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    Denial Codes 05aug2020

    Uploaded by

    naharmampilly
    The document contains a list of codes and descriptions related to reasons for rejecting or denying insurance claims. There are over 80 codes listed covering topics like prior authorization requirements, duplicate claims, non-covered services, coding errors, eligibility issues, and more. The codes have effective date ranges starting from June 2012 through September 2020.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Denial Codes 05aug2020

    Uploaded by

    naharmampilly
    2K views9 pages
    The document contains a list of codes and descriptions related to reasons for rejecting or denying insurance claims. There are over 80 codes listed covering topics like prior authorization requirements, duplicate claims, non-covered services, coding errors, eligibility issues, and more. The codes have effective date ranges starting from June 2012 through September 2020.

    Original Title

    Denial Codes 05Aug2020 (1)

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    © © All Rights Reserved

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    The document contains a list of codes and descriptions related to reasons for rejecting or denying insurance claims. There are over 80 codes listed covering topics like prior authorization requirements, duplicate claims, non-covered services, coding errors, eligibility issues, and more. The codes have effective date ranges starting from June 2012 through September 2020.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    2K views9 pages

    Denial Codes 05aug2020

    Uploaded by

    naharmampilly
    The document contains a list of codes and descriptions related to reasons for rejecting or denying insurance claims. There are over 80 codes listed covering topics like prior authorization requirements, duplicate claims, non-covered services, coding errors, eligibility issues, and more. The codes have effective date ranges starting from June 2012 through September 2020.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 9

    Code

    AUTH-001
    AUTH-003
    AUTH-004
    AUTH-005
    BENX-002
    BENX-005
    CLAI-007
    CLAI-008
    CLAI-009
    CLAI-010
    CLAI-011
    CLAI-012
    CLAI-014
    CODE-010
    CODE-012
    CODE-013
    CODE-014
    CODE-015
    COPY-001
    DUPL-001
    DUPL-002
    ELIG-001
    ELIG-005
    ELIG-006
    ELIG-007
    MNEC-003
    MNEC-004
    MNEC-005
    MNEC-006
    NCOV-001
    NCOV-002
    NCOV-003
    NCOV-025
    PRCE-001
    PRCE-002
    PRCE-003
    PRCE-006
    PRCE-007
    PRCE-008
    PRCE-009
    PRCE-010
    TIME-001
    TIME-002
    TIME-003
    AUTH-006
    AUTH-007
    AUTH-008
    AUTH-009
    AUTH-010
    AUTH-011
    CLAI-017
    CLAI-018
    PRCE-011
    SURC-001
    SURC-002
    SURC-003
    SURC-004
    SURC-005
    SURC-006
    SURC-007
    SURC-008
    WRNG-001
    CLAI-019
    CLAI-020
    AUTH-012
    AUTH-002
    AUTH-013
    BENX-001
    CLAI-013
    CLAI-021
    CLAI-022
    CODE-001
    CODE-002
    CODE-006
    CODE-014
    CODE-016
    MNEC-007
    NCOV-009
    NCOV-010
    NCOV-012
    NCOV-014
    NCOV-018
    NCOV-019
    NCOV-020
    NCOV-021
    NCOV-024
    NCOV-027
    AUTH-014
    PRCE-012
    DRG-001
    DRG-002
    DRG-003
    DRG-004
    COPY-002
    COPY-003
    DRG-005
    BSMA-001
    BSMA-002
    BSMA-003
    Description
    Prior approval is required and was not obtained
    PriorAuthorizationNumber is invalid
    Service(s) is (are) performed outside authorization validity date
    Claim information is inconsistent with pre-certified/authorized services
    Benefit maximum for this time period or occurrence has been reached
    Annual limit/sublimit amount exceeded
    Claim is a work-related injury/illness and thus the liability of the employer
    Claim overlaps inpatient stay. Resubmit only those services rendered outside the inpatient stay
    Date of birth follows the date of service
    Date of death precedes the date of service
    Inpatient admission spans multiple rate periods. Resubmit separate claims
    Submission not compliant with contractual agreement between provider & payer
    Claim not compliant with Resubmission type (used only for resubmissions)
    Activity/diagnosis inconsistent with clinician specialty
    Encounter type inconsistent with service(s) / diagnosis
    Invalid principal diagnosis
    Activity/diagnosis is inconsistent with the patient's age/gender
    Activity/diagnosis is inconsistent with the provider type
    Deductible/co-pay not collected from member
    Claim is a duplicate based on service codes and dates
    Payment already made for same/similar service within set time frame
    Patient is not a covered member
    Services performed after the last date of coverage
    Services performed prior to the effective date of coverage
    Services performed by a non-network provider
    Service is not clinically indicated based on good clinical practice
    Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities
    Service/supply may be appropriate, but too frequent
    Alternative service should have been utilized
    Diagnosis(es) is (are) not covered
    Pre-existing conditions are not covered
    Service(s) is (are) not covered
    Service(s) is (are) not performed (used after audit)
    Calculation discrepancy
    Payment is included in the allowance for another service
    Recovery of Payment
    Consultation within free follow up period
    Service has no contract price
    Multiple procedure payment rules incorrectly applied
    Charges inconsistent with clinician specialty
    Use bundled code
    Time limit for submission has expired
    Requested additional information was not received or was not received within time limit
    Appeal procedures not followed or time limits not met
    Alert drug - drug interaction or drug is contra-indicated
    Drug duplicate therapy
    Inappropriate drug dose
    Prescription out of date
    Authorization request overlaps or is within the period of another paid claim or approved authorization
    Waiting period on pre-existing / specific conditions
    Services not available on direct billing
    Claims Recalled By Provider
    Discount discrepancy
    Severe drug - drug interaction
    Severe drug - age contraindication
    Severe drug - gender contraindication
    Severe drug - diaganosis contraindication
    Severe procedure\service - diagnosis contraindication
    Severe procedure\service - drug contraindication
    Severe procedure\service - procedure contraindication
    Serious safety issue with drug dose
    Wrong submission, receiver is not responsible for the payer within this transaction submission.
    Incorrect IR-DRG code
    Missing IR-DRG code
    Request for information
    Services performed are inconsistent with authorized or approved services
    Missing eRx Reference number
    Service / Medication is above AED threshold
    Missing an Observation (Dental Tooth #)
    Incorrect DRG payment parameter
    Missing DRG payment parameter
    Missing, incomplete or invalid principal diagnosis
    Missing, incomplete or invalid service code
    Diagnosis is inconsistent with the procedure
    Activity/diagnosis is inconsistent with the patient's age/gender
    Activity/diagnosis inconsistent with Service
    Service is not clinically indicated based on good clinical practice, without additional supporting documentation
    Dental treatments are not covered
    Elective procedure is not covered
    Eye exams and treatments are not covered
    Hearing services are not covered
    Immunizations are not covered
    Preventative care is not covered
    Services resulting from attempted suicide or self-infliction are not covered
    Vaccinations are not covered
    Chronic Condition Service(s) is (are) not covered
    Non Coverage of certain medication as per policy
    Medication has been added to a prior request that is not in line with Pharmacist Edit Restrictions
    Recovery of Payment – DHIC Authorized
    Incorrect DRG code
    Missing DRG code
    Incorrect Billing Regime
    Missing Activities
    Incorrect Patient Share
    Missing Patient Share
    Missing Observation (ActivityCost and/or File Attachment)
    Member not covered under Basmah
    Claims is not eligible under Basmah Fund
    Prior approval is required but not taken (Basmah)
    Effective From Effective To
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Jun-12
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Mar-15
    1-Feb-17 31-Mar-20
    1-Feb-17 31-Mar-20
    26-Mar-17
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18 31-Mar-20
    10-Jul-18 31-Mar-20
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    10-Jul-18
    29-Nov-18
    29-Nov-18
    1-Sep-20
    1-Sep-20
    1-Sep-20
    1-Sep-20
    1-Sep-20
    1-Sep-20
    1-Sep-20
    21-Jun-20
    21-Jun-20
    21-Jun-20

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