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Most Common Medicare Remarks

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U.S. Department of Health and Human ServicesA Remark Code is used to explain how the insurance company processed a claim. The Next Steps offers advice on what a member should do when dealing with specific codes.

Code

Description

PR1 Deductible Amount
PR2 Coinsurance Amount
PR3 Co-payment Amount
OA4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
OA5 The procedure code/bill type is inconsistent with the place of service.
OA6 The procedure/revenue code is inconsistent with the patient's age.
OA7 The procedure/revenue code is inconsistent with the patient's gender.
OA8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
OA9 The diagnosis is inconsistent with the patient's age.
OA10 The diagnosis is inconsistent with the patient's gender.
OA11 The diagnosis is inconsistent with the procedure.
OA12 The diagnosis is inconsistent with the provider type.
OA13 The date of death precedes the date of service.
OA14 The date of birth follows the date of service.
CO15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
OA16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI17 Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
OA18 Duplicate claim/service.
OA19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
OA20 Claim denied because this injury/illness is covered by the liability carrier.
OA21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CO22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
PI23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments
CO24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR25 Payment denied. Your Stop loss deductible has not been met.
PR26 Expenses incurred prior to coverage.
PR27 Expenses incurred after coverage terminated.
CO29 The time limit for filing has expired.
PR31 Claim denied as patient cannot be identified as our insured.
PR32 Our records indicate that this dependent is not an eligible dependent as defined.
PR33 Claim denied. Insured has no dependent coverage.
PR34 Claim denied. Insured has no coverage for newborns.
PR35 Lifetime benefit maximum has been reached.
CO38 Services not provided or authorized by designated (network/primary care) providers.
CO39 Services denied at the time authorization/pre-certification was requested.
OA40 Charges do not meet qualifications for emergent/urgent care.
OA44 Prompt-pay discount.
CO45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
CO49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.
CO51 These are non-covered services because this is a pre-existing condition
OA53 Services by an immediate relative or a member of the same household are not covered.
CO54 Multiple physicians/assistants are not covered in this case .
CO55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO56 Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by the payer.
CO58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
OA59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)
CO60 Charges for outpatient services with this proximity to inpatient services are not covered.
OA61 Charges adjusted as penalty for failure to obtain second surgical opinion.
CO66 Blood Deductible.
CO69 Day outlier amount.
CO70 Cost outlier - Adjustment to compensate for additional costs.
OA74 Indirect Medical Education Adjustment.
OA75 Direct Medical Education Adjustment.
CO76 Disproportionate Share Adjustment.
CO78 Non-Covered days/Room charge adjustment.
PR85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)
OA87 Transfer amount.
CO89 Professional fees removed from charges.
OA90 Ingredient cost adjustment.
CO91 Dispensing fee adjustment.
CO94 Processed in Excess of charges.
OA95 Benefits adjusted. Plan procedures not followed.
CO96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
OA100 Payment made to patient/insured/responsible party.
CO101 Predetermination: anticipated payment upon completion of services or claim adjudication.
CO102 Major Medical Adjustment.
CO103 Provider promotional discount (e.g., Senior citizen discount).
OA104 Managed care withholding.
OA105 Tax withholding.
OA106 Patient payment option/election not in effect.
CO107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PI108 Payment adjusted because rent/purchase guidelines were not met.
OA109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO110 Billing date predates service date.
CO111 Not covered unless the provider accepts assignment.
PI112 Payment adjusted as not furnished directly to the patient and/or not documented.
CO114 Procedure/product not approved by the Food and Drug Administration.
PI115 Payment adjusted as procedure postponed or canceled. This change effective 1/1/2008: Payment adjusted as procedure postponed, canceled, or delayed.
OA116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
CO117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
OA118 Charges reduced for ESRD network support.
CO119 Benefit maximum for this time period or occurrence has been reached.
OA121 Indemnification adjustment.
OA122 Psychiatric reduction.
CO125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PR126 Deductible -- Major Medical
PR127 Coinsurance -- Major Medical
CO128 Newborn's services are covered in the mother's Allowance.
CR129 Payment denied - Prior processing information appears incorrect.
OA130 Claim submission fee.
OA131 Claim specific negotiated discount.
OA132 Prearranged demonstration project adjustment.
OA133 The disposition of this claim/service is pending further review.
OA134 Technical fees removed from charges.
CO135 Claim denied. Interim bills cannot be processed.
OA136 Claim adjusted based on failure to follow prior payer's coverage rules. (Use Group Code OA).
OA137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
CO138 Claim/service denied. Appeal procedures not followed or time limits not met.
CO139 Contracted funding agreement - Subscriber is employed by the provider of services.
PR140 Patient/Insured health identification number and name do not match.
OA141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
CR142 Claim adjusted by the monthly Medicaid patient liability amount.
OA143 Portion of payment deferred.
CR144 Incentive adjustment, e.g. preferred product/service.
PI145 Premium payment withholding
CO146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
OA147 Provider contracted/negotiated rate expired or not on file.
OA148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
PR149 Lifetime benefit maximum has been reached for this service/benefit category.
PI150 Payment adjusted because the payer deems the information submitted does not support this level of service.
PI151 Payment adjusted because the payer deems the information submitted does not support this many services.
PI152 Payment adjusted because the payer deems the information submitted does not support this length of service.
PI153 Payment adjusted because the payer deems the information submitted does not support this dosage.
PI154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
OA155 This claim is denied because the patient refused the service/procedure.
OA156 Flexible spending account payments
CO157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
CO158 Payment denied/reduced because the service/procedure was provided outside of the United States.
CO159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
CO160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
OA161 Provider performance bonus
CO162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
CR163 Claim/Service adjusted because the attachment referenced on the claim was not received.
CR164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
CO165 Payment denied /reduced for absence of, or exceeded referral
PR166 These services were submitted after this payers responsibility for processing claims under this plan ended.
CO167 This (these) diagnosis(es) is (are) not covered.
PR168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan
PI169 Payment adjusted because an alternate benefit has been provided
CO170 Payment is denied when performed/billed by this type of provider.
CO171 Payment is denied when performed/billed by this type of provider in this type of facility.
CO172 Payment is adjusted when performed/billed by a provider of this specialty
CR173 Payment adjusted because this service was not prescribed by a physician
CO174 Payment denied because this service was not prescribed prior to delivery
CO175 Payment denied because the prescription is incomplete
CO176 Payment denied because the prescription is not current
PR177 Payment denied because the patient has not met the required eligibility requirements
CR178 Payment adjusted because the patient has not met the required spend down requirements.
CR179 Payment adjusted because the patient has not met the required waiting requirements
CR180 Payment adjusted because the patient has not met the required residency requirements
CR181 Payment adjusted because this procedure code was invalid on the date of service
CR182 Payment adjusted because the procedure modifier was invalid on the date of service
CO183 The referring provider is not eligible to refer the service billed.
CO184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
CO185 The rendering provider is not eligible to perform the service billed.
OA186 Payment adjusted since the level of care changed
OA187 Health Savings account payments
CO188 This product/procedure is only covered when used according to FDA recommendations.
OA189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
CO190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
CO191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers' compensation carrier.
OA192 Non standard adjustment code from paper remittance advice.
CO193 Original payment decision is being maintained. This claim was processed properly the first time.
PI194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician
PI195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service
PI197 Payment adjusted for absence of precertification/authorization. This change effective 1/1/2008: Payment adjusted for absence of precertification/authorization/notification.
PI198 Payment Adjusted for exceeding precertification/ authorization.
OA199 Revenue code and Procedure code do not match.
PR200 Expenses incurred during lapse in coverage
PR201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC ??Medicare set aside arrangement or other agreement. (Use group code PR).
PI202 Payment adjusted due to non-covered personal comfort or convenience services.
PI203 Payment adjusted for discontinued or reduced service.
PR204 This service/equipment/drug is not covered under the patient's current benefit plan
CO205 Pharmacy discount card processing fee
OA206 NPI denial - missing
OA208 NPI denial - not matched
OA209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
PI210 Payment adjusted because pre-certification/authorization not received in a timely fashion
CO211 National Drug Codes (NDC) not eligible for rebate, are not covered.
PIA0 Patient refund amount.
OAA1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
COA4 Medicare Claim PPS Capital Day Outlier Amount.
COA5 Medicare Claim PPS Capital Cost Outlier Amount.
OAA6 Prior hospitalization or 30 day transfer requirement not met.
COA7 Presumptive Payment Adjustment
OAA8 Claim denied; un-groupable DRG
PRB1 Non-covered visits.
COB10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
OAB11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
OAB12 Services not documented in patients' medical records.
OAB13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
COB14 Payment denied because only one visit or consultation per physician per day is covered.
OAB15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
COB16 Payment adjusted because 'New Patient' qualifications were not met.
OAB18 Payment adjusted because this procedure code and modifier were invalid on the date of service
OAB20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
OAB22 This payment is adjusted based on the diagnosis.
COB23 Payment denied because this provider has failed an aspect of a proficiency testing program.
COB4 Late filing penalty.
COB5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
COB7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CRB8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.
PRB9 Services not covered because the patient is enrolled in a Hospice.
PIW1 Workers Compensation State Fee Schedule Adjustment
Last Updated ( Friday, 24 June 2011 21:51 )  
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