Denial Code Lookup

The amount applied to the patient's deductible. This is a patient responsibility amount, not a denial per se, but frequently confuses providers.

The amount applied as the patient's coinsurance responsibility after the deductible has been met.

The amount collected or to be collected from the patient as a co-payment for the service.

These are non-covered services because this is not deemed a 'medical necessity' by the payer. The payer has determined the service is not medically necessary based on their clinical criteria.

Payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

The authorization number is missing, invalid, or does not apply to the billed services or provider.

Precertification/authorization/notification absent. Required precertification, authorization, or notification was not obtained in a timely manner.

Precertification/notification/authorization number may be required but was not provided or was invalid.

The procedure code is inconsistent with the modifier used, or a required modifier is missing.

Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Could be missing demographics, invalid NPI, or missing modifiers.

Exact duplicate claim/service. The payer has already processed an identical claim with the same information.

The time limit for filing has expired. The claim was not submitted within the payer's required timeframe.

Non-covered charge(s). At least one remark code must be provided to explain the non-covered charges.

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This is a bundling denial.

Expenses incurred prior to coverage. The date of service is before the patient's coverage effective date.

Expenses incurred after coverage terminated. The date of service is after the patient's coverage end date.

Claim/service not covered by this payer/contractor. You must send the claim to the correct payer/insurer.

Benefit maximum for this time period or occurrence has been reached. The patient has exhausted their allowed visits or dollar amount for this service category.

This service/equipment/drug is not covered under the patient's current benefit plan.

Services denied at the time of authorization, or at the time the claim was processed, because the service was already provided or paid by another provider.

The rendering provider is not eligible to perform the service billed. This may be due to licensing, credentialing, or network status.

Services not provided by network/primary care provider. The service was rendered by an out-of-network provider.

The procedure code/bill type is inconsistent with the place of service. The billed location does not match where the service should be performed.

The diagnosis is inconsistent with the procedure. The ICD-10 code does not support the CPT/HCPCS code billed.

The diagnosis is inconsistent with the provider type. The diagnosis billed is not within the scope of the billing provider's specialty.

This care may be covered by another payer per coordination of benefits. The payer believes another insurance should be primary.

Patient cannot be identified as our insured. The payer cannot locate the patient in their system with the information provided.

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. The billed amount is greater than the payer's allowed amount.

This (these) diagnosis(es) is (are) not covered, or are missing or are invalid. The diagnosis code is not payable under the patient's plan.

Payment is denied when performed/billed by this type of provider. The payer does not cover this service when performed by the billing provider's specialty.

Procedure code was invalid on the date of service. The CPT/HCPCS code used has been deleted or was not yet effective.

National Provider Identifier - missing. The required NPI was not included on the claim submission.

National Provider Identifier - Invalid format or not a valid NPI. The NPI number submitted is not in the correct format or does not exist in NPPES.

This procedure is not paid separately. The service is considered part of another procedure and is bundled into that procedure's reimbursement.

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day.

An attachment/other documentation is required to adjudicate this claim/service. Additional clinical records or documentation must be submitted.

Sequestration - reduction in federal payment. Automatic across-the-board reduction in Medicare payments required by federal law.

Coverage/program guidelines were not met. The payer's specific coverage criteria for this service were not satisfied.

This is a non-covered service because it is a routine/preventive/screening procedure or service not covered under the patient's benefit plan.

Payment adjusted because charges were paid by the primary payer. This payer is secondary and adjusting based on what the primary already paid.

Procedure/treatment/drug is deemed experimental, investigational, or unproven by the payer. The payer does not consider this an established standard of care.

Procedure/treatment has not been deemed 'not medically necessary' because the same or similar service was recently provided.

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

Charges are adjusted based on multiple/concurrent procedure rules. When multiple procedures are performed at the same session, payment for subsequent procedures is typically reduced.

Services denied at the time of adjudication because the professional component was already billed or included in another service.

The related or qualifying claim/service was not identified on this claim. This service is considered integral to a previously billed procedure.

Submission/billing error(s). Payment adjusted due to errors in the claim submission that need correction.

Newborn care service is not covered because the service is bundled with the mother's delivery charges.

Prior processing information is required from another payer before this claim can be adjudicated.

Claim submission fee was not included with the claim or is insufficient. Some workers' comp or auto payers require a submission fee.

Claim-specific negotiated discount. The payment reflects a negotiated rate for this particular claim.

The disposition of this claim/service is pending further review. The payer has not yet made a final determination.

Claim or plan/benefit is not included in the current plan. The service falls under an exclusion in the patient's specific benefit plan.

Patient/Insured health identification number and target employer's name and/or identification number are not consistent.

A managed care withholding amount has been deducted from the payment. This is a contractual withhold that may be returned based on performance.

Diagnosis was invalid for the date(s) of service reported. The ICD-10 code may be invalid, unspecified, or not supportive of the procedure.

Lifetime benefit maximum has been reached for this service/benefit category. The patient has exhausted their total lifetime allowance.

Payer deems the information submitted does not support the level of service for this date of service. Prior authorization was not obtained.

Injury/illness was the result of work-related activities. Claim should be filed under workers' compensation insurance.

Injury/illness was the result of an auto accident. Claim should be filed under the auto insurance policy.

Injury/illness is the result of an accident other than auto or work. Claim may need to be filed under liability or other insurance.

Attachment/other documentation that was requested to adjudicate this claim/service was not received or was insufficient.

Penalty for failure to comply with payer requirements such as timely claim filing, required notifications, or documentation standards.

Incorrect patient or insured identification used for this claim. Benefits determined based on wrong patient information.

Payment is reduced due to a tax levy against the provider. The IRS or state tax authority has placed a levy on the provider's payments.

Payment is adjusted when performed/billed by a provider of this specialty/type. The contracted rate for this provider type results in a different payment.

Service/equipment has been provided as part of another service or equipment already adjudicated. This is considered a duplicate of a previously paid service.

Service was not authorized by the primary care provider or required referral was not obtained.

Payment adjusted because the patient was not referred to an in-network provider or the out-of-network service was not authorized.

Claim was not submitted within the required timely filing period established by the payer. Different from code 29 which is more general.

Patient was not enrolled with the managed care plan on the date of service. Coverage was not active when the service was rendered.

Dates of service are prior to the patient's date of coverage with this payer.

Services provided after the patient's date of coverage termination with this payer.

The procedure modifier was invalid on the date of service. The modifier used is not valid for the time period or is not recognized.

The revenue code is not valid for the date of service. Common on facility (UB-04) claims when the revenue code has been retired or is not yet effective.

The referring provider is not eligible to refer the service billed. May be due to credentialing, licensing, or network status of the referring provider.

Level of care adjustment. The level of service billed does not match the payer's determination of the appropriate level of care.

The ordering/referring provider is not on file with the payer. The payer has no record of this provider in their system.

Not otherwise classified or the determination is not classified under a standard code. The payer's reason for the adjustment doesn't fit standard categories.

Payment is adjusted when a bilateral procedure is billed. Standard bilateral reduction may apply, or the procedure may not be recognized as bilateral.

Non-standard adjustment code from the payer. The reason for the adjustment is specific to the payer's internal processing rules.

Original payment decision reversed. This service was originally denied but is now being approved for payment.

Anesthesia services are adjusted based on the payer's anesthesia payment methodology (base units + time units).

Refund of overpayment is due back to the payer. A previous payment was made in error and the payer is requesting a refund.

Revenue code and procedure code do not match or revenue code is not valid for the service billed on this institutional claim.

Expenses incurred during a lapse in coverage. Service was rendered during a period when the patient's coverage was not active.

Service is excluded under the patient's workers' compensation plan. The service is not covered under the workers' comp claim.

Non-covered personal comfort or convenience services. The service is considered a personal convenience item not covered under the plan.

Service was discontinued or reduced. The procedure was not completed as planned, and payment is adjusted accordingly.

National Provider Identifier - not matched. The NPI on the claim does not match the payer's records for the billing or rendering provider.

Payment adjusted because the per-day limit for this procedure or service has been exceeded. Only a certain number of units per day is covered.

Payment adjusted because the number of visits or services exceeds the per-visit limitation for this type of service.

Payment adjusted because the service is provided by a plan/network provider, but benefits are not available for this particular service.

Payment adjusted because the laboratory or pathology service is included in the allowance for the primary procedure.

Payment adjusted because the service or supply provided exceeds the contracted maximum for this period.

The information submitted does not support the day and room charges. The payer disagrees with the room and board charges submitted on the institutional claim.

Information requested from patient/provider was not provided or not provided timely. Claim is returned for additional information.

Payment adjusted because the service or supply was not available when the claim was adjudicated. May relate to an item on backorder or a service not yet implemented.

Sales tax adjustment. The payer has adjusted the claim for applicable sales tax on medical supplies or equipment.

Legislated/regulatory penalty or adjustment. Payment reduced based on a government-mandated reduction or penalty.

Claim spans ineligible and eligible dates of service. Part of the claim period falls outside the patient's coverage dates.

Charges adjusted because the service was billed to the incorrect health plan. The patient's coverage is with a different payer or plan.

Payment adjusted because the out-of-network premium has been applied. The patient chose an out-of-network provider, resulting in higher out-of-pocket costs.

Services not authorized. A mandatory second surgical opinion was not obtained prior to the procedure.

Payment adjusted based on provider performance/quality metrics under a value-based contract arrangement.

This service is not payable per your managed care contract. The provider's contract with the payer excludes or does not cover this service.

This service or procedure is not payable because it is considered part of the global surgery package. Services within the global period are included in the surgical payment.