ATTACHMENT J-9 MSN Code Payment Determinations.xls

TOTAL

CO- Deny* OA- Deny* CR- Not Valid 2 Coinsurance Amount PR-Secondary TRM 1.3.1.1 CO- Deny* OA- Deny* CR- Not Valid 3 Co-payment Amount PR-Secondary TRM 1.3.1.1 CO- Deny* OA- Deny* CR- Not Valid 4 The procedure code is inconsistent with the modifier used or a required modifier is missing PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 5 Procedure code/bill type inconsistent with place PR-SecondaryTRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 6 The procedure/revenue code is inconsistent with patient age PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 7 The procedure/revenue code is inconsistent with patient's gender PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 8 The procedure code is inconsistent with the provider type/specialty (taxonomy) PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 9 The diagnosis is inconsistent with the patient's age PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 10 The diagnosis is inconsistent with the patient's gender PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 11 The diagnosis is inconsistent with the provider type PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 12 The diagnosis inconsistent with the provider type PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 13 The date of death precedes date of service PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 14 The date of birth follows date of service PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 15 The authorization number is missing, invalid, or does not apply to the billed services or provider PR-Conditional M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 15 The authorization number is missing, invalid, or does not apply to the billed services or provider PR-Conditional M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 16 Claim/service lacks information which is needed for adjudication. PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 17 Requested info not provided/sufficient/complete PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 19 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 20 This injury/illness is covered by the liability carrier. PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 21 This injury/illness is the liability of the no-fault carrier PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 22 This care may be covered by another payer per coordination of benefits PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 23 The impact of prior payer(s) adjudication including paments and/or adjustments PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 24 Charges covered under capitation agreement/management care plan PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 25 Denied. Stop loss deductible not met PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 27 Expenses incurred after coverage terminated PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 28 Coverage not in effect at time of service PR- Deny TRM 1.3.1.2 CO- Deny OA- Deny

CO- Deny* OA- Deny* CR- Not Valid 30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting or residency requirements PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 32 Our records indicate that this dependent is not an eligible dependent as defined PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 33 Insured has no dependent coverage PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 34 Insured has no coverage for newborns PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 35 Lifetime benefit maximum has been reached PR-Primary TRM 1.3.1.3.1 CO- Deny* OA- Deny* CR- Not Valid 36 Balance does not exceed co-payment amount PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 39 Service denied at time authorization/pre-certification was requested PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 40 Charges to not meet qualifications for emergent/urgent care PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 41 Preferred provider discount agreement PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 45 Charges exceed fee schedule/maximum allowable or contracted/legislated fee arrangement PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 46 Non covered service(s) PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 50 These are non-covered services because this is not deemed a "medical necessity" by the payer PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 51 These are non-covered services because this is a pre-existing condition PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 52 Non-covered service by this specific provider type PR- Deny TRM 1.3.1.2 CO- Deny OA- Deny

CO- Deny* OA- Deny* CR- Not Valid 54 Multiple physicians/ assistants are not covered in this case PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 55 Procedure/treatment is deemed experimental/ investigational by the payer PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 56 Procedure/treatment has not been deemed "proven to be effective" by the payer PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 57 Denied/reduced level of care not supported PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 59 Processed based on multiple or concurrent procedure rules PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 61 Penalty for failure to obtain second surgical opinion PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 62 Denied/reduced. Authorized limit exceeded PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny*

CO- Suspend for review OA- Suspend for review

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 67 Lifetime reserve days PR- Not Valid CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Deny* OA- Deny* CR- Not Valid 70 Cost outlier - adjustment to compensate for additional costs PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 71 Primary payer amount PR- Not Valid CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid CR- Not Valid 75 Direct medical education adjustment PR- Not Valid CO- Not Valid OA- Not Valid CR- Not Valid 76 Disproportionate share adjustment PR- Not Valid CO- Not Valid OA- Not Valid CR- Not Valid 77 Covered days PR-Secondary TRM 1.3.1.1 CO- Not Valid OA- Not Valid

CO- Deny* OA- Deny* CR- Not Valid 79 Cost report days PR- Not Valid CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid CR- Not Valid 86 Statutory adjustment PR- Not Valid CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid CR- Not Valid 88 Adjusted due to recoupment of overpayment PR- Suspend for review CO- Suspend for review OA- Suspend for review

CO- Deny* OA- Deny* CR- Not Valid 90 Ingredient cost adjustment PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 91 Dispensing fee adjustment PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 92 Claim paid in full PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Not Valid OA- Not Valid

CO- Deny* OA- Deny* CR- Not Valid 95 Plan procedures not followed PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 95 Plan procedures not followed PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 96 Non-covered charge(s) PR- Deny TRM 1.3.1.2* CO- Deny* OA- Deny* CR- Not Valid *See exceptions in TRM 1.3.1.3 and 1.3.3 97 Benefit for service inlucluded in the payment/ allowance for another service already adjudicated PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 98 Hospital must file claim PR- Deny TRM 1.3.1.2 CO- Deny OA- Deny

CO- Deny* OA- Deny*

CO- Not Valid OA- Not Valid CR- Not Valid 101 Predetermination: anticipated payment upon completion of services or claim adjustment PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 102 Major medical adjustment PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Not Valid OA- Not Valid CR- Not Valid 103 Provider promotional discount PR- Not Valid CO- Deny* OA- Deny* CR- Not Valid 104 Managed care withholding PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Not Valid OA- Not Valid CR- Not Valid 105 Tax withholding PR- Not Valid CO- Deny* OA- Deny* CR- Not Valid 106 Patient payment option/election not in effect PR- Not Valid CO- Not Valid OA- Not Valid CR- Not Valid 107 The related or qualifying claim/service not identified on this claim PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 108 Rent/purchase guidelines were not met PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 109 Claim not covered by this payer/contractor PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 110 Billing date predates service date PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 111 Not covered unless provider accepts assignment PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 112 Service not furnished directly to the patient and/or not documented PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 113 Denied . Service provided outside the U.S. PR- Primary TRM 1.3.1.3.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 115 Procedure postponed or cancelled or delayed PR- Suspend for review CO- Deny* OA- Deny* CR- Not Valid 116 Advance indemnification notice signed by the patient did not comply with requirements PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 117 Transporation is only covered to the closest facility that can provide the necessary care PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 118 ESRD network support adjustment PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 119 Benefit maximum reached for the time period or occurrence PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.3.1 CO- Deny* OA- Deny* CR- Not Valid 120 Patient covered by managed care plan PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 122 Psychiatric reduction PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 123 Payer refund due to overpayment PR- Suspend for review CO- Suspend for review OA- Suspend for review

CO- Suspend for review OA- Suspend for review

CO- Suspend for review OA- Suspend for review CR- Not Valid 126 Deductible - Major Medical PR-Secondary TRM 1.3.1.1 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 129 Prior processing information appears incorrect PR- Suspend for review CO- Suspend for review OA- Suspend for review CR- Not Valid 130 Claim submission fee PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 131 Claim specific negotiated discount PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 131 Claim specific negotiated discount PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 132 Prearranged demonstration project adjustment PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 133 Disposition of this claim/service is pending further review PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 134 Technical fees removed from charges PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 135 Interim bills cannot be processed PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 136 Failure to follow prior payer's coverage rules PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 137 Regulatory surcharges, assessments, allowances or health related taxes PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 138 Appeal procedures not followed or time limits not met PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 139 Contracted funding agreement. Subscriber is employed by the provider of services PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 140 Patient/insured health identification number and name do not match PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 141 Claim spans eligible and ineligible periods PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 142 Monthly Medicaid patient liability amount PR- Not Valid CO- Deny* OA- Deny* CR- Not Valid 143 Portion of payment deferred PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 144 Incentive adjustment, e.g. preferred product service PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 145 Premium payment withholding PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 147 Provider contracted/ negotiated rate expired or not on file PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 148 Information from another provider was not provided or was insufficient/incomplete PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 149 Lifetime benefit maximum has been reached for this service/benefit category PR-Primary TRM 1.3.1.3.1 CO- Deny* OA- Deny* CR- Not Valid 150 Payer deems the information submitted does not support this level of service PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 151 Payer deems the information submitted does not support this level of service PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 151 Payer deems the information submitted does not support this level of service PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 152 Payer deems the information submitted does not support this length of service PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 153 Payer deems the information submitted does not support this dosage PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 154 Payer deems the information submitted does not support this day's supply PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 155 Patient refused the service/procedure PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 156 Flexible spending account payment PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 158 Service/procedure was provided outside of the United States PR-Deny TRM 1.3.1.3.2 CO- Deny* OA- Deny* CR- Not Valid 159 Service/procedure was as a result of terrorism PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 160 Injury/illness was the result of an activity that is a benefit exclusion PR-Primary TRM 1.3.3 CO- Deny* OA- Deny* CR- Not Valid 161 Provider performance bonus PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 162 State-mandated requirement for property and casualty PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 163 Attachment referenced on the claim was not received PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 164 Attachment referenced on the claim was not received in a timely fashion PR- Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 165 Referral absent or exceeded PR- Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 166 These services were submitted after this payers responsibility for processing claims under this plan ended PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 167 This diagnosis is not covered PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 168 Service has been considered under the patient's medical plan. Benefits are not available under this dental plan PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 169 Alternate benefit has been provided PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 170 Payment is denied when performed/billed by this type of provider PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 171 Payment is denied when performed/billed by this type of provider in this type of facility PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 172 Payment adjusted, when performed/billed by a provider of this specialty PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 173 Service was not prescribed by a physician PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 174 Service was not prescribed prior to delivery PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 175 Prescription is incomplete PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 176 Prescription is not current PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 177 Patient has not met the required eligibility requirements PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 178 Patient has not met the required spend down requirements PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 179 Patient has not met the required waiting requirements PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 180 Patient has not met the required residency requirements PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 181 Procedure code was invalid on the date of service PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 182 Procedure modifier was invalid on date of service PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 183 Referring provider is not eligible to refer the service billed PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 184 Prescribing/ordering provider is not eligible to prescribe/ order the service billed PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 185 Rendering provider is not eligible to perform the service billed PR-Conditional TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 186 Level of care change adjustment PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 187 Consumer spending account payments PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 188 This product/procedure is only covered when used according to FDA recommendations PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 189 Not otherwise classified or unlisted procedure code was billed when there is a specific procedure code for this procedure/service PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 190 Payment is included in the allowance for a Skilled Nursing Facility qualified stay PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 191 Not a work related injury/ illness and thus not the liability of the workers' compensation carrier PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 192 Non standard adjustment code from paper remittance PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 193 Original payment decision is being maintained PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 194 Anesthesia performed by the operating physician, the assistant surgeon or the attending physician PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 195 Refund issued to an erroneous priority payer for this claim service PR- Suspend for review CO- Suspend for review OA- Suspend for review CR- Not Valid 196 Claim/service denied based on prior payers coverage determination PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid 198 Precertification/authorization exceeded PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 199 Revenue code and procedure code do not match PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 200 Expenses incurred during lapse in coverage PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC or other agreement PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 202 Non-covered personal comfort or convenience services PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 203 Discontinued or reduced service PR-Conditional M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2/1.3.3 CO- Deny* OA- Deny* CR- Not Valid 204 This service/equipment/drug is not covered under the patient's current benefit plan PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 205 Pharmacy discount card processing fee PR- Not Valid CO- Not Valid OA- Not Valid CR- Not Valid 206 National Provider Identifier- missing PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 207 National Provider Identifier- invalid format PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 208 National Provider Identifier- not matched PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 209 Per regulatory or other agreement, provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 210 Payment adjusted because pre-certification/authorization not received in a timely manner PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 211 National Drug Codes not eligible for rebate, are not covered PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 212 Administrative surcharges are not covered PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 213 Non-compliance with the physician self referral prohibition legislation or payer policy PR-Primary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid 214 Workers Compensation claim adjudicated as non-compensable. This payer is not liable for claim or service treatment PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 215 Based on subrogatoin of third party settlement PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 216 Based on the findings of a review organization PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 217 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 218 Based on entitlement to benefits (Workers Comp) PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 219 Based on extent of injury (Workers Comp) PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 220 Applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code that best describes the service PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 221 Workers Compensation is under investigation PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.3.1 CO- Deny* OA- Deny* CR- Not Valid 223 Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 224 Patient identification compromised by identity theft. Identity verification required for processing this and future claims PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 225 Penalty or Interest payment by payer PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 226 Information requested from the billing/rendering provider was not providied or was insufficient/incomplete PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 227 Information requested from the patient/insured/ responsible party was not provided or was insufficient/incomplete PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 228 Denied for failure of this provider, another provider or the subscriber to supply requested information to previous payer for their adjudication PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 229 Partial charge amount not considered by Medicare due to the initial claim type of bill being 12X PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 230 No available or correlating CPT/HCPCS code to describe this service. Note: used only by Property and Casualty PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 231 Mutually exclusive procedures cannot be done in the same day/setting PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 232 Institutional transfer amount. Note-Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 233 Services/charges related to the treatment of a hospital- acquired condition or preventable medical error PR-Secondary M/C Payment 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 234 This procedure is not paid separately. PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 235 Sales Tax PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 236 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 PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid 237 Legislated/Regulatory Penalty. PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid A1 Claim/Service denied PR- Deny (TRM 1.3.1.2) CO- Deny* OA- Deny* CR- Not Valid A2 Contractual adjustment PR- Not Valid CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Not Valid OA- Not Valid

CO- Not Valid OA- Not Valid CR- Not Valid A6 Prior hospitalization or 30 day transfer requirement not met PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid A7 Presumptive payment adjustment PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid A8 Ungroupable DRG PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B1 Non-covered visits PR-Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B10 Allowed amount reduced due to component of basic procedure/test was already paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. PR- SecondaryTRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B11 Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor PR- SecondaryTRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B12 Services not documented in patients record PR- SecondaryTRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B13 Previously paid PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B14 Only one visit or consultation per physician per day is covered PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B16 New patient qualifications not met PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B17 Reduced due to inappropriate prescribing information PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid B21 Reduced due to partially provided by another physician PR-Secondary TRM 1.3.1.1 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment proficiency test PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid B3 Covered charges PR-Secondary TRM 1.3.1.1 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid B5 Coverage/program guidelines were not met or were exceeded PR-Secondary TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid B6 Service adjusted by this type provider, in this type facility, or this specialty PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny* CR- Not Valid B8 Alternate services were available, and should have been utilized PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.6 CO- Deny* OA- Deny* CR- Not Valid B9 Patient is enrolled in a Hospice PR-Secondary TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid D1 Denied Level of subluxation needed PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Not Valid OA- Not Valid CR- Not Valid D3 Need to know if patient owns equipment PR- Deny TRM 1.3.1.2 CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Deny* OA- Deny*

CO- Suspend for review OA- Suspend for review CR- Not Valid W2 Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid W2 Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies PR-Secondary M/C Payment TRM 1.3.1.1 M/C Non-Pay TRM 1.3.1.2 CO- Deny* OA- Deny* CR- Not Valid *Medicare adjustments - no patient liability

&C&"Arial,Bold"ATTACHMENT J-9

MSN CODE PAYMENT DETERMINATIONS

&L&"Arial,Bold"HT9402-12-R-0005&CPage &P of &N