explanation claim adjustment remittance advice code …2020-5-18 · v60 adjusted original...

Explanation

CodeShort Description Long Description

Claim Adjustment

Reason Code

Remittance Advice

Reason CodeSource

I90 D.O.S outside of stmt serv date Date of Service outside of statement service date 110 N130ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative

Supplemental PolicyB70 Incorrect Payment for Non Covered Se Recovering Incorrect Payment for Non covered Service 129 MA67

ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyREN 132: 2005 Norton Inpt Rate Increase 2005 Norton Retro Inpatient rate Increase 132 MA132 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative RET 132:2005 Retro Inpatient Rate Increase 2005 Retro Inpatient Rate Increase 132 MA132 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R75 1st Level Screening Paid; submit medical

1st Level Screening Paid; submit medical records for

prudent layperson16 N381



Supplemental PolicyR73 1st Level Screening Pd, medi record 1st Level Screening Pd, medical records not received 49 N627



Supplemental PolicyR18 22: Benefits not coord pending receipt

Benefits not coordinated pending receipt of adjusted

claim from22 MA04



Supplemental PolicyHS3 3 day window OP serv included w IP stay

3 day window (72 hour) outpatient services should be

included in the I60 N130



Supplemental PolicyR22 62:Authorization Expired Authorization Has Expired 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G93 ACA: contract pay amount equal to or gr

ACA: contract pay amount equal to or greater than ACA

rate222 N640



Supplemental PolicyG92 ACA: dos span eligibility dates resubmi ACA: dos span eligibility dates resubmit itemized bill 239 N62



Supplemental PolicyG91 ACA: provider not eligible on attestati ACA: provider not eligible on attestation file for dos B7 N381



Supplemental PolicyG98 ACA: COB claim processed under ACA

ACA: COB claim processed under ACA program

requirements45 N381



Supplemental PolicyG94 ACA: eligible line repriced at the ACA r ACA: eligible line repriced at the ACA rate 222 N640 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G95 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G97 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G90 ACA: member in state only aide category;

ACA: member in state only aide category; not eligible for

enhanced pay177 N381



Supplemental PolicyG96 ACA: member in state only aide category;

ACA: member in state only aide category; not eligible for

enhanced pay177 N381



Supplemental PolicyJ00 ACS Keying Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V00 ACS Keying Error R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZHC Add on Code billed without primary code

An add on code was billed without the presence of the

related primary234 N122



Supplemental PolicyG16 Additional Charges Considered Additional Charges Considered 107 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X14 Additional Diagnosis Emergent

Previously paid. Payment for this claim/service may

have been provided40



Supplemental PolicyH07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code

that requires a

107 N122 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyH07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code

that requires a

107 N122 CMS National Coverage Determinations (NCD) Policy

937 Addt'l information received and reviewedPayment adjusted upon receipt of additional

information.B19 N199



Supplemental PolicyEQ5 Addtnl info needed on itmzd bill Additional information is needed on the itemized bill 163 N26



Supplemental PolicyJ61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G99 Adjusting Historical Claim Adjusting Historical Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

G51 Adjustment For Component Of ProfessioThis health service code has been adjusted to reflect a

component of t97 N67



Supplemental PolicyR30 Adjustment to Previous Payment Adjustment to Previous Payment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HT7 Admin Code without Vaccine Code

Administration Service Billed with Modifier U2 or U3

without4 N519



Supplemental PolicyHC1 Administration Codes exceed Vaccine Code Administration Codes exceed Vaccine Code 94 N381



Supplemental PolicyR56 Administrative Approval Administrative Approval 186 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G17 Administrative Overturn Administrative Overturn 186 N11 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 609 Admission date is prior to member effect Admission date is prior to member effective date 26



Supplemental PolicyH78 Age Doesn't Support DX Billed

The age of the patient does not correlate with the

submitted diagnosis9 N517



Supplemental PolicyHMK All Components of Lab Panel Billed

All of the Components of a Lab Panel Have been billed.

Only the Lab234 M15



Supplemental PolicyG33 Allowed Amount Greater Than Submitted

According to our policy, when a procedure has an

allowed amount greate45



Supplemental PolicyHS4 Ambulance Service while Inpatient

Ambulance Services were provided while the member

was an IP97 M2



Supplemental PolicyR19 Anes Minutes erq for payment calc

Anesthesia minutes required for payment calculation

per IHCP Rules16 N203



Supplemental PolicyX19 Anes Minutes req for payment cacl

Anesthesia minutes required for payment calculation

per IHCP Rules16 N203



Supplemental PolicyHMH Anesthesiologist must use CPT Codes

Anesthesiologist must use CPT Codes (00100-01999)

plus State Specified95 N95



Supplemental PolicyHMI Anethesia Provided by a Non-Anes

Anesthesia Provided by a Non-Anesthesiologist (Check

for Addtional194



Supplemental PolicyR31 Appeal - Denial Overturned Appeal - Denial Overturned 186 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 900 Applied to deductible in error Adjusted - correction to deductible. 192 M25 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZJ6 ASD diagnosis invalid

ASD Dx cannot be primary or secondary without

required modifiers16 MA63



Supplemental PolicyZK6 ASD diagnosis invalid

ASD Dx cannot be primary or secondary without

required modifiers16 MA63



Supplemental PolicyZJ5 ASD diagnosis must be primary

ASD diagnosis must be primary with submitted

modifiers16 MA63



Supplemental PolicyZK5 ASD diagnosis must be primary

ASD diagnosis must be primary with submitted

modifiers16 MA63



Supplemental PolicyI31 Assessment not received Assessment not received 16 N309 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X31 Assessment not received Assessment not received 252 M127 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R34 Assistant Surgeon Payment Assistant Surgeon Payment 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XD9 Attending & Referring not enrolled in Me Attending and Referring not enrolled in Medicaid 183 N767



Supplemental PolicyXD8 Attending not enrolled in Medicaid Progr Attending not enrolled in Medicaid Program 16 N253 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEA Attending NPI is not enrolled with state

Attending NPI is not enrolled with state as provider type

31-physician16 N253



Supplemental PolicyXEB Attending Provider NPI is a non-individu

Attending Provider NPI is a non-individual per NPPES

Registry16 N253



Supplemental PolicyX69 AttendingPhys ID/Name Missing/Invalid Attending Physician ID/Bane is Missing Invalid 16 N253 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5DM Auth denied - services not considered

Authorization is denied, services will not be considered-

member liable39



Supplemental PolicyZF9 Auth/Ref Transferred - Delay in Newborn

Auth/Ref Transferred - Delay in Newborn Enrollment

Information129 MA67



Supplemental Policy210 Auth'ed generic only. Brand was billed. Authorized for generic only. Brand was billed. 204 N448 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

X35 Authorization Denied for this DOS Authorization Denied for this Date of Service 39 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G23 Authorization updated Authorization Updated 186 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B39 Authorization/Referral Expired Authorization/Referral Expired 198 M62 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R59 Authorization/Referral Expired Authorization/Referral Expired 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J28 Auto insurance is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V27 Auto insurance is Primary R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J45 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 MA36 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V44 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HM9 Based on NCCI Two Proc are Mutual Excl

Based on NCCI Two Proc. Are Mutually Excl. If it is not

Possible to231



Supplemental PolicyGB4 Bed Hold Days Exhausted Bed Hold Days Exhausted 96 N43 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 901 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 913 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R29 Beyond Adjustment Period Beyond Adjustment Period 29 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86



Supplemental PolicyX43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86



Supplemental PolicyHB3 Bilateral - Modifier Incorrect

This is a Bilateral Code. Modifiers LT, RT, 50 or qty 2 are

not4 N519



Supplemental PolicyHML Bilateral Proc Code pymt based both side

Bilat Proc Code and pymt based on both sides. Pay

lessor of 100% of4 N644



Supplemental PolicyG36 Bilateral Procedure Inappropriately

This health service code was denied because the

bilateral procedure wa4 N644



Supplemental PolicyHB2 Bilateral Surgery 100% rule applies

This is a Bilateral Procedure Code and payment for the

code is already59 N644



Supplemental PolicyHB1 Bilateral Surgery 150% Rule Applies

Unilateral Procedure Code. The 150% Payment

Adjustment Rule applies59 N644



Supplemental PolicyZM3 Bill charge must be greater than $0

Bill charge must be greater than $0 at the line level or

deny16 M54



Supplemental PolicyZM4 Bill charge must greater than $0

Bill charge must be greater than $0 at the line level or

deny16 M54



Supplemental PolicyB33 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XA1 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HA3 Bill to DME MAC Bill to DME MAC 109 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G44 Bill To Dmerc

This health service code was denied as a procedure

billed with a DME o16 M51



Supplemental PolicyGA6 Bill Type Missing Bill Type Missing 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R55 Billed Info Reflects Lower Degr Billed Info Reflects Lower Degree Acuity/Treatment 150 M25



Supplemental PolicyB42 Billed with Invalid Bill Type Billed with Invalid Bill Type 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEK Billing and Rendering Prov do not have

Billing and Rendering Prov do not have an active license

on claim DOSB7 M143



Supplemental PolicyXEL Billing and Rendering Prov not enrolled

Billing and Rendering Prov not enrolled in Medicaid

Program16 N257



Supplemental PolicyXEG Billing Prov does not have an active lic Billing Prov does not have an active license on claim DOS B7 M143



Supplemental PolicyXE1 Billing Prov not enrolled in Medicaid Billing Prov not enrolled in Medicaid Program 16 N257 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G34 Blood Collection Included In Lab Serv

The venipuncture was denied as it is considered to be an

integral part97 M15



Supplemental PolicyH00 Bundled into Service Not Specified These services are either bundled into other services on

the same day,

97 M15 National Correct Coding Manual Policy

Revised March 2021

H00 Bundled into Service Not Specified These services are either bundled into other services on

the same day,

97 M15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyJ62 Business Processing Rules not followed Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative RBM Capitated Radiology Vendor

Claim Line for radiology services has been forwarded to

the24 N381



Supplemental PolicyR36 Capitated Service Capitated Service 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X36 Capitated Service Capitated Service 24 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSH Carve out Benefit Services are Carved out for payment by another entity 96 N381



Supplemental PolicyHST Carve out Services - State Specific Services are carved out for payment by another entity - 96 N130



Supplemental PolicyR81 Chrgs Considered included in Inpat Ad Charges Considered included in Inpatient Admission 97 M2



Supplemental PolicyX81 ChrgsConsidered Included InpatAdmis Charges Considered included in Inpatient Admission 97 M15



Supplemental Policy940 Claim adjusted based on audit Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EQ4 Claim adjusted following Equian Determin

Claim adjusted following Equian Determination review

with Provider45 N10



Supplemental PolicyWP1 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative WP3 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative WP0 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative WP2 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 910 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding



Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 9B4 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J66 Claim closed incorrectly Rekeyed claim for correct payment/denial 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EB7 Claim EBP does not match member EBP enro Claim EBP does not match member EBP enrollment 204 N448



Supplemental PolicyZML Claim has multiple CLIA Numbers Claim has multiple CLIA Numbers 16 M91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G19 Claim is not a Duplicate Claim is not a Duplicate 129 N758 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZD0 Claim line denied Claim line denied A1 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G11 Claim Previously Processed Incorrect Claim Previously Processed Incorrectly 129 N758 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V11 Claim procesed not following auth R129:Claim not paid according to auth. 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZF7 Claim Processed not following Auth/Ref

Claim Processed not followinig Auth/Referral - Manual

Error129 MA67



Supplemental PolicyJ05 Claim processed to wrong member R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G02 Claim Processed to Wrong Provider

Previous Claim processed to the Wrong Provider

Healthcare129 MA67



Supplemental PolicyB14 Claim Service Denied

Claim Service Denied because the related or qualifying

claims serviceB15 M51



Supplemental PolicyG22 Claim was submitted Timely Claim was Submitted Timely 210 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B48 Claims adj to correct underpayment Claim adjusted to correct underpayment 129 N524 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMP CLIA Number does not cover DOS CLIA Number does not cover DOS B7 MA120 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R95 Clinic Claim without Physician Name Claim without Physician Name 16 N252 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B35 Clinic clm sub w/out phy name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X56 Clinic Clm Submt w/o phys nam Clinic Claim submitted with out physician name 16 N252 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J52 Clinical Edit(Ihealth, NCCI) incorr appl R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H08 Clinical Trial Requires Approp. DX Clinical Trial requires appropriate diagnosis. 16 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J18 Clm denied for EOB,svs excluded from cov R129:Service Not Covered by Other Ins 242 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I15 Clm Pend: app Modifier and/or time un Resubmit with appropriate Modifier and/or time units 4 N519



Supplemental PolicyI12 Clm Pend: clinic claim w/o Phys name Claim w/o Physicians name or number 16 N252 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X95 Clm Pend: clinic claim w/o phys name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

X04 Clm Pend: correct NDC Code req Correct NDC Code required for consideration 16 M119 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X11 Clm Pend: EOB from prim carrier req Resubmit with EOB from Primary Carrier 252 N4 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I02 Clm Pend: Illegible Records Sub Illegible Records Submitted 251 N205 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X02 Clm Pend: illegible records sub Illegible records submitted 251 N205 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I05 Clm Pend: Invalid/Del Code, Mod or D

Invalid/Inappropriate/Deleted Code, Modifier or

Decription182 N657



Supplemental PolicyI05 Clm Pend: Invalid/Del Code, Mod or D

Invalid/Inappropriate/Deleted Code, Modifier or

Decription182 N657



Supplemental PolicyI14 Clm Pend: invalid/miss Rev Code Invalid/missing Revenue Code 16 M50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X06 Clm Pend: itemized bill required Itemized Bill, Date of Service, or Invoice 252 N26 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I03 Clm Pend: Rept Req for Non-Spec Code

Report Required to Support Non-Specific Code; Please

Refile16 N350



Supplemental PolicyI08 Clm Pend:Diag Inv/Missing/Del/4th or5

Diagnosis invalid/missing/deleted/requires 4th or 5th

digit;146 M76



Supplemental PolicyJ01 Clm prev denied incorrectly as duplicate R129:Claim is not a duplicate 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J04 Clm previously processed for wrong prov R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J33 Clm Proc incorr for penny pricing Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X96 ClmPend: EOB/attach illeg/incomplete EOB attachments were illegible/incomplete 251 N4 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B37 ClmPend:AppModifier and/or time units Resubmit with appropriate modifier and/or 4 N517 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X08 ClmPend:diag inv/missing/del 4thor5th

Diagnosis Invalid/missing/deleted/requires 4th or 5th

digit146 M64



Supplemental PolicyX05 ClmPend:invalid/del code,mod or desc Invalid/inappropriate/deleted code, modifier or 4 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J43 Clms adj. to deny for clms billed incorr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V42 Clms adj. To deny for clms billed incorr R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HMO Co- Surgeon - Different Specialties

Co- Surgeons are only allowed if the providers are in

different8 N95



Supplemental PolicyGB3 COB Recovery COB Recovery 22 N420 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 614 COB verification required from member

COB verification/documentation is required from the

member to process22 N197



Supplemental Policy5CJ COB/exceeds fee schedule Coordination of benefits exceeds the fee schedule. 23 N131



Supplemental PolicyHSP Code combination - CC2 Retro

Based on NCCI the specific billed service code combo is

not payable.199 N657



Supplemental PolicyHSQ Code Combination Hosp CCR Retro

Hospital OP NCCI the specific billed service code combo

is not payable199 N657



Supplemental PolicyHMX Code Combo not payable

Based on NCCI the specific billed service code

combination is not236



Supplemental Policy457 Code description required Please submit a full description of the services provided 16 N350



Supplemental Policy5BC Code description required Please submit a full description of the services provided 16 N350



Supplemental PolicyH34 Code is Incident to Service

This was furnished as an integral, although incidental

part of the Drs97 N19



Supplemental PolicyZ96 CodeNotApproved for ProviderSpecialty

Procedure Code not approved by Medicaid for provider

specialty type8 N95



Supplemental PolicyR37 Combined Payment - Mother and Baby Combined Payment - Mother and Baby 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZC0 Complete Medical Records Required

Complete Medical Records Required for Consideration -

Refile163 M127



Supplemental Policy

Revised March 2021

ZC0 Complete Medical Records RequiredComplete Medical Records Required for Consideration -

Refile163 M127



Supplemental PolicyZE2 Complete Medical Records Required

Complete Medical Records Required for consideration -

Please re-file;163 M127



Supplemental PolicyG39 Component Of Critical Care Service

This health service code was denied as it is considered

to be an integ97 M15



Supplemental PolicyG79 Condition Code Not Appropriate For Bi

The health care codes were denied because the

Condition Code is not ap16 M44



Supplemental PolicyV38 Configuration Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R38 Contracted Fee Contracted Fee 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 944 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419



Supplemental Policy952 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419



Supplemental PolicyG43 Convenience Item - Does Not Meet Defi

Item denied because it is an item of convenience, the

item is not medi50



Supplemental Policy9B9 Corrected claim - add'l payment due Adjusted - corrected claim received 63 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 406 Corrected claim - no add'l payment due

Provider corrected claim but no additional payment is

due.18 N702



Supplemental PolicyZR4 Corrected claim with diff Prov Tax ID

Corrected claim has different provider tax ID then

original submission16 N209



Supplemental PolicyZR4 Corrected claim with diff Prov Tax ID

Corrected claim has different provider tax ID then

original submission16 N209



Supplemental PolicyZR3 Corrected claim with different Member ID

Corrected claim has different member ID then original

submission16 N382



Supplemental PolicyZR3 Corrected claim with different Member ID

Corrected claim has different member ID then original

submission16 N382



Supplemental Policy112 Corrected claim. No payment due.

Corrected claim received, reprocessed claim, but no

additionalB13 MA67



Supplemental PolicyHMN Co-Surgeon not allowed for procedure Co- Surgeons are not allowed for this procedure 8 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B08 Co-Surgeons Cannot Be Same Subspecia Cosurgeons need to be of different subspecialties. 172



Supplemental PolicyH62 Co-Surgeons Not Allowed Procedure denied. The procedure code submitted does

not necessitate



Supplemental PolicyM70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 96 N193 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 109 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5C0 CPT invalid DOS Procedure code invalid for date of service 181 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G61 Cpt Modifier Is Not Valid

This health service code was denied because the

modifier is invalid.182 N657



Supplemental PolicyZMN CPT Not Covered by CLIA Certificate Type CPT Not Covered by CLIA Certificate Type B23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G41 CPT Recoded To A CMS Designated Alter

According to CMS guidelines, outpatient hospitals

should bill certain16 M51



Supplemental PolicyH56 CPT Seperate Procedure Policy This procedure/service is not paid separately 97 N19 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 407 CPT/HCPCS invalid for rev code billed

The CPT/HCPCS code on the claim is invalid for the

revenue code billed199 N657



Supplemental Policy5CL CPT/HCPCS invalid for rev code billed

The CPT/HCPCS code on the claim is invalid for the

revenue code billed199 N657



Supplemental PolicyZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95



Supplemental PolicyZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95



Supplemental PolicyIH5 Date of Death proceeds the DOS Date of Death proceeds the date of service 13 CMS Coverage Policies

HM1 Date of service is Later Than Date RecdDate Of Service Is Later Than Date Received Or Future

Date Of Service.110



Supplemental Policy

Revised March 2021

X60 Dates and/or ServicesOutsideRef/Auth Dates and/or Services Outside Authorization/Referral 197ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyR60 Dates and/or Servs Outside Ref/Auth Dates and/or Services Outside Referral/Authorization 197



Supplemental Policy4BM Denial overturned and service is now app

Our denial was overturned and the service is now

approved. This means64 MA91



Supplemental Policy492 Denied - authorized services exceeded

Services exceed authorized amount/days - member not

liable198 N640



Supplemental Policy5CT Denied - authorized services exceeded

Services exceed authorized amount/days - member not

liable198 N54



Supplemental Policy493 Denied - benefit exceeded Denied - benefit exceeded 119 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5CU Denied - benefit exceeded Denied - benefit exceeded 119 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 497 Denied - no NPI Denied - no NPI 206 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 498 Denied - not on fee schedule Denied - not on fee schedule - member not liable 147



Supplemental Policy499 Denied - not payable - member not liable

Denied - not payable (inclusive, exclusive, unbundled or

not payableB1 M39



Supplemental Policy5D1 Denied - payment for donor services

Payment is for donor services and paid under the

recipient'sB1



Supplemental Policy5D2 Denied - provider billing error Denied - provider billing error 16 N296 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5D3 Denied - resubmit to vision vendor Services need to be billed to the vision vendor. 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5D5 Denied - settlement agreement Date of service included in a settlement agreement. 97 N664



Supplemental Policy489 Denied- altered claim, member not liable

Claim has been altered; member not liable; resubmit

corrected claim31 MA130



Supplemental PolicyH02 Denied- Duplicate Service on Same Day

The same or a similar procedure code was billed on the

same date of18 N702



Supplemental PolicyHS7 Denied in Hospital In/Out

Service is not payable in a Hospital Inpatient or

Outpatient setting58



Supplemental PolicyJ72 Denied incorrectly, remit correct Claim denied incorrectly in error 129 MA130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4A2 Denied- NPI incorrect NPI incorrect 208 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4A0 Denied- past reconsideration time period

Claim is past the reconsideration time period. Member

not liable.29



Supplemental Policy4AA Denied -updating of payment information

Denied -updating of payment info-SMT claims only-

member not liable250 MA04



Supplemental PolicyZ09 Denied,corrected claim submitted Correction to a prior claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4AB Denied-auth servs do not match claim

Service code on claim does not match service code on

authorization-284 M62



Supplemental Policy5D9 Denied-auth servs do not match claim

Service code on claim does not match service code on

authorization-284



Supplemental Policy4AE Denied-invalid billing name, addr or TIN

Invalid billing name, address or tin; re-submit claim with

correct16 N258



Supplemental Policy4AF Denied-name and address required

Name and address of facility where services were

rendered16 N256



Supplemental Policy4AG Denied-no add'l pmt,under original DRG

Re-admission applies under original DRG of primary

admit-249



Supplemental Policy5DC Denied-no add'l pmt,under original DRG

Re-admission applies under original DRG of primary

admit-249



Supplemental Policy4AJ Denied-remit/billing addr does not match

Remitting/billing address does not match system

records16 N258



Supplemental Policy4AK Denied-rendering provider required

Rendering physician / facility required and not

submitted.16 N289



Supplemental PolicyH46 Deny due to Interaction with other drug Service denied because potential interactions with

another drug



Supplemental Policy

Revised March 2021

H72 Deny Item doesn't meet definition of DMEItem denied because it is an item of convenience, item is

not medical50 N10



Supplemental Policy4AM Deny-DOS outside statement dates Deny-DOS outside statement dates 16 M53 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5DE Deny-DOS outside statement dates Deny-DOS outside statement dates 16 MA31 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 468 Device/equip invoice required An invoice from the vendor supplying the implantable 252 M23



Supplemental PolicyR08 Diag inv/missing/del 4th or 5th Diagnosis invalid/missing/deleted 4th or 5th digit 16 M76



Supplemental Policy

I09 Diag Inv/Missing/Deleted Req 4th/5/6/7thDiagnosis Invalid/Missing/Deleted or Requires 4th or 5th or 6th or

7th 146 M76ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyZK4 Diagnosis Code Invalid Diagnosis Code Invalid 16 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HS1 Diagnosis Codes missing or inval on DOS All Diagnosis codes are invalid on the DOS or requires a 146 M76



Supplemental Policy408 Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167



Supplemental Policy5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167



Supplemental Policy5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167



Supplemental PolicyH64 Diagnosis Invalid for Age The age of the patient does not correlate with the

submitted diagnosis



Supplemental PolicyH15 Diagnosis Invalid For Gender This was denied because the diagnosis is not

appropriate based on the



Supplemental PolicyGA2 Did not meet minimum unit requirement Did not meet minimum case rate unit requirement 16 M53



Supplemental PolicyR67 Discrep w/Level of Care-Appeal Req Discrepancy with Level of Care - Appeal Required 150 N640



Supplemental PolicyX67 Discrep with Level of Care-AppealReq Discrepancy with Level of Care - Appeal Required 150 N640



Supplemental PolicyZZ0 Documented Service does not support 9929 Documented Service does not support 99292 150 N640



Supplemental PolicyH21 Doesn't Meet Observation Criteria Observation care code requires minimum of 8 hours. 150 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


R97 DOS Cannot be Greater than Received DOS cannot be Greater than Received Date 181 N56 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X97 DOS Cannot be Greater than Recv Date Date of Service cannot be greater then claim received 110



Supplemental Policy581 DRG change due to DX/discharge

DRG change due to incorrect principal or secondary DX

codes and216 N35



Supplemental Policy583 DRG change due to DX/Procedure/discharge


and procedure216 N35



Supplemental Policy584 DRG change due to DX/Procedure/discharge


and procedure216 N35



Supplemental Policy578 DRG change due to incorrect DX


codes(s)216 N35



Supplemental Policy582 DRG change due to proc code/discharge

DRG change due to incorrect principal or secondary

procedure216 N35



Supplemental Policy580 DRG change due to procedure code

DRG change due to incorrect principal or secondary

procedure code(s)216 N35



Supplemental Policy579 DRG change/payment due to discharge stat DRG change/payment due to incorrect discharge status 216 N35



Supplemental Policy585 DRG coding review;Denied med record IP DRG coding review; denied for medical records 252 M127



Supplemental PolicyHB5 DRG Doesn't Match The billed DRG does not match the Grouper DRG 16 N208 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R42 DRG Payment DRG Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

R39 Dup Claim Prev Pd at Correct Rate/CaDuplicate claim previously paid at correct rate or

capitated.B13 M86



Supplemental PolicyR41 Dup Clm Previously Denied Appropriate Duplicate Claim Previously Denied Appropriately B13 M86



Supplemental PolicyI65 Dup Clm-Prev denied approp Duplicate Claim-previously denied appropriately B13 M86 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X39 DupClaimPrevPd at Correct Rate/Cap

Duplicate claim previously paid at correct rate or

capitated.B13 M86



Supplemental Policy409 Duplicate bill, previously considered

This is a duplicate claim that has previously been

considered.18 N702



Supplemental Policy409 Duplicate bill, previously considered


considered.18 N702



Supplemental Policy5CM Duplicate bill, previously considered


considered.18 N702



Supplemental Policy5CM Duplicate bill, previously considered


considered.18 N702



Supplemental PolicyG12 Duplicate Claim Prev Denied appropr Duplicate Claim Previously Denied Appropriately 18 N702



Supplemental Policy485 Duplicate claim, previously considered


considered.18 N702



Supplemental Policy485 Duplicate claim, previously considered


considered.18 N702



Supplemental PolicyH39 Duplicate Condition 1

Duplicate Logic Condition 1 - Everything the same

except Submitted18 N702





except Allowed18 N702





except co-pay.18 N702



Supplemental PolicyH42 Duplicate Condition 4 Duplicate Logic Condition 3 - Everything the same. 18 N702



Supplemental PolicyH44 Duplicate of New/Deleted Proc Code.

During the grace period for a new or deleted procedure

code only16 M84



Supplemental PolicyHMY Duplicate Procedure on Same Day Duplicate Procedure on Same Day 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental Policy

954 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 969 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G45 Duplicate Service Within 30 Days

This health service code was denied because an

inclusive same or similB13 M86



Supplemental PolicyH43 Duplicate Submission This claim has been previously submitted. 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZK3 Dx Code Invalid for Inpatient Claim Dx Code Invalid for Inpatient Claim 11 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H09 Dx Code Not Coded to Highest Level

The billed diagnosis code is not coded to the highest

level of16 M81



Supplemental PolicyH19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS National Coverage Determinations (NCD) Policy

H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS Coverage Policies

469 Dx invalid for DOS Diagnosis invalid for date of service 146 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5BU Dx invalid for DOS Diagnosis invalid for date of service 146 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G47 E & M Level Of Service Recoded

This health service code was changed to one that is

consistent with thB15 N22



Supplemental PolicyH93 E&M Code level Re-coded

The level of the Evaluation and Management visit has

been recoded150 N22



Supplemental Policy

Revised March 2021

HM4 E&M svs. Btwn Global Pre and Post Op Per E&M svs. Btwn Global Pre and Post Op Period 97 N525 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G48 E/M Service Inappropriately Coded

This health service code was denied because it was

inappropriately cod16 M81



Supplemental PolicyIH8 E/M Service inappropriately coded The health code was denied because it was

inappropriately coded based



Supplemental PolicyJ59 EDI issue- incorrect info. mapped R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V57 EDI issue- incorrect info. Mapped R129:Administrative Overturn 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 410 Emergency room report required

The emergency room report is required for

consideration of this claim.16 N391



Supplemental Policy5A0 Emergency room report required

The emergency room report is required for

consideration of this claim.252 N706



Supplemental PolicyJ31 Encounter req change after clm pymt R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5BW EOB cannot be read

Please resubmit legible EOB. Original EOB could not be

read.251 N205



Supplemental PolicyR11 EOB from prim carrier req Resubmit with EOB from Primary Carrier 16 N4 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J17 EOB in system not applied correctly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V16 EOB in system not applied correctly R129:Retro Authorizations 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J19 EOB in system yet processed as primary R129:Valid EOB on File 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GB5 EOB Missing Date Rec or Denial Reas EOB Missing Date Received or Denial Reason 251 N480 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 39 EOB Statement Explanation This explanation will appear on the EOB 23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R96 EOB/Attachmnts were Incomplete/Illeg EOB/Attachments were Incomplete/Illegible 251 N4 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J20 EOB/TPL in system not effective on DOS R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I73 EPSDT Form was Incomplete EPSDT form was incomplete 16 N34 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X73 EPSDT Form was Incomplete EPSDT Form was Incomplete 16 N34 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R63 EPSDT Pay Adj-5 /12 year old screeni

EPSDT Payment Adjustment For 5 And 12 Year Old

Health Screen24



Supplemental PolicyZZ8 ER med record review completed; Denied

ER medical record review completed; records do not

support216 N109



Supplemental PolicyHT0 Established /New Patient

An Established visit should be billed instead of New

PatientB16



Supplemental PolicyJ36 Ex adj clm by mistake/no chge in outcome R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V34 Ex adj clm by mistake/no chge in outcome R129:Settlement Adjustment 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J49 Examiner overlooked addtlmod/dx Examiner overlooked addtl mod/dx 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 917 Exceeded benefit maximums Adjusted - member maximum benefit was exceeded. 119



Supplemental Policy466 Exceeds allowed units

The units submitted on this claim exceed the daily unit

allowance.96 N362



Supplemental Policy5BQ Exceeds allowed units

The units submitted on this claim exceed the daily unit

allowance.96 N362



Supplemental Policy413 Exceeds approved length of stay

The services rendered exceed the approved length of

stay.152 M26



Supplemental PolicyH20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,

the frequency



Supplemental PolicyH20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,

the frequency


H20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,

the frequency

150 N130 CMS Coverage Policies

4AN Exceeds contracted rateBilled charges exceed contracted rate. Member not

liable45



Supplemental Policy5DF Exceeds contracted rate

Billed charges exceed contracted rate. Member not

liable45



Supplemental PolicyG40 Exceeds Coverage Guidelines

This health service code was denied as this service

exceeds the frequ151 N130



Supplemental PolicyZD6 Exceeds daily limitation

Exceeds the daily limitation of 1 ER Visit per date of

service273 N362



Supplemental Policy

Revised March 2021

ZD6 Exceeds daily limitationExceeds the daily limitation of 1 ER Visit per date of

service273 N362





service273 N362





service273 N362



Supplemental Policy5A4 Exceeds DRG reimbursement The services rendered exceed the DRG reimbursement. 45



Supplemental PolicyB36 Exhaustion of Benefits Exhaustion of Benefits 119 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I26 Exhaustion of Benefits Exhaustion of Benefits 119 N587 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G49 Experimental/Investigational

This health service code was denied because it is

considered experime55 N10



Supplemental PolicyZF6 External Error - Auth/Ref Req to Config

External Error - Auth/Ref Requirements to Config

Revised/Reversed129 MA67



Supplemental PolicyJ65 Externally Priced Claims Manual pricing applied for correct payment 45 N442 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XE2 Facility Prov not enrolled in Medicaid Facility Prov not enrolled in Medicaid Program 16 N278 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZZB Fam Plan Consent Form Rev: Missing Info Family Planning Consent Form reviewed: 251 N228 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZZC Fam Plan Consent Form reviewed: payable Family Planning Consent Form Reviewed: Payable 216 N11



Supplemental Policy459 Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5BE Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 601 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XF2 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HMD Gender of Patient Not Consistent w/Code

The Gender Of The Patient Is Not Consistent With

Service Code Billed.7



Supplemental PolicyY98 General Claim adjustment from NaviNet General Claim adjustment from NaviNet 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V77 Global maternity code only payable as sc

The Health Plan only considers payment on a global

maternity code as t22 MA04



Supplemental PolicyH84 HCPCS Code Not Appropriate According to CMS guidelines, the billed HCPCS code has

been

8 CMS Coverage Policies

G67 HCPCS Code Not Appropriate For ProfeAccording to CMS guidelines, the billed HCPCS code has

been designate189 N657



Supplemental PolicyG42 HCPCS Recoded Based On Gender

The health service code has been changed to correlate

to the appropria7



Supplemental PolicyG81 HCPCS Recoded Per Health Plan Policy

The billed HCPCS was recoded to another HCPCS code

based on Health Pla189 N657



Supplemental PolicyIH9 HCPCS recorded based on gender The health service code has been changed to correlate

to the



Supplemental PolicyHDR High Dollar Review Team High Dollar Review Team 133 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J51 High Dollar review, reprocess claim R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V50 High Dollar review, reprocess claim R129:Clm Proc w/o ICD9 surgical code 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZPD HMS - Rebill ER care

HMS identified that ER care should be rebilled at an

appropriate level150 N10



Supplemental PolicyHM0 HMS Overturn Appeals Process Review Appeal Overturn 216 MA91 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 586 HMS Review no findings pay as billed HMS Review no findings pay as billed 216 N11 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HMQ Hosp O/P Specific Billed Serv Code Combo

Hospital Outpatient Based on NCCI. The specific billed

service code is236



Supplemental PolicyHMB Hosp.Outpt Proc.is Mut.Excl.On Prior Clm

Hosp.Outpt Proc.is Mut.Excl to Prior Clm submisson on

same DOS231



Supplemental PolicyHMA Hosp.Outpt Procedure is Mutually Excl.

Hosp Outpt Proc.is Mutally Excl. Two Proc are consid.

Mut Exclusive231



Supplemental PolicyHMC Hosp.Outpt.Based on NCCI Proc

Hosp.Outpt.Bsd on NCCI Proc Mut Excl.Non payable

code was Pd231



Supplemental PolicyM72 I/P Billed as OBSV

Claim was billed as Inpatient but was authorized as

Inpatient186 N54



Supplemental Policy

Revised March 2021

Z86 I/P Billed as OBSVClaim was billed as Inpatient but was authorized as

Inpatient60



Supplemental PolicyV65 ICD-9 surgical code needed on claim R129: Prior Processing Information Appears Incorrect 129 MA67



Supplemental PolicyJ50 ICD-9 surgical code needed on claims R129:Clm Proc w/o ICD9 surgical code 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V48 ICD-9 surgical code needed on claims R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Y99 ICM claims adjustment for CDPS process

Intensive case management process - claim adjustment

for CDPS process45 N381



Supplemental Policy190 If A0999 is billed over 30 units submit

If A0999 is billed over 30 units, please submit supporting

documents252 N706



Supplemental PolicyV17 IIIegible/incomplete EOB attached R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZE3 Illegible Records Submitted

Illegible records submitted Please re-file legible

records; Program251 N237



Supplemental PolicyJ21 Illegible/incomplete EOB attached Illegible/incomplete EOB Attached 251 MA04 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IRR Implant In Review Implant In Review 163 M23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IA2 Implant included in DRG reimb Implant included in DRG reimbursement line item 97 M15



Supplemental PolicyIR1 Implant Invoice Required Implant Invoice Required 163 M23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IA1 Implant payment based on clin rev

Implant payment based on clinical review line item

explan50 N10



Supplemental PolicyB09 Implant Procedure Requires Implant De

This implant procedure code was denied because the

associated implant16 N354



Supplemental PolicyR91 Inappropriate Coding for Contract/Agr Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H92 Inappropriate Place of Service The Place of Service indicated on the claim is not

appropriate for

58 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyH92 Inappropriate Place of Service The Place of Service indicated on the claim is not

appropriate for

58 CMS National Coverage Determinations (NCD) Policy

H92 Inappropriate Place of Service The Place of Service indicated on the claim is not

appropriate for

58 CMS Coverage Policies

HS6 Incidental Phys Service Item or Service is incidental to the Physician's Service 234 N390ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyG54 Include in Monthly Rental Fee


considered to be inc108 N370



Supplemental PolicyG83 Included In Blood/Blood Product Reve

The Revenue code was denied as it is a part of the

Blood/Blood Product97 N19



Supplemental Policy416 Included in contracted rate

The services rendered are included in the contracted

rate.45



Supplemental Policy5A6 Included in contracted rate

The services rendered are included in the contracted

rate.45



Supplemental PolicyHS5 Included in E&M Procedure is included in E&M Code 97 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H03 Included in E&M Service This service is included in the billed Evaluation and

Management code



Supplemental PolicyH24 Included in Global Fee This code is included in the global fee for another

procedure.

97 N19 National Correct Coding Manual Policy

H24 Included in Global Fee This code is included in the global fee for another

procedure.



Supplemental Policy5A7 Included in inpatient per diem

The services rendered are included in the inpatient per

diem.45



Supplemental Policy5A7 Included in inpatient per diem

The services rendered are included in the inpatient per

diem.45



Supplemental PolicyMBC Included in Mom/Baby Case Rate Payment is included in Mom and Baby Case Rate 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

G55 Included In Other CodeThis procedure has been included as part of another

procedure.97 M15



Supplemental PolicyG53 Included In Physical Medicine Service


considered to be an97 M15



Supplemental PolicyH01 Included in Primary Procedure This procedure has been included in the primary

procedure.



Supplemental PolicyH01 Included in Primary Procedure This procedure has been included in the primary

procedure.

97 N19 National Correct Coding Initiative Policy

H01 Included in Primary Procedure This procedure has been included in the primary

procedure.

97 N19 National Correct Coding Initiative Supplemental Policy


procedure.



procedure.


H22 Included in Radiation TX Mgt Svc.These services are included in the weekly radiation

treatment97 N19



Supplemental PolicyB66 Included in Settlement Payment Included in Settlement Payment 97 N45 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X25 Included in Settlement payment Included in Settlement payment 45 N664 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V06 Incorr. Prov info loaded/att to incor ag R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J06 Incorr. Prov info loaded/att to wrg agrm R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V12 Incorrect Auth/Referral applied to claim R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 957 Incorrect charge Adjusted - incorrect charge. 16 M54 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 958 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 971 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B40 Incorrect Contract Amount Prev Paid Incorrect Contract AMount Previously Paid 129 MA130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 959 Incorrect date of service Adjusted - incorrect date of service. 16 MA31 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 960 Incorrect diagnosis code Adjusted - incorrect diagnosis code. 146 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G24 Incorrect Diagnosis Code Entered Incorrect Diagnosis Code Entered on Previous Claim 146 M64



Supplemental PolicyI32 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X65 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 961 Incorrect member/patient

Adjusted - incorrect member/patient selected on

original claim16 MA36



Supplemental Policy972 Incorrect member/patient

Adjusted - incorrect member/patient selected on

original claim16 MA36



Supplemental Policy419 Incorrect modifier

The service submitted has been reported with an

incorrect modifier.4



Supplemental Policy5A9 Incorrect modifier

The service submitted has been reported with an

incorrect modifier.4



Supplemental Policy962 Incorrect number of units Adjusted - incorrect number of units. 16 M53 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 973 Incorrect payee Adjusted - paid to incorrect payee. 16 N279 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G13 Incorrect Place of Service Incorrect Place of Service on Previous Claim 5 M77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I34 Incorrect proc/diag for EPSDT payment Incorrect procedure/Diagnosis for EPSDT payment 16 M51



Supplemental Policy964 Incorrect procedure code Adjusted - incorrect procedure code. 16 M51 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V66 Incorrect provider paid Incorrect provider paid B7 N570 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZA3 Incorrect Provider/TIN ID # submitted Incorrect Provider/TIN ID # submitted 16 N209 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z76 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209



Supplemental PolicyZA6 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209



Supplemental Policy420 Incorrect revenue code / resubmit The revenue codes that has been submitted is incorrect. 16 M50



Supplemental PolicyG09 Incorrect Secondary Liability Incorrect Secondary Liability 252 MA64 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J24 Incorrect TPL info supplied by state R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V22 Incorrect TPL info supplied by state R129:Secondary EOB req 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

462 Incorrect/missing posThe claim has been submitted with an incorrect or

missing place of16 M77



Supplemental PolicyJ53 Inpatient downgrded to lower lvl of care R129:inpt downgrd to lower level of care 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative K51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J54 Interest paid in error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V53 Interest paid in error R129:inpt downgrd to lower level of care 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 975 Interest paid incorrectly Adjusted - interest paid incorrectly. A7 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R64 Interim Bill 1st Cycle Payment Interim Bill 1st Cycle Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R65 Interim Bill 2nd Cycle Payment Interim Bill 2nd Cycle Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R66 Interim Bill Final Cycle Payment Interim Bill Final Cycle Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X33 Interim Bill Resubmit Final Bill Interim Bill Resubmit Final Bill 135 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 421 Interim bill, submit clm for entire stay

This is an interim bill. Please submit claim for the entire

stay.16 MA31



Supplemental PolicyZF8 Internal Delay - Auth/Ref not on file

Internal Delay - Auth/Referral not on file During initial

Processing129 MA67



Supplemental PolicyJ07 Internal enrollment error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZF2 Internal Error - Incomp/Inaccurate Req

Internal Error - Incomplete/Inaccurate Requirements

Provided to Config129 MA67



Supplemental PolicyGA8 Invalid Admission DX Eff Date Invalid Admission Diagnosis Effective Date 146 MA65 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA5 Invalid Bill Type Invalid Bill Type 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I93 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z90 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA4 Invalid CPT/HCPCS Code Invalid CPT/HCPCS Code 16 M51 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H32 Invalid Diagnosis Code The diagnosis code listed on the claim is invalid. 146 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HB6 Invalid Discharge Status Invalid Discharge Status 16 N50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J71 Invalid Gender for DX Invalid Gender for DX 10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R32 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X99 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 185 Invalid Member Date of Birth

Members Date of Birth on Claim does not match DOB in

FACETS16 N329



Supplemental Policy184 Invalid Member Name

Member Name on claim does not match Name in

FACETS16 MA36



Supplemental Policy422 Invalid member number submitted

The claim has been submitted with an invalid member

number.31



Supplemental Policy5AB Invalid member number submitted

The claim has been submitted with an invalid member

number.31



Supplemental PolicyZHA Invalid Modifier

Invalid Modifier used. Submit claim without modifier or

appropriate182 N657



Supplemental PolicyZHA Invalid Modifier

Invalid Modifier used. Submit claim without modifier or

appropriate182 N657



Supplemental PolicyGB1 Invalid NPI Invalid NPI 207 N257 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EB5 Invalid or Multiple Evidence Based Progr

Invalid or Multiple Evidence Based Program Indicators

on Claim95 N182



Supplemental PolicyXE7 Invalid ORP Ordering prov type Invalid ORP Ordering Prov type 170 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEH Invalid ORP Referring and Ordering Prov Invalid ORP Referring and Ordering Prov type 170 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XE8 Invalid ORP Referring Prov type Invalid ORP Referring Prov type 170 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA7 Invalid Patient Status for Bill Type Invalid Patient Status for Bill Type 16 MA43 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I68 Invalid place of service for procedure Invalid Plance of Service for Procedure 5 M77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Q55 Invalid Procedure Code Procedure is invalid for this date of service 181 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ISR Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IST Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

ISU Invalid Sex for Diagnosis Member Sex Invalid for Diagnosis Code 10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA3 Invalid Units Invalid Units 16 M53 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4AW Invalid/missing bill type The submitted bill type is invalid or missing. 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5DP Invalid/missing code - CPT, HCPCS or mod

The submitted procedure code or modifier is missing or

invalid.16 M51



Supplemental Policy5DW Invalid/missing diagnosis code The submitted diagnosis is invalid or missing. 16 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Submitted Claim 16 M50



Supplemental PolicyR86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Claim 16 M50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 458 Invoice pricing Pricing based on submitted invoice. 45 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5BD Invoice pricing Pricing based on submitted invoice. 45 N649 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 424 Invoice required The invoice is required. 252 M23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5AD Invoice required The invoice is required. 252 M23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R57 IP stay if <24 hrs IP stay if<24 hrs, resubmit as observation 150 N640 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZF0 IS Processing Error IS Processing Error 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J68 Itemized bill/invoice/med rec rec'd Itemized bill/invoice/med rec rec'd 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X75 JCode ident as med exp instead pharm

J Code identified as medical expense instead of

pharmacy96 N448



Supplemental PolicyV36 KMHP had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H80 Lab compnt price exceeds lab panel price Price of Lab Panel components exceed lab panel price 45 N70



Supplemental Policy478 Late charge ineligible

Late charge claim cannot be accepted. Combine original

claim and late16 MA30



Supplemental Policy5C7 Late charge ineligible

Late charge claim cannot be accepted. Combine original

claim and lateA1 MA30



Supplemental PolicyJ73 Late charges applied Late charges applied 45 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HB7 LCD - Procedure vs Diagnosis

Billed DIagnosis does not support Medical Necessity -

refer to LCD11 N115



Supplemental PolicyHB8 LCD - Procedure vs Diagnosis

Billed DIagnosis does not support Medical Necessity -

refer to LCD11 N115



Supplemental Policy217 Line Received with Zero Billed Charge Line Received with Zero Billed Charge, Nothing is Due.



Supplemental PolicyMA1 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative MA2 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J69 Mat Kick payment applied Mat Kick payment applied 131 N442 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B46 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7



Supplemental PolicyI23 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7



Supplemental PolicyJ81 McKesson historical clinical edit Correction to a prior claim 129 N377 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z25 Medicaid Fee for Service Medicaid Fee for Service 109 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I99 Medicaid Prov # Missing or Invalid Medicaid provider number is missing or invalid 16 N253 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZE0 Medical Record Review Complete

Medical Record Review Complete; documentation does

not support96 N35



Supplemental PolicyZE1 Medical Record Review Complete

Medical Record Review Complete; documentation does

not support96 N35



Supplemental PolicyZZE Medicare A unavailable submit Part B EOB Medicare A unavailable submit Part B EOB 16 N479 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative MCO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XMO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 9BP Medicare Primary Care Physician Bonus Medicare Primary Care Physician Bonus Payment 161 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R87 Medicare/Medicaid Sanctioned Provider Medicare/Medicaid Sanctioned Provider 184 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

XC7 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M74 Member has Multiple Insurances

Member has multiple insurances. Submit EOB from

other carrier16 MA64



Supplemental PolicyZ75 Member has Multiple Insurances

Member has multiple insurances. Submit EOB from

other carrier22 MA64



Supplemental PolicyTRI Member is tri-eligible; Submit EOBs

Member is tri-eligible; Submit EOBs from all insurance

carriers169 N23



Supplemental PolicyHS2 Member not Eligible at Time of Service Member was not Eligible at Time of Service 200 N650 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EB3 Member not enrolled in Evidence Based Pr Member not enrolled in Evidence Based Program 272



Supplemental PolicyI39 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X55 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZH2 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZH3 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B21 Members Age not valid for procedu code Members Age not valid for procedure code 6 N129 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative A54 Met Monitoring Incentive Metabolic Monitoring Incentive 144 N422 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V55 Mgmt decision to waive business rule R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HB4 Missing CC/MCC Diagnosis

The Provider's billed DRG indicates a

complication/comorbidity that16 M76



Supplemental PolicyZMK Missing CLIA Number on Claim Missing CLIA Number on Claim 16 MA120 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GB2 Missing Discharge Hour for Disc Bill Typ Missing Discharge Hour for Discharge Bill Type 16 N317 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 130 Missing DX for Intensive Case Mgmt Progr Missing Dx for Intensive Case Mgmt Program 16 M76 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA1 Missing HCPCS Code for Bill Type Missing HCPCS Code for Bill Type 16 M20 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I97 Missing/Illegible Charge Billed Missing or Illegible Charge Billed 16 M79 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z41 Missing/Illegible CPT,HCPCS or ICD-9 Missing/Illegible ICD-9 procedure code submitted 16 M51



Supplemental PolicyIH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 CMS Coverage Policies

IH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


ZJ9 Missing/Incomplete/Invalid Revenue Code Missing/Incomplete/Invalid Revenue Code 16 M50ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyHS9 Mod 26/TC Not allowed for Service

Modifiers 26 or TC are not allowed for Professional or

Technical4 N519



Supplemental PolicyH76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


H76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 CMS National Coverage Determinations (NCD) Policy

HMU Mod QW requiredPer CLIA Requirements a modifier QW is required for

this procedure4 N519



Supplemental PolicyHSA Mod TC not allowed for this Service Code Modifier TC is not allowed for this Service Code 4 N519 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H27 Modifier Adjustment The recommended percentage for this procedure has

been adjusted based



Supplemental PolicyZK2 Modifier Combination Invalid Modifier Combination Invalid 4 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G64 Modifier Inappropriate For Place Of Se Modifier Inappropriate For Place Of Service 5 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a

modifier that



Supplemental PolicyH77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a

modifier that


G63 Modifier Inappropriate For Provider Ty N/A 8 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G60 Modifier Inappropriately Coded

The modifier for this service has been changed to reflect

appropriate4 N519



Supplemental PolicyH82 Modifier Inappropriately Coded The modifier for this service has been changed to reflect

appropriate



Supplemental PolicyHSX Modifier not Applicable

Per Plan Requirements, the service code and modifier

cannot be billed4 N519



Supplemental Policy

Revised March 2021

H57 Modifier removed on Termed Proc Code Modifier removed. Terminated procedure can not be

billed bilaterally



Supplemental PolicyH65 Modifiers Re-Ordered

The modifiers on the claim line were reordered based on

the182 N22



Supplemental PolicyH96 More Than 1 Asst Surgeon Not Allowed Only one assistant surgeon is allowed for the procedure

submitted.



Supplemental PolicyHS0 More than one Interp and Reading perfrmd

More than one interpretation and reading being

performed for the same18 N702



Supplemental PolicyX83 Mother's Bill not Received; Refile Mother's Bill not Received; Refile 16 N182 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X12 Motor Vehicle Accident - Auto Primary Motor Vehicle Accident-Auto Carrier Primary 20 MA04 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZD4 MSRP is missing MSRP is missing and is required with the claim 252 M23 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSC MUE for DME Medically Unlikely Edits for DME 151 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSD MUE For Hospitals Medically Unlikely Edits for Hospitals 151 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSB MUE for Physicians Medicallly Unlikely Edits for Physicians 151 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative RB1 Multiple Corrected Claims Submitted

Multiple Corrected Claims Submitted. Last submission

will be used.18 N702



Supplemental PolicyRB1 Multiple Corrected Claims Submitted

Multiple Corrected Claims Submitted. Last submission

will be used.18 N702



Supplemental PolicyH26 Multiple Endoscopy Review Multiple endoscopy, modifier 51 has been removed. 97 N20



Supplemental PolicyG32 Multiple Endoscopy Rules

The claim has been processed using the Multiple

Endoscopy methodology.59 N10



Supplemental PolicyG66 Multiple Nuclear Medicine Studies N/A 59 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HT2 Multiple Paymnt Reduction Imaging

Multiple Procedure Payment Reduction on the Technical

Component59



Supplemental PolicyHT1 Multiple Proc Reduction - Imaging

Multiple Procedure Payment Reduction on the Technical

Component59



Supplemental PolicyG80 Multiple Procedure Reduction for Radi The technical component of this service code was

reduced because more



Supplemental PolicyH28 Multiple Procedure Review

This code is subjected to a multiple procedure reduction

when more97 M15



Supplemental Policy5DZ Multiple same day surgery reductions

The allowable amount for this service has been reduced

according to59 N10



Supplemental PolicyR44 Multiple Surgical Reduction Multiple Surgical Reduction 59 N670 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H58 Mutually Exclusive of Another Proc This code should not be reported since a similar

procedure was


H58 Mutually Exclusive of Another Proc This code should not be reported since a similar

procedure was

97 N20 National Correct Coding Initiative Supplemental Policy

H58 Mutually Exclusive of Another Proc This code should not be reported since a similar

procedure was



Supplemental PolicyM73 Name/DOS on case notes do not match Member name/DOS on case notes do not match claim 250 N206



Supplemental PolicyZ74 Name/DOS on case notes do not match Member name /DOS on case notes do not match claim 16 N329



Supplemental PolicyX91 nappropriateCoding ForContract/Agree Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G38 National Correct Coding Policy Manual

This health service code was denied based on correct

coding guidelines16 M81



Supplemental Policy425 Nbr of units dont correspond w/date span

The number of units billed does not correspond with the

date span16 M23



Supplemental Policy5AE Nbr of units dont correspond w/date span

The number of units billed does not correspond with the

date span16 N345



Supplemental PolicyHT8 NCCI Column 1 denied,Column II paid prev

NCCI Column I and Column II codes billed out of

sequence for same date234 M80



Supplemental PolicyHT8 NCCI Column 1 denied,Column II paid prev

NCCI Column I and Column II codes billed out of

sequence for same date234 M80



Supplemental Policy

Revised March 2021

H17 NCCI Denial- Mutually Exclusive This health service code was denied as mutually

exclusive of another

231 National Correct Coding Initiative Policy

H18 NCCI Denial-Comprehensive/Component This health service code was denied as a component of a

comprehensive

97 N19 National Correct Coding Initiative Policy

5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental Policy5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119



Supplemental PolicyI38 Need Newborn Number Need Newborn Number 32 N15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G69 New Patient Visit Allowed Once Per 3 N/A B16 M86 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZB0 Newborn Birth Weight Required Newborn Birth Weight Required 16 M49 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZA7 Newborn Inpt > 30 days require Auth

Newborn Inpt > 30 days require Auth/submit itemized

bill197



Supplemental PolicyZA8 Newborn Inpt >30 day/pymt reduced no aut Newborn inpt>30 days/payment reduced for no auth 210



Supplemental PolicyA50 Newborn inpt >30 days requires

Newborn inpt > 30 days requires auth/submit itemized

bill197



Supplemental PolicyA51 Newborn inpt>30 day/pymt reduce Newborn inpt > 30 days/payment reduced for no auth 210



Supplemental PolicyZB6 NIA Multiple Procedure Discount Applied NIA Multiple Procedure Discount Applied 59 M75 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H06 No Assist Needed For This Procedure Procedure Denied. The procedure code billed does not

require the



Supplemental PolicyXE6 No Attending NPI Submitted No Attending NPI Submitted 16 N253 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V15 No auth existed at time of processing R129:Authorization/Referral Updated 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R24 No Benefit. OIC Pymt Equals/Exceeds L

No Benefit Due. Other Carrier Payment Equals/Exceeds

our Liability23 N9



Supplemental PolicyZMM No CLIA Number on our File No CLIA Number on our File 16 MA120 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X89 No MAID on File No MAID number on file. Contact Provider Services. 16 N253



Supplemental PolicyZJ7 No MAID on file No MAID on file 183 N767 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M97 No Medicaid Allowable, paid at 30% No Medicaid Allowable, paid at 30% 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R27 No PCP Required for PE Member No PCP Required for Presumptive Eligibility Member 24



Supplemental PolicyZ07 No Pre CertAuthorization/ or Referral Authorization/Referral not obtained 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R01 No Precert/Authorization or Referral

Precert/Auth/Notification not obtained, denied or

invalid197



Supplemental PolicyXD4 No referring or ordering NPI submitted No referring or ordering NPI submitted on claim 16 N265 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z58 No supporting doc or ambul run sheet

No supporting documents or ambulance run sheet

received252 N745



Supplemental PolicyB62 No supporting documents received No supporting documents received 16 N29 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B38 Non contracted level of care Non contracted level of care 96 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IH3 Non Covered Charges Non covered charges 96 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSE Non covered member SIU has never received eligibility for this member 31



Supplemental PolicyHSF Non Covered member/plan Member benefits are not payable through this plan 31



Supplemental PolicyHB9 Non -Covered Revenue Code Not a covered revenue code Healthcare 16 M50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H51 Not a Covered Procedure Certain procedures are not covered as deemed by the

plan.



Supplemental PolicyH51 Not a Covered Procedure Certain procedures are not covered as deemed by the

plan.


H51 Not a Covered Procedure Certain procedures are not covered as deemed by the

plan.


HSG Not a Covered Service Not a Covered Service 96 N643 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

HM3 Not Appr to Bill Ext DX code in 1st posNot Appr to Bill External Cause DX in the First ICD

Position167 MA63



Supplemental PolicyHM2 Not Appr to Bill Ext DX W/O another DX

Not Appropriate To Bill An External Cause Diagnosis

W/O another167



Supplemental PolicyG72 Not considered safe and/or effective.

This service was denied because it is not considered safe

and/or effec56



Supplemental PolicyG68 Not Covered For Diagnosis Indicated

This health service code was denied as it is not a

covered service whe16 M76



Supplemental PolicyH74 Not Covered for Diagnosis Indicated This health service code was denied as it is not a

covered service


H99 Not Covered for Provider Specialty Certain procedures are not covered for specific

specialties as deemed



Supplemental PolicyH99 Not Covered for Provider Specialty Certain procedures are not covered for specific

specialties as deemed


G70 Not covered when performed by this prPayment for services is denied when performed by this

specialty/provid184 N808



Supplemental Policy4AY Not cvrd/prv agreement This service is not covered per your provider agreement. 170



Supplemental Policy5 Not cvrd/prv agreement This service is not covered per your provider agreement. 170



Supplemental PolicyR10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V84 Not enrolled on date of service Not enrolled on date of service 31 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G71 Not Included In Opps

This health service code was denied because it is not

recognized under16 M51



Supplemental Policy5BN Notes required

Please submit corresponding operative, radiology or

office notes.252 N710



Supplemental PolicyB26 Nursing Home Confined > 30 Days - Dis

Nursing Home Confined Greater than 30 days-Member

Disenrolled27 N30



Supplemental PolicyX93 NursingHomeConfined >30 Days - Disenr

Nursing Home Confined Greater then 30 days-Member

Disenrolled27 N30



Supplemental PolicyJ70 Observation < 24 hrs Observation < 24 hrs 186 M25 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M71 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 186 N54



Supplemental PolicyZ72 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 60 N676



Supplemental PolicyH95 Only 1 E&M Code Allowed Per Day This E&M service was denied because only 1 E&M

service is allowed for

B14 M86 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyH29 Only 1 Service Allowed per Treatment The allowed course of treatment for this procedure code

has been



Supplemental PolicyG65 Only One Anesthesia Service Per Opera

This procedure was denied because only the anesthesia

service which ha59 N10



Supplemental PolicyHMZ Only one visit allowed per day Only one visit allowed per day B14 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XE3 Operating Prov not enrolled in Medicaid Operating Prov not enrolled in Medicaid Program 16 N262



Supplemental Policy4AP Operative report required

Claim should be re-submitted with copy of operative

report163 M29



Supplemental Policy5DG Operative report required

Claim should be re-submitted with copy of operative

report252 M29



Supplemental PolicyXEM Ordering and Referring Prov NPI is a non

Ordering and Referring Prov NPI is a non-individual per

NPPES Registry16 N265



Supplemental PolicyXD6 Ordering not enrolled in Medicaid Progra Ordering not enrolled in Medicaid Program 184 N767 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEC Ordering NPI is not enrolled with state

Ordering NPI is not enrolled with state as provider type

31- physician16 N265



Supplemental Policy

Revised March 2021

XED Ordering Provider NPI is a non-individuaOrdering Provider NPI is a non-individual per NPPES

Registry16 N265



Supplemental PolicyZB5 Orgl clm processed submit corrected clm

The Original claim has been processed submit a

corrected claim16 N152



Supplemental PolicyV13 Original auth updated w/add'l info R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GA9 Original Claim Number missing or invalid Original Claim Number missing or invalid 16 N152 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XE0 ORP Provider not enrolled in Medicaid

Ordering, Referring, Prescribing Provider not enrolled in

Medicaid16 N253



Supplemental PolicyXE9 ORP Provider not submitted Ordering, Referring, Prescribing Provider not submitted 16 N253



Supplemental Policy920 Other COB

Payment adjusted as the result of coordination of

benefits.22 N4



Supplemental PolicyG18 Other Insurance not Effective on DOS Other insurance was not effective on Date of Service 23 MA17



Supplemental PolicyXE4 Other operating prov not enrolled in Med Other operating prov not enrolled in Medicaid Program 16 N262



Supplemental PolicyR46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limited 119 N362 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limit 119 N362 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J47 Overpayment of physician services R129Total Comp Phy svs incl in Fac paymt 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V46 Overpayment of Physician Services R129:Non-covered svs paid incorrectly 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J48 Overpayment on SPU R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V47 Overpayment on SPU R129Total Comp Phy svs incl in Fac paymt 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V63 Overpayments identified by Concentra R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J46 Overpaymt due to non cover svs pd incorr R129:Non-covered svs paid incorrectly 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V45 Overpymt due to non cover svs pd incorr R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H98 Packaged Incidental Service Payment is included in the allowance for another

service/procedure



Supplemental PolicyJ35 PAD- Passport advantage Lob 1300 R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R83 Paid at Average Wholesale Price Paid at Average Wholesale Price 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 7A1 Paid by auto insurance The claim has been paid by auto insurance. 21 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J58 Panel transfer R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G76 Partial Hospitalization Not Indicate

This health service code was denied because condition

code 41 (Partial16 M44



Supplemental PolicyG52 Partial Hospitalization Requires Men

This health service code was denied because a partial

hospitalization135 MA93



Supplemental PolicyHSL Partial Payment Hold - DOS Partial Payment Hold Based on Date of Service 133 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSK Partial Payment Hold - Rec'd Date Partial Payment Hold based on Received Date 133 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H55 Payable Only W/ Active Intervention

Procedure requires active intervention and is not

payable when107 N674



Supplemental PolicyIH4 Payment adj invalid place of service Payment Adj- treatment deemed rendered in inapp POS 16 M77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


MAT Payment Adj Maternity Kick Payment Payment adjustment for Maternity Kick Payment 144 N422 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IH7 Payment denied when performed by provide Payment is denied when performed /billed by provider

type in type of



Supplemental PolicyHA2 Payment for this service/item is bundled Payment for this service/item is bundled 97 M15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSI Payment Hold - Rec'd Date Payment hold based on Received Date 133 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSJ Payment Hold - DOS Payment hold based on Date of Service 133 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 181 Payment included in DRG Payment included in DRG 97 M86 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R00 Payment Included in Other Billed Serv Payment Included in Other Billed Service 97 M15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZRD Payment Reduced Incomplete PASRR Payment Reduced Due to Incomplete PASRR 272 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I46 Payment reflects combined DRG payment Payment reflects combined DRG payment 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HME Phys.Ther Svs not payble in Hosp.Setting

Physical Therapy Service Is Not Payable In A Hospital

Inpatient5 M77



Supplemental Policy

Revised March 2021

HT3 Place of Service FacilityPlace of Service for this procedure is invalid or not

normally58



Supplemental PolicyJ37 Plan had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R84 Please Obtain Individual Provider ID# Resubmit w/Individual Provider Name/Number 16 N77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 519 Please resub family planning related

Please resubmit family planning related charges to

IUMG109 N130



Supplemental Policy5AJ Please submit charges to Medicare Please submit charges to Medicare. 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5AK Please submit other carrier's info. Please submit other carrier's information. 16 N4 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZR2 Please submit the correct original claim

Please submit the correct original claim number for

consideration95



Supplemental PolicyZR2 Please submit the correct original claim

Please submit the correct original claim number for

consideration95



Supplemental PolicyZQ1 Please Submit to Coastal Care Services 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X84 PleaseObtain Individual Provider ID # Please Obtain Individaul Provider Identification Number 16 N253



Supplemental PolicyI47 Pmt based on DRG transfer policy

Payment is based on DRG transfer policy, DRG discharge

formula45 N381



Supplemental Policy4B3 POA required Present on admission indicator is required 16 N434 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSM POS - Non Facility

POS for this Procedure is invalid or not normally

performed in this5 M77



Supplemental PolicyHSO POS Plan Specific Service Code

Per Plan requirements service code cannot be billed

with the POS5 M77



Supplemental PolicyHSN POS Plan Specific/Service Code

Per Plan requirements specific place of service(s) are

required when5 M77



Supplemental PolicyH04 Post-Op Follow Up Incl in Global Fee The procedure is included in the global surgical fee for a

procedure



Supplemental PolicyRA9 PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109



Supplemental PolicyZZD PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109



Supplemental PolicyHSW Pre Admit Service included in Hospitaliz

3 Day window OP Serv s/b included in IP Stay. Non

Payable Code pd60 N130



Supplemental PolicyR48 Pre-Adm Testing Included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15



Supplemental PolicyX48 Pre-Adm Testing included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15



Supplemental PolicyZ42 Pregnancy Risk Assessment Form Req'd Completed Pregnancy Risk Assessment Form Required 252 N80



Supplemental PolicyZA9 Pregnancy Risk Assessment Form Required Completed Pregnancy Risk Assessment Form Required 252 N80



Supplemental PolicyH50 Prev Proc/Paid to Same/Diff Provider Same procedure has been paid or processed to the

same or different



Supplemental PolicyR49 Previous Payments = to Purchase Pric Previous Payments Equal to Purchase Price B13 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X49 PreviousPayments = to Purchase Price Previous Payments Equal to Purchase Price 119 M7 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G57 Price of Lab Panel Components Exceed

The price of the individual lab panel components have

exceeded the pri97 N130



Supplemental PolicyV25 Prim ins listed in Facets(Non Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J27 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V26 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J26 Primary ins listed in Facets/Non Medicar R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H12 Primary Procedure Must be Billed The procedure was denied because it requires an

accompanying procedure

107 MA66 CMS Coverage Policies

H12 Primary Procedure Must be Billed The procedure was denied because it requires an


107 MA66 CMS National Coverage Determinations (NCD) Policy

Revised March 2021

H12 Primary Procedure Must be Billed The procedure was denied because it requires an


107 MA66 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyA52 Primary/Sec Diagnosis POA Error Primary/Sec Diagnosis POA Missing/Invalid 167 N607 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z67 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76



Supplemental PolicyZ68 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76



Supplemental PolicyG46 Principal Diagnosis Inappropriately C

The principal diagnosis has been inappropriately coded

based upon ICD-11 MA63



Supplemental PolicyG75 Principal Diagnosis Invalid

This health service code was denied because it was

submitted with an i11 MA63



Supplemental PolicyZC8 Principal Surg Code is missing/invalid Principal Surgical Procedure is missing or invalid 16 MA66 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H66 Principle Diagnosis incorrectly utilized Missing/Incomplete/Invalid Principle Diagnosis 16 MA63 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative IH2 Proc Code and Mod inval of DOS Payment adjustment because the procedure and

Modifier invl on DOS


IH6 Proc code changed to acc desc svs Procedure code changed to accurately desc. The

services rendered



Supplemental PolicyV76 Proc Code isnt payable w T1015 Procedure Code isnt payable w T1015 236 N657 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V75 Proc Code required with T1015 Procedure Code required with T1015 16 M51 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 461 Proc processed on separate claim id This claim has been processed under a separate claim id. B13



Supplemental PolicyHM8 Proc. is Mut. Excl, Non Pay Cd pd prior

Mutually Excl.Proc is listed on Prior claims run For the

same DOS.231



Supplemental Policy433 Procedural modifier(s) required The service submitted requires a procedural modifier. 4



Supplemental Policy5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4



Supplemental Policy5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4



Supplemental PolicyH31 Procedure Bilateral in Nature This procedure was adjusted because the service is

bilateral in nature



Supplemental PolicyEB4 Procedure Billed not part of Members Evi

Procedure Billed not part of Members Evidence Based

Program16 M51



Supplemental PolicyB15 Procedure code billed is not correct

Procedure code billed is not correct/valid or the date of

service bill16 N56



Supplemental PolicyG29 Procedure Code Definition


included in the CPT97 M51



Supplemental PolicyG30 Procedure Code Guideline

This service code was denied because it is

inappropriately coded based4 N657



Supplemental PolicyH16 Procedure Code Inapp. for Age The age of the patient does not correlate with the

submitted procedure



Supplemental PolicyH71 Procedure Code Inappropriately Coded This service was denied because it is inappropriately

coded based on



Supplemental PolicyH91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more

appropriate



Supplemental PolicyH91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more

appropriate

16 M81 CMS Coverage Policies

H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the

circumstances in

16 M81 National Correct Coding Manual Policy


circumstances in



Supplemental PolicyH97 Procedure Code Inappropriately Coded This procedure code has been denied based on the

circumstances in

16 M81 National Correct Coding Initiative Supplemental Policy


circumstances in

16 M81 CMS Coverage Policies

Revised March 2021


circumstances in

16 M81 CMS National Coverage Determinations (NCD) Policy

434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5AP Procedure code incorrect The procedure code submitted is not correct. 16 M20 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H14 Procedure Code Incorrect For Gender The gender of the patient does not correlate with the

submitted



Supplemental PolicyV78 Procedure code is age restricted

Members age is not within the coverage range for this

procedure code6 N129



Supplemental PolicyHMR Procedure code is missing or invalid

The Procedure code is missing or invalid at Time of

Service16 M20



Supplemental Policy435 Procedure code not eligible for reimburs

The submitted procedure code is not eligible for

reimbursement.181 N56



Supplemental Policy5AQ Procedure code not eligible for reimburs

The submitted procedure code is not eligible for

reimbursement.16 M20



Supplemental PolicyH13 Procedure Code Not Valid for DOS The submitted procedure code is no longer valid. Please

resubmit



Supplemental Policy550 Procedure does not require team surg Procedure does not require team surgery 54 N646 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G77 Procedure Included With E/M Service


included as part of97 M15



Supplemental PolicyG78 Procedure Invalid For Medicare Purpos

This health service code was recoded to a valid code for

Medicare.16 M51



Supplemental PolicyHM7 Procedure is Mutually Exclusive

Procedure is Mutually Ex. Not Poss.For both Proc.to

Occur at same time231



Supplemental PolicyH63 Procedure Recoded Based on Age The procedure code has been recoded based on the age

of the patient.



Supplemental PolicyG73 Procedure Recoded To Delivery Only Se

This health service code was changed to reflect that the

provider did169 N10



Supplemental PolicyH83 Procedure Recoded To Delivery Only Servi

Code was changed to reflect that the provider did not

provide the45 N22



Supplemental PolicyHMJ Procedure should be bundled

Procedure should be bundled in an All Inclusive

Procedure234 M15



Supplemental Policy436 Processed according to negotiated rate.

The claim has been processed according to a negotiated

rate.45



Supplemental Policy5AR Processed according to negotiated rate.

The claim has been processed according to a negotiated

rate.45



Supplemental PolicyJ55 Processin rules(OLH) incorr/ not updated R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V54 Processing rules(OLH) incorr/ not update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G74 Professional Component Not Payable Fo

This procedure was either billed as a professional

component or it was16 N184



Supplemental PolicyV64 Prov rec'd pymnt from pri/no reimb rec'd R129: Prior Processing Information Appears Incorrect 129 MA67



Supplemental PolicyV40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R94 Prov#Submitted via EDI Incorrect/Ter Provider# Submitted EDI Incorrect/Termed 16 N77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X94 Prov#Submitted viaEDI Incorrect/Termd

Provider Number Submitted via EDI

Incorrect/Terminated16 N77



Supplemental PolicyG21 Provider Adjustment Provider Adjustment 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EB1 Provider and Member not enrolled in Evid

Provider and Member not enrolled in Evidence Based

Program272



Supplemental Policy438 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5AT Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 620 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 7AE Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZJ8 Provider Not Active in Facets Provider Not Active in Facets 16 N253 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

439 Provider not certified for service The provider is not certified for the service provided. B7ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyEB2 Provider not enrolled in Evidence Based Provider not enrolled in Evidence Based Program 272



Supplemental PolicyXB2 Provider on Payment Suspension Provider on Payment Suspension 133 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 9C2 Provider payment adjustment Copay extension, provider payment adjusted 45 N419 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 472 Provider terminated Billed after providers termination date with plan. B7



Supplemental Policy5BZ Provider terminated Billed after providers termination date with plan. 147



Supplemental PolicyX77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209



Supplemental PolicyX77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209



Supplemental PolicyHT5 Provider Type Billed Services

The Provider's Specialty Type has a limitation of service

codes8 N95



Supplemental PolicyHT4 Provider Type/Service not allowed

The Specialty of the provider performing this service is

not allowed170 N95



Supplemental PolicyHT6 Provider Type/Service Specialized

This Service Code can only be billed by Certain Provider

Types.8 N95



Supplemental PolicyR72 Provider was Not Member's PCP Provider was not the members PMP 242 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B43 Provider was not members PMP Provider was not the members PMP 184 N808 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R74 Pru Layperson Review Completed; Emer

Prudent Layperson Review Completed; Emergent rate

paid16 N78



Supplemental PolicyJ67 Prudent lay review complete Prudent lay review complete 45 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 111 Prudent lay review completed;nonemerg Prudent lay review completed; nonemergent 40 N627 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 99 Prudent Layperson Rev Comp: Prudent Layperson Rev Comp: 1st Level Screening Paid 216 N115



Supplemental Policy96 Prudent Layperson Rev Comp 1st Level Prudent Layperson Rev Comp: 1st Level Screening Paid 150 N115



Supplemental PolicyB44 Prudent Layperson Review Completed;E

Prudent Layperson Review Completed: Emergent rate

paid216 N115



Supplemental PolicyJ60 Prvdr billed proc units > than allowed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V59 Prvdr billed proc units > than allowed. R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J34 Prvdr settlmt- settlmt adjustment R129:Settlement Adjustment 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V32 Prvdr settlmt- settlmt adjustment R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M01 Pymt $150,000 or over may be audited

Any payment of $150,000 or over may be subject to

audit133 N26



Supplemental PolicyH33 Pymt Includes Svcs for Pre/Intra Op Each provider is reimbursed according to the portion of

surgical

B20 N22 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyEAO Pymt reflects COB for QMB Plus member

Payment reflects Coordination of Benefits for a QMB

Plus member23



Supplemental PolicyEA0 Pymt reflects COB for QMB Plus membr

Payment reflects Coordination of Benefits for QMB Plus

member23



Supplemental PolicyJ82 Pymt reflects COB for QMB Plus membr

Payment reflects Coordination of Benefits for QMB Plus

member23



Supplemental PolicyR47 Pymt reflects COB, if $0, max liab me

Payment reflects Coordination of Benefits, if $0, max

liability met23 N9



Supplemental PolicyB60 Pymt reflects COB,if $0, max liab met

Payment reflects Coordination of Benefits, if $0, max

liability met23 N23



Supplemental PolicyHC6 Qty Exceeds Max - Specified Rolling(Deny

Per Plan Guidelines, the quantity maximum for specified

time period119 N640



Supplemental Policy

Revised March 2021

HC2 Qty Exceeds Max - Unspecified(Roll/Deny)Per Plan guidelines, the Quantity Maximum for Specified

time period119 N640



Supplemental PolicyHC5 Qty Exceeds Max Specified Calendar(Deny)


time period119 N640



Supplemental PolicyHC4 Qty Exceeds Max -Specified Fiscal


time period119 N640



Supplemental PolicyHC3 Qty Exceeds Max- Unspecified


time period119 N640



Supplemental PolicyHC7 Qty Exceeds Max-Time Span Rule/One Day


time pd has119 N640



Supplemental PolicyB07 Quality Review Processing Quality Review Processing 133 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HC9 Quantity Invalid Quantity of service exceeds the payor specified limit 119 N640



Supplemental PolicyHC8 Quantity Payor Specific Quantity of service exceeds the payor specified limit 119 N362



Supplemental PolicyJ39 RCA R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J41 RCC-use this code on Orig. claim R129: Revd Corrected Claim from Prvdr 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 9D1 Rebundled to current/historical claim

Adjustment-Current or added procedure has been

rebundled to a global97 M15



Supplemental PolicyR07 Received after Timely Filing Limit Received after Timely Filing Limit 29 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H90 Recoded Procedure Code

The billed procedure was recoded to a more appropriate

procedure code181 N22



Supplemental PolicyH25 Recoded to Complete Procedure Code Based on the other procedures billed for this service

date, this code



Supplemental PolicyG58 Recoded To The Least Costly Alternat

The procedure has been recoded to a procedure code

representing the le189 N657



Supplemental PolicyH75 Recoded to the least Costly Alternative The Procedure has been recoded to a procedure code 181 N22



Supplemental PolicyG25 Recover Review Recovery Review 133 N421 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X58 RecoveryForwardedToState per Contract Recovery Forwarded to State per Contract Agreement 129 MA67



Supplemental PolicyH23 Reduction for Ionic Contrast Media

When non-ionic contrast media is submitted a reduction

will be taken97 M15



Supplemental Policy982 Reduction for multiple surgical proc Adjusted - reduction for multiple surgical procedures. 59 N10



Supplemental PolicyXD7 Referring & Ordering not enrolled in Med

Referring and Ordering not enrolled in Medicaid

Program.183 N767



Supplemental PolicyXD5 Referring not enrolled in Medicaid Progr Referring not enrolled in Medicaid Program 183 N767 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEE Referring NPI is not enrolled with state

Referring NPI is not enrolled with state as provider type

31-physician16 N286



Supplemental PolicyXEF Referring Provider NPI is a non-individu

Referring Provider NPI is a non-individual per NPPES

Registry16 N286



Supplemental PolicyEQ1 Reimbursement exceeds $50K resubmit with

Anticipated reimbursement exceeds $50K resubmit with

Itemized Bill252 N26



Supplemental PolicyM75 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative Z84 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 183 Rendering NPI not for Provider ID Box 31 Rendering NPI not for Provider ID in Box 31 208 N77 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XEJ Rendering Prov does not have an active

Rendering Prov does not have an active license on claim

DOSB7 M143



Supplemental PolicyXE5 Rendering prov not enrolled in Medicaid Rendering prov not enrolled in Medicaid Program 16 N290



Supplemental PolicyZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290



Supplemental PolicyZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290



Supplemental Policy

Revised March 2021

G37 Rental Cap ExceededThe billed equipment was denied because the maximum

number of rentals108 N370



Supplemental PolicyH73 Rental Cap Exceeded The billed equipment was denied because the maximum

number



Supplemental PolicyR62 Reprocessed - Claim Subject to Intere Reprocessed - Claim Subject to Interest 225 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I28 Reprocessed-claim subject to interest Reprocessed-claim subject to interest 225 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B25 Req'd Prescrip. from MD not Attach/Va Required Prescription from MD not Valid/Attached 16 N31



Supplemental PolicyX92 Req'dPrescrip. fromMDnot Attach/Valid Required Presciption from MD not Attached/Valid 175



Supplemental Policy4B1 Request info not recd from pvdr Requested information not received from provider 226 N517



Supplemental PolicyR09 Requested Hosp Documents not Rec'd Requested Hospital Documents not Received 252 M127 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4AT Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5DK Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZD3 Required Medicaid Elements Missing Required Medicaid Encounter Data Elements Missing 16 N350



Supplemental PolicyHS8 Required Modifier Missing

This service was billed without the plan required

modifier4 N519



Supplemental PolicyXA8 Required Service not performed/reported Required Service not performed/reported 16 N149 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZA4 Restricted Member Auth Required Restricted Member Auth Required 243 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 182 Restricted Member-Auth Required Restricted Member-Auth Required 197 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I48 Resub Primary Carrier/Appeal Process Resubmit to Primary Carrier for Appeals Process 22 N36 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZA5 Resub Primary Carrier/Appeals Process Resubmit to Primary Carrier for appeals processing 22 N598



Supplemental PolicyB16 Resub w/ ICD prin proc, HCPC or CPT

Resubmit with ICD9 pinciple procedure code or valid

HCPCS or CPT Code16 M20



Supplemental PolicyI69 Resub w/ICD prin proc, HCPC or CPT

Resubmit with ICD9 principle procedure code or valid

HCPCS or CPT Code16 MA66



Supplemental Policy460 Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5BF Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 4AX Resubmit on ub04 Please resubmit these charges on a ub04 claim form. 16 N34



Supplemental PolicyA85 Resubmit to Behavioral Health Contractor Resubmit to Behavioral Health Contractor 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZC7 Resubmit to MCNA

Dental Claims for members under 21 should be

submitted to MCNA109



Supplemental PolicyZC7 Resubmit to MCNA

Dental Claims for members under 21 should be

submitted to MCNA109



Supplemental PolicyI37 Resubmit w/ Approp. Modifier and/or U Resubmit with Appropriate Modifier and/or Units 4 N517



Supplemental PolicyI44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 181 N56



Supplemental PolicyX44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 16 MA66



Supplemental Policy180 Resubmit w/Registered Billing Provider Resubmit w/Registered Billing Provider 170 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G50 Resubmit With Appropriate G Code

This health service code was denied because it was not

reported with t16 M51



Supplemental PolicyGB6 Resubmit with breakdown of pri ins pymt Resubmit with breakdown of primary ins payment 251 N480



Supplemental Policy575 Resubmit with Medicaid RID, Former PE Resubmit with Medicaid RID, Former PE 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B22 Resubmit with NDC# Resubmit with Valid NDC# 16 M119 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G31 Resubmit With Supporting Documentati

Supporting documentation is needed in order to

adjudicate this claim.151 N435



Supplemental PolicyHA1 Resubmit with Supporting Documentation Resubmit with Supporting Documentation 16 M127 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B34 Resubmit with visit codes & charges Resubmit with visit codes & charges 16 M49 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

Z48 ResubPrimaryCarrier/Appeals Process Resubmit to primary carrier for appeals processing 22 N598ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental PolicyR05 ResubtoPassport Advantage(primary)

Please submit to Passport Advantage (primary carrier)

for processing109 N130



Supplemental PolicyJ30 Retro Benefit change former PE Mbr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G26 Retro benefit Change Former PE Memb Retro Benefit change-Former Presumptive Eligibility 96 N30



Supplemental PolicyV29 Retro Benefit change former PE member R129:Work Comp is Primary 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 984 Retro change to the provider's contract Adjusted - retroactive change to the provider's contract. 45 N419



Supplemental PolicyJ09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J38 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V37 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M96 Retro Review/Continued Stay Project Retro Review and Continued Stay Project 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G82 Return To OR Payment Adjustment

This health service code was adjusted to reflect that the

billed servi172



Supplemental PolicyHMV Rev Code cannot be billed w othr Rev Cod

Revenue Code cannot be billed with other billed

Revenue Code16 M50



Supplemental PolicyHMT Rev Code requires a Procedure Code This Revenue Code Requires a Procedure Code 16 M20 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 444 Revenue code requires CPT/HCPCS code

The revenue code submitted requires a CPT/HCPCS

code.16 M51



Supplemental Policy925 Reviewed v no additional payment made Reviewed v no additional payment made 193 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J56 RHC(Rural Health Center) not applied R129:RHC (Rural Health Center) Not App. 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative EQ2 Rmbrsmnt amnt determined by Equian Reimbursement amount determined by Equian 45 N10 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZPC Same day dschrg, rsbmt as optnt Same day discharge, resubmit as outpatient 152 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J44 Same proc. pd to different prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V43 Same Proc. Pd to different Prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B20 M86 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B13 N472 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure

code has been



Supplemental PolicyH52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure

code has been


H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure

code has been


H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure

code has been


J22 Secondary coverage listed,no EOB on file R129:Secondary EOB req 16 MA64 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H81 Secondary Diagnosis Missing Or Invalid This health service code was denied because a required

secondary

16 M76 CMS National Coverage Determinations (NCD) Policy

V21 Secondary ins listed, no EOB on file R129:Illegible/incomplete EOB Attached 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M02 Send itemized bill to MDHA Send itemized bill to: MDHA 5604 Fortune Circle S, 133 N26



Supplemental PolicyG85 Separate Payment For Services Not Pro

The billed services were denied because services on the

Separate Payme97 M15



Supplemental PolicyG56 Separate Procedures Not Separately Pa This procedure was denied because procedures

designated as inpatient o



Supplemental PolicyG84 Service Denied Because Of Potential I

The drug was denied because another drug was billed

recently that coul18 N702



Supplemental PolicyB47 Service Exceeds Lifetime Limitation Service Exceeds Lifetime Limitation 149 N587 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 N587 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R51 Service Not Covered Service Not Covered 96 N30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021

X51 Service Not Covered Services Not Covered 96 N30 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative GB7 Service not in Provider's Profile Service not in Provider's Profile B7 N570 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 449 Service not payable in this specialty The service provided is not payable in this specialty. B7 N95



Supplemental PolicyR04 Service Not payable with other serv

Service not payable with other service rendered on the

same date97 M15



Supplemental Policy5B5 Service performed by another provider

The service submitted was performed by another

provider.B20



Supplemental PolicyG35 Service Processed As A Bilateral Pro

This health service code was adjusted to reflect the

allowed amount fo59 N644



Supplemental Policy451 Service rendered by ineligible provider The service rendered was by an ineligible provider. B7



Supplemental Policy4BN Service was adjusted due to fee schedule Service was adjusted due to fee schedule update 169 N10



Supplemental PolicyRA4 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15



Supplemental PolicyRA5 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15



Supplemental Policy906 Services after policy expiration date

Adjusted - expenses incurred after coverage

termination.27



Supplemental PolicyR76 Services Denied Telephonically Services Denied Telephonically at Time of Service 39



Supplemental Policy483 Services disallowed by UM Services were disallowed by Utilization Management. 96 N35



Supplemental Policy5CD Services disallowed by UM Services were disallowed by Utilization Management. 96 N35



Supplemental Policy9A5 Services included in primary procedure Adjusted - services included in primary procedure. 97 N19



Supplemental Policy988 Services not authorized Adjusted - required authorization was not obtained. 16 M62



Supplemental Policy9C9 Services not authorized Adjusted - required authorization was not obtained. 197



Supplemental Policy929 Services not cov'rd per benefit package Adjusted - services are not covered per benefit package. 204 N130



Supplemental PolicyB31 Services not medically necessary Services not medically necessary 50 N372 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative B57 Services not medically necessary Services not medically necessary 50 N661 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 990 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 9A7 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 991 Services performed by another provider Adjusted - services performed by another provider. B20



Supplemental Policy9C5 Services performed by another provider Services performed by another provider B20 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 909 Services prior to policy effective date

Adjusted - expenses incurred before coverage effective

date.26



Supplemental Policy930 Services prior to policy effective date

Adjusted - expenses incurred before coverage effective

date.26



Supplemental Policy179 Services to be paid on separate remit Services to be paid on separate remit B11 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R53 Services were not Provided Services were not Provided 112 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X53 Services were not Provided Services were not Provided 16 N99 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270



Supplemental PolicyZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270



Supplemental PolicyZI3 Servicing Provider Taxonomy not match

Servicing Provider Taxonomy does not match with the

Taxonomy on file16 N94



Supplemental Policy

Revised March 2021

ZI3 Servicing Provider Taxonomy not matchServicing Provider Taxonomy does not match with the

Taxonomy on file16 N94



Supplemental PolicyZI4 Servicing Provider Taxonomy not present

Servicing Provider Taxonomy not present on Submitted

Claim16 N94



Supplemental PolicyZI4 Servicing Provider Taxonomy not present

Servicing Provider Taxonomy not present on Submitted

Claim16 N94



Supplemental PolicyG59 Site Of Service Differential

The payment for this procedure was reduced because it

was performed at5 M77



Supplemental PolicyZG0 SIU Adjustment SIU Adjustment-Program Integrity 216 N35 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZG1 SIU Overpayment Settlement SIU Overpayment Settlement-Program Integrity 216 N35 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 80 SIU Settlement Adjustment

Settlement Adjustment/no change in outcome-Program

Integrity216 N35



Supplemental PolicyZG2 SIU Settlement Adjustment

Settlement Adjustment/no change in outcome-Program

Integrity216 N35



Supplemental PolicyHMP Spec Billed Serv Code combo not payable

Based on NCCI, the Specific billed service code combo is

not payable.236



Supplemental PolicyR79 Special Project-Adjustment Special Project-Adjustment 45 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X79 Special Project-Adjustment Special Project-Adjustment 45 N381 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSR State Code Combination

Per State Regulations the specific Billed Service code

Combination is199 N657



Supplemental PolicyHSS State Code Combination - Hospital

Hospital Outpatient - Per State Regulations the specfic

billed service199 N657



Supplemental PolicyJ32 State Encounter error received R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V30 State Encounter error received R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative XA4 Sub. itemized bill does not match UB/CMS

Submitted itemized bill does not match UB/CMS Please

resubmit16 N232



Supplemental PolicyBEH Submit claim to Magellan Behav Healt Submit claim to Magellan Behavioral Health 109 N130 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZZA Submit Consent Form Submit Consent Form 252 N3 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 454 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5B9 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5B7 Submit original billed amount Please submit claim with the original billed amount. 16 M54



Supplemental PolicyXEI Supervising provider not enrolled in Med Supervising provider not enrolled in Medicaid Program 16 N253



Supplemental PolicyZZ1 Supporting documentation missing/invalid

Speciifc documentation required for payment is missing

/illegible/dupl252 N729



Supplemental PolicyZZ2 Supporting documentation missing/invalid

Speciifc documentation required for payment is missing

/illegible/dupl252 N729



Supplemental Policy482 Supporting documentation required Supporting documentation required 16 N29 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5CC Supporting documentation required Supporting documentation or medical records required 252 M127



Supplemental PolicyH94 Surg & Asst Surg Can't Be The Same This code can not be paid as a Surgical assist when the

same provider



Supplemental PolicyHM5 Surgical Proc Rptd after E&M Payment

Surgical Proc Rptd after pymt of E&M. E&M Svs are

Between The Global97 M15



Supplemental PolicyHM6 Surgical Proc Rptd after E&M Payment

Surg. Proc Rptd after pymt of E&M. Svs. E&M Svs is

between the Global.97 M15



Supplemental Policy640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130



Supplemental Policy640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130



Supplemental Policy7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130



Supplemental Policy

Revised March 2021

7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Supplemental Policy932 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130



Supplemental Policy993 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130



Supplemental Policy9B0 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130



Supplemental PolicyV74 T1015 cant be billed for your prv type T1015 cant be billed for your provider type 8 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V73 T1015 must be billed for your prv type T1015 must be billed for your prv type 8 N95 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSV Team Surgeons not allowed Team Surgeons not allowed for this procedure 54 N646 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative H54 Technical Service Not Payable for POS This procedure is billed as a technical component and is

not payable



Supplemental PolicyG87 Technical/ Professional Service Inapp

The technical and professsional components of the

procedure were inapp16 N184



Supplemental PolicyG86 Terminated Procedure Cannot Be Billed

The procedure was denied because, it is inappropriate

to bill a proced181 N56



Supplemental PolicyG62 The Service Code Is Inconsistent With

This health service code was either denied or modified

because it is n4 M20



Supplemental PolicyHMM This is a Bilateral Code

This is a Bilat code. Modifier LT, RT, 50 or Qty 2 not

applicable.4 N519



Supplemental PolicyHMF This Procedure is an Add On Code

This Procedure is an Add on Code and must be billed

with the234 N122



Supplemental PolicyHMG This Procedure is an Add On Code

This Procedure is an Add On Code and must be billed

with the234 N122



Supplemental PolicyHMS This Revenue code is invalid This Revenue code is invalid 16 M50 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative I81 Time not Validated on Medical Record Time not Validated on Medical Records B12 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative HSU Time of Filing - 1 year

Date of Procedure in Excess of 1 year prior to receipt of

claim29



Supplemental PolicyJ10 Timely filing inappr or paid incorr. R129:Timely Filing Incorrectly Applied 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative M98 Total Amt Still Under Consideration Total Billed Amount Still Under Consideration 133 N372 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V62 TPL identified by PCG R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J23 TPL information input incorrectly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V61 TPL information input incorrectly R129: Prior Processing Information Appears Incorrect 129 N48



Supplemental PolicyV24 TPL received/updated after clm proces'd R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J25 TPL received/updated after clm processed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative R17 Under Review for COB processing Under Review for COB processing 133 N35 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 0UN Ungroupable DRG

Claim data is missing, incomplete or invalid. No DRG

found.A8 N208



Supplemental PolicyH30 Units Adjusted Exceeds Allowed Amt

The units for the billed procedure code have been

adjusted to reflect151 CMS National Coverage Determinations (NCD) Policy

H30 Units Adjusted Exceeds Allowed AmtThe units for the billed procedure code have been

adjusted to reflect152



Supplemental Policy655 Units exceed UM authorization Units exceed a utilization management authorization 222



Supplemental Policy7B7 Units exceed UM authorization Units exceed a utilization management authorization 222



Supplemental Policy7B7 Units exceed UM authorization Units exceed a utilization management authorization 222



Supplemental PolicyZB9 Units reduced by NIA authorization Units reduced by NIA authorization 39 N35 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 658 Unlisted procedure code

The submitted code is disallowed because the

procedure code is189 N657



Supplemental Policy659 Unlisted procedure code

The submitted code is disallowed because the

procedure code is189 N657



Supplemental Policy

Revised March 2021

G15 Valid EOB on File Valid EOB on File 23 M32 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative G14 Valid Referral/Authorization on File Reprocessed Claim-Valid Referral/Authorization 198 N758 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative ZH7 VBP Payment-FBMH

Value Based Purchasing Payment-Family Based Mental

Health144 N422



Supplemental PolicyZH8 VBP Payment-FBMH

Value Based Purchasing Payment-Family Based Mental

Health144 N422



Supplemental PolicyHMW Verfiy Benefits and Elig

Verfiy Benefits and Eligibility for Services Provided in a

State58



Supplemental Policy90 Void/cancel of prior claim Adjusted - void/cancel of prior claim 16 N798 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J29 Workers Comp is Primary R129:Work Comp is Primary 19 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative V28 Workers Comp is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative X13 Workers Comp Primary Carrier Workers Compensation Primary Carrier 19 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative 5C3 Wrong CPT-modifier combo Inappropriate procedure-modifier combination 4 N519 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding

Manual Policy; CMS Coverage Policies; National Correct Coding Initiative Policy; National Correct Coding Initiative J08 Wrong info received from state R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy is in alignment with CMS National Coverage Determinations (NCD) Policy; National Correct Coding


Revised March 2021