Reason Codes

Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. If there is no adjustment to a claim/line, then there is no adjustment reason code.

The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR).

The following is a list of reason codes:

CO10 The diagnosis is inconsistent with the patient's gender.
CO100 Payment made to patient/insured/responsible party.
CO101 Predetermination: anticipated payment upon completion of services or claim adjudication.
CO102 Major Medical Adjustment.
CO103 Provider promotional discount (e.g., Senior citizen discount).
CO104 Managed care withholding.
CO105 Tax withholding.
CO106 Patient payment option/election not in effect.
CO107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim.
CO108 Payment adjusted because rent/purchase guidelines were not met.
CO109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO11 The diagnosis is inconsistent with the procedure.
CO110 Billing date predates service date.
CO111 Not covered unless the provider accepts assignment.
CO112 Payment adjusted as not furnished directly to the patient and/or not documented.
CO113 Payment denied because service/procedure was provided outside the United States or as a result of war.
CO114 Procedure/product not approved by the Food and Drug Administration.
CO115 Payment adjusted as procedure postponed or canceled.
CO116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
CO117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
CO118 Charges reduced for ESRD network support.
CO119 Benefit maximum for this time period has been reached.
CO12 The diagnosis is inconsistent with the provider type.
CO120 Patient is covered by a managed care plan.
CO121 Indemnification adjustment.
CO122 Psychiatric reduction.
CO123 Payer refund due to overpayment.
CO124 Payer refund amount - not our patient.
CO125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.
CO126 Deductible -- Major Medical
CO127 Coinsurance -- Major Medical
CO128 Newborn's services are covered in the mother's Allowance.
CO129 Payment denied - Prior processing information appears incorrect.
CO13 The date of death precedes the date of service.
CO130 Claim submission fee.
CO131 Claim specific negotiated discount.
CO132 Prearranged demonstration project adjustment.
CO133 The disposition of this claim/service is pending further review.
CO134 Technical fees removed from charges.
CO135 Claim denied. Interim bills cannot be processed.
CO136 Claim Adjusted. Plan procedures of a prior payer were not followed.
CO137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
CO138 Claim/service denied. Appeal procedures not followed or time limits not met.
CO139 Contracted funding agreement - Subscriber is employed by the provider of services.
CO14 The date of birth follows the date of service.
CO140 Patient/Insured health identification number and name do not match.
CO141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
CO142 Claim adjusted by the monthly Medicaid patient liability amount.
CO143 Portion of payment deferred.
CO144 Incentive adjustment, e.g. preferred product/service.
CO145 Premium payment withholding
CO146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
CO147 Provider contracted/negotiated rate expired or not on file.
CO148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
CO149 Lifetime benefit maximum has been reached for this service/benefit category.
CO15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
CO150 Payment adjusted because the payer deems the information submitted does not support this level of service.
CO151 Payment adjusted because the payer deems the information submitted does not support this many services.
CO152 Payment adjusted because the payer deems the information submitted does not support this length of service.
CO153 Payment adjusted because the payer deems the information submitted does not support this dosage.
CO154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
CO155 This claim is denied because the patient refused the service/procedure.
CO16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.
CO165 Payment denied/reduced for absence of, or exceeded, referral.
CO167 This (these) diagnosis (es) is (are) not covered.
CO169 Payment adjusted because an alternate benefit has been provided.
CO17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate.
CO170 Payment denied when performed/billed by this type of provider.
CO171 Payment denied when performed/billed by this type of provider in this type of facility.
CO172 Payment adjusted when performed/billed by a provider of this specialty.
CO177 Payment denied because patient has not met the required eligibility requirements.
CO178 Payment adjusted because the patient has not met the required spend down requirements.
CO18 Duplicate claim/service.
CO181 Payment adjusted because this procedure code was invalid on the date of service.
CO183 The referring provider is not eligible to refer the service billed.
CO185 The rendering provider is not eligible to perform the service billed.
CO19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
CO2 Coinsurance Amount
CO20 Claim denied because this injury/illness is covered by the liability carrier.
CO21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CO22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
CO23 Payment adjusted because charges have been paid by another payer.
CO24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
CO25 Payment denied. Your Stop loss deductible has not been met.
CO26 Expenses incurred prior to coverage.
CO27 Expenses incurred after coverage terminated.
CO28 Coverage not in effect at the time the service was provided.
CO29 The time limit for filing has expired.
CO3 Co-payment Amount
CO30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
CO31 Claim denied as patient cannot be identified as our insured.
CO32 Our records indicate that this dependent is not an eligible dependent as defined.
CO33 Claim denied. Insured has no dependent coverage.
CO34 Claim denied. Insured has no coverage for newborns.
CO35 Lifetime benefit maximum has been reached.
CO36 Balance does not exceed co-payment amount.
CO37 Balance does not exceed deductible.
CO38 Services not provided or authorized by designated (network/primary care) providers.
CO39 Services denied at the time authorization/pre-certification was requested.
CO4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
CO40 Charges do not meet qualifications for emergent/urgent care.
CO41 Discount agreed to in Preferred Provider contract.
CO42 Charges exceed our fee schedule or maximum allowable amount.
CO43 Gramm-Rudman reduction.
CO44 Prompt-pay discount.
CO45 Charges exceed your contracted/ legislated fee arrangement.
CO46 This (these) service(s) is (are) not covered.
CO47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
CO48 This (these) procedure(s) is (are) not covered.
CO49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO5 The procedure code/bill type is inconsistent with the place of service.
CO50 These are non-covered services because this is not deemed a `medical necessity' by the payer.
CO51 These are non-covered services because this is a pre-existing condition.
CO52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
CO53 Services by an immediate relative or a member of the same household are not covered.
CO54 Multiple physicians/assistants are not covered in this case.
CO55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
CO57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
CO58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
CO59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
CO6 The procedure/revenue code is inconsistent with the patient's age.
CO60 Charges for outpatient services with this proximity to inpatient services are not covered.
CO61 Charges adjusted as penalty for failure to obtain second surgical opinion.
CO62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
CO63 Correction to a prior claim.
CO64 Denial reversed per Medical Review.
CO65 Procedure code was incorrect. This payment reflects the correct code.
CO66 Blood Deductible.
CO67 Lifetime reserve days. (Handled in QTY, QTY01=LA)
CO68 DRG weight. (Handled in CLP12)
CO69 Day outlier amount.
CO7 The procedure/revenue code is inconsistent with the patient's gender.
CO70 Cost outlier - Adjustment to compensate for additonal costs.
CO71 Primary Payer amount.
CO72 Coinsurance day. (Handled in QTY, QTY01=CD)
CO73 Administrative days.
CO74 Indirect Medical Education Adjustment.
CO75 Direct Medical Education Adjustment.
CO76 Disproportionate Share Adjustment.
CO77 Covered days. (Handled in QTY, QTY01=CA)
CO78 Non-Covered days/Room charge adjustment.
CO79 Cost Report days. (Handled in MIA15)
CO8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
CO80 Outlier days. (Handled in QTY, QTY01=OU)
CO81 Discharges.
CO82 PIP days.
CO83 Total visits.
CO84 Capital Adjustment. (Handled in MIA)
CO85 Interest amount.
CO86 Statutory Adjustment.
CO87 Transfer amount.
CO88 Adjustment amount represents collection against receivable created in prior overpayment.
CO89 Professional fees removed from charges.
CO9 The diagnosis is inconsistent with the patient's age.
CO90 Ingredient cost adjustment.
CO91 Dispensing fee adjustment.
CO92 Claim Paid in full.
CO93 No Claim level Adjustments.
CO94 Processed in Excess of charges.
CO95 Benefits adjusted. Plan procedures not followed.
CO96 Non-covered charge(s).
CO97 Payment is included in the allowance for another service/procedure.
CO98 The hospital must file the Medicare claim for this inpatient non-physician service.
CO99 Medicare Secondary Payer Adjustment Amount.
COA0 Patient refund amount.
COA1 Claim denied charges.
COA2 Contractual adjustment.
COA3 Medicare Secondary Payer liability met.
COA4 Medicare Claim PPS Capital Day Outlier Amount.
COA5 Medicare Claim PPS Capital Cost Outlier Amount.
COA6 Prior hospitalization or 30 day transfer requirement not met.
COA7 Presumptive Payment Adjustment
COA8 Claim denied; ungroupable DRG
COB1 Non-covered visits.
COB10 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.
COB11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
COB12 Services not documented in patients' medical records.
COB13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
COB14 Payment denied because only one visit or consultation per physician per day is covered.
COB15 Payment adjusted because this procedure/service is not paid separately.
COB16 Payment adjusted because `New Patient' qualifications were not met.
COB17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
COB18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
COB19 Claim/service adjusted because of the finding of a Review Organization.
COB2 Covered visits.
COB20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
COB21 The charges were reduced because the service/care was partially furnished by another physician.
COB22 This payment is adjused based on the diagnosis.
COB23 Payment denied because this provider has failed an aspect of a proficiency testing program.
COB3 Covered charges.
COB4 Late filing penalty.
COB5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
COB6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
COB7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
COB8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.
COB9 Services not covered because the patient is enrolled in a Hospice.
COD1 Claim/service denied. Level of subluxation is missing or inadequate.
COD10 Claim/service denied. Completed physician financial relationship form not on file.
COD11 Claim lacks completed pacemaker registration form.
COD12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
COD13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
COD14 Claim lacks indication that plan of treatment is on file.
COD15 Claim lacks indication that service was supervised or evaluated by a physician.
COD18 Inactive for 4010 as of 2/99.
COD19 Claim service lacks physician/operative or other supporting documentation (inactive as of version 5010; use code 16).
COD2 Claim lacks the name, strength, or dosage of the drug furnished.
COD21 This (these) diagnosis (es) is (are) missing or is (are) invalid.
COD3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
COD4 Claim/service does not indicate the period of time for which this will be needed.
COD5 Claim/service denied. Claim lacks individual lab codes included in the test.
COD6 Claim/service denied. Claim did not include patient's medical record for the service.
COD7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
COD8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
COD9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
COW1 Workers Compensation State Fee Schedule Adjustment
CR A2 Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CR07 The procedure/revenue code is inconsistent with the patients gender.
CR1 Deductible amount.
CR10 The diagnosis is inconsistent with the patients gender.
CR100 Payment made to patient/insured/responsible party.
CR102 Major medical adjustment.
CR104 Managed care withholding.
CR107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
CR109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CR11 The diagnosis is inconsistent with the patients gender.
CR112 Payment adjusted as not furnished directly to the patient and/or not documented.
CR119 Benefit maximum for this time period or occurrence has been reached.
CR121 Indemnification adjustment.
CR125 Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
CR127 Coinsurance - major medical.
CR129 Payment denied. Prior processing information appears incorrect.
CR13 The date of death precedes the date of service.
CR131 Claim specific negotiated discount.
CR133 The disposition of the claim/service is pending further review.
CR137 Payment/reduction for surcharges, assessments, allowances, or health related taxes.
CR144 Incentive adjustment, e.g., preferred product/service.
CR145 Premium payment withholding.
CR148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
CR149 Lifetime benefit maximum has been reached for this service/benefit category.
CR150 Payment adjusted because the payer deems the information submitted does not support this level of service.
CR151 Payment adjusted because the payer deems the information submitted does not support this many services.
CR16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
CR165 Payment denied/reduced for absence of, or exceeded, referral.
CR17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever .appropriate. This change to be effective 4/1/07: at least one remark code
CR170 Payment adjusted when performed/billed by a provider of this type of provider.
CR172 Payment adjusted when performed/billed by a provider of this specialty.
CR179 Payment adjusted because the patient has not met the required waiting requirements.
CR18 Duplicate claim/service.
CR180 Payment adjusted because the patient has not met the required residency requirements.
CR183 The referring provider is not eligible to refer the service billed.
CR185 The rendering provider is not eligible to perform the service billed.
CR187 Health savings account payments.
CR19 Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
CR2 Coinsurance amount.
CR20 Claim denied because this injury/illness is covered by the liability carrier.
CR21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CR22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
CR23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.
CR24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
CR26 Expenses incurred prior to coverage.
CR27 Expenses incurred after coverage terminated.
CR29 The time limit for filing has expired.
CR3 Copayment amount.
CR30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
CR31 Claim denied as patient cannot be identified as our insured.
CR32 Our records indicate that this dependent is not an eligible dependent as defined.
CR33 Claim denied - insured has no dependent coverage.
CR34 Claim denied - insured has no coverage for newborns.
CR35 Lifetime benefit maximum has been reached.
CR38 Services not provided or authorized by designated (network/primary care) providers.
CR39 Services denied at the time authorization/precertification was requested.
CR4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
CR40 Charges do not meet qualifications for emergent/urgent care.
CR42 Charges exceed our fee schedule or maximum allowable amount.
CR45 Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CR46 This (these) service (s) is (are) not covered.
CR47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
CR48 This (these) procedure (s) is (are) not covered.
CR49 These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CR5 The procedure code/bill type is inconsistent with the place of service.
CR50 These are noncovered services because this is not deemed a "medical necessity" by the payer.
CR51 These are noncovered services because this is a preexisting condition.
CR52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
CR54 Multiple physicians/assistants are not covered in this case.
CR55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CR56 Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
CR57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
CR58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
CR59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
CR6 The procedure/revenue code is inconsistent with the patient's age.
CR62 Payment denied/reduced for absence of, or exceeded, precertification/authorization.
CR63 Correction to a prior claim.
CR7 The procedure/revenue code is inconsistent with the patients gender.
CR85 Interest amount.
CR88 Adjustment amount represents collection against receivable created in prior overpayment.
CR9 The diagnosis is inconsistent with the patients age.
CR94 Processed in excess of charges.
CR95 Benefits adjusted. Plan procedures not followed.
CR96 Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
CR97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
CRA1 Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
CRA2 Contractual adjustment (inactive for 004060; use code 45 with group code CO).
CRA6 Prior hospitalization or 30-day transfer requirement not met.
CRB1 Noncovered visits.
CRB10 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.
CRB11 Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
CRB12 Services not documented in patient's medical records.
CRB13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
CRB14 Payment denied because only one visit or consultation per physician per day is covered.
CRB15 Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
CRB16 Payment adjusted because "new patient" qualifications were not met.
CRB18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
CRB20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
CRB22 This payment is adjusted based on the diagnosis.
CRB3 Covered charges.
CRB5 Payment adjusted because coverage/program guidelines were not met or were exceeded. CRB6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
CRB7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CRB9 Services not covered because the patient is enrolled in hospice.
CRD19 Claim/service lacks physician/operative or other supporting documentation.
CRD21 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
NC Precert not obtained.
PR02 Coinsurance amount.
PR07 The procedure/revenue code is inconsistent with the patients gender.
PR1 Deductible amount.
PR10 The diagnosis is inconsistent with the patients gender.
PR100 Payment made to patient/insured/responsible party.
PR104 Managed care withholding.
PR107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PR109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
PR11 The diagnosis is inconsistent with the procedure.
PR111 Not covered unless the provider accepts assignment.
PR112 Payment adjusted as not furnished directly to the patient and/or not documented.
PR117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
PR119 Benefit maximum for this time period or occurrence has been reached.
PR125 Payment adjusted due to a submission/billing error (s). Additional information is supplied using the remittance advice remarks codes whenever possible.
PR126 Deductible - major medical.
PR127 Coinsurance - major medical.
PR129 Payment denied. Prior processing information appears incorrect.
PR13 The date of death precedes the date of service.
PR131 Claim specific negotiated discount.
PR133 The disposition of the claim/service is pending further review.
PR136 Claim adjusted based on failure to follow prior payer's coverage rules.
PR137 Payment/reduction for regulatory surcharges, assessments, allowances, or health related taxes.
PR138 Claim/service denied. Appeal procedures not followed or time limits not met.
PR140 Patient/insured health identification number and name do not match.
PR141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
PR145 Premium payment withholding.
PR147 Provider contracted/negotiated rate expired or not on file.
PR149 Lifetime benefit maximum has been reached for this service/benefit category.
PR15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
PR150 Payment adjusted because the payer deems the information submitted does not support this level of service.
PR151 Payment adjusted because the payer deems the information submitted does not support this many services.
PR156 Flexible spending account payments.
PR16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one remark code must be provided (may be comprised of either the remittance advice remark code or NCPDP reject reason code).
PR167 This (these) diagnosis (es) is (are) not covered.
PR17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/07: at least one remark code
PR170 Payment denied when performed/billed by this type of provider.
PR171 Payment denied when performed/billed by this type of provider in this type of facility.
PR172 Payment adjusted when performed/billed by a provider of this specialty.
PR177 Payment denied because the patient has not met the required eligibility requirements.
PR179 Payment adjusted because the patient has not met the required waiting requirements.
PR18 Duplicate claim/service.
PR180 Payment adjusted because the patient has not met the required residency requirements.
PR183 The referring provider is not eligible to refer the service billed.
PR184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
PR185 The rendering provider is not eligible to perform the service billed.
PR19 Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier.
PR2 Coinsurance amount.
PR20 Claim denied because this injury/illness is covered by the liability carrier.
PR21 Claim denied because this injury/illness is the liability of the no-fault carrier.
PR22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
PR23 Payment adjusted due to the impact of prior payer's) adjudication including payments and/or adjustments.
PR24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR26 Expenses incurred prior to coverage.
PR27 Expenses incurred after coverage terminated.
PR28 Coverage not in effect at the time the service was provided.
PR29 The time limit for filing has expired.
PR3 Copayment amount.
PR30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
PR31 Claim denied as patient cannot be identified as our insured.
PR32 Our records indicate that this dependent is not an eligible dependent as defined.
PR33 Claim denied - insured has no dependent coverage.
PR34 Claim denied - insured has no coverage for newborns.
PR35 Lifetime benefit maximum has been reached.
PR38 Services not provided or authorized by designated (network/primary care) providers.
PR39 Services denied at the time authorization/precertification was requested.
PR4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
PR40 Charges do not meet qualifications for emergent/urgent care.
PR42 Charges exceed our fee schedule or maximum allowable amount.
PR45 Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
PR46 This (these) service (s) is (are) not covered.
PR47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
PR48 This (these) procedure (s) is (are) not covered.
PR49 These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
PR5 Procedure code/bill type is inconsistent with the place of service.
PR50 These are noncovered services because this is not deemed a "medical necessity" by the payer.
PR51 These are noncovered services because this is a preexisting condition.
PR52 The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
PR54 Multiple physicians/assistants are not covered in this case.
PR55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
PR56 Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer.
PR57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
PR58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
PR59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
PR6 The procedure/revenue code is inconsistent with the patient's age.
PR62 Payment denied/reduced for absence of, or exceeded, precertification/authorization.
PR63 Correction to a prior claim.
PR7 The procedure/revenue code is inconsistent with the patients gender.
PR8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
PR87 Transfer amount.
PR9 The diagnosis is inconsistent with the patients age.
PR92 Claim paid in full.
PR94 Processed in excess of charges.
PR95 Benefits adjusted. Plan procedures not followed.
PR96 Noncovered charge (s). This change to be effective 4/1/2007: at least one remark code must be provided (may be compromised of either the remittance advice remark code or NCPDP Reject .reason code)
PR97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
PRA1 Claim/service denied. At least one remark code must be provided; may be comprised of either the remittance advice remark code or NCPDP reject reason code.
PRA2 Contractual adjustment (inactive for 004060; use code 45 with group code CO).
PRA6 Prior hospitalization or 30-day transfer requirement not met.
PRB1 Noncovered visits.
PRB11 Claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
PRB12 Services not documented in patient's medical records.
PRB13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
PRB14 Payment denied because only one visit or consultation per physician per day is covered.
PRB15 Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure/has not been received/ .adjudicated.
PRB16 Payment adjusted because "new patient" qualifications were not met.
PRB18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
PRB20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
PRB22 This payment is adjusted based on the diagnosis.
PRB5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
PRB6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
PRB7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
PRB8 Claim/service not covered/reduced because alternative services were available and should have been utilized.
PRB9 Services not covered because the patient is enrolled in hospice.
PRD19 Claim/service lacks physician/operative or other supporting documentation.
PRD21 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
WB Paid at wrong benefit amount.

Use this reason code list to help you identify why the insurance carrier has reduced or adjusted the payment. If the reason code is valid, you will want to include this information on your statement if and when you pass the responsibility along to the patient. In some cases you will want to correct your claim and resubmit it or appeal the decision. In any case, the reason code is essential information to have in order to successfully handle your medical billing.

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