code replaces deactivated code Y3
P24	Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. Use only with Group Code CO.Start: 11/01/2017
P25	Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).Start: 11/01/2017
P26	Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).Start: 11/01/2017
P27	Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2017
P28	Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2017
P29	Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Start: 11/01/2017
P30	Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.Start: 11/01/2020
P31	Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.Start: 11/01/2020
P32	Payment adjusted due to Apportionment.Start: 08/01/2022
W1	Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.Start: 02/29/2000 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P12
W2	Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Start: 10/17/2010 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P13
W3	The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.Start: 09/30/2012 \| Stop: 07/01/2014Notes: Use code P14
W4	Workers' Compensation Medical Treatment Guideline Adjustment.Start: 09/30/2012 \| Stop: 07/01/2014Notes: Use code P15
W5	Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P16
W6	Referral not authorized by attending physician per regulatory requirement.Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P17
W7	Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P18
W8	Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P19
W9	Service not paid under jurisdiction allowed outpatient facility fee schedule.Start: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P20
Y1	Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P21
Y2	Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P22
Y3	Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Start: 09/30/2012 \| Last Modified: 06/02/2013 \| Stop: 07/01/2014Notes: Use code P23

EDI Academy 2

Glass
Licensing Program
External Code Lists
Technical Reports
X12 Transaction Sets
By Industry
Intellectual Property Use

Feedback

Tag » Code B1-208-08

X12 Members List

Membership Benefits

Membership Categories

Membership Application

Renew Membership

Glass

Licensing Program

External Code Lists

Technical Reports

All X12 Transaction Sets

By Industry

Intellectual Property Use

About X12

neX12

Officers

Committees

Liaisons

Industry Groups and Caucuses

Awards

Terms, Policies, and Licenses

News

X12 Blog

Meetings

Important Dates

Release Schedule

X12 Recommendations to NCVHS

Feedback

Policies and Procedures

Forms

Meeting Minutes

Requests for Interpretation

Info Center

X12 EDI Standard Examples

Transaction Flow

Membership & Licensing Help

Contact Us

Reference Menu

Follow @x12standards

Breadcrumb

Maintenance Request Status

Maintenance Request Status

Maintenance Request Form

Maintenance Request Form

Products

Contact