Medical Denial Code Reference

The procedure code billed is inconsistent with the modifier used, or the combination is not covered under the patient's benefit plan.

The procedure or revenue code billed does not match the place of service where the service was actually rendered.

The procedure or revenue code billed is not appropriate for the patient's age as defined by payer policies or CPT guidelines.

The procedure code billed is not consistent with the patient's gender as recorded in payer records.

The procedure billed is not within the scope of practice or billing privileges of the provider type submitting the claim.

The diagnosis code submitted is not consistent with the patient's age.

The diagnosis code submitted is not consistent with the patient's gender as recorded.

The diagnosis code does not support the medical necessity of the procedure code billed.

The diagnosis code submitted is not consistent with the type of provider billing the service.

The authorization number is absent, does not match payer records, or does not cover the billed service, provider, or date of service.

The claim is missing required information or contains data that does not match payer records.

The information provided was not sufficient or complete enough for the payer to process the claim.

An exact duplicate claim or service has already been processed and paid.

The injury or illness is work-related and is the liability of the Workers' Compensation carrier, not the health plan.

The service is believed to be covered by an auto, homeowners, or other liability insurance policy.

The injury or illness is covered under a no-fault automobile insurance policy.

The payer believes another insurance should be primary for this claim based on coordination of benefits.

The services are covered under a capitation agreement with the provider, meaning a separate fee-for-service claim should not be submitted.

The date of service is before the patient's coverage effective date.

The patient's coverage was not active on the date of service.

The claim was not submitted within the payer's timely filing deadline.

The payer cannot locate an active member record matching the patient demographics submitted on the claim.

The payer's records do not show the billed patient as an eligible dependent under the subscriber's plan.

The patient has exhausted their lifetime maximum benefit under the plan.

The service was not rendered by or authorized by the patient's designated network or primary care provider.

Prior authorization was requested for this service but was denied by the payer before the service was rendered.

The payer has determined the service does not meet the criteria for emergency or urgent care coverage.

The billed charges exceed the payer's allowed or fee schedule amount.

The billed amount exceeds the payer's contracted or legislated fee arrangement.

The service billed is not covered under the patient's benefit plan.

The service billed is not covered when performed by the type of provider submitting the claim.

The service is not covered because it is a routine or preventive procedure performed in conjunction with a routine exam.

The payer has determined the service does not meet their criteria for medical necessity.

The service is denied because the condition was present before coverage began and is subject to a pre-existing condition exclusion.

The payer has determined the service, drug, or device is experimental, investigational, or unproven.

The number of units billed exceeds the payer's allowed frequency for the procedure.

Payment was reduced due to multiple procedure or concurrent procedure billing rules.

Payment denied or reduced because prior authorization was absent or the authorized amount was exceeded.

The procedure code billed was incorrect; the payer has adjudicated under what they determined to be the correct code.

The claim was denied because the provider or patient did not follow the plan's required procedures (e.g., step therapy, network requirements).

The billed service is not covered based on the terms of the patient's benefit plan.

The benefit for this service is included in the payment/allowance for another service already adjudicated.

The related or qualifying claim/service was not identified on this claim, preventing adjudication.

This claim is not covered by this payer/contractor. The claim must be sent to the correct payer.

The patient has exhausted their benefit limit for this service category within the plan period.

Payment was adjusted due to a submission or billing error on the original claim.

The payer has identified that information from a prior claim processing appears to be incorrect.

The claim is pending additional review by the payer and has not been finally adjudicated.

The service was denied because the provider or patient did not obtain the required prior authorization or referral.

The appeal was denied because the correct appeal procedures or time limits were not followed.

The patient was not eligible for benefits under this plan on the date of service.

The claim covers dates of service that span both periods when the patient was and was not covered.

A portion of payment was deducted to satisfy a previous overpayment on another claim.

The diagnosis code submitted was not valid or had been deleted on the date of service.

The payer's contracted or negotiated rate has expired or was not found in the payer's system.

Information requested from another provider was not provided or was insufficient to process the claim.

The payer has determined that the submitted information does not support the level of service billed.

The payer has determined the documentation does not support the number or frequency of services billed.

The payer has determined the documentation does not support the duration or length of the service billed.

The information submitted does not support the dosage of the drug or service billed.

An attachment referenced on the claim was not received by the payer.

The rendering provider is not credentialed, licensed, or otherwise eligible to perform and bill the service on the claim.

Payment denied because the required referral was not obtained or the authorized number of referral visits was exceeded.

The diagnosis code is not recognized or covered by the payer for the service billed.

Payment was adjusted because the service was not rendered in an appropriate setting based on medical necessity or benefit policy.

The service was denied because coverage or program guidelines were not met or were exceeded.

The service was denied because the rendering provider was not certified or eligible to receive payment for this procedure on this date.

The procedure code submitted was not valid on the date of service, either newly added after the DOS or deleted before the DOS.

The modifier submitted was not valid or approved for use on the date of service.

The referring provider listed on the claim is not eligible or authorized to provide a referral for the service billed.

The prescribing or ordering provider is not eligible or authorized to order the service billed.

The service required prior authorization that was not obtained before the date of service.

The amount, frequency, or duration of services billed exceeded the scope of the prior authorization granted.

The revenue code and procedure code submitted on the institutional claim do not match payer requirements.

The service or equipment is not covered under the patient's current benefit plan.

Payment has already been made for the same or a similar procedure within the payer's set time frame.

The applicable fee schedule does not contain the billed procedure code.

Information requested from the billing or rendering provider was not provided or was insufficient.

The procedures billed are mutually exclusive and cannot both be billed on the same date of service.

The service is related to the treatment of a hospital-acquired condition or preventable medical error that CMS does not reimburse.

The service is not separately payable because it is included within the global surgical package period.

The diagnosis does not meet the coverage criteria in the Medicare Coverage Issues Manual, the Medicare Hospital Manual, or the Medicare Coverage Database.

Payment reduced because the service was not provided by a provider in the patient's required network.

The service was not authorized by the patient's designated network or primary care provider.

The amount applied to the patient's deductible.

The amount of coinsurance the patient owes based on their plan benefits.

The fixed co-payment amount assigned to the patient under their benefit plan.

The patient's out-of-network cost-sharing responsibility has not been met.

The date of service predates the patient's coverage effective date, making it a patient financial responsibility.

The patient's coverage was not active on the date of service, creating patient financial responsibility.

The patient cannot be identified in payer records, creating patient financial responsibility.

A service that is not covered by the plan has been assigned as the patient's financial responsibility.

The service has been denied as not medically necessary and assigned as the patient's financial responsibility.

A pre-existing condition exclusion has been applied, assigning patient financial responsibility.

Services provided by an immediate relative or household member are not covered under the plan.

The service was denied as experimental and the cost has been assigned to the patient.

Units above the payer's covered maximum have been assigned to the patient.

Non-covered charges have been assigned as the patient's financial responsibility.

The patient has exhausted their plan benefit maximum and costs have been assigned as patient responsibility.

The service is not covered under the patient's current plan and has been assigned to the patient.

Higher patient cost-sharing applied because the service was rendered by an out-of-network provider.

The provider's charges exceed the allowed amount; the balance may be the patient's responsibility depending on network status.

The patient has not met the required spend-down or deductible requirements for Medicaid eligibility.

The Medicare blood deductible applies, creating patient financial responsibility for the first three pints of blood.

The patient elected a payment option that is not currently in effect or applicable to this service.

The billing date on the claim predates the actual date of service.

The specific service or drug is not covered under the patient's current benefit plan, creating patient financial responsibility.

Information requested from the patient was not provided or was insufficient/incomplete.

Sales tax on medical services or supplies has been assigned as the patient's financial responsibility.

A penalty or increased cost-sharing has been assessed because the patient did not follow required plan procedures.

The patient's cost-sharing for the ineligible portion of a claim that spans eligible and ineligible coverage periods.

The patient's deductible for a professional service rendered in an institutional setting billed on an institutional claim.

Expenses incurred during a lapse in coverage are assigned as the patient's financial responsibility.

The fixed copayment amount required under the patient's benefit plan for this service type.

Deductible amount applied under an other adjustment category (e.g., secondary payer context).

Coinsurance amount applied as an other adjustment.

Copayment applied under an other adjustment category.

A duplicate service was identified under the other adjustment category.

The payment was adjusted to reflect the impact of prior payer(s) adjudication, including payments and/or adjustments.

A discount applied due to a prompt-pay arrangement between the provider and payer.

Charges exceed the fee schedule or maximum allowable under the applicable payment arrangement.

Payment reduced due to failure to obtain a required second surgical opinion before the procedure.

The claim payment was made directly to the patient or insured rather than to the provider.

The claim was submitted to the incorrect payer or contractor.

Compensation for outstanding member responsibility adjustment.

An other adjustment has been made due to a submission or billing error.

An other adjustment applied because authorization or referral requirements were not followed.

An incentive adjustment for a preferred product or service (e.g., generic drug incentive).

Payment made from a consumer spending account (HRA, FSA, HSA, etc.).

A non-standard adjustment code from a paper remittance that does not map to a standard electronic code.

The original payment decision has been reviewed and is being maintained; the claim was processed correctly.

Adjustment for expenses incurred during a lapse in coverage.

Payment adjusted because the drug dispensed was identified as incompatible with another drug the patient is taking.

Payment adjusted based on subrogation related to a third-party settlement.

Alert notifying the provider that the patient has Medicare coverage that should be primary. This is an informational code, not a denial.

The plan has identified itself as a secondary payer for this service and the claim should have been submitted to the primary payer first.

The claim is missing a valid prior authorization, or the authorization on file is incomplete or invalid for the service billed.

Payment was calculated based on the Medicare Physician Fee Schedule (MPFS) rather than the billed amount.

The service cannot be paid separately when billed with another service on the same date due to NCCI or payer bundling rules.

The patient has not yet met the eligibility requirements for the billed service.

Informational code noting services were denied as not medically necessary.

The units billed exceed the payer's maximum allowed number of units for the service.

The payer is alerting the provider that this claim may have been processed incorrectly and should be reviewed.

The coverage or payment decision was based on a Medicare Local Coverage Determination (LCD) for this service.

Informational code directing the provider to their contract or fee schedule for the reimbursement calculation.

The diagnosis code submitted does not clinically justify or align with the procedure code billed.

Informational code advising the provider of their right to appeal the coverage or payment decision.

The adjustment is contractual and may not be appealed (e.g., contractual write-off).

The rendering provider's primary identifier (NPI) is missing, incomplete, or invalid on the claim.

The referring provider's NPI is missing, incomplete, or invalid.

The quantity billed exceeds the maximum units the payer allows per claim or per day for this service.

The service facility's primary address is missing, incomplete, or invalid on the claim.

Alert indicating that patient financial responsibility applies for this claim or service.

Medicare informational remark advising of appeal rights for the approved amount.

The claim must be submitted to the correct Medicare Administrative Contractor (MAC) for secondary processing.

Medicare has forwarded the claim information to Medicaid for secondary review under the crossover program.

Alert that incorrect Medicare billing practices may result in penalties under the False Claims Act or other statutes.

Medicare has forwarded claim information to the patient's supplemental (Medigap) insurer for secondary processing.

The payment was calculated using the provider's submitted specialty or classification code.

The Medicare beneficiary identifier (MBI) or entitlement information on the claim is missing, incorrect, or invalid.

Required occurrence code(s) and/or associated dates are missing or invalid on the institutional claim.

The patient name on the claim is missing, incomplete, or does not match payer records.

Medicare has identified the submitted claim as a duplicate of a previously processed claim.

The Social Security Number or Health Insurance Claim Number (HICN) — now the Medicare Beneficiary Identifier (MBI) — is missing or invalid.

Medicare's records indicate it should be the secondary payer, not the primary, for this claim.

Informational code regarding Medicare's coverage frequency for PAP screening tests.

The payment adjustment is the result of a post-payment medical review, not the initial adjudication.

The diagnosis or condition code(s) required to support the claim are missing, incomplete, or invalid.

The CLIA (Clinical Laboratory Improvement Amendments) certification number is missing or invalid for the laboratory service billed.