Explanation Claim Adjustment Remittance Advice Code Short ... · Explanation of Benefits (EOB)...

Explanation of Benefits (EOB) Matrix

Explanation

Code Short Description Long Description

Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

I90 D.O.S outside of stmt serv date Date of Service outside of statement service date 110 N130

ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B70 Incorrect Payment for Non Covered Se Recovering Incorrect Payment for Non covered Service 129 MA67


REN 132: 2005 Norton Inpt Rate Increase 2005 Norton Retro Inpatient rate Increase 132 MA132 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

RET 132:2005 Retro Inpatient Rate Increase 2005 Retro Inpatient Rate Increase 132 MA132 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R75 1st Level Screening Paid; submit medical

1st Level Screening Paid; submit medical records for

prudent layperson 16 N381


R73 1st Level Screening Pd, medi record 1st Level Screening Pd, medical records not received 49 N627


R18 22: Benefits not coord pending receipt

Benefits not coordinated pending receipt of adjusted

claim from 22 MA04


HS3 3 day window OP serv included w IP stay

3 day window (72 hour) outpatient services should be

included in the I 60 N130


R22 62:Authorization Expired Authorization Has Expired 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G93 ACA: contract pay amount equal to or gr

ACA: contract pay amount equal to or greater than ACA

rate 222 N640


G92 ACA: dos span eligibility dates resubmi ACA: dos span eligibility dates resubmit itemized bill 239 N62


G91 ACA: provider not eligible on attestati ACA: provider not eligible on attestation file for dos B7 N381


G98 ACA: COB claim processed under ACA

ACA: COB claim processed under ACA program

requirements 45 N381


G94 ACA: eligible line repriced at the ACA r ACA: eligible line repriced at the ACA rate 222 N640 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G95 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G97 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G90 ACA: member in state only aide category;

ACA: member in state only aide category; not eligible for

enhanced pay 177 N381


G96 ACA: member in state only aide category;

ACA: member in state only aide category; not eligible for

enhanced pay 177 N381


J00 ACS Keying Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V00 ACS Keying Error R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZHC Add on Code billed without primary code

An add on code was billed without the presence of the

related primary 234 N122


G16 Additional Charges Considered Additional Charges Considered 107 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X14 Additional Diagnosis Emergent

Previously paid. Payment for this claim/service may

have been provided 40


H07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code

that requires a

107 N122 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code

that requires a

107 N122 CMS National Coverage Determinations (NCD) Policy

937 Addt'l information received and reviewed

Payment adjusted upon receipt of additional

information. B19 N199


EQ5 Addtnl info needed on itmzd bill Additional information is needed on the itemized bill 163 N26


J61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G99 Adjusting Historical Claim Adjusting Historical Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G51 Adjustment For Component Of Professio

This health service code has been adjusted to reflect a

component of t 97 N67


R30 Adjustment to Previous Payment Adjustment to Previous Payment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HT7 Admin Code without Vaccine Code

Administration Service Billed with Modifier U2 or U3

without 4 N519


HC1 Administration Codes exceed Vaccine Code Administration Codes exceed Vaccine Code 94 N381


R56 Administrative Approval Administrative Approval 186 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

G17 Administrative Overturn Administrative Overturn 186 N11 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

609 Admission date is prior to member effect Admission date is prior to member effective date 26


H78 Age Doesn't Support DX Billed

The age of the patient does not correlate with the

submitted diagnosis 9 N517


HMK All Components of Lab Panel Billed

All of the Components of a Lab Panel Have been billed.

Only the Lab 234 M15


G33 Allowed Amount Greater Than Submitted

According to our policy, when a procedure has an

allowed amount greate 45


HS4 Ambulance Service while Inpatient

Ambulance Services were provided while the member

was an IP 97 M2


R19 Anes Minutes erq for payment calc

Anesthesia minutes required for payment calculation

per IHCP Rules 16 N203


X19 Anes Minutes req for payment cacl

Anesthesia minutes required for payment calculation

per IHCP Rules 16 N203


HMH Anesthesiologist must use CPT Codes

Anesthesiologist must use CPT Codes (00100-01999)

plus State Specified 95 N95


HMI Anethesia Provided by a Non-Anes

Anesthesia Provided by a Non-Anesthesiologist (Check

for Addtional 194


R31 Appeal - Denial Overturned Appeal - Denial Overturned 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

900 Applied to deductible in error Adjusted - correction to deductible. 192 M25 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZJ6 ASD diagnosis invalid

ASD Dx cannot be primary or secondary without

required modifiers 16 MA63


ZK6 ASD diagnosis invalid

ASD Dx cannot be primary or secondary without

required modifiers 16 MA63


ZJ5 ASD diagnosis must be primary

ASD diagnosis must be primary with submitted

modifiers 16 MA63


ZK5 ASD diagnosis must be primary

ASD diagnosis must be primary with submitted

modifiers 16 MA63


I31 Assessment not received Assessment not received 16 N309 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X31 Assessment not received Assessment not received 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R34 Assistant Surgeon Payment Assistant Surgeon Payment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XD9 Attending & Referring not enrolled in Me Attending and Referring not enrolled in Medicaid 183 N767


XD8 Attending not enrolled in Medicaid Progr Attending not enrolled in Medicaid Program 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEA Attending NPI is not enrolled with state

Attending NPI is not enrolled with state as provider type

31-physician 16 N253


XEB Attending Provider NPI is a non-individu

Attending Provider NPI is a non-individual per NPPES

Registry 16 N253


X69 AttendingPhys ID/Name Missing/Invalid Attending Physician ID/Bane is Missing Invalid 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5DM Auth denied - services not considered

Authorization is denied, services will not be considered-

member liable 39


ZF9 Auth/Ref Transferred - Delay in Newborn

Auth/Ref Transferred - Delay in Newborn Enrollment

Information 129 MA67


210 Auth'ed generic only. Brand was billed. Authorized for generic only. Brand was billed. 204 N448 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X35 Authorization Denied for this DOS Authorization Denied for this Date of Service 39 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G23 Authorization updated Authorization Updated 186 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B39 Authorization/Referral Expired Authorization/Referral Expired 198 M62 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R59 Authorization/Referral Expired Authorization/Referral Expired 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J28 Auto insurance is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V27 Auto insurance is Primary R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J45 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 MA36 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V44 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HM9 Based on NCCI Two Proc are Mutual Excl

Based on NCCI Two Proc. Are Mutually Excl. If it is not

Possible to 231


GB4 Bed Hold Days Exhausted Bed Hold Days Exhausted 96 N43 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

901 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

913 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R29 Beyond Adjustment Period Beyond Adjustment Period 29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86


X43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86


HB3 Bilateral - Modifier Incorrect

This is a Bilateral Code. Modifiers LT, RT, 50 or qty 2 are

not 4 N519


HML Bilateral Proc Code pymt based both side

Bilat Proc Code and pymt based on both sides. Pay

lessor of 100% of 4 N644


G36 Bilateral Procedure Inappropriately

This health service code was denied because the

bilateral procedure wa 4 N644


HB2 Bilateral Surgery 100% rule applies

This is a Bilateral Procedure Code and payment for the

code is already 59 N644


HB1 Bilateral Surgery 150% Rule Applies

Unilateral Procedure Code. The 150% Payment

Adjustment Rule applies 59 N644


ZM3 Bill charge must be greater than $0

Bill charge must be greater than $0 at the line level or

deny 16 M54


ZM4 Bill charge must greater than $0

Bill charge must be greater than $0 at the line level or

deny 16 M54


B33 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XA1 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HA3 Bill to DME MAC Bill to DME MAC 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G44 Bill To Dmerc

This health service code was denied as a procedure

billed with a DME o 16 M51


GA6 Bill Type Missing Bill Type Missing 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R55 Billed Info Reflects Lower Degr Billed Info Reflects Lower Degree Acuity/Treatment 150 M25


B42 Billed with Invalid Bill Type Billed with Invalid Bill Type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEK Billing and Rendering Prov do not have

Billing and Rendering Prov do not have an active license

on claim DOS B7 M143


XEL Billing and Rendering Prov not enrolled

Billing and Rendering Prov not enrolled in Medicaid

Program 16 N257


XEG Billing Prov does not have an active lic Billing Prov does not have an active license on claim DOS B7 M143


XE1 Billing Prov not enrolled in Medicaid Billing Prov not enrolled in Medicaid Program 16 N257 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G34 Blood Collection Included In Lab Serv

The venipuncture was denied as it is considered to be an

integral part 97 M15


H00 Bundled into Service Not Specified These services are either bundled into other services on

the same day,

97 M15 National Correct Coding Manual Policy

H00 Bundled into Service Not Specified These services are either bundled into other services on

the same day,

97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J62 Business Processing Rules not followed Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

RBM Capitated Radiology Vendor

Claim Line for radiology services has been forwarded to

the 24 N381


R36 Capitated Service Capitated Service 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X36 Capitated Service Capitated Service 24 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSH Carve out Benefit Services are Carved out for payment by another entity 96 N381


HST Carve out Services - State Specific Services are carved out for payment by another entity - 96 N130


R81 Chrgs Considered included in Inpat Ad Charges Considered included in Inpatient Admission 97 M2


X81 ChrgsConsidered Included InpatAdmis Charges Considered included in Inpatient Admission 97 M15


940 Claim adjusted based on audit Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EQ4 Claim adjusted following Equian Determin

Claim adjusted following Equian Determination review

with Provider 45 N10


WP1 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

WP3 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

WP0 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

WP2 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

910 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations



9B4 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J66 Claim closed incorrectly Rekeyed claim for correct payment/denial 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EB7 Claim EBP does not match member EBP enro Claim EBP does not match member EBP enrollment 204 N448


ZML Claim has multiple CLIA Numbers Claim has multiple CLIA Numbers 16 M91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G19 Claim is not a Duplicate Claim is not a Duplicate 129 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZD0 Claim line denied Claim line denied A1 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G11 Claim Previously Processed Incorrect Claim Previously Processed Incorrectly 129 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V11 Claim procesed not following auth R129:Claim not paid according to auth. 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZF7 Claim Processed not following Auth/Ref

Claim Processed not followinig Auth/Referral - Manual

Error 129 MA67


J05 Claim processed to wrong member R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G02 Claim Processed to Wrong Provider

Previous Claim processed to the Wrong Provider

Healthcare 129 MA67


B14 Claim Service Denied

Claim Service Denied because the related or qualifying

claims service B15 M51


G22 Claim was submitted Timely Claim was Submitted Timely 210 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B48 Claims adj to correct underpayment Claim adjusted to correct underpayment 129 N524 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMP CLIA Number does not cover DOS CLIA Number does not cover DOS B7 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R95 Clinic Claim without Physician Name Claim without Physician Name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B35 Clinic clm sub w/out phy name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X56 Clinic Clm Submt w/o phys nam Clinic Claim submitted with out physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J52 Clinical Edit(Ihealth, NCCI) incorr appl R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H08 Clinical Trial Requires Approp. DX Clinical Trial requires appropriate diagnosis. 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J18 Clm denied for EOB,svs excluded from cov R129:Service Not Covered by Other Ins 242 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I15 Clm Pend: app Modifier and/or time un Resubmit with appropriate Modifier and/or time units 4 N519


I12 Clm Pend: clinic claim w/o Phys name Claim w/o Physicians name or number 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X95 Clm Pend: clinic claim w/o phys name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X04 Clm Pend: correct NDC Code req Correct NDC Code required for consideration 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X11 Clm Pend: EOB from prim carrier req Resubmit with EOB from Primary Carrier 252 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I02 Clm Pend: Illegible Records Sub Illegible Records Submitted 251 N205 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X02 Clm Pend: illegible records sub Illegible records submitted 251 N205 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I05 Clm Pend: Invalid/Del Code, Mod or D

Invalid/Inappropriate/Deleted Code, Modifier or

Decription 182 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I05 Clm Pend: Invalid/Del Code, Mod or D

Invalid/Inappropriate/Deleted Code, Modifier or

Decription 182 N657


I14 Clm Pend: invalid/miss Rev Code Invalid/missing Revenue Code 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X06 Clm Pend: itemized bill required Itemized Bill, Date of Service, or Invoice 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I03 Clm Pend: Rept Req for Non-Spec Code

Report Required to Support Non-Specific Code; Please

Refile 16 N350


I08 Clm Pend:Diag Inv/Missing/Del/4th or5

Diagnosis invalid/missing/deleted/requires 4th or 5th

digit; 146 M76


J01 Clm prev denied incorrectly as duplicate R129:Claim is not a duplicate 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J04 Clm previously processed for wrong prov R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J33 Clm Proc incorr for penny pricing Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X96 ClmPend: EOB/attach illeg/incomplete EOB attachments were illegible/incomplete 251 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B37 ClmPend:AppModifier and/or time units Resubmit with appropriate modifier and/or 4 N517 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

X08 ClmPend:diag inv/missing/del 4thor5th

Diagnosis Invalid/missing/deleted/requires 4th or 5th

digit 146 M64


X05 ClmPend:invalid/del code,mod or desc Invalid/inappropriate/deleted code, modifier or 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J43 Clms adj. to deny for clms billed incorr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V42 Clms adj. To deny for clms billed incorr R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HMO Co- Surgeon - Different Specialties

Co- Surgeons are only allowed if the providers are in

different 8 N95


GB3 COB Recovery COB Recovery 22 N420 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

614 COB verification required from member

COB verification/documentation is required from the

member to process 22 N197


5CJ COB/exceeds fee schedule Coordination of benefits exceeds the fee schedule. 23 N131


HSP Code combination - CC2 Retro

Based on NCCI the specific billed service code combo is

not payable. 199 N657


HSQ Code Combination Hosp CCR Retro

Hospital OP NCCI the specific billed service code combo

is not payable 199 N657


HMX Code Combo not payable

Based on NCCI the specific billed service code

combination is not 236


457 Code description required Please submit a full description of the services provided 16 N350


5BC Code description required Please submit a full description of the services provided 16 N350


H34 Code is Incident to Service

This was furnished as an integral, although incidental

part of the Drs 97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z96 CodeNotApproved for ProviderSpecialty

Procedure Code not approved by Medicaid for provider

specialty type 8 N95


R37 Combined Payment - Mother and Baby Combined Payment - Mother and Baby 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZC0 Complete Medical Records Required

Complete Medical Records Required for Consideration -

Refile 163 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZC0 Complete Medical Records Required

Complete Medical Records Required for Consideration -

Refile 163 M127


ZE2 Complete Medical Records Required

Complete Medical Records Required for consideration -

Please re-file; 163 M127


G39 Component Of Critical Care Service

This health service code was denied as it is considered

to be an integ 97 M15


G79 Condition Code Not Appropriate For Bi

The health care codes were denied because the

Condition Code is not ap 16 M44


V38 Configuration Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R38 Contracted Fee Contracted Fee 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

944 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419


952 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419


G43 Convenience Item - Does Not Meet Defi

Item denied because it is an item of convenience, the

item is not medi 50


9B9 Corrected claim - add'l payment due Adjusted - corrected claim received 63 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

406 Corrected claim - no add'l payment due

Provider corrected claim but no additional payment is

due. 18 N702


ZR4 Corrected claim with diff Prov Tax ID

Corrected claim has different provider tax ID then

original submission 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZR4 Corrected claim with diff Prov Tax ID

Corrected claim has different provider tax ID then

original submission 16 N209


ZR3 Corrected claim with different Member ID

Corrected claim has different member ID then original

submission 16 N382 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZR3 Corrected claim with different Member ID

Corrected claim has different member ID then original

submission 16 N382


112 Corrected claim. No payment due.

Corrected claim received, reprocessed claim, but no

additional B13 MA67


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

HMN Co-Surgeon not allowed for procedure Co- Surgeons are not allowed for this procedure 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B08 Co-Surgeons Cannot Be Same Subspecia Cosurgeons need to be of different subspecialties. 172


H62 Co-Surgeons Not Allowed Procedure denied. The procedure code submitted does

not necessitate


M70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 96 N193 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5C0 CPT invalid DOS Procedure code invalid for date of service 181 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G61 Cpt Modifier Is Not Valid

This health service code was denied because the

modifier is invalid. 182 N657


ZMN CPT Not Covered by CLIA Certificate Type CPT Not Covered by CLIA Certificate Type B23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G41 CPT Recoded To A CMS Designated Alter

According to CMS guidelines, outpatient hospitals

should bill certain 16 M51


H56 CPT Seperate Procedure Policy This procedure/service is not paid separately 97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

407 CPT/HCPCS invalid for rev code billed

The CPT/HCPCS code on the claim is invalid for the

revenue code billed 199 N657


5CL CPT/HCPCS invalid for rev code billed

The CPT/HCPCS code on the claim is invalid for the

revenue code billed 199 N657


ZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95


IH5 Date of Death proceeds the DOS Date of Death proceeds the date of service 13 CMS Coverage Policies

HM1 Date of service is Later Than Date Recd

Date Of Service Is Later Than Date Received Or Future

Date Of Service. 110


X60 Dates and/or ServicesOutsideRef/Auth Dates and/or Services Outside Authorization/Referral 197


R60 Dates and/or Servs Outside Ref/Auth Dates and/or Services Outside Referral/Authorization 197


4BM Denial overturned and service is now app

Our denial was overturned and the service is now

approved. This means 64 MA91


492 Denied - authorized services exceeded

Services exceed authorized amount/days - member not

liable 198 N640


5CT Denied - authorized services exceeded

Services exceed authorized amount/days - member not

liable 198 N54


493 Denied - benefit exceeded Denied - benefit exceeded 119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5CU Denied - benefit exceeded Denied - benefit exceeded 119 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

497 Denied - no NPI Denied - no NPI 206 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

498 Denied - not on fee schedule Denied - not on fee schedule - member not liable 147


499 Denied - not payable - member not liable

Denied - not payable (inclusive, exclusive, unbundled or

not payable B1 M39


5D1 Denied - payment for donor services

Payment is for donor services and paid under the

recipient's B1


5D2 Denied - provider billing error Denied - provider billing error 16 N296 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5D3 Denied - resubmit to vision vendor Services need to be billed to the vision vendor. 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5D5 Denied - settlement agreement Date of service included in a settlement agreement. 97 N664


489 Denied- altered claim, member not liable

Claim has been altered; member not liable; resubmit

corrected claim 31 MA130


H02 Denied- Duplicate Service on Same Day

The same or a similar procedure code was billed on the

same date of 18 N702


HS7 Denied in Hospital In/Out

Service is not payable in a Hospital Inpatient or

Outpatient setting 58


J72 Denied incorrectly, remit correct Claim denied incorrectly in error 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4A2 Denied- NPI incorrect NPI incorrect 208 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4A0 Denied- past reconsideration time period

Claim is past the reconsideration time period. Member

not liable. 29


4AA Denied -updating of payment information

Denied -updating of payment info-SMT claims only-

member not liable 250 MA04


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

Z09 Denied,corrected claim submitted Correction to a prior claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4AB Denied-auth servs do not match claim

Service code on claim does not match service code on

authorization- 284 M62


5D9 Denied-auth servs do not match claim

Service code on claim does not match service code on

authorization- 284


4AE Denied-invalid billing name, addr or TIN

Invalid billing name, address or tin; re-submit claim with

correct 16 N258


4AF Denied-name and address required

Name and address of facility where services were

rendered 16 N256


4AG Denied-no add'l pmt,under original DRG

Re-admission applies under original DRG of primary

admit- 249


5DC Denied-no add'l pmt,under original DRG

Re-admission applies under original DRG of primary

admit- 249


4AJ Denied-remit/billing addr does not match

Remitting/billing address does not match system

records 16 N258


4AK Denied-rendering provider required

Rendering physician / facility required and not

submitted. 16 N289


H46 Deny due to Interaction with other drug Service denied because potential interactions with

another drug


H72 Deny Item doesn't meet definition of DME

Item denied because it is an item of convenience, item is

not medical 50 N10


4AM Deny-DOS outside statement dates Deny-DOS outside statement dates 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5DE Deny-DOS outside statement dates Deny-DOS outside statement dates 16 MA31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

468 Device/equip invoice required An invoice from the vendor supplying the implantable 252 M23


R08 Diag inv/missing/del 4th or 5th Diagnosis invalid/missing/deleted 4th or 5th digit 16 M76


I09 Diag Inv/Missing/Deleted Req 4th/5/6/7th

Diagnosis Invalid/Missing/Deleted or Requires 4th or 5th

or 6th or 7th 146 M76

ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations.

ZK4 Diagnosis Code Invalid Diagnosis Code Invalid 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HS1 Diagnosis Codes missing or inval on DOS All Diagnosis codes are invalid on the DOS or requires a 146 M76


408 Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167


5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167


H64 Diagnosis Invalid for Age The age of the patient does not correlate with the

submitted diagnosis


H15 Diagnosis Invalid For Gender This was denied because the diagnosis is not

appropriate based on the


GA2 Did not meet minimum unit requirement Did not meet minimum case rate unit requirement 16 M53


R67 Discrep w/Level of Care-Appeal Req Discrepancy with Level of Care - Appeal Required 150 N640


X67 Discrep with Level of Care-AppealReq Discrepancy with Level of Care - Appeal Required 150 N640


ZZ0 Documented Service does not support 9929 Documented Service does not support 99292 150 N640


H21 Doesn't Meet Observation Criteria Observation care code requires minimum of 8 hours. 150 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R97 DOS Cannot be Greater than Received DOS cannot be Greater than Received Date 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X97 DOS Cannot be Greater than Recv Date Date of Service cannot be greater then claim received 110


581 DRG change due to DX/discharge

DRG change due to incorrect principal or secondary DX

codes and 216 N35


583 DRG change due to DX/Procedure/discharge


and procedure 216 N35


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

584 DRG change due to DX/Procedure/discharge


and procedure 216 N35


578 DRG change due to incorrect DX


codes(s) 216 N35


582 DRG change due to proc code/discharge

DRG change due to incorrect principal or secondary

procedure 216 N35


580 DRG change due to procedure code

DRG change due to incorrect principal or secondary

procedure code(s) 216 N35


579 DRG change/payment due to discharge stat DRG change/payment due to incorrect discharge status 216 N35


585 DRG coding review;Denied med record IP DRG coding review; denied for medical records 252 M127


HB5 DRG Doesn't Match The billed DRG does not match the Grouper DRG 16 N208 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R42 DRG Payment DRG Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R39 Dup Claim Prev Pd at Correct Rate/Ca

Duplicate claim previously paid at correct rate or

capitated. B13 M86


R41 Dup Clm Previously Denied Appropriate Duplicate Claim Previously Denied Appropriately B13 M86


I65 Dup Clm-Prev denied approp Duplicate Claim-previously denied appropriately B13 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X39 DupClaimPrevPd at Correct Rate/Cap

Duplicate claim previously paid at correct rate or

capitated. B13 M86


409 Duplicate bill, previously considered

This is a duplicate claim that has previously been

considered. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

409 Duplicate bill, previously considered


considered. 18 N702


5CM Duplicate bill, previously considered



5CM Duplicate bill, previously considered


considered. 18 N702


G12 Duplicate Claim Prev Denied appropr Duplicate Claim Previously Denied Appropriately 18 N702


485 Duplicate claim, previously considered



485 Duplicate claim, previously considered


considered. 18 N702


H39 Duplicate Condition 1

Duplicate Logic Condition 1 - Everything the same

except Submitted 18 N702




except Allowed 18 N702




except co-pay. 18 N702


H42 Duplicate Condition 4 Duplicate Logic Condition 3 - Everything the same. 18 N702


H44 Duplicate of New/Deleted Proc Code.

During the grace period for a new or deleted procedure

code only 16 M84


HMY Duplicate Procedure on Same Day Duplicate Procedure on Same Day 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

954 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

969 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G45 Duplicate Service Within 30 Days

This health service code was denied because an

inclusive same or simil B13 M86


H43 Duplicate Submission This claim has been previously submitted. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZK3 Dx Code Invalid for Inpatient Claim Dx Code Invalid for Inpatient Claim 11 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H09 Dx Code Not Coded to Highest Level

The billed diagnosis code is not coded to the highest

level of 16 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS National Coverage Determinations (NCD) Policy

H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS Coverage Policies

469 Dx invalid for DOS Diagnosis invalid for date of service 146 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BU Dx invalid for DOS Diagnosis invalid for date of service 146 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G47 E & M Level Of Service Recoded

This health service code was changed to one that is

consistent with th B15 N22


H93 E&M Code level Re-coded

The level of the Evaluation and Management visit has

been recoded 150 N22


HM4 E&M svs. Btwn Global Pre and Post Op Per E&M svs. Btwn Global Pre and Post Op Period 97 N525 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G48 E/M Service Inappropriately Coded

This health service code was denied because it was

inappropriately cod 16 M81


IH8 E/M Service inappropriately coded The health code was denied because it was

inappropriately coded based


J59 EDI issue- incorrect info. mapped R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V57 EDI issue- incorrect info. Mapped R129:Administrative Overturn 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

410 Emergency room report required

The emergency room report is required for

consideration of this claim. 16 N391


5A0 Emergency room report required

The emergency room report is required for

consideration of this claim. 252 N706


J31 Encounter req change after clm pymt R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BW EOB cannot be read

Please resubmit legible EOB. Original EOB could not be

read. 251 N205


R11 EOB from prim carrier req Resubmit with EOB from Primary Carrier 16 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J17 EOB in system not applied correctly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V16 EOB in system not applied correctly R129:Retro Authorizations 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J19 EOB in system yet processed as primary R129:Valid EOB on File 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GB5 EOB Missing Date Rec or Denial Reas EOB Missing Date Received or Denial Reason 251 N480 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

039 EOB Statement Explanation This explanation will appear on the EOB 23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R96 EOB/Attachmnts were Incomplete/Illeg EOB/Attachments were Incomplete/Illegible 251 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J20 EOB/TPL in system not effective on DOS R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I73 EPSDT Form was Incomplete EPSDT form was incomplete 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X73 EPSDT Form was Incomplete EPSDT Form was Incomplete 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R63 EPSDT Pay Adj-5 /12 year old screeni

EPSDT Payment Adjustment For 5 And 12 Year Old

Health Screen 24


ZZ8 ER med record review completed; Denied

ER medical record review completed; records do not

support 216 N109


HT0 Established /New Patient

An Established visit should be billed instead of New

Patient B16


J36 Ex adj clm by mistake/no chge in outcome R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V34 Ex adj clm by mistake/no chge in outcome R129:Settlement Adjustment 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J49 Examiner overlooked addtlmod/dx Examiner overlooked addtl mod/dx 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

917 Exceeded benefit maximums Adjusted - member maximum benefit was exceeded. 119


466 Exceeds allowed units

The units submitted on this claim exceed the daily unit

allowance. 96 N362


5BQ Exceeds allowed units

The units submitted on this claim exceed the daily unit

allowance. 96 N362


413 Exceeds approved length of stay

The services rendered exceed the approved length of

stay. 152 M26


H20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,

the frequency



the frequency



the frequency

150 N130 CMS Coverage Policies

4AN Exceeds contracted rate

Billed charges exceed contracted rate. Member not

liable 45


5DF Exceeds contracted rate

Billed charges exceed contracted rate. Member not

liable 45


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

G40 Exceeds Coverage Guidelines

This health service code was denied as this service

exceeds the frequ 151 N130


ZD6 Exceeds daily limitation

Exceeds the daily limitation of 1 ER Visit per date of

service 273 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations



service 273 N362




service 273 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations



service 273 N362


5A4 Exceeds DRG reimbursement The services rendered exceed the DRG reimbursement. 45


B36 Exhaustion of Benefits Exhaustion of Benefits 119 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I26 Exhaustion of Benefits Exhaustion of Benefits 119 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G49 Experimental/Investigational

This health service code was denied because it is

considered experime 55 N10


ZF6 External Error - Auth/Ref Req to Config

External Error - Auth/Ref Requirements to Config

Revised/Reversed 129 MA67


J65 Externally Priced Claims Manual pricing applied for correct payment 45 N442 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XE2 Facility Prov not enrolled in Medicaid Facility Prov not enrolled in Medicaid Program 16 N278 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZZB Fam Plan Consent Form Rev: Missing Info Family Planning Consent Form reviewed: 251 N228 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZZC Fam Plan Consent Form reviewed: payable Family Planning Consent Form Reviewed: Payable 216 N11


459 Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BE Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

601 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XF2 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HMD Gender of Patient Not Consistent w/Code

The Gender Of The Patient Is Not Consistent With

Service Code Billed. 7


Y98 General Claim adjustment from NaviNet General Claim adjustment from NaviNet 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V77 Global maternity code only payable as sc

The Health Plan only considers payment on a global

maternity code as t 22 MA04


H84 HCPCS Code Not Appropriate According to CMS guidelines, the billed HCPCS code has

been

8 CMS Coverage Policies

G67 HCPCS Code Not Appropriate For Profe

According to CMS guidelines, the billed HCPCS code has

been designate 189 N657


G42 HCPCS Recoded Based On Gender

The health service code has been changed to correlate

to the appropria 7


G81 HCPCS Recoded Per Health Plan Policy

The billed HCPCS was recoded to another HCPCS code

based on Health Pla 189 N657


IH9 HCPCS recorded based on gender The health service code has been changed to correlate

to the


HDR High Dollar Review Team High Dollar Review Team 133 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J51 High Dollar review, reprocess claim R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V50 High Dollar review, reprocess claim R129:Clm Proc w/o ICD9 surgical code 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZPD HMS - Rebill ER care

HMS identified that ER care should be rebilled at an

appropriate level 150 N10


HM0 HMS Overturn Appeals Process Review Appeal Overturn 216 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

586 HMS Review no findings pay as billed HMS Review no findings pay as billed 216 N11 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HMQ Hosp O/P Specific Billed Serv Code Combo

Hospital Outpatient Based on NCCI. The specific billed

service code is 236


HMB Hosp.Outpt Proc.is Mut.Excl.On Prior Clm

Hosp.Outpt Proc.is Mut.Excl to Prior Clm submisson on

same DOS 231


HMA Hosp.Outpt Procedure is Mutually Excl.

Hosp Outpt Proc.is Mutally Excl. Two Proc are consid.

Mut Exclusive 231


HMC Hosp.Outpt.Based on NCCI Proc

Hosp.Outpt.Bsd on NCCI Proc Mut Excl.Non payable

code was Pd 231


M72 I/P Billed as OBSV

Claim was billed as Inpatient but was authorized as

Inpatient 186 N54


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

Z86 I/P Billed as OBSV

Claim was billed as Inpatient but was authorized as

Inpatient 60


V65 ICD-9 surgical code needed on claim R129: Prior Processing Information Appears Incorrect 129 MA67


J50 ICD-9 surgical code needed on claims R129:Clm Proc w/o ICD9 surgical code 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V48 ICD-9 surgical code needed on claims R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Y99 ICM claims adjustment for CDPS process

Intensive case management process - claim adjustment

for CDPS process 45 N381


190 If A0999 is billed over 30 units submit

If A0999 is billed over 30 units, please submit supporting

documents 252 N706


V17 IIIegible/incomplete EOB attached R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZE3 Illegible Records Submitted

Illegible records submitted Please re-file legible

records; Program 251 N237


J21 Illegible/incomplete EOB attached Illegible/incomplete EOB Attached 251 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IRR Implant In Review Implant In Review 163 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IA2 Implant included in DRG reimb Implant included in DRG reimbursement line item 97 M15


IR1 Implant Invoice Required Implant Invoice Required 163 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IA1 Implant payment based on clin rev

Implant payment based on clinical review line item

explan 50 N10


B09 Implant Procedure Requires Implant De

This implant procedure code was denied because the

associated implant 16 N354


R91 Inappropriate Coding for Contract/Agr Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H92 Inappropriate Place of Service The Place of Service indicated on the claim is not

appropriate for

58 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations


appropriate for

58 CMS National Coverage Determinations (NCD) Policy


appropriate for

58 CMS Coverage Policies

HS6 Incidental Phys Service Item or Service is incidental to the Physician's Service 234 N390


G54 Include in Monthly Rental Fee


considered to be inc 108 N370


G83 Included In Blood/Blood Product Reve

The Revenue code was denied as it is a part of the

Blood/Blood Product 97 N19


416 Included in contracted rate

The services rendered are included in the contracted

rate. 45


5A6 Included in contracted rate

The services rendered are included in the contracted

rate. 45


HS5 Included in E&M Procedure is included in E&M Code 97 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H03 Included in E&M Service This service is included in the billed Evaluation and

Management code


H24 Included in Global Fee This code is included in the global fee for another

procedure.

97 N19 National Correct Coding Manual Policy

H24 Included in Global Fee This code is included in the global fee for another

procedure.


5A7 Included in inpatient per diem

The services rendered are included in the inpatient per

diem. 45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5A7 Included in inpatient per diem

The services rendered are included in the inpatient per

diem. 45


MBC Included in Mom/Baby Case Rate Payment is included in Mom and Baby Case Rate 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G55 Included In Other Code

This procedure has been included as part of another

procedure. 97 M15


G53 Included In Physical Medicine Service


considered to be an 97 M15


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

H01 Included in Primary Procedure This procedure has been included in the primary

procedure.



procedure.

97 N19 National Correct Coding Initiative Policy


procedure.

97 N19 National Correct Coding Initiative Supplemental Policy


procedure.



procedure.


H22 Included in Radiation TX Mgt Svc.

These services are included in the weekly radiation

treatment 97 N19


B66 Included in Settlement Payment Included in Settlement Payment 97 N45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X25 Included in Settlement payment Included in Settlement payment 45 N664 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V06 Incorr. Prov info loaded/att to incor ag R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J06 Incorr. Prov info loaded/att to wrg agrm R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V12 Incorrect Auth/Referral applied to claim R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

957 Incorrect charge Adjusted - incorrect charge. 16 M54 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

958 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

971 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B40 Incorrect Contract Amount Prev Paid Incorrect Contract AMount Previously Paid 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

959 Incorrect date of service Adjusted - incorrect date of service. 16 MA31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

960 Incorrect diagnosis code Adjusted - incorrect diagnosis code. 146 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G24 Incorrect Diagnosis Code Entered Incorrect Diagnosis Code Entered on Previous Claim 146 M64


I32 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X65 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

961 Incorrect member/patient

Adjusted - incorrect member/patient selected on

original claim 16 MA36


972 Incorrect member/patient

Adjusted - incorrect member/patient selected on

original claim 16 MA36


419 Incorrect modifier

The service submitted has been reported with an

incorrect modifier. 4


5A9 Incorrect modifier

The service submitted has been reported with an

incorrect modifier. 4


962 Incorrect number of units Adjusted - incorrect number of units. 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

973 Incorrect payee Adjusted - paid to incorrect payee. 16 N279 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G13 Incorrect Place of Service Incorrect Place of Service on Previous Claim 5 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I34 Incorrect proc/diag for EPSDT payment Incorrect procedure/Diagnosis for EPSDT payment 16 M51


964 Incorrect procedure code Adjusted - incorrect procedure code. 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V66 Incorrect provider paid Incorrect provider paid B7 N570 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZA3 Incorrect Provider/TIN ID # submitted Incorrect Provider/TIN ID # submitted 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z76 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209


ZA6 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209


420 Incorrect revenue code / resubmit The revenue codes that has been submitted is incorrect. 16 M50


G09 Incorrect Secondary Liability Incorrect Secondary Liability 252 MA64 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J24 Incorrect TPL info supplied by state R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V22 Incorrect TPL info supplied by state R129:Secondary EOB req 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

462 Incorrect/missing pos

The claim has been submitted with an incorrect or

missing place of 16 M77


J53 Inpatient downgrded to lower lvl of care R129:inpt downgrd to lower level of care 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

K51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J54 Interest paid in error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V53 Interest paid in error R129:inpt downgrd to lower level of care 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

975 Interest paid incorrectly Adjusted - interest paid incorrectly. A7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

R64 Interim Bill 1st Cycle Payment Interim Bill 1st Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R65 Interim Bill 2nd Cycle Payment Interim Bill 2nd Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R66 Interim Bill Final Cycle Payment Interim Bill Final Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X33 Interim Bill Resubmit Final Bill Interim Bill Resubmit Final Bill 135 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

421 Interim bill, submit clm for entire stay

This is an interim bill. Please submit claim for the entire

stay. 16 MA31


ZF8 Internal Delay - Auth/Ref not on file

Internal Delay - Auth/Referral not on file During initial

Processing 129 MA67


J07 Internal enrollment error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZF2 Internal Error - Incomp/Inaccurate Req

Internal Error - Incomplete/Inaccurate Requirements

Provided to Config 129 MA67


GA8 Invalid Admission DX Eff Date Invalid Admission Diagnosis Effective Date 146 MA65 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA5 Invalid Bill Type Invalid Bill Type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I93 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z90 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA4 Invalid CPT/HCPCS Code Invalid CPT/HCPCS Code 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H32 Invalid Diagnosis Code The diagnosis code listed on the claim is invalid. 146 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HB6 Invalid Discharge Status Invalid Discharge Status 16 N50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J71 Invalid Gender for DX Invalid Gender for DX 10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R32 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X99 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

185 Invalid Member Date of Birth

Members Date of Birth on Claim does not match DOB in

FACETS 16 N329


184 Invalid Member Name

Member Name on claim does not match Name in

FACETS 16 MA36


422 Invalid member number submitted

The claim has been submitted with an invalid member

number. 31


5AB Invalid member number submitted

The claim has been submitted with an invalid member

number. 31


ZHA Invalid Modifier

Invalid Modifier used. Submit claim without modifier or

appropriate 182 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZHA Invalid Modifier

Invalid Modifier used. Submit claim without modifier or

appropriate 182 N657


GB1 Invalid NPI Invalid NPI 207 N257 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EB5 Invalid or Multiple Evidence Based Progr

Invalid or Multiple Evidence Based Program Indicators

on Claim 95 N182


XE7 Invalid ORP Ordering prov type Invalid ORP Ordering Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEH Invalid ORP Referring and Ordering Prov Invalid ORP Referring and Ordering Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XE8 Invalid ORP Referring Prov type Invalid ORP Referring Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA7 Invalid Patient Status for Bill Type Invalid Patient Status for Bill Type 16 MA43 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I68 Invalid place of service for procedure Invalid Plance of Service for Procedure 5 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Q55 Invalid Procedure Code Procedure is invalid for this date of service 181 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ISR Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IST Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ISU Invalid Sex for Diagnosis Member Sex Invalid for Diagnosis Code 10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA3 Invalid Units Invalid Units 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4AW Invalid/missing bill type The submitted bill type is invalid or missing. 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5DP Invalid/missing code - CPT, HCPCS or mod

The submitted procedure code or modifier is missing or

invalid. 16 M51


5DW Invalid/missing diagnosis code The submitted diagnosis is invalid or missing. 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Submitted Claim 16 M50


R86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Claim 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

458 Invoice pricing Pricing based on submitted invoice. 45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

5BD Invoice pricing Pricing based on submitted invoice. 45 N649 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

424 Invoice required The invoice is required. 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5AD Invoice required The invoice is required. 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R57 IP stay if <24 hrs IP stay if<24 hrs, resubmit as observation 150 N640 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZF0 IS Processing Error IS Processing Error 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J68 Itemized bill/invoice/med rec rec'd Itemized bill/invoice/med rec rec'd 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X75 JCode ident as med exp instead pharm

J Code identified as medical expense instead of

pharmacy 96 N448


V36 KMHP had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H80 Lab compnt price exceeds lab panel price Price of Lab Panel components exceed lab panel price 45 N70 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

478 Late charge ineligible

Late charge claim cannot be accepted. Combine original

claim and late 16 MA30


5C7 Late charge ineligible

Late charge claim cannot be accepted. Combine original

claim and late A1 MA30


J73 Late charges applied Late charges applied 45 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HB7 LCD - Procedure vs Diagnosis

Billed DIagnosis does not support Medical Necessity -

refer to LCD 11 N115


HB8 LCD - Procedure vs Diagnosis

Billed DIagnosis does not support Medical Necessity -

refer to LCD 11 N115


217 Line Received with Zero Billed Charge Line Received with Zero Billed Charge, Nothing is Due.


MA1 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

MA2 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J69 Mat Kick payment applied Mat Kick payment applied 131 N442 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B46 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7


I23 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7


J81 McKesson historical clinical edit Correction to a prior claim 129 N377 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z25 Medicaid Fee for Service Medicaid Fee for Service 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I99 Medicaid Prov # Missing or Invalid Medicaid provider number is missing or invalid 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZE0 Medical Record Review Complete

Medical Record Review Complete; documentation does

not support 96 N35


ZE1 Medical Record Review Complete

Medical Record Review Complete; documentation does

not support 96 N35


ZZE Medicare A unavailable submit Part B EOB Medicare A unavailable submit Part B EOB 16 N479 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

MCO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XMO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

9BP Medicare Primary Care Physician Bonus Medicare Primary Care Physician Bonus Payment 161 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R87 Medicare/Medicaid Sanctioned Provider Medicare/Medicaid Sanctioned Provider 184 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XC7 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M74 Member has Multiple Insurances

Member has multiple insurances. Submit EOB from

other carrier 16 MA64


Z75 Member has Multiple Insurances

Member has multiple insurances. Submit EOB from

other carrier 22 MA64


TRI Member is tri-eligible; Submit EOBs

Member is tri-eligible; Submit EOBs from all insurance

carriers 169 N23


HS2 Member not Eligible at Time of Service Member was not Eligible at Time of Service 200 N650 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EB3 Member not enrolled in Evidence Based Pr Member not enrolled in Evidence Based Program 272


I39 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X55 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZH2 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZH3 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B21 Members Age not valid for procedu code Members Age not valid for procedure code 6 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

A54 Met Monitoring Incentive Metabolic Monitoring Incentive 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

V55 Mgmt decision to waive business rule R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HB4 Missing CC/MCC Diagnosis

The Provider's billed DRG indicates a

complication/comorbidity that 16 M76


ZMK Missing CLIA Number on Claim Missing CLIA Number on Claim 16 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GB2 Missing Discharge Hour for Disc Bill Typ Missing Discharge Hour for Discharge Bill Type 16 N317 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

130 Missing DX for Intensive Case Mgmt Progr Missing Dx for Intensive Case Mgmt Program 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA1 Missing HCPCS Code for Bill Type Missing HCPCS Code for Bill Type 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I97 Missing/Illegible Charge Billed Missing or Illegible Charge Billed 16 M79 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z41 Missing/Illegible CPT,HCPCS or ICD-9 Missing/Illegible ICD-9 procedure code submitted 16 M51


IH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 CMS Coverage Policies

IH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZJ9 Missing/Incomplete/Invalid Revenue Code Missing/Incomplete/Invalid Revenue Code 16 M50


HS9 Mod 26/TC Not allowed for Service

Modifiers 26 or TC are not allowed for Professional or

Technical 4 N519


H76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 CMS National Coverage Determinations (NCD) Policy

HMU Mod QW required

Per CLIA Requirements a modifier QW is required for

this procedure 4 N519


HSA Mod TC not allowed for this Service Code Modifier TC is not allowed for this Service Code 4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H27 Modifier Adjustment The recommended percentage for this procedure has

been adjusted based


ZK2 Modifier Combination Invalid Modifier Combination Invalid 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G64 Modifier Inappropriate For Place Of Se Modifier Inappropriate For Place Of Service 5 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a

modifier that


H77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a

modifier that


G63 Modifier Inappropriate For Provider Ty N/A 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G60 Modifier Inappropriately Coded

The modifier for this service has been changed to reflect

appropriate 4 N519


H82 Modifier Inappropriately Coded The modifier for this service has been changed to reflect

appropriate


HSX Modifier not Applicable

Per Plan Requirements, the service code and modifier

cannot be billed 4 N519


H57 Modifier removed on Termed Proc Code Modifier removed. Terminated procedure can not be

billed bilaterally


H65 Modifiers Re-Ordered

The modifiers on the claim line were reordered based on

the 182 N22


H96 More Than 1 Asst Surgeon Not Allowed Only one assistant surgeon is allowed for the procedure

submitted.


HS0 More than one Interp and Reading perfrmd

More than one interpretation and reading being

performed for the same 18 N702


X83 Mother's Bill not Received; Refile Mother's Bill not Received; Refile 16 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X12 Motor Vehicle Accident - Auto Primary Motor Vehicle Accident-Auto Carrier Primary 20 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZD4 MSRP is missing MSRP is missing and is required with the claim 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSC MUE for DME Medically Unlikely Edits for DME 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSD MUE For Hospitals Medically Unlikely Edits for Hospitals 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSB MUE for Physicians Medicallly Unlikely Edits for Physicians 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

RB1 Multiple Corrected Claims Submitted

Multiple Corrected Claims Submitted. Last submission

will be used. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

RB1 Multiple Corrected Claims Submitted

Multiple Corrected Claims Submitted. Last submission

will be used. 18 N702


H26 Multiple Endoscopy Review Multiple endoscopy, modifier 51 has been removed. 97 N20


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

G32 Multiple Endoscopy Rules

The claim has been processed using the Multiple

Endoscopy methodology. 59 N10


G66 Multiple Nuclear Medicine Studies N/A 59 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HT2 Multiple Paymnt Reduction Imaging

Multiple Procedure Payment Reduction on the Technical

Component 59


HT1 Multiple Proc Reduction - Imaging

Multiple Procedure Payment Reduction on the Technical

Component 59


G80 Multiple Procedure Reduction for Radi The technical component of this service code was

reduced because more


H28 Multiple Procedure Review

This code is subjected to a multiple procedure reduction

when more 97 M15


5DZ Multiple same day surgery reductions

The allowable amount for this service has been reduced

according to 59 N10


R44 Multiple Surgical Reduction Multiple Surgical Reduction 59 N670 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H58 Mutually Exclusive of Another Proc This code should not be reported since a similar

procedure was



procedure was

97 N20 National Correct Coding Initiative Supplemental Policy


procedure was


M73 Name/DOS on case notes do not match Member name/DOS on case notes do not match claim 250 N206


Z74 Name/DOS on case notes do not match Member name /DOS on case notes do not match claim 16 N329


X91 nappropriateCoding ForContract/Agree Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G38 National Correct Coding Policy Manual

This health service code was denied based on correct

coding guidelines 16 M81


425 Nbr of units dont correspond w/date span

The number of units billed does not correspond with the

date span 16 M23


5AE Nbr of units dont correspond w/date span

The number of units billed does not correspond with the

date span 16 N345


HT8 NCCI Column 1 denied,Column II paid prev

NCCI Column I and Column II codes billed out of

sequence for same date 234 M80 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HT8 NCCI Column 1 denied,Column II paid prev

NCCI Column I and Column II codes billed out of

sequence for same date 234 M80


H17 NCCI Denial- Mutually Exclusive This health service code was denied as mutually

exclusive of another

231 National Correct Coding Initiative Policy

H18 NCCI Denial-Comprehensive/Component This health service code was denied as a component of a

comprehensive

97 N19 National Correct Coding Initiative Policy

5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119


I38 Need Newborn Number Need Newborn Number 32 N15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G69 New Patient Visit Allowed Once Per 3 N/A B16 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZB0 Newborn Birth Weight Required Newborn Birth Weight Required 16 M49 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZA7 Newborn Inpt > 30 days require Auth

Newborn Inpt > 30 days require Auth/submit itemized

bill 197


ZA8 Newborn Inpt >30 day/pymt reduced no aut Newborn inpt>30 days/payment reduced for no auth 210


A50 Newborn inpt >30 days requires

Newborn inpt > 30 days requires auth/submit itemized

bill 197


A51 Newborn inpt>30 day/pymt reduce Newborn inpt > 30 days/payment reduced for no auth 210


ZB6 NIA Multiple Procedure Discount Applied NIA Multiple Procedure Discount Applied 59 M75 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H06 No Assist Needed For This Procedure Procedure Denied. The procedure code billed does not

require the


XE6 No Attending NPI Submitted No Attending NPI Submitted 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V15 No auth existed at time of processing R129:Authorization/Referral Updated 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

R24 No Benefit. OIC Pymt Equals/Exceeds L

No Benefit Due. Other Carrier Payment Equals/Exceeds

our Liability 23 N9


ZMM No CLIA Number on our File No CLIA Number on our File 16 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X89 No MAID on File No MAID number on file. Contact Provider Services. 16 N253


ZJ7 No MAID on file No MAID on file 183 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M97 No Medicaid Allowable, paid at 30% No Medicaid Allowable, paid at 30% 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R27 No PCP Required for PE Member No PCP Required for Presumptive Eligibility Member 24


Z07 No Pre CertAuthorization/ or Referral Authorization/Referral not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R01 No Precert/Authorization or Referral

Precert/Auth/Notification not obtained, denied or

invalid 197


XD4 No referring or ordering NPI submitted No referring or ordering NPI submitted on claim 16 N265 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z58 No supporting doc or ambul run sheet

No supporting documents or ambulance run sheet

received 252 N745


B62 No supporting documents received No supporting documents received 16 N29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B38 Non contracted level of care Non contracted level of care 96 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IH3 Non Covered Charges Non covered charges 96 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSE Non covered member SIU has never received eligibility for this member 31


HSF Non Covered member/plan Member benefits are not payable through this plan 31


HB9 Non -Covered Revenue Code Not a covered revenue code Healthcare 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H51 Not a Covered Procedure Certain procedures are not covered as deemed by the

plan.



plan.



plan.


HSG Not a Covered Service Not a Covered Service 96 N643 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HM3 Not Appr to Bill Ext DX code in 1st pos

Not Appr to Bill External Cause DX in the First ICD

Position 167 MA63


HM2 Not Appr to Bill Ext DX W/O another DX

Not Appropriate To Bill An External Cause Diagnosis

W/O another 167


G72 Not considered safe and/or effective.

This service was denied because it is not considered safe

and/or effec 56


G68 Not Covered For Diagnosis Indicated

This health service code was denied as it is not a

covered service whe 16 M76


H74 Not Covered for Diagnosis Indicated This health service code was denied as it is not a

covered service


H99 Not Covered for Provider Specialty Certain procedures are not covered for specific

specialties as deemed


H99 Not Covered for Provider Specialty Certain procedures are not covered for specific

specialties as deemed


G70 Not covered when performed by this pr

Payment for services is denied when performed by this

specialty/provid 184 N808


4AY Not cvrd/prv agreement This service is not covered per your provider agreement. 170


5E0 Not cvrd/prv agreement This service is not covered per your provider agreement. 170


R10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V84 Not enrolled on date of service Not enrolled on date of service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G71 Not Included In Opps

This health service code was denied because it is not

recognized under 16 M51


5BN Notes required

Please submit corresponding operative, radiology or

office notes. 252 N710


B26 Nursing Home Confined > 30 Days - Dis

Nursing Home Confined Greater than 30 days-Member

Disenrolled 27 N30


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

X93 NursingHomeConfined >30 Days - Disenr

Nursing Home Confined Greater then 30 days-Member

Disenrolled 27 N30


J70 Observation < 24 hrs Observation < 24 hrs 186 M25 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M71 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 186 N54


Z72 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 60 N676


H95 Only 1 E&M Code Allowed Per Day This E&M service was denied because only 1 E&M

service is allowed for

B14 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H29 Only 1 Service Allowed per Treatment The allowed course of treatment for this procedure code

has been


G65 Only One Anesthesia Service Per Opera

This procedure was denied because only the anesthesia

service which ha 59 N10


HMZ Only one visit allowed per day Only one visit allowed per day B14 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XE3 Operating Prov not enrolled in Medicaid Operating Prov not enrolled in Medicaid Program 16 N262


4AP Operative report required

Claim should be re-submitted with copy of operative

report 163 M29


5DG Operative report required

Claim should be re-submitted with copy of operative

report 252 M29


XEM Ordering and Referring Prov NPI is a non

Ordering and Referring Prov NPI is a non-individual per

NPPES Registry 16 N265


XD6 Ordering not enrolled in Medicaid Progra Ordering not enrolled in Medicaid Program 184 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEC Ordering NPI is not enrolled with state

Ordering NPI is not enrolled with state as provider type

31- physician 16 N265


XED Ordering Provider NPI is a non-individua

Ordering Provider NPI is a non-individual per NPPES

Registry 16 N265


ZB5 Orgl clm processed submit corrected clm

The Original claim has been processed submit a

corrected claim 16 N152


V13 Original auth updated w/add'l info R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GA9 Original Claim Number missing or invalid Original Claim Number missing or invalid 16 N152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XE0 ORP Provider not enrolled in Medicaid

Ordering, Referring, Prescribing Provider not enrolled in

Medicaid 16 N253


XE9 ORP Provider not submitted Ordering, Referring, Prescribing Provider not submitted 16 N253


920 Other COB

Payment adjusted as the result of coordination of

benefits. 22 N4


G18 Other Insurance not Effective on DOS Other insurance was not effective on Date of Service 23 MA17


XE4 Other operating prov not enrolled in Med Other operating prov not enrolled in Medicaid Program 16 N262


R46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limited 119 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limit 119 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J47 Overpayment of physician services R129Total Comp Phy svs incl in Fac paymt 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V46 Overpayment of Physician Services R129:Non-covered svs paid incorrectly 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J48 Overpayment on SPU R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V47 Overpayment on SPU R129Total Comp Phy svs incl in Fac paymt 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V63 Overpayments identified by Concentra R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J46 Overpaymt due to non cover svs pd incorr R129:Non-covered svs paid incorrectly 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V45 Overpymt due to non cover svs pd incorr R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H98 Packaged Incidental Service Payment is included in the allowance for another

service/procedure


J35 PAD- Passport advantage Lob 1300 R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R83 Paid at Average Wholesale Price Paid at Average Wholesale Price 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

7A1 Paid by auto insurance The claim has been paid by auto insurance. 21 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J58 Panel transfer R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G76 Partial Hospitalization Not Indicate

This health service code was denied because condition

code 41 (Partial 16 M44


G52 Partial Hospitalization Requires Men

This health service code was denied because a partial

hospitalization 135 MA93


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

HSL Partial Payment Hold - DOS Partial Payment Hold Based on Date of Service 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSK Partial Payment Hold - Rec'd Date Partial Payment Hold based on Received Date 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H55 Payable Only W/ Active Intervention

Procedure requires active intervention and is not

payable when 107 N674


IH4 Payment adj invalid place of service Payment Adj- treatment deemed rendered in inapp POS 16 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

MAT Payment Adj Maternity Kick Payment Payment adjustment for Maternity Kick Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IH7 Payment denied when performed by provide Payment is denied when performed /billed by provider

type in type of


HA2 Payment for this service/item is bundled Payment for this service/item is bundled 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSI Payment Hold - Rec'd Date Payment hold based on Received Date 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSJ Payment Hold - DOS Payment hold based on Date of Service 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

181 Payment included in DRG Payment included in DRG 97 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R00 Payment Included in Other Billed Serv Payment Included in Other Billed Service 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZRD Payment Reduced Incomplete PASRR Payment Reduced Due to Incomplete PASRR 272 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I46 Payment reflects combined DRG payment Payment reflects combined DRG payment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HME Phys.Ther Svs not payble in Hosp.Setting

Physical Therapy Service Is Not Payable In A Hospital

Inpatient 5 M77


HT3 Place of Service Facility

Place of Service for this procedure is invalid or not

normally 58


J37 Plan had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R84 Please Obtain Individual Provider ID# Resubmit w/Individual Provider Name/Number 16 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

519 Please resub family planning related

Please resubmit family planning related charges to

IUMG 109 N130


5AJ Please submit charges to Medicare Please submit charges to Medicare. 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5AK Please submit other carrier's info. Please submit other carrier's information. 16 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZR2 Please submit the correct original claim

Please submit the correct original claim number for

consideration 95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZR2 Please submit the correct original claim

Please submit the correct original claim number for

consideration 95


ZQ1 Please Submit to Coastal Care Services 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X84 PleaseObtain Individual Provider ID # Please Obtain Individaul Provider Identification Number 16 N253


I47 Pmt based on DRG transfer policy

Payment is based on DRG transfer policy, DRG discharge

formula 45 N381


4B3 POA required Present on admission indicator is required 16 N434 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSM POS - Non Facility

POS for this Procedure is invalid or not normally

performed in this 5 M77


HSO POS Plan Specific Service Code

Per Plan requirements service code cannot be billed

with the POS 5 M77


HSN POS Plan Specific/Service Code

Per Plan requirements specific place of service(s) are

required when 5 M77


H04 Post-Op Follow Up Incl in Global Fee The procedure is included in the global surgical fee for a

procedure


RA9 PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109


ZZD PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109


HSW Pre Admit Service included in Hospitaliz

3 Day window OP Serv s/b included in IP Stay. Non

Payable Code pd 60 N130


R48 Pre-Adm Testing Included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15


X48 Pre-Adm Testing included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15


Z42 Pregnancy Risk Assessment Form Req'd Completed Pregnancy Risk Assessment Form Required 252 N80


ZA9 Pregnancy Risk Assessment Form Required Completed Pregnancy Risk Assessment Form Required 252 N80


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

H50 Prev Proc/Paid to Same/Diff Provider Same procedure has been paid or processed to the

same or different


R49 Previous Payments = to Purchase Pric Previous Payments Equal to Purchase Price B13 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X49 PreviousPayments = to Purchase Price Previous Payments Equal to Purchase Price 119 M7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G57 Price of Lab Panel Components Exceed

The price of the individual lab panel components have

exceeded the pri 97 N130


V25 Prim ins listed in Facets(Non Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J27 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V26 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J26 Primary ins listed in Facets/Non Medicar R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H12 Primary Procedure Must be Billed The procedure was denied because it requires an

accompanying procedure

107 MA66 CMS Coverage Policies



107 MA66 CMS National Coverage Determinations (NCD) Policy



107 MA66 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

A52 Primary/Sec Diagnosis POA Error Primary/Sec Diagnosis POA Missing/Invalid 167 N607 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z67 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76


Z68 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76


G46 Principal Diagnosis Inappropriately C

The principal diagnosis has been inappropriately coded

based upon ICD- 11 MA63


G75 Principal Diagnosis Invalid

This health service code was denied because it was

submitted with an i 11 MA63


ZC8 Principal Surg Code is missing/invalid Principal Surgical Procedure is missing or invalid 16 MA66 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H66 Principle Diagnosis incorrectly utilized Missing/Incomplete/Invalid Principle Diagnosis 16 MA63 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

IH2 Proc Code and Mod inval of DOS Payment adjustment because the procedure and

Modifier invl on DOS


IH6 Proc code changed to acc desc svs Procedure code changed to accurately desc. The

services rendered


V76 Proc Code isnt payable w T1015 Procedure Code isnt payable w T1015 236 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V75 Proc Code required with T1015 Procedure Code required with T1015 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

461 Proc processed on separate claim id This claim has been processed under a separate claim id. B13


HM8 Proc. is Mut. Excl, Non Pay Cd pd prior

Mutually Excl.Proc is listed on Prior claims run For the

same DOS. 231


433 Procedural modifier(s) required The service submitted requires a procedural modifier. 4


5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4


H31 Procedure Bilateral in Nature This procedure was adjusted because the service is

bilateral in nature


EB4 Procedure Billed not part of Members Evi

Procedure Billed not part of Members Evidence Based

Program 16 M51


B15 Procedure code billed is not correct

Procedure code billed is not correct/valid or the date of

service bill 16 N56


G29 Procedure Code Definition


included in the CPT 97 M51


G30 Procedure Code Guideline

This service code was denied because it is

inappropriately coded based 4 N657


H16 Procedure Code Inapp. for Age The age of the patient does not correlate with the

submitted procedure


H71 Procedure Code Inappropriately Coded This service was denied because it is inappropriately

coded based on


H91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more

appropriate


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

H91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more

appropriate

16 M81 CMS Coverage Policies

H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the

circumstances in

16 M81 National Correct Coding Manual Policy


circumstances in



circumstances in

16 M81 National Correct Coding Initiative Supplemental Policy


circumstances in

16 M81 CMS Coverage Policies


circumstances in

16 M81 CMS National Coverage Determinations (NCD) Policy

434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5AP Procedure code incorrect The procedure code submitted is not correct. 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H14 Procedure Code Incorrect For Gender The gender of the patient does not correlate with the

submitted


V78 Procedure code is age restricted

Members age is not within the coverage range for this

procedure code 6 N129


HMR Procedure code is missing or invalid

The Procedure code is missing or invalid at Time of

Service 16 M20


435 Procedure code not eligible for reimburs

The submitted procedure code is not eligible for

reimbursement. 181 N56


5AQ Procedure code not eligible for reimburs

The submitted procedure code is not eligible for

reimbursement. 16 M20


H13 Procedure Code Not Valid for DOS The submitted procedure code is no longer valid. Please

resubmit


550 Procedure does not require team surg Procedure does not require team surgery 54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G77 Procedure Included With E/M Service


included as part of 97 M15


G78 Procedure Invalid For Medicare Purpos

This health service code was recoded to a valid code for

Medicare. 16 M51


HM7 Procedure is Mutually Exclusive

Procedure is Mutually Ex. Not Poss.For both Proc.to

Occur at same time 231


H63 Procedure Recoded Based on Age The procedure code has been recoded based on the age

of the patient.


G73 Procedure Recoded To Delivery Only Se

This health service code was changed to reflect that the

provider did 169 N10


H83 Procedure Recoded To Delivery Only Servi

Code was changed to reflect that the provider did not

provide the 45 N22


HMJ Procedure should be bundled

Procedure should be bundled in an All Inclusive

Procedure 234 M15


436 Processed according to negotiated rate.

The claim has been processed according to a negotiated

rate. 45


5AR Processed according to negotiated rate.

The claim has been processed according to a negotiated

rate. 45


J55 Processin rules(OLH) incorr/ not updated R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V54 Processing rules(OLH) incorr/ not update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G74 Professional Component Not Payable Fo

This procedure was either billed as a professional

component or it was 16 N184


V64 Prov rec'd pymnt from pri/no reimb rec'd R129: Prior Processing Information Appears Incorrect 129 MA67


V40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R94 Prov#Submitted via EDI Incorrect/Ter Provider# Submitted EDI Incorrect/Termed 16 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X94 Prov#Submitted viaEDI Incorrect/Termd

Provider Number Submitted via EDI

Incorrect/Terminated 16 N77


G21 Provider Adjustment Provider Adjustment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EB1 Provider and Member not enrolled in Evid

Provider and Member not enrolled in Evidence Based

Program 272


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

438 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5AT Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

620 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

7AE Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZJ8 Provider Not Active in Facets Provider Not Active in Facets 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

439 Provider not certified for service The provider is not certified for the service provided. B7


EB2 Provider not enrolled in Evidence Based Provider not enrolled in Evidence Based Program 272


XB2 Provider on Payment Suspension Provider on Payment Suspension 133 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

9C2 Provider payment adjustment Copay extension, provider payment adjusted 45 N419 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

472 Provider terminated Billed after providers termination date with plan. B7


5BZ Provider terminated Billed after providers termination date with plan. 147


X77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209


HT5 Provider Type Billed Services

The Provider's Specialty Type has a limitation of service

codes 8 N95


HT4 Provider Type/Service not allowed

The Specialty of the provider performing this service is

not allowed 170 N95


HT6 Provider Type/Service Specialized

This Service Code can only be billed by Certain Provider

Types. 8 N95


R72 Provider was Not Member's PCP Provider was not the members PMP 242 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B43 Provider was not members PMP Provider was not the members PMP 184 N808 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R74 Pru Layperson Review Completed; Emer

Prudent Layperson Review Completed; Emergent rate

paid 16 N78


J67 Prudent lay review complete Prudent lay review complete 45 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

111 Prudent lay review completed;nonemerg Prudent lay review completed; nonemergent 40 N627 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

099 Prudent Layperson Rev Comp: Prudent Layperson Rev Comp: 1st Level Screening Paid 216 N115


096 Prudent Layperson Rev Comp 1st Level Prudent Layperson Rev Comp: 1st Level Screening Paid 150 N115


B44 Prudent Layperson Review Completed;E

Prudent Layperson Review Completed: Emergent rate

paid 216 N115


J60 Prvdr billed proc units > than allowed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V59 Prvdr billed proc units > than allowed. R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J34 Prvdr settlmt- settlmt adjustment R129:Settlement Adjustment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V32 Prvdr settlmt- settlmt adjustment R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M01 Pymt $150,000 or over may be audited

Any payment of $150,000 or over may be subject to

audit 133 N26


H33 Pymt Includes Svcs for Pre/Intra Op Each provider is reimbursed according to the portion of

surgical

B20 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EAO Pymt reflects COB for QMB Plus member

Payment reflects Coordination of Benefits for a QMB

Plus member 23


EA0 Pymt reflects COB for QMB Plus membr

Payment reflects Coordination of Benefits for QMB Plus

member 23


J82 Pymt reflects COB for QMB Plus membr

Payment reflects Coordination of Benefits for QMB Plus

member 23


R47 Pymt reflects COB, if $0, max liab me

Payment reflects Coordination of Benefits, if $0, max

liability met 23 N9


B60 Pymt reflects COB,if $0, max liab met

Payment reflects Coordination of Benefits, if $0, max

liability met 23 N23


HC6 Qty Exceeds Max - Specified Rolling(Deny

Per Plan Guidelines, the quantity maximum for specified

time period 119 N640


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

HC2 Qty Exceeds Max - Unspecified(Roll/Deny)

Per Plan guidelines, the Quantity Maximum for Specified



HC5 Qty Exceeds Max Specified Calendar(Deny)




HC4 Qty Exceeds Max -Specified Fiscal




HC3 Qty Exceeds Max- Unspecified




HC7 Qty Exceeds Max-Time Span Rule/One Day


time pd has 119 N640


B07 Quality Review Processing Quality Review Processing 133 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HC9 Quantity Invalid Quantity of service exceeds the payor specified limit 119 N640


HC8 Quantity Payor Specific Quantity of service exceeds the payor specified limit 119 N362


J39 RCA R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J41 RCC-use this code on Orig. claim R129: Revd Corrected Claim from Prvdr 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

9D1 Rebundled to current/historical claim

Adjustment-Current or added procedure has been

rebundled to a global 97 M15


R07 Received after Timely Filing Limit Received after Timely Filing Limit 29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H90 Recoded Procedure Code

The billed procedure was recoded to a more appropriate

procedure code 181 N22


H25 Recoded to Complete Procedure Code Based on the other procedures billed for this service

date, this code


G58 Recoded To The Least Costly Alternat

The procedure has been recoded to a procedure code

representing the le 189 N657


H75 Recoded to the least Costly Alternative The Procedure has been recoded to a procedure code 181 N22


G25 Recover Review Recovery Review 133 N421 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X58 RecoveryForwardedToState per Contract Recovery Forwarded to State per Contract Agreement 129 MA67


H23 Reduction for Ionic Contrast Media

When non-ionic contrast media is submitted a reduction

will be taken 97 M15


982 Reduction for multiple surgical proc Adjusted - reduction for multiple surgical procedures. 59 N10


XD7 Referring & Ordering not enrolled in Med

Referring and Ordering not enrolled in Medicaid

Program. 183 N767


XD5 Referring not enrolled in Medicaid Progr Referring not enrolled in Medicaid Program 183 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEE Referring NPI is not enrolled with state

Referring NPI is not enrolled with state as provider type

31-physician 16 N286


XEF Referring Provider NPI is a non-individu

Referring Provider NPI is a non-individual per NPPES

Registry 16 N286


EQ1 Reimbursement exceeds $50K resubmit with

Anticipated reimbursement exceeds $50K resubmit with

Itemized Bill 252 N26


M75 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z84 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

183 Rendering NPI not for Provider ID Box 31 Rendering NPI not for Provider ID in Box 31 208 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XEJ Rendering Prov does not have an active

Rendering Prov does not have an active license on claim

DOS B7 M143


XE5 Rendering prov not enrolled in Medicaid Rendering prov not enrolled in Medicaid Program 16 N290


ZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290


G37 Rental Cap Exceeded

The billed equipment was denied because the maximum

number of rentals 108 N370


H73 Rental Cap Exceeded The billed equipment was denied because the maximum

number


R62 Reprocessed - Claim Subject to Intere Reprocessed - Claim Subject to Interest 225 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

I28 Reprocessed-claim subject to interest Reprocessed-claim subject to interest 225 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B25 Req'd Prescrip. from MD not Attach/Va Required Prescription from MD not Valid/Attached 16 N31


X92 Req'dPrescrip. fromMDnot Attach/Valid Required Presciption from MD not Attached/Valid 175


4B1 Request info not recd from pvdr Requested information not received from provider 226 N517


R09 Requested Hosp Documents not Rec'd Requested Hospital Documents not Received 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4AT Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5DK Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZD3 Required Medicaid Elements Missing Required Medicaid Encounter Data Elements Missing 16 N350


HS8 Required Modifier Missing

This service was billed without the plan required

modifier 4 N519


XA8 Required Service not performed/reported Required Service not performed/reported 16 N149 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZA4 Restricted Member Auth Required Restricted Member Auth Required 243 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

182 Restricted Member-Auth Required Restricted Member-Auth Required 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I48 Resub Primary Carrier/Appeal Process Resubmit to Primary Carrier for Appeals Process 22 N36 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZA5 Resub Primary Carrier/Appeals Process Resubmit to Primary Carrier for appeals processing 22 N598


B16 Resub w/ ICD prin proc, HCPC or CPT

Resubmit with ICD9 pinciple procedure code or valid

HCPCS or CPT Code 16 M20


I69 Resub w/ICD prin proc, HCPC or CPT

Resubmit with ICD9 principle procedure code or valid

HCPCS or CPT Code 16 MA66


460 Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5BF Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

4AX Resubmit on ub04 Please resubmit these charges on a ub04 claim form. 16 N34


A85 Resubmit to Behavioral Health Contractor Resubmit to Behavioral Health Contractor 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZC7 Resubmit to MCNA

Dental Claims for members under 21 should be

submitted to MCNA 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZC7 Resubmit to MCNA

Dental Claims for members under 21 should be

submitted to MCNA 109


I37 Resubmit w/ Approp. Modifier and/or U Resubmit with Appropriate Modifier and/or Units 4 N517


I44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 181 N56


X44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 16 MA66


180 Resubmit w/Registered Billing Provider Resubmit w/Registered Billing Provider 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G50 Resubmit With Appropriate G Code

This health service code was denied because it was not

reported with t 16 M51


GB6 Resubmit with breakdown of pri ins pymt Resubmit with breakdown of primary ins payment 251 N480


575 Resubmit with Medicaid RID, Former PE Resubmit with Medicaid RID, Former PE 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B22 Resubmit with NDC# Resubmit with Valid NDC# 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G31 Resubmit With Supporting Documentati

Supporting documentation is needed in order to

adjudicate this claim. 151 N435


HA1 Resubmit with Supporting Documentation Resubmit with Supporting Documentation 16 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B34 Resubmit with visit codes & charges Resubmit with visit codes & charges 16 M49 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

Z48 ResubPrimaryCarrier/Appeals Process Resubmit to primary carrier for appeals processing 22 N598


R05 ResubtoPassport Advantage(primary)

Please submit to Passport Advantage (primary carrier)

for processing 109 N130


J30 Retro Benefit change former PE Mbr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G26 Retro benefit Change Former PE Memb Retro Benefit change-Former Presumptive Eligibility 96 N30


V29 Retro Benefit change former PE member R129:Work Comp is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

984 Retro change to the provider's contract Adjusted - retroactive change to the provider's contract. 45 N419


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

J09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J38 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V37 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M96 Retro Review/Continued Stay Project Retro Review and Continued Stay Project 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G82 Return To OR Payment Adjustment

This health service code was adjusted to reflect that the

billed servi 172


HMV Rev Code cannot be billed w othr Rev Cod

Revenue Code cannot be billed with other billed

Revenue Code 16 M50


HMT Rev Code requires a Procedure Code This Revenue Code Requires a Procedure Code 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

444 Revenue code requires CPT/HCPCS code

The revenue code submitted requires a CPT/HCPCS

code. 16 M51


925 Reviewed v no additional payment made Reviewed v no additional payment made 193 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J56 RHC(Rural Health Center) not applied R129:RHC (Rural Health Center) Not App. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

EQ2 Rmbrsmnt amnt determined by Equian Reimbursement amount determined by Equian 45 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZPC Same day dschrg, rsbmt as optnt Same day discharge, resubmit as outpatient 152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J44 Same proc. pd to different prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V43 Same Proc. Pd to different Prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B20 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B13 N472 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure

code has been



code has been



code has been



code has been


J22 Secondary coverage listed,no EOB on file R129:Secondary EOB req 16 MA64 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H81 Secondary Diagnosis Missing Or Invalid This health service code was denied because a required

secondary

16 M76 CMS National Coverage Determinations (NCD) Policy

V21 Secondary ins listed, no EOB on file R129:Illegible/incomplete EOB Attached 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M02 Send itemized bill to MDHA Send itemized bill to: MDHA 5604 Fortune Circle S, 133 N26


G85 Separate Payment For Services Not Pro

The billed services were denied because services on the

Separate Payme 97 M15


G56 Separate Procedures Not Separately Pa This procedure was denied because procedures

designated as inpatient o


G84 Service Denied Because Of Potential I

The drug was denied because another drug was billed

recently that coul 18 N702


B47 Service Exceeds Lifetime Limitation Service Exceeds Lifetime Limitation 149 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R51 Service Not Covered Service Not Covered 96 N30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X51 Service Not Covered Services Not Covered 96 N30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

GB7 Service not in Provider's Profile Service not in Provider's Profile B7 N570 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

449 Service not payable in this specialty The service provided is not payable in this specialty. B7 N95


R04 Service Not payable with other serv

Service not payable with other service rendered on the

same date 97 M15


5B5 Service performed by another provider

The service submitted was performed by another

provider. B20


G35 Service Processed As A Bilateral Pro

This health service code was adjusted to reflect the

allowed amount fo 59 N644


451 Service rendered by ineligible provider The service rendered was by an ineligible provider. B7


4BN Service was adjusted due to fee schedule Service was adjusted due to fee schedule update 169 N10


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

RA4 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15


RA5 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15


906 Services after policy expiration date

Adjusted - expenses incurred after coverage

termination. 27


R76 Services Denied Telephonically Services Denied Telephonically at Time of Service 39


483 Services disallowed by UM Services were disallowed by Utilization Management. 96 N35


5CD Services disallowed by UM Services were disallowed by Utilization Management. 96 N35


9A5 Services included in primary procedure Adjusted - services included in primary procedure. 97 N19


988 Services not authorized Adjusted - required authorization was not obtained. 16 M62


9C9 Services not authorized Adjusted - required authorization was not obtained. 197


929 Services not cov'rd per benefit package Adjusted - services are not covered per benefit package. 204 N130


B31 Services not medically necessary Services not medically necessary 50 N372 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

B57 Services not medically necessary Services not medically necessary 50 N661 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

990 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

9A7 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

991 Services performed by another provider Adjusted - services performed by another provider. B20


9C5 Services performed by another provider Services performed by another provider B20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

909 Services prior to policy effective date

Adjusted - expenses incurred before coverage effective

date. 26


930 Services prior to policy effective date

Adjusted - expenses incurred before coverage effective

date. 26


179 Services to be paid on separate remit Services to be paid on separate remit B11 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R53 Services were not Provided Services were not Provided 112 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X53 Services were not Provided Services were not Provided 16 N99 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270


ZI3 Servicing Provider Taxonomy not match

Servicing Provider Taxonomy does not match with the

Taxonomy on file 16 N94 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZI3 Servicing Provider Taxonomy not match

Servicing Provider Taxonomy does not match with the

Taxonomy on file 16 N94


ZI4 Servicing Provider Taxonomy not present

Servicing Provider Taxonomy not present on Submitted

Claim 16 N94 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZI4 Servicing Provider Taxonomy not present

Servicing Provider Taxonomy not present on Submitted

Claim 16 N94


G59 Site Of Service Differential

The payment for this procedure was reduced because it

was performed at 5 M77


ZG0 SIU Adjustment SIU Adjustment-Program Integrity 216 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZG1 SIU Overpayment Settlement SIU Overpayment Settlement-Program Integrity 216 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

080 SIU Settlement Adjustment

Settlement Adjustment/no change in outcome-Program

Integrity 216 N35


ZG2 SIU Settlement Adjustment

Settlement Adjustment/no change in outcome-Program

Integrity 216 N35


HMP Spec Billed Serv Code combo not payable

Based on NCCI, the Specific billed service code combo is

not payable. 236


R79 Special Project-Adjustment Special Project-Adjustment 45 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X79 Special Project-Adjustment Special Project-Adjustment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSR State Code Combination

Per State Regulations the specific Billed Service code

Combination is 199 N657


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

HSS State Code Combination - Hospital

Hospital Outpatient - Per State Regulations the specfic

billed service 199 N657


J32 State Encounter error received R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V30 State Encounter error received R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

XA4 Sub. itemized bill does not match UB/CMS

Submitted itemized bill does not match UB/CMS Please

resubmit 16 N232


BEH Submit claim to Magellan Behav Healt Submit claim to Magellan Behavioral Health 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZZA Submit Consent Form Submit Consent Form 252 N3 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

454 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5B9 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5B7 Submit original billed amount Please submit claim with the original billed amount. 16 M54


XEI Supervising provider not enrolled in Med Supervising provider not enrolled in Medicaid Program 16 N253


ZZ1 Supporting documentation missing/invalid

Speciifc documentation required for payment is missing

/illegible/dupl 252 N729


ZZ2 Supporting documentation missing/invalid

Speciifc documentation required for payment is missing

/illegible/dupl 252 N729


482 Supporting documentation required Supporting documentation required 16 N29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5CC Supporting documentation required Supporting documentation or medical records required 252 M127


H94 Surg & Asst Surg Can't Be The Same This code can not be paid as a Surgical assist when the

same provider


HM5 Surgical Proc Rptd after E&M Payment

Surgical Proc Rptd after pymt of E&M. E&M Svs are

Between The Global 97 M15


HM6 Surgical Proc Rptd after E&M Payment

Surg. Proc Rptd after pymt of E&M. Svs. E&M Svs is

between the Global. 97 M15


640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130


7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130


932 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130


993 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130


9B0 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130


V74 T1015 cant be billed for your prv type T1015 cant be billed for your provider type 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V73 T1015 must be billed for your prv type T1015 must be billed for your prv type 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSV Team Surgeons not allowed Team Surgeons not allowed for this procedure 54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

H54 Technical Service Not Payable for POS This procedure is billed as a technical component and is

not payable


G87 Technical/ Professional Service Inapp

The technical and professsional components of the

procedure were inapp 16 N184


G86 Terminated Procedure Cannot Be Billed

The procedure was denied because, it is inappropriate

to bill a proced 181 N56


G62 The Service Code Is Inconsistent With

This health service code was either denied or modified

because it is n 4 M20


HMM This is a Bilateral Code

This is a Bilat code. Modifier LT, RT, 50 or Qty 2 not

applicable. 4 N519


HMF This Procedure is an Add On Code

This Procedure is an Add on Code and must be billed

with the 234 N122


HMG This Procedure is an Add On Code

This Procedure is an Add On Code and must be billed

with the 234 N122


As of 5/18/2020


Explanation


Claim Adjustment

Reason Code

Remittance Advice

Reason Code Source

HMS This Revenue code is invalid This Revenue code is invalid 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

I81 Time not Validated on Medical Record Time not Validated on Medical Records B12 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

HSU Time of Filing - 1 year

Date of Procedure in Excess of 1 year prior to receipt of

claim 29


J10 Timely filing inappr or paid incorr. R129:Timely Filing Incorrectly Applied 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

M98 Total Amt Still Under Consideration Total Billed Amount Still Under Consideration 133 N372 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V62 TPL identified by PCG R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J23 TPL information input incorrectly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V61 TPL information input incorrectly R129: Prior Processing Information Appears Incorrect 129 N48


V24 TPL received/updated after clm proces'd R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J25 TPL received/updated after clm processed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

R17 Under Review for COB processing Under Review for COB processing 133 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

0UN Ungroupable DRG

Claim data is missing, incomplete or invalid. No DRG

found. A8 N208


H30 Units Adjusted Exceeds Allowed Amt

The units for the billed procedure code have been

adjusted to reflect 151 CMS National Coverage Determinations (NCD) Policy

H30 Units Adjusted Exceeds Allowed Amt

The units for the billed procedure code have been

adjusted to reflect 152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

655 Units exceed UM authorization Units exceed a utilization management authorization 222


7B7 Units exceed UM authorization Units exceed a utilization management authorization 222 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

7B7 Units exceed UM authorization Units exceed a utilization management authorization 222


ZB9 Units reduced by NIA authorization Units reduced by NIA authorization 39 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

658 Unlisted procedure code

The submitted code is disallowed because the

procedure code is 189 N657


659 Unlisted procedure code

The submitted code is disallowed because the

procedure code is 189 N657


G15 Valid EOB on File Valid EOB on File 23 M32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

G14 Valid Referral/Authorization on File Reprocessed Claim-Valid Referral/Authorization 198 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

ZH7 VBP Payment-FBMH

Value Based Purchasing Payment-Family Based Mental

Health 144 N422


ZH8 VBP Payment-FBMH

Value Based Purchasing Payment-Family Based Mental

Health 144 N422


HMW Verfiy Benefits and Elig

Verfiy Benefits and Eligibility for Services Provided in a

State 58


9E1 Void/cancel of prior claim Adjusted - void/cancel of prior claim 16 N798 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J29 Workers Comp is Primary R129:Work Comp is Primary 19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

V28 Workers Comp is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

X13 Workers Comp Primary Carrier Workers Compensation Primary Carrier 19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

5C3 Wrong CPT-modifier combo Inappropriate procedure-modifier combination 4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

J08 Wrong info received from state R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations

As of 5/18/2020

Explanation Claim Adjustment Remittance Advice Code Short ... · Explanation of Benefits (EOB)...

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