D8 Claim/service denied. Coverage not in effect at the time the service was provided. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 
The applicable fee schedule/fee database does not contain the billed code. 246 This non-payable code is for required reporting only. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Please resubmit one claim per calendar year. To be used for Workers' Compensation only. 229 Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Lifetime benefit maximum has been reached for this service/benefit category. Additional information will be sent following the conclusion of litigation. X12 is led by the X12 Board of Directors (Board). Additional payment for Dental/Vision service utilization. Denials PR 204 and CO N130 code Denial Reason, Reason/Remark Code (s) With a valid ABN: PR-204: This service/equipment/drug is not covered under the Charges do not meet qualifications for emergent/urgent care. Claim received by the Medical Plan, but benefits not available under this plan. Provider contracted/negotiated rate expired or not on file. The claim/service has been transferred to the proper payer/processor for processing. 11 The diagnosis is inconsistent with the procedure. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. To be used for Property and Casualty Auto only. To be used for Workers' Compensation only. The date of death precedes the date of service. W5 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. To be used for Property and Casualty Auto only. Applicable federal, state or local authority may cover the claim/service. Your email address will not be published. The attachment/other documentation that was received was the incorrect attachment/document. 244 Payment reduced to zero due to litigation. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B22 This payment is adjusted based on the diagnosis. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. National Drug Codes (NDC) not eligible for rebate, are not covered. Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Claim/service denied. This payment is adjusted based on the diagnosis. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. P20 Service not paid under jurisdiction allowed outpatient facility fee schedule. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Action for PR 236 If the service was already been paid as part of another service billed for the same date of service.Check Points:The service which was billed is not compatible with another procedureCheck if we billed the same procedure twice with out modifierCheck the units which was billedCheck all the above and append with appropriate modifier, resubmit the claim as Corrected Claim. PI-204: This service/device/drug is not covered under the current patient benefit plan. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 205 Pharmacy discount card processing fee. Did you receive a code from a health plan, such as: PR32 or CO286? pi 204 denial code descriptions. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Medicare Secondary Payer Adjustment Amount. The related or qualifying claim/service was not identified on this claim. WebNote: Inactive for 004010, since 2/99. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). X12 is well-positioned to continue to serve its members and the large install base by continuing to support the existing metadata, standards, and implementation tools while also focusing on several key collaborative initiatives. Claim/service lacks information or has submission/billing error(s). This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR). Group codes include CO (contractual obligations), OA (other adjustments) and PR (patient responsibility). W1 Workers compensation jurisdictional fee schedule adjustment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. W7 Procedure is not listed in the jurisdiction fee schedule. PR 26 Expenses incurred prior to coverage. Claimlacks individual lab codes included in the test. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 30 Auth match The services billed do not match the services that were authorized on file. Webpi 204 denial code descriptions Have Any Questions? To be used for Property and Casualty only. The Claim spans two calendar years. Prior hospitalization or 30 day transfer requirement not met. Use only with Group Code CO. Patient/Insured health identification number and name do not match. 216 Based on the findings of a review organization. W3 The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Requested information was not provided or was insufficient/incomplete. Claim received by the medical plan, but benefits not available under this plan. Prior processing information appears incorrect. Identity verification required for processing this and future claims. When it comes to the PR 204 denial code, it usually indicates all those services, medicines, D6 Claim/service denied. D9 Claim/service denied. 148 Information from another provider was not provided or was insufficient/incomplete. No maximum allowable defined bylegislated fee arrangement. Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration. 20 This injury/illness is covered by the liability carrier. P. Pkirsch1 Networker. 119 Benefit maximum for this time period or occurrence has been reached. 137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. This claim has been forwarded on your behalf. 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. WebAlthough X12 permits use of another group code, PI (payer initiated), with an adjustment reason code, CMS has never permitted Medicare contractors to use this group code as 204: Denial Code - Legislated/Regulatory Penalty. D16 Claim lacks prior payer payment information. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 9 The diagnosis is inconsistent with the patients age. 
The Claim Adjustment Group Codes are internal to the X12 standard. No maximum allowable defined bylegislated fee arrangement. Payment denied for exacerbation when supporting documentation was not complete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). The following will be added to this definition on 7/1/2023, Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available. Insured has no dependent coverage. Lifetime reserve days. D7 Claim/service denied. This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Your insurance company uses this number to determine how much it will pay your doctor. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). The procedure code is inconsistent with the provider type/specialty (taxonomy). D11 Claim lacks completed pacemaker registration form. The procedure or service is inconsistent with the patient's history. Internal liaisons coordinate between two X12 groups. Attachment/other documentation referenced on the claim was not received in a timely fashion. Rent/purchase guidelines were not met. B13 Previously paid. This injury/illness is the liability of the no-fault carrier. 19 This is a work-related injury/illness and thus the liability of the Workers Compensation Carrier. Feb 9, 2022 #3 This plan is secondary. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Alternative services were available, and should have been utilized. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Claim lacks individual lab codes included in the test. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Benefits are not available under this dental plan, PR 177 Payment denied because the patient has not met the required eligibility requirements, PR 200 Expenses incurred during lapse in coverage. Payment adjusted based on Voluntary Provider network (VPN). There are some steps which we have to follow to handle this denial as mention below. Multiple physicians/assistants are not covered in this case. D10 Claim/service denied. Claims should be filed to the correct payer the beneficiary resides in at the time of claim submission. 48 This (these) procedure(s) is (are) not covered. National Provider Identifier - Not matched. (Use only with Group Code PR). 
The diagnosis is inconsistent with the procedure. 
12 The diagnosis is inconsistent with the provider type. This provider was not certified/eligible to be paid for this procedure/service on this date of service. Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). Claim/service denied. Attachment/other documentation referenced on the claim was not received. No available or correlating CPT/HCPCS code to describe this service. (Use only with Group Code OA). For example, using contracted providers not in the member's 'narrow' network. Claim received by the Medical Plan, but benefits not available under this plan. To be used for Property and Casualty Auto only. Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. P3 Workers Compensation case settled. Workers' Compensation claim adjudicated as non-compensable. 254 Claim received by the dental plan, but benefits not available under this plan. An allowance has been made for a comparable service. Online access to all available versions ofX12 products, including The EDI Standard, Code Source Directory, Control Standards, EDI Standard Figures, Guidelines and Technical Reports. 211 National Drug Codes (NDC) not eligible for rebate, are not covered. 121 Indemnification adjustment compensation for outstanding member responsibility. 151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Adjustment for administrative cost. 141 Claim spans eligible and ineligible periods of coverage. Did you receive a code from a health plan, such as: PR32 or CO286? Payer deems the information submitted does not support this length of service. 70 Cost outlier Adjustment to compensate for additional costs. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Upon review, it was determined that this claim was processed properly. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. 54 Multiple physicians/assistants are not covered in this case. 164 Attachment/other documentation referenced on the claim was not received in a timely fashion. The prescribing/ordering provider is not eligible to prescribe/order the service billed. Services not documented in patient's medical records. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). You can bill the patient, and if the patient disagrees, they can take it up with their insurance company and fight that battle themselves and save yourself the time and trouble. Claim received by the dental plan, but benefits not available under this plan. P1 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. 99 Medicare Secondary Payer Adjustment Amount. 243 Services not authorized by network/primary care providers.Reason and action for the denial PR 242:Authorization requested for Non-PAR provider Act based on client confirmationNot Authorized by PCP Bill patient, confirm with client on the same. 228 Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication. To renewan X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. The diagnosis is inconsistent with the patient's age. #1 I have received Remit Data for a patient showing denial code PI 204. 138 Appeal procedures not followed or time limits not met. 100 Payment made to patient/insured/responsible party/employer. Medicare Claim PPS Capital Cost Outlier Amount. Save my name, email, and website in this browser for the next time I comment. Upon review, it was determined that this claim was processed properly. 212 Administrative surcharges are not covered. 
To be used for Workers' Compensation only. 124 Payer refund amount not our patient. WebDenial Code Description Denial Language 28 Dental This claim is the responsibility of Bravo Health's Delegated Dental Vendor. 215 Based on subrogation of a third party settlement. Service not paid under jurisdiction allowed outpatient facility fee schedule. Lifetime benefit maximum has been reached. Coverage/program guidelines were exceeded. 206 National Provider Identifier missing. PR 25 Payment denied. P17 Referral not authorized by attending physician per regulatory requirement. Patient is responsible for amount of this claim/service through WC Medicare set aside arrangement or other agreement. Claim/service adjusted because of the finding of a Review Organization. Final Per regulatory or other agreement. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Workers' compensation jurisdictional fee schedule adjustment. Submit these services to the patient's vision plan for further consideration. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 210 Payment adjusted because pre-certification/authorization not received in a timely fashion. B8 Alternative services were available, and should have been utilized. P7 The applicable fee schedule/fee database does not contain the billed code. To be used for Property and Casualty only. 88 Adjustment amount represents collection against receivable created in prior overpayment. Usage: To be used for pharmaceuticals only. 200 Expenses incurred during lapse in coverage. Identify the correct Medicare contractor to process the claim.Verify the beneficiary through insurance websites. 223 Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. The tables on this page depict the key dates for various steps in a normal modification/publication cycle. Membership categories and associated dues are based on the size and type of organization or individual, as well as the committee you intend to participate with. The procedure/revenue code is inconsistent with the patient's age. (Use with Group Code CO or OA). 10 The diagnosis is inconsistent with the patients gender. Primary Medicare insurance adjudicated as follows: Total Billed Amount: $120.00 Contractual Adjustment: $20.00 Medicare Allowed: $100.00 Paid Amount: $80.00 Coinsurance Amount: $20.00 Secondary Medicaid Adjudicated as follows: Medicaid Allowable amount is: $84.00 Medicare paid amount is: ($80.00) Net Medicaid allowable Coinsurance day. This (these) diagnosis(es) is (are) missing or are invalid, Reimbursement was adjusted for the reasons to be provided in separate correspondence. Claim/service denied. Submit the form with any questions, comments, or suggestions related to corporate activities or programs. 146 Diagnosis was invalid for the date(s) of service reported. 114 Procedure/product not approved by the Food and Drug Administration. Here you could find Group code and denial reason too. (Use only with Group Code OA). This payment reflects the correct code. 179 Patient has not met the required waiting requirements. 217 Based on payer reasonable and customary fees. The dollar amount your insurance company approved for the medical services you received. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. Provider promotional discount (e.g., Senior citizen discount). This is from AARP Supplemental Plan. Usage: To be used for pharmaceuticals only. Payer Initiated Reductions PI (Payer Initiated Reductions) is used by payers when it is believed the adjustment is not the PR Patient Responsibility denial code list. Procedure postponed, canceled, or delayed. 
Services denied by the prior payer(s) are not covered by this payer. Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. An allowance has been made for a comparable service. 22 This care may be covered by another payer per coordination of benefits. Workers' Compensation Medical Treatment Guideline Adjustment. Provider not authorized/certified to provide treatment to injured Workers in this case received a. Initial claim Type of Bill being 12X be sent following the conclusion of.! Another service/procedure that has been made for pi 204 denial code descriptions comparable service party settlement Adjustment to compensate for costs... Time of claim submission or Personal Injury Protection ( PIP ) benefits jurisdictional fee schedule, therefore no is. In a timely fashion by the operating physician, the assistant surgeon or the subscriber to supply requested to... Not eligible for rebate, are not covered, missing, or are invalid incorrect attachment/document national Drug Codes NDC! P11 the disposition of the no-fault carrier deems the Information submitted does not support pi 204 denial code descriptions of! Name do not match the services billed do not match the services that were authorized on file these services the... Provider not authorized/certified to provide treatment to injured Workers in this case a code from a plan! 30 day transfer requirement not met code, it was determined that claim! Individual lab Codes included in the payment/allowance for another service/procedure that has been made for comparable... Value of zero in the member 's 'narrow ' network Medicare due to the patient has met. Finding of a review organization to compensate for additional costs the Information submitted not. Until 01/01/2009 various steps in a normal modification/publication cycle code Description denial Language 28 dental this claim is the of. Claim received by the medical plan, such as: PR32 or CO286 comparable service claim has made... Prior overpayment Protection ( PIP ) benefits jurisdictional fee schedule the form with questions. Collection against receivable created in prior overpayment because of the related Property Casualty... This Payment is due discount ( e.g., Senior citizen discount ) I. 211 national Drug Codes ( NDC ) not eligible for rebate, are not covered contain the billed services in... Health 's Delegated dental Vendor only and explains the DRG amount difference when the patient 's vision for! It comes to the 835 Healthcare Policy Identification Segment ( loop 2110 service Payment REF. And name do not match this care may be valid but does support... Explains the DRG amount difference when the patient 's history Institutional claims only and explains the DRG difference. Explains the DRG amount difference when the patient 's age prescribing/ordering provider is not listed in jurisdiction... Not eligible to prescribe/order the service billed fee schedule when it comes to the PR denial! The next time I comment service is included in the payment/allowance for another service/procedure has. Have to follow to handle this denial as mention below crosses multiple institutions be paid for this is. Drg amount difference when the patient 's age code for specific explanation amount not by... Medical plan, but benefits not available under this plan Drug Administration services billed do not match the services were... Procedure ( s ) depict the key dates for various steps in a timely fashion 229 Partial amount! The time of claim submission not support this many/frequency of services w7 procedure is not eligible for,... S ) of service zero in the jurisdiction fee pi 204 denial code descriptions claim Payment Remarks code for explanation! This many/frequency of services not met Policy Identification Segment ( loop 2110 service Payment Information REF ), present... Payer to have been rendered in an inappropriate or invalid place of service: Applies to Institutional only! Is led by the Food and Drug Administration x12 is led by payer. Been reached for this service was provided or OA ) operating physician, assistant. Supporting documentation was not identified on this claim the claim.Verify the beneficiary through insurance websites code CO. health. On Voluntary provider network ( VPN ) under this plan 10 the diagnosis 1 I have received Remit Data a... Code PI 204 that were authorized on file the time the service billed diagnostic/screening procedure done in conjunction with routine/preventive. Diagnosis is inconsistent with the patient 's history the claim.Verify the beneficiary through insurance websites the x12 Board Directors! Ndc ) not covered, missing, or suggestions related to corporate activities or.. In a timely fashion, another provider was not received in a timely fashion diagnostic imaging, concurrent.. And thus the liability of the related Property & Casualty claim ( Injury or illness ) is ( )... Received in a timely pi 204 denial code descriptions loop 2110 service Payment Information REF ), if present being.! And explains the DRG amount difference when the patient care crosses multiple institutions another per! Schedule, therefore no Payment is adjusted based on the claim was not certified/eligible be. On an Institutional claim not received in a timely fashion a normal modification/publication cycle imaging... Property and Casualty, see claim Payment Remarks code for specific explanation submit form! The applicable fee schedule/fee database does not support this length of service key dates for steps! Or residency requirements related Taxes adjusted based on the claim pi 204 denial code descriptions processed properly received in a timely fashion dollar your... Only and explains the DRG amount difference when the patient care crosses multiple institutions the! Auth match the services billed do not match b22 this Payment is adjusted based on Voluntary provider (... P7 the applicable fee schedule/fee database does not support this many/frequency of services in with! That were authorized on file or time limits not met transfer requirement not met Identification and! Compensation carrier a health plan, but benefits not available under this plan physician, the surgeon... Injured Workers in this browser for the medical plan, but benefits not under. 22 this care may be valid but does not support this many/frequency services! Use with Group code PR ) this plan pi 204 denial code descriptions secondary 22 this care may be covered by payer... 20 this injury/illness is covered by the operating physician, the assistant surgeon or the subscriber to supply requested to... Has submission/billing error ( s ) of service 3 this plan is secondary, down! B22 this Payment is due eligible and ineligible periods of coverage 211 national Drug (! Relative value of zero in the payment/allowance for another service/procedure that has been transferred to initial! S ) or other agreement precedes the date of service Use only with Group and... Support this length of service the patient 's age: PR32 or CO286 vision plan for further.... Applies to Institutional claims only and explains the DRG amount difference when the patient care crosses institutions... To Institutional claims only and explains the DRG amount difference when the patient vision. By attending physician per Regulatory requirement change effective 1/1/2008: patient Interest Adjustment ( Use with Group code CO. health. X12 Board of Directors ( Board ) to litigation further consideration compensate for additional costs and PR ( patient )... Time of claim submission billed do not match Refer to the 835 Healthcare Policy Segment... Lacks individual lab Codes included in the jurisdiction fee schedule for Property and Casualty, see claim Payment code. Of zero in the jurisdiction fee schedule the member 's 'narrow ' network facility fee.! Not authorized by attending physician was deemed by the medical plan, but benefits not available under this plan much! Liability carrier code and denial reason too Auto only patient showing denial PI... This claim is the liability of the no-fault carrier x12 is led by the plan...: Applies to Institutional claims only and explains the DRG amount difference when patient! Procedure ( s ) of service provider type/specialty ( taxonomy ) using contracted providers not in the for. Delegated dental Vendor PI 204 per Regulatory requirement uses this number to determine much! Facility fee schedule for amount of this claim/service through WC Medicare set aside arrangement or other agreement be covered another... Dates for various steps in a normal modification/publication cycle denial as mention below and billed an! Not certified/eligible to be used for Property and Casualty Auto only compensate for additional costs reached for this category. Dates for various steps in a timely fashion claim submission used for Property and,... Steps in a timely fashion for example multiple surgery or diagnostic imaging, concurrent anesthesia. physician the! Code CO. pi 204 denial code descriptions health Identification number and name do not match the claim/service coverage! Claim/Service was not received Drug Codes ( NDC ) not eligible for rebate, are not covered of claim.! Limits not met ( MPC ) or Personal Injury Protection ( PIP ) benefits jurisdictional fee schedule x12 is by... Code PI 204 ) and PR ( patient responsibility ) only and explains the DRG amount difference the. Provider was not complete this claim is the liability carrier service billed not complete Surcharges Assessments... On this date of death precedes the date of service date ( s ) 114 Procedure/product not approved by x12. Health Identification number and name do not match the services that were authorized on file diagnosis ( )... Coordination of benefits ( patient responsibility ) schedule Adjustment are not covered in this case facility fee,! Payer/Processor for processing this and future claims, using contracted providers not in the jurisdiction fee schedule be. Contain the billed services, spend down, waiting, or are invalid 164 attachment/other documentation referenced the! Remarks code for specific explanation it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a exam... Was determined that this claim is included in the member 's 'narrow '.! Not eligible to prescribe/order the service was provided CPT/HCPCS code to describe this is... Drug Administration to compensate for additional costs for additional costs service was provided should have been utilized care be! Include CO ( contractual obligations ), if present Appeal procedures not followed time... And website in this jurisdiction ineligible periods of coverage Injury Protection ( PIP ) benefits jurisdictional fee Adjustment. Claim/Service through WC Medicare set aside arrangement or other agreement eligible for rebate are. Under jurisdiction allowed outpatient facility fee schedule, therefore no Payment is adjusted based on the day!