Medicaid denial code List

 Medicaid claim adjustment codes list

004 The procedure code is inconsistent with the modifier used or a required modifier is missing.
005 The procedure code or bill type is inconsistent with the place of service.
006 The procedure code is inconsistent with the patient's age.
007 The procedure code is inconsistent with the patient's gender.
008 The procedure code is inconsistent with the provider type.
009 The diagnosis is inconsistent with the patient's age.
010 The diagnosis is inconsistent with the patient's gender.
011 The diagnosis is inconsistent with the procedure.
012 The diagnosis is inconsistent with the provider type.
013 The date of death precedes the date of service.
014 The date of birth follows the date of service.
015 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
016 Claim or service lacks information, which is needed for adjudication.
018 Duplicate claim or service
022 Payment adjusted because this care may be covered by another payer per coordination of benefits.
023 Payment adjusted because charges have been paid by another payer.
028 Coverage not in effect at the time the service was provided.
029 The time limit for filing has expired.
031 Claim denied as patient cannot be identified as our insured.
035 Benefit maximum has been reached.
036 Balance does not exceed co-payment amount.
037 Balance does not exceed deductible.
038 Services not provided or authorized by designated (network) providers.
039 Services denied at the time authorization or pre-certification was requested.
040 Charges do not meet qualifications for emergent or urgent care.
042 Charges exceed our fee schedule or maximum allowable amount.
045 Charges exceed your contracted or legislated fee arrangement.
047 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
048 This (these) procedure(s) is (are) not covered.
052 The referring or prescribing or rendering provider is not eligible to refer or prescribe or order or perform the service billed.
056 Claim or service denied because procedure or treatment has not been deemed 'proven to be effective' by the payer.
057 Payment denied or reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
062 Payment denied or reduced for absence of, or exceeded, pre-certification or authorization.
078 Non-Covered days or Room charge adjustment
096 Non-Covered charge(s)
097 Payment is included in the allowance for another service or procedure.
110 Billing date precedes service date.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period has been reached.
120 Patient is covered by a managed care plan.
125 Payment adjusted due to a submission or billing error(s).
133 The disposition of this claim or service is pending further review.
135 Claim denied, Interim bills cannot be processed.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
148 Claim or service rejected at this time because information from another provider was not provided or was insufficient or incomplete.

1 comment:

Anonymous said...

I work in a hospital. There is much confusion as how to handle medical necessity for outpatient ancillary testing. Admissions is the first place the patient goes and medical necessity is checked. If a test will not be covered can they call the physician for more information? If the patient makes it to the lab, can they try to reach the physician before the test is done? And finally, is the coder allowed to attempt to reach the physician before coding the record even though the test was already done and the patient has left?

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