Reason codes
The codes payers use to explain every adjustment. The meanings here are plain-language summaries written for this product, not the official code text. The official lists are maintained by X12 and change several times a year, so check the current list before an appeal.
Claim adjustment reason codes
28 codes seen most often in physician billing
| Code | Meaning | Kind | Usual next step |
|---|---|---|---|
| 1 Deductible | The amount the patient owes toward their annual deductible. | Expected reduction Patient share | Bill the patient. Bill the patient for the deductible amount shown. |
| 2 Coinsurance | The patient percentage share of the allowed amount. | Expected reduction Patient share | Bill the patient. Bill the patient for the coinsurance amount shown. |
| 3 Copay | The fixed copay the patient owes for the visit. | Expected reduction Patient share | Bill the patient. Collect the copay if it was not collected at check in. |
| 4 Modifier does not fit the code | The procedure code does not agree with the modifier billed, or a required modifier is missing. | Denial Coding error | Send a corrected claim. Fix the modifier and send a corrected claim. |
| 11 Diagnosis does not support the procedure | The diagnosis on the claim does not support the service billed. | Denial Coding error | Send a corrected claim. Check the diagnosis pointers against the note, correct and resubmit. |
| 16 Missing or invalid information | The claim is missing information or has a billing error. A remark code usually says which field. | Denial Missing or invalid information | Send a corrected claim. Read the remark code, fix the field it names, and resubmit. |
| 18 Exact duplicate | The payer already received this exact claim or service. | Denial Duplicate | No action needed. Confirm the original claim was paid. If it was, no action is needed. |
| 22 Another payer may be primary | Coordination of benefits: the payer believes another plan should pay first. | Denial Another payer is responsible | Bill the correct payer. Update coverage order with the patient and bill the primary plan. |
| 23 Prior payer already paid | The amount reflects what an earlier payer already paid or allowed. | Expected reduction Another payer is responsible | No action needed. Expected on secondary claims. No action unless the math is wrong. |
| 26 Before coverage started | The service date is before the patient coverage began. | Denial Eligibility | Bill the correct payer. Verify eligibility for the service date and bill the plan that covered it. The patient can be billed only when the payer sends it as patient responsibility (group PR). |
| 27 After coverage ended | The service date is after the patient coverage ended. | Denial Eligibility | Bill the correct payer. Verify eligibility for the service date and bill the plan that covered it. The patient can be billed only when the payer sends it as patient responsibility (group PR). |
| 29 Filing deadline passed | The claim reached the payer after its timely filing limit. | Denial Filed too late | Appeal. Appeal only with proof of timely submission; otherwise write it off. It cannot be billed to the patient. |
| 31 Patient not identified as a member | The payer could not match the patient to one of its members. | Denial Eligibility | Send a corrected claim. Check the member ID and name against the insurance card and resubmit. |
| 45 Above the contracted rate | The charge is higher than the fee schedule or contracted amount. The difference is written off. | Expected reduction Contract rate | No action needed. Expected. Only a problem if the allowed amount is below your contract rate. |
| 50 Not medically necessary | The payer decided the service was not medically necessary. | Denial Medical necessity | Appeal. Appeal with the visit note and any supporting records. |
| 59 Multiple procedure reduction | Reduced under multiple or concurrent procedure rules. | Expected reduction Bundled into another service | No action needed. Usually expected. Check the reduction matches the contract. |
| 96 Non-covered charge | The service is not covered. A remark code usually says why. | Denial Not covered by the plan | Bill the patient. Bill the patient only if they signed a waiver or the plan allows it; otherwise write off. |
| 97 Bundled into another service | Payment for this service is included in another service on the same day. | Denial Bundled into another service | Send a corrected claim. If the service was separate and distinct, add the right modifier and send a corrected claim. |
| 109 Wrong payer | This payer does not cover the claim. Send it to the correct payer. | Denial Another payer is responsible | Bill the correct payer. Find the correct payer for this patient and bill them. |
| 119 Benefit maximum reached | The patient has used the maximum benefit for this period. | Denial Not covered by the plan | Bill the patient. Bill the patient or a secondary plan. |
| 151 More services than the payer allows | The payer says the information does not support this many services or this frequency. | Denial Frequency or quantity limit | Appeal. Appeal with documentation supporting the number of services. |
| 170 Wrong provider type | The payer does not pay this service when billed by this type of provider. | Denial Provider not eligible | Write off. Check which provider type may bill it. Usually written off. |
| 181 Code not valid on that date | The procedure code was not valid on the date of service. | Denial Coding error | Send a corrected claim. Replace the code with one valid for the service date and resubmit. |
| 185 Rendering provider not eligible | The rendering provider is not eligible to perform the service billed. | Denial Provider not eligible | Appeal. Check the provider enrollment with this payer. A credentialing gap is the usual cause. |
| 197 Prior authorization missing | Authorization or notification was required and not on file. | Denial Prior authorization | Appeal. If authorization was obtained, appeal with the number. If not, write off; it cannot be billed to the patient. |
| 204 Not covered by this plan | The service is not covered under the patient current benefit plan. | Denial Not covered by the plan | Bill the patient. Bill the patient if they were told in advance; otherwise write off. |
| 242 Out of network | The service was not provided by a network provider. | Denial Provider not eligible | Appeal. Check the provider network status for this plan and appeal if they are in network. |
| 253 Sequestration | The federal sequestration reduction (currently 2 percent) on Medicare and Medicare Advantage payments. | Expected reduction Contract rate | No action needed. Expected on Medicare business. Not an underpayment. |
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Group codes
Who carries the adjustment.
| CO | Contractual obligation. The practice absorbs this amount under its contract or the payer rules. It may not be billed to the patient. |
| PR | Patient responsibility. The patient owes this amount (deductible, coinsurance, copay or a non-covered service the patient agreed to). |
| OA | Other adjustment. An adjustment that is neither the practice nor the patient liability, often tied to another payer. |
| PI | Payer initiated reduction. The payer reduced the payment on its own judgment. It is not the patient liability, and the practice can dispute it. |
| CR | Correction or reversal. A correction to an earlier claim. Older files use this group; current files use CO, PR, OA or PI. |
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Claim status codes
How the payer processed the claim.
| 1 | Processed as primary |
| 2 | Processed as secondary |
| 3 | Processed as tertiary |
| 4 | Denied |
| 19 | Processed as primary, forwarded to another payer |
| 20 | Processed as secondary, forwarded to another payer |
| 21 | Processed as tertiary, forwarded to another payer |
| 22 | Reversal of a previous payment |
| 23 | Not our claim, forwarded to another payer |
| 25 | Predetermination only, not paid |
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Provider adjustment codes
Provider adjustments change the whole payment, not one claim: WO is money the payer takes back for an earlier overpayment, and L6 is interest the payer adds for paying late.
| 50 | Late charge |
| 72 | Authorized return (money the practice sent back) |
| CS | Adjustment (see the reference for detail) |
| FB | Forwarding balance (carried from or to another payment) |
| J1 | Non reimbursable |
| L6 | Interest owed to the practice |
| WO | Overpayment recovery (money taken back) |
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Remark codes in the demo
Remark codes add detail to a reason code.
| M15 | Separately billed services were bundled as parts of the same procedure. |
| MA130 | The claim was incomplete or invalid and has no appeal rights. Submit a new, corrected claim. |
| N130 | Check the plan benefit documents for restrictions on this service. |
| N290 | The rendering provider identifier was missing or invalid. |
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