SNF-Member Share of Cost Reduced From Contracted 2 … Companion Guides/WV... · WV Medical CAQH Phase 3 CARC-RARC Modifications.xlsx System Edit Edit Description Previous HIPAA Group

WV Medical CAQH Phase 3 CARC-RARC Modifications.xlsx

System Edit Edit Description Previous HIPAA Group Code Previous CARC Previous RARC New HIPAA Group Code New CARC New RARC

1 SNF-No Authorization CO B5 CO 15 N517

2

SNF-Member Share of Cost

Reduced From Contracted

Amount CO 142 CO 142

3

Benefit Exhaustion Period

Reported CO 119 CO 119

7

Medicare Crossover QMB

processing rules applied CO A1 N192 CO 109 N193

10

Medicare Crossover Claim

Pays at Zero Dollars CO 23 CO 23

11 HMO Guidelines Apply CO 24 CO 24

12

Medicare covered service

must be billed to Medicare CO 22 CO 22

14 TPL Claim Pays At Zero Dollars CO 23 CO 23

15

Service not covered for

patients in a Medicaid

supported fac CO A1 N106 CO 96 N448

16 No COB Info on Claim Line CO A1 MA04 CO 16 MA04

17

Xover SQL pays zero dollars

based on TOB logic CO B5 CO B5

18 SNF Part A - Claim Pays Zero CO 23 CO 23

20

Revenue Codes 183 & 185 are

Present on Part A Claim CO A1 N30 CO A1 N30

22 Missing or Multiple AAA Codes CO 186 CO 186

23

Revenue Code Not Valid for

SNF Part A Claim CO 185 CO 185

24 NDC is Missing/Invalid CO 16 M119 CO 16 M119

25 NDC is not Rebate Eligible CO 211 CO 96

26 Invalid NDC Units CO 125 M53 CO 16 M53

Page 1 of 27



27

SNF SQL denies claim when

one or more lines are in deny

stat CO A1 N142 CO A1 N142

28

DOS not within LTC effect &

term dates CO B5 CO B5

29

Product Service Not Covered -

DESI - for Non-Compound

Drug CO 203 CO 96

30

Rehab Services Not Valid for

this provider CO 171 CO 171

100 Patient is Expired CO 13 CO 13

101 No active provider contract CO 147 CO B7 N570

102

Provider not active for Plan on

DOS CO 147 CO B7 N570

103

Not an approved service for

provider CO B7 CO B7

104 Incomplete provider CO B7 CO B7

105 Provider on Pay hold CO 133 N35 CO 170

106

No attending physician ID

(outpatient) CO 125 N253 CO 16 N253

107 Negative charge on claim line CO 125 M54 CO 16 M54

108 Uncredentialed provider CO 185 CO 185

109

Claim amt exceeds maximum

allowed during mass

adjudication CO A1 N220 CO 16 M54

111 Provider Watch CO 197 CO 197

112

Claim amount exceeds the

maximum allowed CO 45 CO 170

113

Specialty code required for

provider CO 172 N95 CO 172 N95

114

Provider does not match

required type CO 170 CO 170

Page 2 of 27



116

Annual Benefit Amount

Exceeded CO 119 CO 119

117 Lifetime Benefit Max Exceeded CO 35 CO 35

119

Family Benefit Lifetime Max


120 Family Annual Limit exceeded CO 119 CO 119

121

Validate External Provider's

Program CO A1 N220

122

PCP reassignment override

days CO A1 N220

123

Individual Lifetime Visits


124

Family Lifetime Visits


125

Partial Units on

Lifetime/Individual Visit Limits CO 119 CO 119

126

Partial Units on

Lifetime/Family Visit Limits CO 119 CO 119

127 Sponsor Watch CO A1 N220

128

Remaining visits less than date

span. Units not allocated. CO 125 M53 CO 16 M53

130 Program Watch CO A1 N220

132

Sum of Individual Coinsured

Charges Exceeds Maximum CO 2

Page 3 of 27



133

Sum of Family Coinsured

Charge Maximum Exceeded CO 2

134

Claim payment amt exceeds

max allowed for mass

adjudication CO 45 CO 45

135

Claim payment amount

exceeds the maximum allowed CO 45 CO 45

149

Benefit does NOT meet date

criteria of the claim CO 204 CO 204

150

No contract term found for

service CO 185 CO 185

151

Excluded Contract Term for

Service CO 185 CO 185

152

Provider type does not match

type required by benefit CO 170 N95 CO 170 N95

153

PCP is solely responsible for

service: pay as capitated CO 24 CO 24

154

Benefit requires Specialty

Code not found on Provider CO 172 N95 CO 170 N95

155 Benefit has age restriction CO 6 N30 CO 6 N129

156

Provider type does NOT match

type required by contract term CO 170 CO 170

157

Contract Term requires

Specialty Code not found on

Provider CO 8 N95 CO 8 N95

158 Invalid Service Code on DOS CO 181 CO 181

Page 4 of 27



162

Contract term requires

documentation CO 16 N29 CO 163

163

Benefit requires

documentation CO 16 N29 CO 163

164

Contract requires document

review CO 16 N29 CO 163

165

Dental Areas on Claim Line

and Benefit do not match CO 168 CO 204 N130

166

Benefit procedure NOT found

in claims history CO 107 N161 CO 107

167

Benefit requires prosthesis

designation CO 16 N29

168

Member does NOT meet age

criteria for term CO 6 N30 CO 6 N129

169

Claim and contract term

modifiers do NOT match CO 4 CO 4

170

Claim and contract term type

of service do NOT match CO A1 N220

171

Term Applies to assigned

members only CO 24 CO 24

172

Term does NOT meet date

criteria of the claim CO 204 CO 204

173

Diagnosis on claim does NOT

match terms valid range CO 167 CO 167

174

Procedure code on claim does

NOT match terms valid

procedure CO 204 CO 204

175

Bill type on claim does NOT

match contract term CO 16 MA30 CO 16 MA30

176

Emergency requirements on

claim do NOT match contract

term CO 40 N180 CO 40

Page 5 of 27



177 Term is for EPSDT claims only CO A1 N78

178

Member is NOT in capitation

and contract term is capitated CO 95 N52 CO 95 N627

179

Location specific term does

NOT match claim CO 5 CO 5

180 No Sponsor Fee for service CO 133

181 Stop Loss Applied to Claim CO 45 CO 45

182

No external price found for

provider CO 147 CO B7 N570

183

Submission date exceeds

policy termination run-off

period CO 27 CO 27

184

DOS end date exceeds policy

termination date CO 27 CO 27

185

Location-specific benefit does

NOT match claim CO 5 CO 5

186 No skilled nursing coverage CO 204 CO 204

187

Benefit requires documents to

be reviewed CO 16 N29

188

Noncontracted provider

requires EOMB CO 16 N4 CO 252 N4

189

Level of Care Benefit Not

Found CO 204 CO 204

190

Authorization contract

overriding contracted provider CO 45 N45 CO 45 N45

192

Benefit requires contracted

(PAR) provider CO 38 CO 38

194

Restrict Benefit by Date of

ONSET CO A1 N130

Page 6 of 27



195

Date of Onset is Missing on

Claim CO 16 MA122 CO 16 MA122

196

Benefit requires non-

contracted (NONPAR) provider CO 38

197

Procedure code on claim NOT

valid for benefit CO 204 CO 204

198

Date of Service is after paid

through date CO 125 M59 CO 16 M59

199

Benefit Rider not valid for

member/DOS CO B5 N30 CO B5 N30

200 Benefit Day Limit Exceeded CO 119 CO 119

201

No enrollment exists for claim

start date CO 177 CO 177

202 No Benefit for Service CO 204 CO 204

203

Benefit is excluded from

benefit plan CO 204 CO 204

204 Invalid accommodation days CO 125 M53 CO 16 M53

205 Benefit requires authorization CO 197 CO 197

206 Benefit Visit Limit Exceeded CO 119 CO 119

207 Benefit Dollar Limit Exceeded CO 119 CO 119

208 Benefit Applies to PCP Only CO 24 N52 CO 24 N52

209 Benefit coverage not started CO 26 CO 26

210 Member NOT enrolled on DOS CO 177 CO 177

211

Provider is not part of network

required for benefit CO 38

Page 7 of 27



214

Bill Type does NOT match

Benefit CO A1 MA30 CO 16 MA30

215

Member's share of cost

different than entered value CO 178 CO 178

216

No COB entered with a

Secondary Enrollment CO 22 MA04 CO 22

217

Member has an active

restriction on enrollment CO 177 CO 177

218

Member lost eligibility during

date span CO 239 CO 239

219

Provider overlap of global days

period CO 97 N19 CO 97 N19

221 Assistant surgeon not allowed CO 54 CO 54

222 Co-Surgeon not allowed CO 54 CO 54

223 Team surgeon not allowed CO 54 CO 54

224

Benefit Requires Manual

Review CO 16 N225 CO 16 N225

225

Contract Term Requires

Manual Review CO 16 N225 CO 16 N225

226

Reimburse Member On Non-

Par Contract CO A1 N220

230 Multiple surgeries detected CO 59 CO 59

235

Override Reimburse Member

option CO A1 N220

236

Benefit requires either

authorization or referral

document CO 197 CO 197

237

COB will be manually

distributed on claim lines CO A1 N220

238 Invalid Medicare Action Code CO 136 CO 16 N245

Page 8 of 27



240

Not all standard reserve days

have been used CO A1 N220

241

Exceeds number of covered

days in a standard benefit

period CO 119 CO 119

242

Service days submitted exceed

standard reserve days CO 119 CO 119

243

Service days submitted exceed

extended reserve days CO 119 CO 119

244

No claim in std benefit period

before use of reserve days CO 107 CO 107

245

Multiple surgeries - claim

submitted missing modifier 51 CO 4 CO 4

246

Member has Preexisting

Condition on DOS for

Diagnosis CO 51 CO 51

247

Preexisting Condition May

Exist CO 51 CO 51

248 Member policy is Suspended CO A1 N220 CO 31

252

Pend claim if COB is 0 on

secondary enrollment claim CO 22 MA04 CO 16 MA04

253

Internal enrollment and COB

amounts entered CO 23 N155 CO 16 MA04

254

Medicare non-allowed claim

submitted hard copy CO 22 N4 CO 22

255

Medicare non-allowed claim

submitted electronically CO A1 N220 CO 22 N598

Page 9 of 27



256 Invalid Medicare COB Amount CO 22 CO 22

257 Visit units have been traded CO A1 N220

258

Emergency Claim does not

match Emergency Benefit CO A1 N220 CO 40

260

Pursue and pay for

Professional claims with no

information CO 22 CO 22

261

Pursue and pay for

Institutional claims with no

information CO 22 CO 22

262 Claim requires Pursue and Pay CO 22 CO 22

263

Auto Accident indicated on

claim - Pursue and Pay CO 20 CO 20

264

Auto Insurance information on


265

Other Insurance indicated on


266

Other Insurance information

unknown - Pursue and Pay CO 22 CO 22

267

COB: LOI No Response or

Outdated - Pursue and Pay CO 16 MA04 CO 16 MA04

268

COB Coverage Not for Claim

Type CO 22 CO 22

269

Benefit requires authorization

and has associated penalty CO 197 CO 197

271

Benefit Restriction Group

Validation Failed CO B5 CO B5

Page 10 of 27



272

Member does not have

coverage code required on

benefit CO B5 N30 CO B5 N30

300

Duplicate Claim

(member/DOS) CO 18 OA 18

301

Invalid or missing admission

date CO 125 MA40 CO 16 MA40

302

Attending Physician Required

for Inpatient Claims CO 125 N253 CO 16 N253

303 Claim Total Mismatch CO 125 M54 CO 16 M54

304 Invalid Bill Type CO 16 MA30 CO 16 MA30

305

Primary diagnosis code is

required CO A1 M76 CO 16 M76

306

Discharge status is required

for inpatient and SNF claims CO 125 N50 CO 16 N50

307

Duplicate Claim (Same

Provider/Member/DOS) CO 18 M86 OA 18

308 Invalid Admit Hour (0 -- 23) CO 125 N46 CO 16 N46

309 Invalid Discharge Hour (0 -- 23) CO 125 N317 CO 16 N317

311

Submission Window Exceeded

for Claim Start Date CO 29 CO 29

312

Invalid coinsurance days for

11x bill type CO 125 MA34 CO 16 MA34

313

Covered days do not match

accommodation revcode days CO 125 M53 CO 16 M53

314

Non-covered days less than

leave of absence days CO 125 M53 CO 16 M53

315 Invalid Lifetime Reserve Days CO 125 M53 CO 16 M53

Page 11 of 27



316

Admit type does not match

admit source CO 125 MA42 CO 16 MA42

317

Other agency may be

responsible for payment CO A1 N193 CO 22 N598

318

Invalid coinsurance days for

21x bill type CO 125 MA34 CO 16 MA34

319

Coinsurance days exceeds

covered days CO 125 MA34 CO 16 MA34

320

Coinsurance days missing

associated value codes CO 125 M49 CO 16 M49

321

Covered days and coinsured

days exceed maximum for

hospital CO 125 MA34 CO 16 MA34

322

Covered days exceeds

maximum for hospital CO 119 MA32 CO 119 N130

323

Covered days and coinsured

days exceed maximum for SNF CO 119 MA34 CO 119 N130

324

Covered days exceed

maximum for SNF CO 119 M53 CO 119 M53

325

Non-covered days exceed

statement-covered period CO 125 M53 CO 16 M53

326

Life reserve days exceed

maximum CO 35 M53 CO 35

327

Admit type requires 450

revcode CO 125 M50 CO 16 M50

328 Admission Source Required CO 125 MA42 CO 16 MA42

329

Invalid patient status for bill

type CO 125 MA43 CO 16 MA43

330

Invalid diagnosis code for

benefit CO 167 N569 CO 11 N657

332

DRG mismatch with DRGActive

product CO A8 CO A8

Page 12 of 27



333 DRGActive Product Error CO A1 N220 CO A1 N220

334 APCActive component error CO 147

335

HIPPS RUGS DOS is not within

assessment modifier time

period CO 125 MA31 CO 16 MA31

336

HIPPS RUGS billed amount

should not have a dollar

amount CO 125 M54 CO 16 M54

337

HIPPS RUG rate code requires

rehabilitation therapy CO 16 M50 CO 16 M50

338

HIPPS RUGS length of stay not

in sync with accommodation

day CO 16 M53 CO 16 M53

339

APC claim has lines that have

rolled up into other lines CO B15 CO B15

340

HH PPS too many SCICs

detected. Manual review is

required. CO 133

341

HH PPS No Rap present for

claim CO A1 N220

342

HH PPS Therapy threshold not

met. Fallback used for

payment CO A1 N220

343 No matching RAP claim lines CO A1 N220

344

No previously processed RAP

claim lines CO A1 N220

345 Detail line REV code not 0023 CO 16 M50 CO 16 M50

346 Unable to locate fee schedule CO 147

Page 13 of 27



347

RAP has more than one detail

line CO A1 N220

348

Line #1 date must equal

episode start date CO A1 N220 CO 16 M52

349 LUPA episode is not 60 days CO 16 MA31 CO 16 MA31

350

Valid admit date required for

HHPPS CO 125 MA40 CO 16 MA40

351 Credit for prior RAP payment CO 23 CO 23

352

Previous RAP payment

exceeds claim amount CO 23 CO 23

353 Detail line REV code not 0022 CO 16 M50 CO 16 M50

354

Base fee not found or equals

$0.00 CO 147

355

SNF provider missing SNF per

diem amount CO 147

356 Overlapping RAP episodes CO 18 OA 18

357

HHPPS RAP From and Through

DOS not equal CO 16 MA31 CO 16 MA31

358

Micro-Dyn PricerActive

component error CO A8 CO A8

359

Micro-Dyn DRGActive

component error CO A8 CO A8

360

DRG is NOT in the selected

DRG Group CO A8 CO A8

361

No end date on claim

configured for Micro-Dyn

PricerActive CO 125 M59 CO 16 M59

362

Provider ID NOT valid for

MicroDyn PricerActive CO 125 N290 CO 16 N290

Page 14 of 27



364

Pricing requires provider DRG

values-values are not defined CO 147 N208

365

Pricing requires DRG values-

values are not defined CO A8 CO A8

366 Workers Compensation Claim CO 19 CO 19

367

Contract term requires

authorization CO 197 CO 197

376

Contract Term Restriction

Group Validation Failed CO 16 N180 CO 16 N190

377 EOB not received on Claim CO 22 MA04 CO 22

378 No COB Amount on claim CO 22 MA04 CO 22

379

Member has privacy payee

defined for claim CO A1 N220

380

Other Carrier Paid exceeds

Other Carrier Allowed CO 23 CO 23

382 Global payment allocated CO 97 M15 CO 97 M15

384 Potential Other Accident CO A1 N220 CO 22 N598

400

Gender is invalid for Medical

Policy CO 7 CO 7

401

Age is invalid for Medical

Policy CO 6 CO 6

402

Maximum units exceeded for

Medical Policy CO 119 CO 119

403

Diagnoses invalid for Medical

Policy CO 11 CO 11

404

Place of Service invalid for


405

Provider Type is invalid for


406

Physician specialty is invalid

for Medical Policy CO 172 N95 CO 8 N95

Page 15 of 27



407

Modifier(s) is invalid for


408

Line failed for Medical Policy

Rule CO A1 N220 CO 50 N130

409

Line failed for Medical Policy

rule overridden on Cert CO A1 N220 CO 50 N130

501

Entry in Local Use field is

required CO A1 N220

502 Duplicate Line on Same Claim CO 18 OA 18

503 Invalid CPT Modifier CO 182 CO 182

504 Invalid CPT/HCPCS code CO A1 M20 CO 181 M20

505 Invalid Revenue Code CO 16 M50 CO 16 M50

506

Modifier Required for

CPT/HCPCS CO 4 CO 4

507 Revenue Code Requires HCPCS CO 125 M20 CO 16 M20

511 Invalid From DOS CO 125 M52 CO 16 M52

512 Invalid Thru DOS CO 125 M59 CO 16 M59

514

Invalid Revenue Code for Bill

Type CO 16 M50 CO 16 M50

515

Invalid HCPCS for Revenue

Code CO 199 CO 199

516

Surgical Procedure Requires

HCPCS CO 125 M20 CO 16 M20

518

Admit type required for 11x

bill type CO 125 MA41 CO 16 MA41

519

Duplicate Claim Line (Same

Member/DOS/CPT(Rev)) CO 18 OA 18

521

Procedure code not found or

invalid for date of service CO 181 CO 181

Page 16 of 27



522

Duplicate Claim Line (Same

Provider/Member/DOS/CPT(R

ev)) CO 18 OA 18

523 Diagnosis code does not exist CO 16 M64 CO 16 M64

524

CPT codes billed include

bundled and unbundled CPTs CO 97 M15 CO 97 M15

525

Diagnosis code is not valid on

DOS CO 146 CO 146

526

Claim submitted out of

sequence CO A1 N220 CO B5

530 Insufficient units for date span CO 16 M53 CO 16 M53

531

Duplicate Mem/DOS/Service

code/Pay To/Modifier CO 18 OA 18

532

Duplicate Mem/DOS/Service

code/Pay To/Rendering

Phys/Modifie CO 18 OA 18

533

Duplicate Mem/DOS/Pay

To/Rendering Phys/Charges CO 18 OA 18

534 Duplicate Modifer Exact Match CO 18 OA 18

536

CPT Code is Bundled wth

Other CPT CO 236 M15 CO 236

538

Diagnosis Pointer Required on

Srvce Line for Diagnosis Codes CO 16 M64 CO 16 M64

539

Date of Service beyond Paid

Thru Date and Grace Period

Date CO 27 N30 CO 27 N30

Page 17 of 27



540

Date of Service is during the

Grace Period CO 27 N30 CO 27 N30

542

Claim Line Submission

Window Overlap CO 45

601 Prior Authorization Is Closed CO 197 CO 197

602

Prior Authorization Is Awaiting

Medical Review CO 197 CO 197

603 Prior Authorization Is Pended CO 197 CO 197

604 Prior Authorization Is Denied CO 39 M62 CO 39

606

Prior authorization number

NOT found CO 15 CO 15

607

Prior authorization not for

same member CO 15 N54 CO 15

608

Prior authorization not for

same provider CO 15 CO 15

609

Prior authorization dates do

not match claim CO 15 N351 CO 15

610

Prior Authorization Services do

not match claim CO 15 N54 CO 15

611

Prior authorization has no

available units CO 198 CO 198

612

Prior authorization has

insufficient units remaining CO 198 CO 198

613

Claim Requires Manual

Processing CO 133

614 No Available Bed Days on Auth CO 198 CO 198

Page 18 of 27



615

Claim Line Exceeds Available

Bed Days-Partial Units Paid CO 198 CO 198

616 Authorization Line Denied CO 39 CO 39

617

Provider's specialty does not

match authorized specialty CO 172 N95 CO 170 N95

618

Provider's group does not

match authorized group CO 15 N54 CO 15

619

Provider's network does not

match authorized network CO 38

620

Provider's participation status

does not match authorized CO B7 CO B7

621

Provider type does not match

authorized provider type CO 170 CO 170

622

Place of Service does not

Match Authorized CO 15 N54 CO 15

623

NDC Code Mismatch on

Authorization CO 15 N54 CO 15

624

Authorization Line Manually

Denied CO 39 N54 CO 198 N54

625

Authorization Line Manually

Pended CO 197 CO 197

627

Allow manual setting of

Benefit Preference on Auth CO 133

628

Claim Line date span crosses

calendar/policy year CO 125 N74 CO 16 N74

Page 19 of 27



629

Multi unit Claim Line date span

crosses calendar/policy year CO 125 N74 CO 16 N74

632 No Determining Claims Found CO 107 CO 107

633

A determining claim matched -

using that benefit preference CO 133

634

Benefit preference selection

forced manually through the

UI CO 45

638

Allow override of contract amt

based on benefit preference CO 45

641

Multiple Instances of Revenue

Code 0024 on Claim CO A1 N220 CO 16 M50

642

Invalid Bill Type found on an

IRF claim CO 125 MA30 CO 16 MA30

643

Multiple or invalid HIPPS codes

found on IRF claim CO A1 N220

644

Charges were not set to zero

on an IRF claim CO 125 M54 CO 16 M54

645

Non-covered days reported

with code 74 not accurate CO 125 M53 CO 16 M53

646

Days must equal payable days

+ loa days + non-covered days CO 125 M53 CO 16 M53

647

Claim line has a revenue code

of 018X and a HCPCS/Rate CO 125 M20 CO 16 M20

Page 20 of 27



648

Claim line units not = days

reflected with span code 74 CO 125 M53 CO 16 M53

649

Sum of units with

accommodation codes not

equal covered days CO 125 M53 CO 16 M53

650

Charges not equal to daily

room rate multiplied by days CO 125 M54 CO 16 M54

651 Claim is an interrupted stay CO A1 N30

652

Length of stay on claim was

less than average length of

stay CO 150 CO 150

653 Claim is a short stay CO 150 CO 150

654

Benefits were exhausted

during stay CO 119 N30 CO 119

655

Benefits were exhausted prior

to admission CO 119 N30 CO 119

656 Claim is an Interim IRF bill CO 135

657

Error encountered with Micro-

Dyn IRF Priceractive

component CO A8 CO A8

658

Invalid claim data found on IRF

claim CO A1 N220

662

Contract for service location

on claim was not found CO 5 M77 CO 5 M77

700 Invalid Dental Procedure CO 125 M51 CO 16 M51

701 Invalid Dental Warranty Period CO A1 N220 CO 119 N130

702 Invalid CDT code on DOS CO 181 CO 181

703 Invalid tooth number CO 125 N39 CO 16 N39

704 Invalid tooth surface for tooth CO 125 N75 CO 16 N75

Page 21 of 27



705

Submitted code requires

billing package CO A1 N220

706

CDT already billed on this date

by same provider CO 18 OA 18

707 CDT already billed on this date CO 18 OA 18

708 Invalid Tooth for CDT CO 125 N37 CO 16 N37

709

CDT requires tooth surface

min/max count CO 125 N75 CO 16 N75

710

Service Line has been

Downcoded CO 97 N22 CO 97 N22

711 Replace obsolete code CO 181 CO 181

750

Inclusively priced ITS claim

cannot be priced CO A1 N220

800 Claim Check: Rebundling CO 97 N20 CO 97 N20

801

Claim Check: Incidental

Services CO 97 N19 CO 97 N19

802

Claim Check: Mutually

Exclusive Service CO 97 N20 CO 97 N20

803

Claim Check: Assistant

Surgeon CO 54 CO 54

804 Claim Check: Age Conflict CO 6 CO 6

805 Claim Check: Age Replacement CO 6 N22 CO 6 N22

806 Claim Check: Gender Conflict CO 7 CO 7

807

Claim Check: Gender

Replacement CO 7 N22 CO 7 N22

808 Claim Check: Cosmetic Surgery CO 50 N30 CO 50 N383

809

Claim Check: Unlisted

Procedure CO A1 N220 CO 16 N350

810

Claim Check: Experimental

Procedure CO 55 CO 55

Page 22 of 27



811 Claim Check: Pre-Op Audit CO 97 M15 CO 97 M15

812 Claim Check: Post-Op Audit CO 97 M15 CO 97 M15

813 Claim Check: Medical Visit CO 97 N20 CO 97 N20

814

Claim Check: New Visit E&M

Audit CO B16 N30 CO B16

815

Claim Check: Intensity of

Service Audit CO 150 CO 150

816

Claim Check: Diag to

Procedure Audit CO 11 M76 CO 11

817

Claim Check: Cross Provider

Total Audit CO B20 CO B20

818 Claim Check: TPL Audit CO 20 MA04 CO 20

819 Claim Check: Claim Stop audit CO 97 CO 97

821 Claim Check: General Error CO A1 N220 CO A1 N220

822

Claim Check: Exceeded 40

Claim Lines CO A1 N220

824

Claim Check: Future Date of

Service Error CO 110 CO 110

825

Claim Check: Add modifier 26

or TC to global billed claim CO B20 CO B20

828

Invalid procedure

code/modifier combination. CO 4 CO 4

837 ClaimCheck: Medically Unlikely CO A1 N362 CO 96 N362

911 Invalid For Male CO 7 CO 7

912 Invalid For Female CO 7 CO 7

913 Manual Pend of Claim CO 133

914 Electronic Claim has COB CO 22 MA04 CO 22 N598

915

Claim has been manually

denied CO A1 N220 CO A1 N220

Page 23 of 27



916

Claim does not have any

service lines CO 16 M51 CO 16 M51

917 Manually-altered pay amount CO A1 N220 CO A1 N220

918 Connect requires claim review CO 107 CO 107

919

Contract Price on Service Line

has been Manually Overridden CO A1 N220

920

Contract Price on Service Line

Manually Overridden to Zero CO A1 N220

921

Claim manually priced with no

balance checks or validation CO A1 N220 CO A1 N220

922

Manual Contract Price exceeds

Billed Amount on Service Line CO A1 N220

930 ITS: Alim Initialization Failed CO A1 N220

931 ITS: Alim L2 Call Failed CO A1 N220

932 ITS: Alim L3 Call Failed CO A1 N220

933 ITS: Alim 90 Call Failed CO A1 N220

934 ITS: Alim C2 Call Failed CO A1 N220

935 ITS: Alim C3 Call Failed CO A1 N220

938 Unable to Adjust ITS Claim CO A1 N220

939

Duplicate SCCF number found

during SF import CO A1 N220

940

Status change caused by SF

Message Code CO A1 N220

941

Previous claim not found for

adjustment CO 129 CO 16 N152

942

Previous claim for adjustment

not finalized CO 129 CO 16 N152

Page 24 of 27



943

Claim reversal for adjustment

failed CO A1 N220 CO 16 N152

944

Multiple enrollments found for

member name but no DOB

match CO 177 CO 177

945

Multiple enrollments found for

member name and DOB CO 177 CO 177

946

SF submitted under incorrect

prefix, DF message code 1083 CO A1 N220

947

Local contracted provider

found for claim CO A1 N220

948

Multiple local contracted

providers found for claim CO A1 N220

949

Must pay provider for assigned

ITS Medicare claim CO A1 N220

951 ITS - Initial Global Fee on Claim CO A1 N220

952

ITS - Follow-up Global Fee on

Claim CO A1 N220

953

ITS - Late Follow-up Global Fee

on Claim CO A1 N220

954

SF indicates Host plan pays

provider for ECRP claim CO A1 N220

955

SF indicates Host plan pays

subscriber for ECRP claim CO A1 N220

1000

History group not effective on

dates of service CO CO B7 N570

1007

Validate Min/Max Work Units

for Occupation Code CO 177 CO 177

1008

Claim Line not eligible for

COPC Processing CO 177 CO 177

Page 25 of 27



1009

Operating Physician

Information Required CO 125 N58 CO 16 N58

2000

OP Surgery NO PA - DENY

Entire Claim CO 197 CO 197

3000

Servicing provider does not

match member CO 24 CO 24

6000

R&B Denied - DENY Entire

Claim CO 16 N180 CO 16 N180

6005 HOSPICE_SQL CO A1 N143 CO 96 N143

6007 Member not AD Waiver on dos CO 177 CO 177

6008

Member is not MRDD Waiver

on dos CO 177 CO 177

6009 Patient Resource Mismatch CO 125 N58 CO 16 N58

6010 Member is not TBI Waiver CO 177 CO 177

6011 Member is not IMD CO 177 CO 177

6012 UB Form Denial CO 125 N34 CO 16 N34

6018 Medically Unlikely Edit CO A1 N435 CO 96 N435

6110

Claim payment exceeds

monetary allotment PR 147 N381 PR 147 N381

8001 CCI Incidental CO 236 CO 236

8002 CCI Mutually Exclusive CO 236 CO 236

8004

Line has been modified to add

or remove modifier 51 CO 59 CO 59

8005

Add-on code cannot be billed

without the primary procedure CO B15 CO B15

8006

Procedure not appropriate for

gender CO 7 CO 7

8007

Co-surgeon is not covered for

this procedure CO 54 CO 54

8008

Co-surgeon not covered

without documentation CO 16 N29 CO 16 N29

Page 26 of 27



8009

Surgical team is not covered

for this procedure CO 54 CO 54

8010

Surgical team not covered

without documentation CO 16 N29 CO 16 N29

8011

Patient has received prior care

from this provider CO B16 CO B16

8012

The number of units does not

match the number of days

billed CO A1 N345 CO 16 N345

8013

Units does not match the

number of site specific

modifiers CO A1 M53 CO 16 M53

8280

Invalid procedure-modifier

combination per BMS policy CO 4 CO 4

Page 27 of 27

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SNF-Member Share of Cost Reduced From Contracted 2 … Companion Guides/WV... · WV Medical CAQH Phase 3 CARC-RARC Modifications.xlsx System Edit Edit Description Previous HIPAA Group