D00022_837D_Acute_Care_Companion_Guide.pdf

TEXAS MEDICAID

HIPAA TRANSACTION STANDARD COMPANION

GUIDE

Refers to the Implementation Guide Acute Care 837 Health Care Claim: Dental

Based on ASC X12 version 005010 CORE v5010 Companion Guide

June 2025

837D Health Care Claim: Dental

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Table of Contents

1 INTRODUCTION

Scope

Overview

References

Additional Information

2 GETTING STARTED

Working with Texas Medicaid

Trading Partner Registration

3 TESTING WITH TEXAS MEDICAID

4 CONNECTIVITY WITH TEXAS MEDICAID/COMMUNICATIONS

Transmission Administrative Procedures

Communication protocol specifications

Passwords

5 CONTACT INFORMATION

Customer Service

Texas Medicaid EDI Help Desk

Applicable websites/e-mail

EDI Helpful Links:

6 CONTROL SEGMENTS/ENVELOPES

ISA-IEA

GS-GE

7 TEXAS MEDICAID SPECIFIC BUSINESS RULES AND LIMITATIONS

PWK06 Paperwork Identifier Definition

CAS02 Texas Medicaid Disposition Code Chart

Disposition Code: D (denied) – Payment denied by Third Party Resource

Disposition Code: P (paid) - Any form of payment received from Third Party Resource.

Disposition Code: Y (research) - A question requiring more research by clerk

8 ACKNOWLEDGEMENTS AND/OR REPORTS

9 TRADING PARTNER AGREEMENTS

Trading Partners

10 TRANSACTION SPECIFIC INFORMATION

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11 APPENDICES

Transmission Examples

Texas Medicaid Example Transaction:

11.1 Change Summary

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Disclosure Statement

Copyright © 2016 by Texas Medicaid. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder.

This document is provided “as is” without any expressed or implied warranty. Note that the copyright on the underlying Accredited Standards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association (DISA) on behalf of ASC X12.

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Preface

This Companion Guide to the v5010 ASC X12N Implementation Guide and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging electronically with Texas Medicaid. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12N syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

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1 INTRODUCTION

Scope Under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Secretary of the Department of Health and Human Services (HHS) is directed to adopt standards to support the electronic exchange of administrative and financial health care transactions. The purpose of the Administrative Simplification portion of HIPAA is to enable health information to be exchanged electronically and to adopt standards for those transactions.

Texas Medicaid defines a Trading Partner as any entity trading data with Texas Medicaid EDI. Trading partners include vendors, clearinghouses, Providers and billing agents.

The 5010 Technical Report Type 3 (TR3) dated May 2006 was used to create this Companion Guide for the 837 file format. All instructions in this document are written using information known at the time of publication and are subject to change.

Overview This guide is intended as a resource to assist submitters in successfully conducting EDI 837 Health Care Claims: Dental transactions with Texas Medicaid. This document does not provide detailed data specifications, which are published separately by the industry committees responsible for their creation and maintenance.

The purpose of this document is to assist the provider with Texas Medicaid-particular data sets for information specified in the National Electronic Data Interchange Transaction Set Implementation Guide for the file type. The federal government has set standards to simplify Electronic Data Interchange (EDI). To comply with the standard, Texas Medicaid has updated the data sets for EDI files to be in accordance with HIPAA and is utilizing the ASC X12 nomenclatures.

The instructions in this companion guide are not intended to be stand-alone requirements documents and must be used in conjunction with the associated ANSI ASC X12N National Implementation Guide. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guide and is in conformance with ASC X12’s Fair Use and Copyright statements.

References The ANSI ASC X12N Implementation Guides are available for purchase at the Washington Publishing Company web site at: https://x12.org/products/technical-reports

The Texas Medicaid EDI Connectivity Guide which contains instructions regarding connectivity options including CORE compliant Safe Harbor information, can be found on the EDI page of the Texas Medicaid website at: https://www.tmhp.com/topics/edi

The Companion Guides, published by Texas Medicaid, can be found on:

https://www.tmhp.com/topics/edi https://x12.org/products/technical-reports

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Additional Information Security and Privacy Statement

Covered entities were required to implement HIPAA Privacy Regulations no later than April 14, 2003. A covered entity is defined as a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. Providers that conduct certain electronic transmissions are responsible for ensuring these privacy regulations are implemented in their business practices. Health and Human Services Commission (HHSC) is a HIPAA Covered Entity.

Accordingly, Texas Medicaid is operating as a HIPAA Business Associate of HHSC as defined by the federally mandated rules of HIPAA. A Business Associate is defined as a person or organization that performs a function or activity on behalf of a covered entity but is not part of the covered entity's workforce.

The privacy regulation has three major purposes:

• To protect and enhance the rights of consumers by providing them access to their health information and controlling the appropriate use of that information;

• To improve the quality of health care in the United States by restoring trust in the health care system among consumers, health care professionals and the many organizations and individuals committed to the delivery of health care; and

• To improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy and protection.

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2 GETTING STARTED

Working with Texas Medicaid This section describes how to interact with Texas Medicaid’s Electronic Data Interchange (EDI) systems.

EDI Help Desk is available to assist trading partners in exchanging data with Texas Medicaid. Below are details on how to register and contact the department for assistance.

Trading Partner Registration HHSC requires any entity exchanging electronic data with Texas Medicaid to be enrolled in the Texas Medicaid Program and approved for the submission of X12 transaction sets.

Texas Medicaid Enrollment Forms and instructions are available at:

https://www.tmhp.com/topics/provider-enrollment

Successful enrollment in Texas Medicaid is required before proceeding with EDI.

To get started with EDI transactions, the necessary forms and instructions are available at:

https://www.tmhp.com/resources/forms?field_topics_target_id=96

3 TESTING WITH TEXAS MEDICAID

Texas Medicaid requires that all Trading Partners who connect directly to successfully complete the testing process prior to submitting claims.

If the Provider or Billing Agent utilizes a Clearinghouse to submit the electronic claims, the entity connecting with Texas Medicaid must have successfully completed the testing process prior to claim submission.

Texas Medicaid provides a self-testing tool through Edifecs. Testing and Certification instructions, along with setup information can be found in Section 9.1 of the Texas Medicaid EDI Connectivity Guide found at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/topics/provider-enrollment https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

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4 CONNECTIVITY WITH TEXAS MEDICAID/COMMUNICATIONS

Transmission Administrative Procedures The Texas Medicaid EDI Connectivity Guide that contains specific instructions regarding connectivity options, can be found on the EDI page of the Texas Medicaid website at:

https://www.tmhp.com/topics/edi

Communication protocol specifications The Texas Medicaid EDI Connectivity Guide that contains specific instructions regarding connectivity options, along with CORE compliant Safe Harbor information, can be found on the EDI page of the Texas Medicaid website at:

https://www.tmhp.com/topics/edi

Passwords Texas Medicaid provides instruction on resetting of passwords in section 5.1 of the Texas Medicaid EDI Connectivity Guide found at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

5 CONTACT INFORMATION

Customer Service Texas Medicaid EDI Help Desk The EDI Help Desk provides technical assistance only by troubleshooting Texas Medicaid EDI issues. Contact your system administrator for assistance with network, hardware, or telephone line issues.

To reach the Texas Medicaid EDI Help Desk, select one of the following methods:

• Fax 1-512-514-4230 or 1-512-514-4228

• Call 1-888-863-3638, option 3 (or call 1-512-514-4150, option 3)

The Texas Medicaid EDI Help Desk is available Monday through Friday, 7 a.m. to 7 p.m. CST.

Applicable websites/e-mail This section contains detailed information about useful web sites and email addresses.

Texas Medicaid EDI Technical Information, such as code references, vendor file specifications, and additional Companion Guides can be found at:

https://www.tmhp.com/topics/edi

The Texas Medicaid Provider Procedures Manual is found at:

https://www.tmhp.com/resources/provider-manuals https://www.tmhp.com/topics/edi https://www.tmhp.com/topics/edi https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/resources/provider-manuals

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EDI Helpful Links:

Washington Publishing Company – The Washington Publishing Company site includes reference documents pertaining to HIPAA, such as: implementation guides, data conditions, and the data dictionary for X12N standards.

Workgroup for Electronic Data Interchange (WEDI) – This site provides implementation materials and information.

National Uniform Billing Committee (NUBC) – This site is the official source of UB-04 billing information.

Texas Department of State Health Services (DSHS)

Texas Health and Human Services Commission

6 CONTROL SEGMENTS/ENVELOPES

ISA-IEA

• Texas Medicaid does not support repetition of a simple data element or a composite data structure.

• Texas Medicaid will accept one ISA/IEA in each file and one GS/GE per ISA.

• Texas Medicaid uses “*” (asterisk) as the element separator, and “~” (tilde) as the segment separator.

Page

Loop

ID

Reference Name Codes Length Notes/Comments

Control Segments

C.3 ISA Interchange Control Header

C.4 ISA01 Authorization Information Qualifier

C.4 ISA03 Security Information Qualifier

C.4 ISA05 Interchange ID Qualifier

ZZ

C.5 ISA06 Interchange Sender ID

Provider Submitter

ID

C.5 ISA07 Interchange ID Qualifier

ZZ

C.5

ISA08

Interchange Receiver ID

Production = 617591011C21P Testing = 617591011C21T

C.5 ISA11 Repetition Separator

| (pipe character) https://wpc-edi.com/ https://www.wedi.org/ https://www.nubc.org/ https://www.dshs.state.tx.us/ https://www.hhs.texas.gov/

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Page

Loop

ID

Reference Name Codes Length Notes/Comments

Control Segments

C.6 ISA14 Acknowledgemen t Requested

0 (zero)

C.6 ISA15 Interchange Usage Indicator

P ISA15=”P” for both Production and Test

C.6 ISA16 Component

Element Separator

: (colon character)

GS-GE

Page

Loop

ID

Reference Name Codes Length Notes/Comments

Control Segments

C.7 GS Functional Group Header

C.7 GS02 Application Sender’s Code

Provider Submitter

ID

C.7

GS03

Application Receiver’s Code

617591011C21P

This is Texas Medicaid’s Electronic Transmitter Group Identifier.

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7 TEXAS MEDICAID SPECIFIC BUSINESS RULES AND

LIMITATIONS

Texas Medicaid will accept up to 5000 transactions per batch. If a file is submitted with more than 5000 transactions the entire file will be rejected and not processed by Texas Medicaid.

X12 files with more than one GS-GE Functional Group will fail to process in the Texas Medicaid system.

The Texas Medicaid Provider Procedures Manual is the providers’ principal source of information about Texas Medicaid. The most recent version is found at:

https://www.tmhp.com/resources/provider-manuals

PWK06 Paperwork Identifier Definition Texas Medicaid has specific qualifiers that must be used when transmitting other insurance information. Please utilize the following qualifiers for the PWK01 and PWK02:

PWK01

Attachment Report Type Code

EB

Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer)

PWK02

Attachment Transmission

EL

Electronically only

The PWK06 is broken down below. In order for Texas Medicaid to recognize the other insurance information, the data structure below must be adhered to.

Texas Medicaid requires that the submitter use V5X and V5Y as the first 3 characters of this data element (s) to indicate that a denial has been received verbally from an insurance company. Verbal Denials required additional information regarding the insurance company and contact information about the verbal statement.

NOTE: x – the rest of the value after the requirement

Qualifiers V5X and V5Y Required if other insurance gave a verbal denial.

Send in the following format:

First PWK Segment:

Position 1-3 = V5X Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition Position 5 = space Position 6-15 = Phone Number Position 16 = space Position 17- 41 = name of insurance representative Position 42 = space Position 43 – 50 = date of inquiry in CCYYMMDD format Second PWK Segment:

Position 1-3 = V5Y https://www.tmhp.com/resources/provider-manuals

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Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition (Must be the same as position 4 ofV5X) Position 5 – 34 = Reason given for denial

Qualifiers A5Q and A5R Insurance company information required if other insurance was billed. Send in the following format:

First PWK Segment:

Position 1-3 = A5Q Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition Position 5-14 = Phone Number Position 15 – 32 = Ins. Co. Address Second PWK Segment:

Position 1-3 = A5R Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition (Must be the same as position 4 of A5Q) Position 5 – 24 = Ins. Co. City Position 25 – 26 = Ins. Co. State Position 27 – 35 = Ins. Co. Zip

Qualifier B8Z Position 1 – 3 = B8Z Texas Medicaid requires that for insurance disposition the submitter follow the below segment layout:

Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition Position 5 – 12 = date in CCYYMMDD format follow the below segment layout:

Position 4 = indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurance disposition, and 3 if for 3rd other insurance disposition Position 5 – 12 = date in CCYYMMDD format

NTE02 Claim Note Description Definition

Texas Medicaid requires the submitter follow the below layout:

Position 1 through 3: "DPC" Position 4 through 8: remark code

When billing for comprehensive orthodontic treatment, procedure code D8080, three local codes must be submitted along with procedure code D8080. Local codes (procedure codes Z2009, Diagnostic workup approved; Z2011, Orthodontic appliance, upper; or Z2012, Orthodontic appliance, lower) must be placed in the NTE02. Use “01”, “02” or “03” prior to the local code to indicate the associated service line.

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Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code Z2009, enter the information as follows: DPC01Z2009. The total billed would be $175.

Example 2: For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are Z2009 and Z2011, enter the information as follows:

DPC01Z200902Z2011.

Example 3: For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPC01Z200902Z201103Z2012.

When billing for emergency or trauma-related dental services, the provider must enter the service line number associated with the emergency service followed by the word “Emergency” or

“Trauma” in the NTE02 (also enter a brief description of the Current Dental Terminology [CDT] procedure code used). Example: NTE*ADD*03Emergency D9110 Treatment of dental pain due to infection.

CAS02 Texas Medicaid Disposition Code Chart The code list is current as of the publication date. The code list is subject to change. Criteria for CAS codes and Disposition Indicators

CAS (Claims Adjudication System) codes will be submitted by providers to drive Other

Insurance/Third Party Resource disposition code for electronic claim submissions. Clerk will view disposition code on claim as before. Clerk will also view reason code on submitted claim image.

Disposition Code: D (denied) – Payment denied by Third Party Resource.

CAS Description Disp.

1 Deductible Amount. D

The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The procedure code/type of bill is inconsistent with the place of service.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The procedure/revenue code is inconsistent with the patient's age. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The procedure/revenue code is inconsistent with the patient's gender.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

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CAS Description Disp.

The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

13 The date of death precedes the date of service. D

14 The date of birth follows the date of service. D

Claim/service lacks information or has submission/billing error(s).

Usage: Do not use this code for claims attachment(s)/other documentation. 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.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Exact duplicate claim/service. (Use only with Group Code OA, except where state workers' compensation regulations require CO.)

D

This is a work-related injury/illness and thus the liability of the Workers’ Compensation Carrier.

D

20 This injury/illness is covered by the liability carrier. D

21 This injury/illness is the liability of the no-fault carrier. D

22 This care may be covered by another payer per coordination of benefits. D

26 Expenses incurred prior to coverage. D

27 Expenses incurred after coverage terminated. D

29 The time limit for filing has expired. D

31 Patient cannot be identified as our insured. D

32 Our records indicate the patient is not an eligible dependent. D

33 Insured has no dependent coverage. D

34 Insured has no coverage for newborns. D

35 Lifetime benefit maximum has been reached. D

39 Services denied at the time authorization/pre-certification was requested. D

Charges do not meet qualifications for emergent/urgent care. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

This is a non-covered service because it is a routine/preventive exam, or a diagnostic/screening procedure done in conjunction with a

D00022 16 June 2, 2025 routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

These are non-covered services because this is a pre-existing condition.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Services by an immediate relative or a member of the same household are not covered.

D

Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

D

61 Adjusted for failure to obtain second surgical opinion. D

74 Indirect Medical Education Adjustment. D

75 Direct Medical Education Adjustment. D

76 Disproportionate Share Adjustment. D

78 Non-Covered days/Room charge adjustment. D

90 Ingredient cost adjustment. Usage: To be used for pharmaceuticals only. D

91 Dispensing fee adjustment. D

95 Plan procedures not followed. D

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.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110

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Service Payment Information REF), if present.

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

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

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

D

110 Billing date predates service date. D

111 Not covered unless the provider accepts assignment. D

112 Service not furnished directly to the patient and/or not documented. D

114 Procedure/product not approved by the Food and Drug Administration. D

115 Procedure postponed, canceled, or delayed. D

The advance indemnification notice signed by the patient did not comply with requirements.

D

Transportation is only covered to the closest facility that can provide the necessary care.

D

118 ESRD network support adjustment. D

119 Benefit maximum for this time period or occurrence has been reached. D

Indemnification adjustment - compensation for outstanding member responsibility.

D

122 Psychiatric reduction. D

128 Newborn's services are covered in the mother's Allowance. D

Prior processing information appears incorrect. 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.)

D

130 Claim submission fee. D

The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).

D

135 Interim bills cannot be processed. D

Failure to follow prior payer's coverage rules. (Use only with Group Code

OA.)

D

137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. D

140 Patient/Insured health identification number and name do not match. D

142 Monthly Medicaid patient liability amount. D

143 Portion of payment deferred. D

146 Diagnosis was invalid for the date(s) of service reported. D

147 Provider contracted/negotiated rate expired or not on file. D

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Information from another provider was not provided or was insufficient/incomplete. 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.)

D

Lifetime benefit maximum has been reached for this service/benefit category.

D

Payer deems the information submitted does not support this level of service.

D

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

D

Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

153 Payer deems the information submitted does not support this dosage. D

Payer deems the information submitted does not support this day's supply.

D

155 Patient refused the service/procedure. D

157 Service/procedure was provided as a result of an act of war. D

158 Service/procedure was provided outside of the United States. D

159 Service/procedure was provided as a result of terrorism. D

160 Injury/illness was the result of an activity that is a benefit exclusion. D

Attachment/other documentation referenced on the claim was not received.

D

Attachment/other documentation referenced on the claim was not received in a timely fashion.

D

These services were submitted after this payer's responsibility for processing claims under this plan ended.

D

This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

169 Alternate benefit has been provided. D

Payment is denied when performed/billed by this type of provider.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

173 Service/equipment was not prescribed by a physician. D

174 Service was not prescribed prior to delivery. D

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175 Prescription is incomplete. D

176 Prescription is not current. D

177 Patient has not met the required eligibility requirements. D

178 Patient has not met the required spend down requirements. D

Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

180 Patient has not met the required residency requirements. D

181 Procedure code was invalid on the date of service. D

182 Procedure modifier was invalid on the date of service. D

The referring provider is not eligible to refer the service billed. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

The rendering provider is not eligible to perform the service billed. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

186 Level of care change adjustment. D

This product/procedure is only covered when used according to FDA recommendations.

D

‘Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.

D

Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

D

Nonstandard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.

D

Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.

D

Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.

D

195 Refund issued to an erroneous priority payer for this claim/service. D

197 Precertification/authorization/notification/pre-treatment absent. D

198 Precertification/notification/authorization/pre-treatment exceeded. D

199 Revenue code and Procedure code do not match. D

200 Expenses incurred during lapse in coverage. D

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Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR.) 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.)

D

202 Non-covered personal comfort or convenience services. D

203 Discontinued or reduced service. D

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

D

206 National Provider Identifier - missing. D

207 National Provider identifier - Invalid format. D

208 National Provider Identifier - Not matched. D

Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA.)

D

Payment adjusted because pre-certification/authorization not received in a timely fashion.

D

211 National Drug Codes (NDC), not eligible for rebate, are not covered. D

212 Administrative surcharges are not covered. D

Non-compliance with the physician self-referral prohibition legislation or payer policy.

D

Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send, and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 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).

D

Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

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.

D

Patient identification compromised by identity theft. Identity verification required for processing this and future claims.

D

Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. 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.)

D00022 21 June 2, 2025

Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 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.)

D

Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication.

D

Mutually exclusive procedures cannot be done in the same day/setting.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.

D

This procedure is not paid separately. 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.)

D

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

D

Legislated/Regulatory Penalty. 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.)

D

Claim spans eligible and ineligible periods of coverage. This is the reduction for the ineligible period. (Use only with Group Code PR.)

D

Claim spans eligible and ineligible periods of coverage. Rebill separate claims.

D

The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

241 Low Income Subsidy (LIS) Co-payment Amount. D

242 Services not provided by network/primary care providers. D

243 Services not authorized by network/primary care providers. D

245 Provider performance program withhold. D

246 This non-payable code is for required reporting only. D

Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.

D

This claim has been identified as a readmission. (Use only with Group Code CO.)

D

The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. 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).

251 The attachment/other documentation that was received was incomplete D

D00022 22 June 2, 2025 or deficient. The necessary information is still needed to process the claim. 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).

An attachment/other documentation is required to adjudicate this claim/service. 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).

D

Claim received by the dental plan but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.

D

256 Service not payable per managed care contract. D

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA.)

D

Claim/service not covered when patient is in custody/incarcerated.

Applicable federal, state or local authority may cover the claim/service.

D

261 The procedure or service is inconsistent with the patient's history. D

262 Adjustment for delivery cost. Usage: To be used for pharmaceuticals only. D

263 Adjustment for shipping cost. Usage: To be used for pharmaceuticals only. D

264 Adjustment for postage cost. Usage: To be used for pharmaceuticals only. D

Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.

D

Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.

D

Claim/service spans multiple months. 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.)

D

The Claim spans two calendar years. Please resubmit one claim per calendar year.

D

Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Claim received by the medical plan but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration.

D

Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA.)

D

272 Coverage/program guidelines were not met. D

273 Coverage/program guidelines were exceeded. D

D00022 23 June 2, 2025

274 Fee/Service not payable per patient Care Coordination arrangement. D

Prior payer's (or payers') patient responsibility (deductible, coinsurance, co- payment) not covered. (Use only with Group Code PR.)

D

276 Services denied by the prior payer(s) are not covered by this payer. D

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA.)

D

Performance program proficiency requirements not met. (Use only with Group Codes CO or PI.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network.

D

Claim received by the medical plan but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.

D

Deductible waived per contractual agreement. Use only with Group Code

CO.

D

The procedure/revenue code is inconsistent with the type of bill. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

283 Attending provider is not eligible to provide direction of care. D

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.

D

285 Appeal procedures not followed. D

286 Appeal time limits not met. D

287 Referral exceeded. D

288 Referral absent. D

Services considered under the dental and medical plans. Benefits not available.

D

Claim received by the dental plan but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.

D

Claim received by the medical plan but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.

D

Claim received by the medical plan but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.

D00022 24 June 2, 2025

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.

D

Claim received by the medical plan but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.

D

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.

D

The billing provider is not eligible to receive payment for the service billed.

D

Claim received by the Medical Plan but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.

D

Claim received by the Medical Plan but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.

D

Precertification/notification/authorization/pre-treatment time limit has expired.

D

Prior payer's patient responsibility not covered for Qualified Medicare and Medicaid Beneficiaries.

D

Benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.

D

Benefits not available under this plan and has been forwarded to the patient's hearing plan for further consideration.

D

306 Type of bill is inconsistent with the patient status. D

A1 Claim/Service denied. 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.)

D

A6 Prior hospitalization or 30-day transfer requirement not met. D

A8 Ungroupable DRG. D

B1 Non-covered visits. D

B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

D

B12 Services not documented in patient's medical records. D

B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

D

B14 Only one visit or consultation per physician per day is covered. D

B15

This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D00022 25 June 2, 2025

B16 'New Patient' qualifications were not met. D

B20 Procedure/service was partially or fully furnished by another provider. D

B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.

D

B4 Late filing penalty. D

B7

This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

B8 Alternative services were available and should have been utilized. Usage:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

D

P12

Workers' compensation jurisdictional fee schedule adjustment. Usage: 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). 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. To be used for Workers' Compensation only.

D

P13

Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send, and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. 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. To be used for Workers' Compensation only.

D

P15 Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.

D

P16 Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA.)

D

P2

Not a work-related injury/illness and thus not the liability of the workers' compensation carrier. Usage: If adjustment is at the Claim Level, the payer must send, and the provider should refer to the 835 Insurance Policy Number Segment (loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 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). To be used for Workers' Compensation only.

P3 Workers' Compensation case settled. Patient is responsible for amount of D

D00022 26 June 2, 2025 this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR.)

P4

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send, and the provider should refer to the 835 Insurance Policy Number Segment (loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. 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). To be used for Workers’ Compensation only.

D

P32 Payment adjusted due to Apportionment. D

Disposition Code: P (paid) - Any form of payment received from Third Party Resource.

CAS Description Disp.

2 Coinsurance Amount. P

3 Co-payment Amount. P

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA.)

P

24 Charges are covered under a capitation agreement/managed care plan. P

44 Prompt-pay discount. P

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability.)

P

Processed based on multiple or concurrent procedure rules. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

P

66 Blood Deductible. P

69 Day outlier amount. P

70 Cost outlier - Adjustment to compensate for additional costs. P

85 Patient Interest Adjustment (Use Only Group code PR.) P

89 Professional fees removed from charges. P

94 Processed in Excess of charges. P

102 Major Medical Adjustment. P

103 Provider promotional discount (e.g., Senior citizen discount). P

131 Claim specific negotiated discount. P

D00022 27 June 2, 2025

132 Prearranged demonstration project adjustment. P

134 Technical fees removed from charges. P

Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.

P

144 Incentive adjustment, e.g., preferred product/service. P

259 Additional payment for Dental/Vision service utilization. P

B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.

P

B22 This payment is adjusted based on the diagnosis. P

Disposition Code: Y (research) - A question requiring more research by clerk.

CAS Description Disp.

100 Payment made to patient/insured/responsible party. Y

104 Managed care withholding. Y

105 Tax withholding. Y

106 Patient payment option/election not in effect. Y

187 Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)

Y

215 Based on subrogation of a third-party settlement. Y

216 Based on the findings of a review organization. Y

293 Payment made to employer. Y

294 Payment made to attorney. Y

A0 Patient refund amount. Y

B9 Patient is enrolled in a Hospice. Y

SBR03 Benefit Code Definition

The code list is current as of the publication date. The code list is subject to change.

CA1: County Indigent Health Care Program (CIHCP) CCP: Comprehensive Care Program (CCP) CSN: Children with Special Health Care Needs (CSHCN) Services Program Provider DE1: Texas Health Steps (THSteps) Dental…