Medical Claim Denial Codes
A complete reference guide to the most common insurance claim denial codes. Each entry explains what the code means, why it's triggered, how to appeal it, and how to prevent it from happening again.
84
Denial Codes Covered
54%
Of Denials Overturned on Appeal
<1%
Of Denials Are Appealed
60s
RediClaim Appeal Generation
Contractual Obligation (CO)
Adjustments that are the provider's responsibility due to contractual agreements with the payer.
Procedure Code Inconsistent with Modifier
The procedure code is inconsistent with the modifier used, or a required modifier is missing.
Diagnosis Inconsistent with Procedure
The diagnosis is inconsistent with the procedure. This means the ICD-10 code submitted does not support the medical necessity of the CPT procedure billed.
Missing or Invalid Authorization
The submitted authorization number is missing, incomplete, or invalid. The service required prior authorization that was not obtained or was not properly documented on the claim.
Missing or Incorrect Information
Claim/service lacks information or has submission/billing error(s) needed for adjudication. This is one of the broadest and most common denial codes, covering a wide range of missing or incorrect data.
Duplicate Claim or Service
Exact duplicate claim/service. The payer has identified this claim as a duplicate of a previously submitted and processed claim.
Coordination of Benefits
This care may be covered by another payer per coordination of benefits. The payer believes another insurance should be primary.
Capitation Agreement Applies
Charges are covered under a capitation agreement or managed care plan. The service is included in the capitated payment the provider already receives.
Expenses Incurred Prior to Coverage
Expenses incurred prior to coverage. The date of service is before the patient's coverage effective date with this payer.
Expenses After Coverage Terminated
Expenses incurred after coverage terminated. The date of service is after the patient's coverage end date with this payer.
Timely Filing Limit Exceeded
The time limit for filing has expired. The claim was not submitted within the payer's timely filing deadline.
Patient Not Identified as Insured
Patient cannot be identified as our insured. The payer cannot locate the patient in their system based on the submitted information.
Lifetime Benefit Maximum Reached
Lifetime benefit maximum has been reached. The patient has exhausted their lifetime benefit allowance for this service or benefit category.
Authorization Request Denied
Services denied at the time authorization/pre-certification was requested. The payer denied the prior authorization request for this service.
Not Qualified as Emergent/Urgent
Charges do not meet qualifications for emergent/urgent care. The payer has determined that the services do not qualify as emergency or urgent care.
Charges Exceed Fee Schedule
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. The billed amount is higher than what the payer allows for this service.
Not Medically Necessary
These are non-covered services because they are not deemed medically necessary. The payer has determined that the submitted clinical information does not establish medical necessity for the billed service.
Experimental or Investigational
Procedure, treatment, or drug is deemed experimental or investigational by the payer. The service is not covered because the payer considers it unproven or not yet accepted as standard practice.
Non-Covered Charges
Non-covered charge(s). At least one remark code must be provided to explain why the charge is not covered.
Service Included in Another (Bundling)
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This is a bundling denial.
Claim Not Covered by This Payer
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Benefit Maximum for Period Reached
Benefit maximum for this time period or occurrence has been reached. The patient has used their full benefit allowance for this service category within the current benefit period.
Submission or Billing Error
Submission/billing error(s). The claim contains one or more errors that prevent proper adjudication.
Prior Processing Information Incorrect
Prior processing information appears incorrect. The payer's records from a previous adjudication or processing cycle contain information that conflicts with the current submission.
Claim Submission Fee
Claim submission fee. This adjustment represents a fee charged by the payer for processing the claim submission.
Claim Specific Negotiated Discount
Claim specific negotiated discount. This adjustment reflects a negotiated discount applied to this specific claim.
Service Pending Further Review
The disposition of this service line is pending further review. The payer has not made a final determination and the claim is still under review.
Failure to Follow Prior Payer Rules
Failure to follow prior payer's coverage rules. The provider did not comply with the primary payer's coverage requirements, affecting the secondary payer's adjudication.
Patient ID and Name Mismatch
Patient/Insured health identification number and name do not match. The payer's records show a different name for the submitted member ID, or vice versa.
Diagnosis Invalid for Date of Service
Diagnosis was invalid for the date(s) of service reported. The ICD-10 code used was not effective or was terminated on the date the service was rendered.
Lifetime Maximum for Service Reached
Lifetime benefit maximum has been reached for this service or benefit category. The patient has used their full lifetime allowance for this specific type of service.
Frequency or Units Exceeds Limit
Payment adjusted because the payer deems the information submitted does not support this many services or this frequency of services. The number of units or frequency of the service exceeds what the payer considers appropriate.
Diagnosis Not Covered
This/these diagnosis(es) is/are not covered. The payer does not provide coverage for the submitted diagnosis code.
Alternate Benefit Provided
Alternate benefit has been provided. The payer has applied payment for a different or substitute service rather than the one billed.
Payment Denied for Provider Type
Payment is denied when performed/billed by this type of provider. The payer does not cover this service when rendered by the billing provider's specialty or credential type.
Denied for Provider Type in Facility
Payment is denied when performed/billed by this type of provider in this type of facility. The combination of provider type and facility setting is not covered.
Eligibility Requirements Not Met
Patient has not met the required eligibility requirements. The patient does not meet the payer's criteria for coverage eligibility.
Spend Down Requirements Not Met
Patient has not met the required spend down requirements. The patient's income-based spend down obligation has not been satisfied for the coverage period.
Waiting Requirements Not Met
Patient has not met the required waiting requirements. A mandatory waiting period must be satisfied before coverage applies for this service.
Procedure Code Invalid on Date of Service
Procedure code was invalid on the date of service. The CPT or HCPCS code used was not effective or had been terminated on the date the service was performed.
Procedure Modifier Invalid on Date of Service
Procedure modifier was invalid on the date of service. The modifier appended to the procedure code was not effective or recognized on the date the service was rendered.
Referring Provider Not Eligible to Refer
The referring provider is not eligible to refer the service billed. The payer has determined that the referring provider does not have the credentials or authorization to make referrals for this service.
Consumer Spending Account Payment
Consumer Spending Account payments, including Flexible Spending Account (FSA), Health Savings Account (HSA), and Health Reimbursement Arrangement (HRA). This adjustment reflects a payment made from the patient's consumer spending account.
Non-Standard Adjustment from Paper Remittance
Non-standard adjustment code from paper remittance. This is a non-standard adjustment that was communicated via a paper remittance advice and does not map to a standard CARC code.
Original Payment Decision Maintained
Original payment decision is being maintained. Upon review, the payer has determined that the original claim was processed properly and the payment decision stands.
Anesthesia by Operating/Attending Physician
Anesthesia performed by the operating physician, the assistant surgeon, or the attending physician. Payment is adjusted because the anesthesia was provided by the surgeon or attending rather than a separate anesthesiologist.
Precertification/Authorization/Notification Absent
Precertification, authorization, and/or notification was absent. Required approval was not obtained before the service was rendered.
Authorization Exceeded
Precertification, notification, authorization, or pre-treatment number of services or period of time exceeded. The services rendered went beyond what was approved in the authorization.
Revenue Code and Procedure Code Mismatch
Revenue code and procedure code do not match. The revenue code submitted on the institutional claim is not compatible with the procedure code billed.
Service Not Covered Under Patient Plan
This service/equipment/drug is not covered under the patient's current benefit plan.
National Provider Identifier Missing
National Provider Identifier (NPI) is missing. The claim does not include a required NPI for the billing, rendering, referring, or ordering provider.
National Provider Identifier Not Matched
National Provider Identifier (NPI) is not matched. The NPI submitted does not match the payer's records for the provider or entity.
Regulatory Agreement Adjustment
Per regulatory or other agreement, the provider cannot collect this amount from the patient. This adjustment reflects an amount the provider is contractually or legally prohibited from billing to the patient.
Late Precertification/Authorization
Payment adjusted because precertification/authorization was not received in a timely fashion. The required authorization or notification was obtained but not within the payer's required timeframe.
NDC Not Covered
National Drug Codes (NDC) not eligible for rebate, are not covered, or are otherwise invalid. The drug identified by the submitted NDC is not covered by the payer.
Based on Extent of Injury
Based on extent of injury. The payment or denial is determined by the documented extent or severity of the injury.
Provider Information Not Provided Timely
Information requested from the billing/rendering provider was not provided or was not provided in a timely manner. The payer requested additional information from the provider but did not receive it within the required timeframe.
Patient Information Not Provided
Information requested from the patient/insured/responsible party was not provided or was insufficient. The payer requested information from the patient that was not received.
Procedure Not Paid Separately (234)
This procedure is not paid separately. The service is considered included in another service or payment and does not qualify for separate reimbursement.
Procedure Not Paid Separately
This procedure or procedure/modifier combination is not paid separately. The service is considered incidental to or included in another procedure.
Legislated/Regulatory Penalty
Legislated/Regulatory Penalty. This adjustment reflects a payment reduction mandated by legislation or regulation as a penalty.
Claim Spans Ineligible Coverage Period
Claim spans eligible and ineligible periods of coverage. This is the reduction for the ineligible period. The claim includes dates of service when the patient was not covered.
Diagnosis Inconsistent with Birth Weight
The diagnosis is inconsistent with the patient's birth weight. The ICD-10 code submitted is not compatible with the documented birth weight for neonatal claims.
Services Not Provided by Network Provider
Services/procedures not provided by network/primary care providers.
Services Not Authorized by Network/PCP
Services not authorized by network/primary care providers. The required referral or authorization from the patient's network or primary care provider was not obtained.
Non-Payable Reporting Code
This non-payable code is for required reporting only. The code is used for tracking and reporting purposes and does not generate separate payment.
Institutional Setting Professional Deductible
Deductible for professional service rendered in an institutional setting and billed on an institutional claim. This adjustment applies the deductible to professional charges submitted on an institutional claim form.
Incorrect Attachment/Documentation Received
The attachment/other documentation that was received was the incorrect attachment/document. The payer received documentation but it was not the documentation that was requested.
Additional Documentation Required
An attachment/other documentation is required to adjudicate this claim/service. The payer needs additional information before processing.
Sequestration Reduction
Sequestration - reduction in federal payment. This adjustment reflects the mandatory across-the-board reduction in Medicare Fee-for-Service payments required by federal sequestration law.
Dental Plan Benefits Not Available
Claim received by the dental plan, but benefits are not available under this plan. The dental plan acknowledges receipt of the claim but the service is not covered.
Property & Casualty Claim Pending Litigation
The disposition of the related Property & Casualty claim is pending due to litigation. Payment is held because the associated liability or P&C claim is in litigation.
Not Payable Per Managed Care Contract
Service not payable per managed care contract. The payer has determined that this service is not reimbursable under the terms of the managed care contract.
Patient Responsibility (PR)
Amounts that are the patient's responsibility, including deductibles, copays, and coinsurance.
Deductible Amount
Deductible amount. The patient is responsible for this portion of the charges as part of their plan deductible.
Coinsurance Amount
Coinsurance amount. The patient is responsible for this percentage of the allowed amount as their coinsurance.
Co-payment Amount
Co-payment amount. The patient is responsible for this fixed dollar amount as their co-pay for the service.
Non-Covered Charges (Patient Responsibility)
Non-covered charge(s). The patient is responsible for these charges because the service is not covered under their benefit plan.
Not Covered Under Patient Plan (Patient Liable)
This service/equipment/drug is not covered under the patient's current benefit plan, and the patient is responsible for payment.
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