Code

ELIG-001
ELIG-002
ELIG-003
ELIG-004
ELIG-005
ELIG-006
ELIG-007
AUTH-001
AUTH-002
AUTH-003
AUTH-004
AUTH-005
BENX-001
BENX-002
BENX-003
BENX-004
BENX-005
CLAI-007
CLAI-008
CLAI-009
CLAI-010
CLAI-011
CLAI-012
CLAI-013
CLAI-014
CODE-001
CODE-002
CODE-003
CODE-004
CODE-005
CODE-006
CODE-007
CODE-008
CODE-009
CODE-010
CODE-011
CODE-012
CODE-013
CODE-014
CODE-015
DUPL-001
DUPL-002
MNEC-001
MNEC-002
MNEC-003
MNEC-004
MNEC-005
MNEC-006
NCOV-001
NCOV-002
NCOV-003
NCOV-004
NCOV-005
NCOV-006
NCOV-007
NCOV-008
NCOV-009
NCOV-010
NCOV-011
NCOV-012
NCOV-013
NCOV-014
NCOV-015
NCOV-016
NCOV-017
NCOV-018
NCOV-019
NCOV-020
NCOV-021
NCOV-022
NCOV-023
NCOV-024
NCOV-025
PRCE-001
PRCE-002
PRCE-003
PRCE-004
PRCE-005
PRCE-006
PRCE-007
PRCE-008
PRCE-009
PRCE-010
TIME-001
TIME-002
TIME-003
AUDT-001
COPY-001
Description
Patient is not a covered member
Services performed after the last date of coverage are not covered
Services performed prior to the effective date of coverage are not covered
Services performed by a non-network provider are not covered
Services performed after the last date of coverage
Services performed prior to the effective date of coverage
Services performed by a non-network provider
Prior approval is required and was not obtained
Services performed are inconsistent with authorized or approved services
PriorAuthorizationNumber is invalid
Service(s) is (are) performed outside authorization validity date
Claim information is inconsistent with pre-certified/authorized services
Service / Medication is above AED threshold
Benefit maximum for this time period or occurrence has been reached
Lifetime benefit maximum has been reached for this service/benefit category
Lifetime benefit maximum has been reached
Annual limit/sublimit amount exceeded
Claim is a work-related injury/illness and thus the liability of the employer
Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay
Date of birth follows the date of service
Date of death precedes the date of service
Inpatient admission spans multiple rate periods. Resubmit separate claims
Submission not compliant with contractual agreement between provider & payer
Missing an Observation (Dental Tooth #)
Claim not compliant with Resubmission type (used only for resubmissions)
Missing, incomplete or invalid principal diagnosis
Missing, incomplete or invalid service code
Missing or invalid Clinician
Diagnosis is inconsistent with the patient's age
Diagnosis is inconsistent with the patient's gender
Diagnosis is inconsistent with the procedure
Diagnosis is inconsistent with the provider type
Service code is inconsistent with the patient's age
Service code is inconsistent with the patient's gender
Activity/diagnosis inconsistent with clinician specialty
Incorrect DRG calculated
Encounter type inconsistent with service(s) / diagnosis
Invalid principal diagnosis (for example E-codes)
Activity/diagnosis is inconsistent with the patient's age/gender
Activity/diagnosis is inconsistent with the provider type
Claim is a duplicate based on service codes and dates
Payment already made for same/similar service within set time frame
Tests or treatments were not ordered by a Medical doctor
Services performed were not medically necessary
Service is not clinically indicated based on good clinical practice
Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/act
Service/supply may be appropriate, but too frequent
Alternative service should have been utilized
Diagnosis(es) is (are) not covered
Pre-existing conditions are not covered
Service(s) is (are) not covered
Acupuncture, acupressure, hypnotism, and other forms of alternative treatment are not covered
Air ambulance transportation services are not covered
Allergy services and treatments are not covered
Ambulance transportation for non-emergency situations are not covered
Behavioral and mental health services, treatments and medications are not covered
Dental treatments are not covered
Elective procedure is not covered
Experimental or investigational services, treatments, devices and medications are not covered
Eye exams and treatments are not covered
Gender manipulation services and associated expenses including voluntary sterilizations or reversal of sterili
Hearing services are not covered
Home Health (Private Nurse) services are not covered
Home Health (Respite) services are not covered
Home Health services are not covered
Immunizations are not covered
Preventative care is not covered
Services resulting from attempted suicide or self-infliction are not covered
Vaccinations are not covered
Service(s) is (are) not performed
Service(s) is (are) performed outside period of hospitalization/admission
Chronic Condition Service(s) is (are) not covered
Service(s) is (are) not performed (used after audit)
Calculation discrepancy
Payment is included in the allowance for another service
Recovery of Payment
Recharge
Denial reversed because of medical review
Consultation within free follow up period
Service has no contract price
Multiple procedure payment rules incorrectly applied
Charges inconsistent with clinician specialty
Use bundled code
Time limit for submission has expired
Requested additional information was not received or was not received within time limit
Appeal procedures not followed or time limits not met
Audit
Deductible/co-pay not collected from member
Type
Eligibility
Eligibility
Eligibility
Eligibility
Eligibility
Eligibility
Eligibility
Authorization
Authorization
Authorization
Authorization
Authorization
Benefit expiration
Benefit expiration
Benefit expiration
Benefit expiration
Benefit expiration
Administrative information
Administrative information
Administrative information
Administrative information
Administrative information
Administrative information
Administrative information
Administrative information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Clinical information
Duplicate
Duplicate
Medical Necessity
Medical Necessity
Medical Necessity
Medical Necessity
Medical Necessity
Medical Necessity
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Non-coverage
Price
Price
Price
Price
Price
Price
Price
Price
Price
Price
Timely filing
Timely filing
Timely filing
Audit
Copay