Any questions pertaining to the license or use of the CPT must be addressed to the AMA. Charges exceed your contracted/legislated fee arrangement. CDT is a trademark of the ADA. Pr. Prearranged demonstration project adjustment. Provider contracted/negotiated rate expired or not on file. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Claim/service does not indicate the period of time for which this will be needed. Based on Provider's consent bill patient either for the whole billed amount or the carrier's allowable. Ask VA (AVA) Customer Call Centers Contact Us Ask VA (AVA) Customer Call Centers the procedure code 16 Claim/service lacks information or has submission/billing error(s). Siemens has produced a new version to mitigate this vulnerability. Your stop loss deductible has not been met. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. Claim/service lacks information which is needed for adjudication. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Reason Code 16 | Remark Codes MA13 N265 N276 Common Reasons for Denial Item (s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS) Next Step Resubmit claim with a valid ordering physician NPI registered in PECOS How to Avoid Future Denials For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. . Missing/incomplete/invalid patient identifier. If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. Coverage not in effect at the time the service was provided, Pre-Certification or Authorization absent, Amerihealth Caritas Directory Healthcare, Health Insurance in United States of America, Place of Service Codes List Medical Billing. Last, we have denial code CO 167, which is used when the payer does not cover the diagnosis or diagnoses. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Remittance Advice Remark Code (RARC). This (these) service(s) is (are) not covered. Services denied at the time authorization/pre-certification was requested. The ADA is a third-party beneficiary to this Agreement. Payment denied because this procedure code/modifier was invalid on the date of service or claim submission. Jan 7, 2015. The three digit EOB on your remittance advice explains how L&I processed a bill, and how to make corrections if needed. Applications are available at the AMA Web site, https://www.ama-assn.org. No appeal right except duplicate claim/service issue. We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. Beneficiary was inpatient on date of service billed, HCPCScode billed is included in the payment/allowance for another service/procedure that has already been adjudicated. 16. For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 10 years . Denial Code - 140 defined as "Patient/Insured health identification number and name do not match". This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Provider promotional discount (e.g., Senior citizen discount). . If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. Charges for outpatient services with this proximity to inpatient services are not covered. M67 Missing/incomplete/invalid other procedure code(s). HCPCS code is inconsistent with modifier used or a required modifier is missing, HCPCScode is inconsistent with modifier used or required modifier is missing. Ask the same questions as denial code - 5, but here check which procedure code submitted is incompatible with provider type. Steps include: Step #1 - Discover the Specific Reason - Why sometimes denials have generic denial codes and it can be tough to figure out the real reason it was denied. All rights reserved. This denial code generally occurs when the diagnosis is inconsistent with the procedure as long as the procedure code shows an inappropriate diagnostic code. The advance indemnification notice signed by the patient did not comply with requirements. LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT"). Expenses incurred after coverage terminated. Force a job applicant or an employee to resign because of denial of a reasonable 46 accommodation; 47 (4) Deny employment opportunities to a job applicant or an employee, if such denial is . At least one Remark Code must be provided (may be comprised of either the . Change the code accordingly. The diagnosis is inconsistent with the provider type. Denial code 50 defined as "These are non covered services because this is not deemed a medical necessity by the payer". To license the electronic data file of UB-04 Data Specifications, contact AHA at (312) 893-6816. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. E2E Medical Billing Servicescan assist you in addressing these denials and recover the insurance reimbursement. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. Remark codes that apply to an entire claim must be reported in either an ASC X12 835 MIA (inpatient) or MOA (non-inpatient) segment, as applicable. Claim adjusted by the monthly Medicaid patient liability amount. The diagnosis is inconsistent with the patients age. Resubmit claim with a valid ordering physician NPI registered in PECOS. A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews (including pre-pay and post-pay) and Pre-Claim reviews. Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS), Please follow the steps under claim submission for this error on the. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. Missing/incomplete/invalid rendering provider primary identifier. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. Claim Denial Codes List as of 03/01/2021 Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC) Medicaid Denial Reason CORE Business . In the above example, Primary Medicare paid $80.00 and the balance coinsurance $20.00 has been forwarded to secondary Medicaid. The information provided does not support the need for this service or item. Charges exceed our fee schedule or maximum allowable amount. Denials. Not covered unless submitted via electronic claim. Medicare Claim PPS Capital Cost Outlier Amount. Services not covered because the patient is enrolled in a Hospice. 2023 Noridian Healthcare Solutions, LLC Terms & Privacy. PR 96 DENIAL CODE: PATIENT RELATED CONCERNS When a patient meets and undergoes treatment from an Out-of-Network provider. Cross verify in the EOB if the payment has been made to the patient directly. 16. You must send the claim to the correct payer/contractor. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. Swift Code: BARC GB 22 . A group code is a code identifying the general category of payment adjustment. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. Denial Code 119 defined as "Benefit maximum for this time period or occurrence has been reached". You may also contact AHA at ub04@healthforum.com. 160 16 Claim/service lacks information which is needed for adjudication. Appeal procedures not followed or time limits not met. PR Deductible: MI 2; Coinsurance Amount. PR 149 Lifetime benefit maximum has been reached for this service/benefit category. Code 16: MA13 N264 N575: Item(s) billed did not have a valid ordering physician name: Code 16: The ADA does not directly or indirectly practice medicine or dispense dental services. A16(27) (2001) 1761-1773 July 20, 2001 arXiv:hep-th/0107167 . There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. Remark New Group / Reason / Remark Invalid place of service for this Service Facility Location NPI. B. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. Note: sometimes these qualifications can change, be sure you meet all up-to-date qualifications. THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. Missing/incomplete/invalid ordering provider name. Payment adjusted because rent/purchase guidelines were not met. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Documentation requested was not received or was not received timely, Item billed may require a specific diagnosis or modifier code based on related Local Coverage Determination (LCD). Denial code co -16 - Claim/service lacks information which is needed for adjudication. Examples of EOB Claim Adjustments are CO 45, CO 97, OA 23, PR 1, and PR 2. Medicare Secondary Payer Adjustment amount. Claim/service denied. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Prior hospitalization or 30 day transfer requirement not met. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. FOURTH EDITION. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim/service denied. Procedure code billed is not correct/valid for the services billed or the date of service billed. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR) PR 126 Deductible -- Major Medical PR 127 Coinsurance -- Major Medical PR 140 Patient/Insured health identification number and name do not match. Cost outlier. Applicable federal, state or local authority may cover the claim/service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Workers Compensation State Fee Schedule Adjustment. Increased Acceptance of RPM Remote patient monitoring is a form On November 2, 2021, the Centers for Medicare and Medicaid Beginning January 1, 2022, psychologists and other health care providers cms mental health services billing guide 2019, coding and payment guide for behavioral health services 2019, Coding Guidelines for Coronavirus for Medicare Beneficiaries, cpt code 90791 documentation requirements, cpt codes for psychiatric nurse practitioners, evaluation and management of a new patient, Information about billing for coronavirus, Information about billing for coronavirus (COVID-19), telemedicine strategies for novel corona virus, Billing for Remote Patient Monitoring (RPM), No Surprises in 2022 due to No Surprises Act (NSA). Explanation and solutions - It means some information missing in the claim form. Medicare denial codes are standard messages used to provide or describe the information to a medical patient or provider by insurances about why a claim was denied. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Review the service billed to ensure the correct code was submitted. Successful exploitation of these vulnerabilities may allow an attacker to cause a denial-of-service condition or remotely exploit arbitrary code. 3. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) AMA Disclaimer of Warranties and Liabilities Even if a provider has an individual NPI, it does not mean that his/her enrollment record is in PECOS and/or is active. Payment denied/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 days supply. Payment made to patient/insured/responsible party. Illustration by Lou Reade. CO/171/M143 : CO/16/N521 Beneficiary not eligible. var pathArray = url.split( '/' ); Denial Code 16: The service performed is not a covered benefit o The provider should verify that the service is covered for the . October - December 2022, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes. If so read About Claim Adjustment Group Codes below. CO/16/N521. If there is no adjustment to a claim/line, then there is no adjustment reason code. All Rights Reserved. Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. 65 Procedure code was incorrect. Missing/incomplete/invalid procedure code(s). Denial Code 16 described as "Claim/service lacks information or has submission/billing error(s) which is required for adjudication". Claim/service denied. This system is provided for Government authorized use only. Step #2 - Have the Claim Number - Remember . Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. Even if you get a CO 50, it's a good idea to dig deeper, talk to the payer, and get an accurate explanation for non-payment. LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE ("NUBC"), Point and Click American Hospital Association Copyright Notice, Copyright 2021, the American Hospital Association, Chicago, Illinois. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Payment adjusted because new patient qualifications were not met. Main equipment is missing therefore Medicare will not pay for supplies, Item(s) billed did not have a valid ordering physician name, Item(s) billed did not have a valid ordering physician National Provider Identifier (NPI) registered in Medicare Provider Enrollment, Chain and Ownership System (PECOS), Claim/service lacks information or has submission/billing error(s). Do not use this code for claims attachment(s)/other . Missing patient medical record for this service. Missing/incomplete/invalid billing provider/supplier primary identifier. Of the 17 security vulnerabilities patched by these new kernel updates, 14 of them affect all the Ubuntu systems mentioned above. Denial code CO16 is a "Contractual Obligation" claim adjustment reason code (CARC). As a result, you should just verify the secondary insurance of the patient. Claim/service denied because procedure/ treatment is deemed experimental/ investigational by the payer. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. Last Updated Mon, 30 Aug 2021 18:01:22 +0000. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. The provider can collect from the Federal/State/ Local Authority as appropriate. Plan procedures of a prior payer were not followed. How do you handle your Medicare denials? This care may be covered by another payer per coordination of benefits. SpecialityAllergy & ImmunologyAnesthesiologyChiropracticDurable Medical EquipmentGastroenterologyInternal MedicineMental HealthOccupational HealthOral and MaxilofacialPain ManagementPharmacy BillingPodiatryRadiation OncologyRheumatologySports MedicineWound CareAmbulance TransportationBehavioural HealthDentalEmergency Medicine BillingGeneral SurgeryMassage TherapyNeurologyOncologyOrthopaedicPathologyPhysical TherapyPrimary CareRadiologySkilled Nursing FacilityTeleradiologyAmbulatory Surgical CentersCardiologyDermatologyFamily PracticeHospital BillingMedical BillingOB GYNOptometryOtolaryngologyPaediatricsPlastic SurgeryPulmonologyRehab BillingSleep DisorderUrology, StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhodeIslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This (these) procedure(s) is (are) not covered. 16: M20: WL5 Home Health Claim is missing the Core Based Statistical Area in the UB-04 Value Amount with UB-04 Value . Ask the same questions with representative as denial code - 5, but here check which procedure code submitted is incompatible with patient's gender. Oxygen equipment has exceeded the number of approved paid rentals. It may help to contact the payer to determine which code they're saying is not covered, if you submitted multiple diagnosis codes. Account Number: 50237698 . appropriate CPT/ HCPC's code 16 Claim/service lacks information which is needed for adjudication. To access a denial description, select the applicable Reason/Remark code found on Noridian's Remittance Advice. Warning: you are accessing an information system that may be a U.S. Government information system. Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. CARC 16 is used if a reject is reported when the claim is not being processed in real time and trading partners agree that it is required or when the claim is not processed in real time. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Prior processing information appears incorrect. Check eligibility to find out the correct ID# or name. Denial Code - 183 described as "The referring provider is not eligible to refer the service billed". The following information affects providers billing the 11X bill type in . PR 27 denial code description - expenses incurred after patient's insurance coverage terminated. Newborns services are covered in the mothers allowance. Claim/Service denied. Applications are available at the American Dental Association web site, http://www.ADA.org. If you encounter this denial code, you'll want to review the diagnosis codes within the claim. Claim lacks the name, strength, or dosage of the drug furnished. Check to see the indicated modifier code with procedure code on the DOS is valid or not? You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Receive Medicare's "Latest Updates" each week. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice . 1. var url = document.URL; CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The Washington Publishing Company publishes the CMS-approved Reason Codes and Remark Codes. This license will terminate upon notice to you if you violate the terms of this license. Do not use this code for claims attachment(s)/other documentation. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. Benefits adjusted. Patient cannot be identified as our insured. The CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. A Remark on Non-conformal Non-supersymmetric Theories with Vanishing Vacuum Energy Density Mod. Multiple physicians/assistants are not covered in this case. CO or PR 27 is one of the most common denial code in medical billing. Procedure/service was partially or fully furnished by another provider. . Procedure/service was partially or fully furnished by another provider. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. Usage: . Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose. Additional . The use of the information system establishes user's consent to any and all monitoring and recording of their activities. either the Remittance Advice Remark Code or NCPDP Reject Reason Code). Therapeutic Behavioral Service valid only with a Full Scope Aid Code and an EPSDT Aid Code. Please click here to see all U.S. Government Rights Provisions. These materials contain Current Dental Terminology, (CDT), copyright 2020 American Dental Association (ADA). If you choose not to accept the agreement, you will return to the Noridian Medicare home page. 64 Denial reversed per Medical Review. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Balance $16.00 with denial code CO 23. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. PR 1 Denial Code - Deductible Amount; CO 4 Denial Code - The procedure code is inconsistent with the modifier used or a required modifier is missing; . Denial Code 39 defined as "Services denied at the time auth/precert was requested". Claims lacking any one of the elements will be denied with the PR16 and a remittance remark code of M124, which indicates the charge is denied because it is missing an indication of whether the patient owns the equipment that requires the part or supply. Separately billed services/tests have been bundled as they are considered components of the same procedure. PR Patient Responsibility. The procedure code/bill type is inconsistent with the place of service. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Missing/incomplete/invalid initial treatment date. Payment denied because this provider has failed an aspect of a proficiency testing program. Therefore, you have no reasonable expectation of privacy. Payment adjusted because this service/procedure is not paid separately. CMS Disclaimer Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Completed physician financial relationship form not on file. Applications are available at the AMA Web site, https://www.ama-assn.org. If the patient did not have coverage on the date of service, you will also see this code. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. The Washington Publishing Company publishes the CMS-approved Reason Codes and Remark Codes. Did you receive a code from a health plan, such as: PR32 or CO286? The scope of this license is determined by the ADA, the copyright holder. This payment reflects the correct code. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Charges are covered under a capitation agreement/managed care plan. Refer to the 835 Healthcare Policy Identification Segment (loop CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. pi old reason code new group code new reason code 204 co 139 204 pr b5 204 pr b8 204 pr 227 n102 204 pr 227 n102 pi 125 m49, ma92 204 pi 5 204 pi 7 204 pr b7 204 pi 6 204 pi 16 204 pi 4 49 35 pr pr 49 119 10 pi 7 9 pi 9 b7 pr 111 16 16 old remark codes m49, m56 ma06, n318 pi 125 new remark codes m54 n318 . This service was included in a claim that has been previously billed and adjudicated. Researching and resubmitting denied claims can lead to long, frustrating hours trying to figure out why the claim was denied in the first place. PR 42 - Use adjustment reason code 45, effective 06/01/07. Claim lacks date of patients most recent physician visit. 3) Each Adjustment Reason Code begins the string of Adjustment Reason Codes / RA Remark Codes that translate to one or more PHC EX Code(s). Claim/service not covered when patient is in custody/incarcerated. No fee schedules, basic unit, relative values or related listings are included in CPT. A: The denial was received because the service billed is statutorily excluded from coverage under the Medicare program. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment adjusted due to a submission/billing error(s). Denial Codes in Medical Billing - Lists: CO - Contractual Obligations OA - Other Adjsutments PI - Payer Initiated reductions PR - Patient Responsibility Let us see some of the important denial codes in medical billing with solutions: Show Showing 1 to 50 of 50 entries Previous Next Timely Filing Limit of Insurances It occurs when provider performed healthcare services to the . Check to see the procedure code billed on the DOS is valid or not? If the denial code you're looking for is not listed below, you can contact VA by using the Inquiry Routing & Information System (IRIS), a tool that allows secure email communications, or you can call our Customer Call Center at one of the sites or centers listed below. PR - Patient Responsibility: . This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier, Misrouted claim. These are non-covered services because this is not deemed a medical necessity by the payer. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Payment denied/reduced for absence of, or exceeded, precertification/ authorization. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes. Same as denial code - 11, but here check which DX code submitted is incompatible with provider type. 2. This payment reflects the correct code.