Explanation Claim Adjustment Remittance Advice Code Short ... · Explanation of Benefits (EOB)...
Transcript of Explanation Claim Adjustment Remittance Advice Code Short ... · Explanation of Benefits (EOB)...
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
I90 D.O.S outside of stmt serv date Date of Service outside of statement service date 110 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B70 Incorrect Payment for Non Covered Se Recovering Incorrect Payment for Non covered Service 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
REN 132: 2005 Norton Inpt Rate Increase 2005 Norton Retro Inpatient rate Increase 132 MA132 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RET 132:2005 Retro Inpatient Rate Increase 2005 Retro Inpatient Rate Increase 132 MA132 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R75 1st Level Screening Paid; submit medical
1st Level Screening Paid; submit medical records for
prudent layperson 16 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R73 1st Level Screening Pd, medi record 1st Level Screening Pd, medical records not received 49 N627
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R18 22: Benefits not coord pending receipt
Benefits not coordinated pending receipt of adjusted
claim from 22 MA04
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS3 3 day window OP serv included w IP stay
3 day window (72 hour) outpatient services should be
included in the I 60 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R22 62:Authorization Expired Authorization Has Expired 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R21 62:Dates and/or Services outside of Auth Dates and/or Services outside of Authorization 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G93 ACA: contract pay amount equal to or gr
ACA: contract pay amount equal to or greater than ACA
rate 222 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G92 ACA: dos span eligibility dates resubmi ACA: dos span eligibility dates resubmit itemized bill 239 N62
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G91 ACA: provider not eligible on attestati ACA: provider not eligible on attestation file for dos B7 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G98 ACA: COB claim processed under ACA
ACA: COB claim processed under ACA program
requirements 45 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G94 ACA: eligible line repriced at the ACA r ACA: eligible line repriced at the ACA rate 222 N640 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G95 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G97 ACA: FQHC/RHC/DHC not eligible ACA: FQHC/RHC/DHC not eligible 185 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G90 ACA: member in state only aide category;
ACA: member in state only aide category; not eligible for
enhanced pay 177 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G96 ACA: member in state only aide category;
ACA: member in state only aide category; not eligible for
enhanced pay 177 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J00 ACS Keying Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V00 ACS Keying Error R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZHC Add on Code billed without primary code
An add on code was billed without the presence of the
related primary 234 N122
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G16 Additional Charges Considered Additional Charges Considered 107 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X14 Additional Diagnosis Emergent
Previously paid. Payment for this claim/service may
have been provided 40
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code
that requires a
107 N122 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H07 Add-On Code Requires Primary Service This procedure was denied because it is an add-on code
that requires a
107 N122 CMS National Coverage Determinations (NCD) Policy
937 Addt'l information received and reviewed
Payment adjusted upon receipt of additional
information. B19 N199
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EQ5 Addtnl info needed on itmzd bill Additional information is needed on the itemized bill 163 N26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J61 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V60 Adjusted original submission R129:Corrected clm rec'd adj orig claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G99 Adjusting Historical Claim Adjusting Historical Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G51 Adjustment For Component Of Professio
This health service code has been adjusted to reflect a
component of t 97 N67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R30 Adjustment to Previous Payment Adjustment to Previous Payment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT7 Admin Code without Vaccine Code
Administration Service Billed with Modifier U2 or U3
without 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC1 Administration Codes exceed Vaccine Code Administration Codes exceed Vaccine Code 94 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R56 Administrative Approval Administrative Approval 186 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
G17 Administrative Overturn Administrative Overturn 186 N11 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
609 Admission date is prior to member effect Admission date is prior to member effective date 26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H78 Age Doesn't Support DX Billed
The age of the patient does not correlate with the
submitted diagnosis 9 N517
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMK All Components of Lab Panel Billed
All of the Components of a Lab Panel Have been billed.
Only the Lab 234 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G33 Allowed Amount Greater Than Submitted
According to our policy, when a procedure has an
allowed amount greate 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS4 Ambulance Service while Inpatient
Ambulance Services were provided while the member
was an IP 97 M2
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R19 Anes Minutes erq for payment calc
Anesthesia minutes required for payment calculation
per IHCP Rules 16 N203
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X19 Anes Minutes req for payment cacl
Anesthesia minutes required for payment calculation
per IHCP Rules 16 N203
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMH Anesthesiologist must use CPT Codes
Anesthesiologist must use CPT Codes (00100-01999)
plus State Specified 95 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMI Anethesia Provided by a Non-Anes
Anesthesia Provided by a Non-Anesthesiologist (Check
for Addtional 194
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R31 Appeal - Denial Overturned Appeal - Denial Overturned 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
900 Applied to deductible in error Adjusted - correction to deductible. 192 M25 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZJ6 ASD diagnosis invalid
ASD Dx cannot be primary or secondary without
required modifiers 16 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK6 ASD diagnosis invalid
ASD Dx cannot be primary or secondary without
required modifiers 16 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZJ5 ASD diagnosis must be primary
ASD diagnosis must be primary with submitted
modifiers 16 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK5 ASD diagnosis must be primary
ASD diagnosis must be primary with submitted
modifiers 16 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I31 Assessment not received Assessment not received 16 N309 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X31 Assessment not received Assessment not received 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R34 Assistant Surgeon Payment Assistant Surgeon Payment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD9 Attending & Referring not enrolled in Me Attending and Referring not enrolled in Medicaid 183 N767
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD8 Attending not enrolled in Medicaid Progr Attending not enrolled in Medicaid Program 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEA Attending NPI is not enrolled with state
Attending NPI is not enrolled with state as provider type
31-physician 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEB Attending Provider NPI is a non-individu
Attending Provider NPI is a non-individual per NPPES
Registry 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X69 AttendingPhys ID/Name Missing/Invalid Attending Physician ID/Bane is Missing Invalid 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DM Auth denied - services not considered
Authorization is denied, services will not be considered-
member liable 39
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF9 Auth/Ref Transferred - Delay in Newborn
Auth/Ref Transferred - Delay in Newborn Enrollment
Information 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
210 Auth'ed generic only. Brand was billed. Authorized for generic only. Brand was billed. 204 N448 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R35 Authorization Denied for this DOS Authorization Denied for this Date of Service 198 N351 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X35 Authorization Denied for this DOS Authorization Denied for this Date of Service 39 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R89 Authorization on File for Technical C Authorization on File for Technical Component 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G23 Authorization updated Authorization Updated 186 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B39 Authorization/Referral Expired Authorization/Referral Expired 198 M62 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R59 Authorization/Referral Expired Authorization/Referral Expired 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J28 Auto insurance is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V27 Auto insurance is Primary R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J45 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 MA36 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V44 Baby Claim Processed under Mom R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM9 Based on NCCI Two Proc are Mutual Excl
Based on NCCI Two Proc. Are Mutually Excl. If it is not
Possible to 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB4 Bed Hold Days Exhausted Bed Hold Days Exhausted 96 N43 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
901 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
913 Benefits loaded incorrectly Adjusted - correction to benefits. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R29 Beyond Adjustment Period Beyond Adjustment Period 29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X43 Bi-Lat proc prev paid w/mod "50" Bi-Lateral procedure previously paid with modifier "50" B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB3 Bilateral - Modifier Incorrect
This is a Bilateral Code. Modifiers LT, RT, 50 or qty 2 are
not 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HML Bilateral Proc Code pymt based both side
Bilat Proc Code and pymt based on both sides. Pay
lessor of 100% of 4 N644
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G36 Bilateral Procedure Inappropriately
This health service code was denied because the
bilateral procedure wa 4 N644
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB2 Bilateral Surgery 100% rule applies
This is a Bilateral Procedure Code and payment for the
code is already 59 N644
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB1 Bilateral Surgery 150% Rule Applies
Unilateral Procedure Code. The 150% Payment
Adjustment Rule applies 59 N644
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM3 Bill charge must be greater than $0
Bill charge must be greater than $0 at the line level or
deny 16 M54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM4 Bill charge must greater than $0
Bill charge must be greater than $0 at the line level or
deny 16 M54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B33 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XA1 Bill through pharmacy program Bill through pharmacy program 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HA3 Bill to DME MAC Bill to DME MAC 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G44 Bill To Dmerc
This health service code was denied as a procedure
billed with a DME o 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA6 Bill Type Missing Bill Type Missing 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R55 Billed Info Reflects Lower Degr Billed Info Reflects Lower Degree Acuity/Treatment 150 M25
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B42 Billed with Invalid Bill Type Billed with Invalid Bill Type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEK Billing and Rendering Prov do not have
Billing and Rendering Prov do not have an active license
on claim DOS B7 M143
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEL Billing and Rendering Prov not enrolled
Billing and Rendering Prov not enrolled in Medicaid
Program 16 N257
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEG Billing Prov does not have an active lic Billing Prov does not have an active license on claim DOS B7 M143
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE1 Billing Prov not enrolled in Medicaid Billing Prov not enrolled in Medicaid Program 16 N257 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G34 Blood Collection Included In Lab Serv
The venipuncture was denied as it is considered to be an
integral part 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H00 Bundled into Service Not Specified These services are either bundled into other services on
the same day,
97 M15 National Correct Coding Manual Policy
H00 Bundled into Service Not Specified These services are either bundled into other services on
the same day,
97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J62 Business Processing Rules not followed Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RBM Capitated Radiology Vendor
Claim Line for radiology services has been forwarded to
the 24 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R36 Capitated Service Capitated Service 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X36 Capitated Service Capitated Service 24 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSH Carve out Benefit Services are Carved out for payment by another entity 96 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HST Carve out Services - State Specific Services are carved out for payment by another entity - 96 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R81 Chrgs Considered included in Inpat Ad Charges Considered included in Inpatient Admission 97 M2
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X81 ChrgsConsidered Included InpatAdmis Charges Considered included in Inpatient Admission 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
940 Claim adjusted based on audit Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EQ4 Claim adjusted following Equian Determin
Claim adjusted following Equian Determination review
with Provider 45 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
WP1 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
WP3 Claim adjusted Member Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
WP0 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
WP2 Claim adjusted Provider Appeal 186 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
910 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
935 Claim audit adjustment Payment adjusted as result of compliance audit. 216 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
998 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9B4 Claim audit adjustment Payment adjusted as result of compliance audit. 129 N199 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J66 Claim closed incorrectly Rekeyed claim for correct payment/denial 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB7 Claim EBP does not match member EBP enro Claim EBP does not match member EBP enrollment 204 N448
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZML Claim has multiple CLIA Numbers Claim has multiple CLIA Numbers 16 M91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G19 Claim is not a Duplicate Claim is not a Duplicate 129 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD0 Claim line denied Claim line denied A1 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G11 Claim Previously Processed Incorrect Claim Previously Processed Incorrectly 129 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V11 Claim procesed not following auth R129:Claim not paid according to auth. 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF7 Claim Processed not following Auth/Ref
Claim Processed not followinig Auth/Referral - Manual
Error 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J05 Claim processed to wrong member R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G02 Claim Processed to Wrong Provider
Previous Claim processed to the Wrong Provider
Healthcare 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B14 Claim Service Denied
Claim Service Denied because the related or qualifying
claims service B15 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G22 Claim was submitted Timely Claim was Submitted Timely 210 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B48 Claims adj to correct underpayment Claim adjusted to correct underpayment 129 N524 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMP CLIA Number does not cover DOS CLIA Number does not cover DOS B7 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R95 Clinic Claim without Physician Name Claim without Physician Name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B35 Clinic clm sub w/out phy name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X56 Clinic Clm Submt w/o phys nam Clinic Claim submitted with out physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J52 Clinical Edit(Ihealth, NCCI) incorr appl R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H08 Clinical Trial Requires Approp. DX Clinical Trial requires appropriate diagnosis. 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J18 Clm denied for EOB,svs excluded from cov R129:Service Not Covered by Other Ins 242 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I15 Clm Pend: app Modifier and/or time un Resubmit with appropriate Modifier and/or time units 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I12 Clm Pend: clinic claim w/o Phys name Claim w/o Physicians name or number 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X95 Clm Pend: clinic claim w/o phys name Clinic claim submitted without physician name 16 N252 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I04 Clm Pend: Correct NDC Code Req Correct NDC Code Required 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X04 Clm Pend: correct NDC Code req Correct NDC Code required for consideration 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X11 Clm Pend: EOB from prim carrier req Resubmit with EOB from Primary Carrier 252 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I13 Clm Pend: EOB/attach illeg/incomplet EOB/attached illegible/Incomplete 16 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I02 Clm Pend: Illegible Records Sub Illegible Records Submitted 251 N205 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X02 Clm Pend: illegible records sub Illegible records submitted 251 N205 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I05 Clm Pend: Invalid/Del Code, Mod or D
Invalid/Inappropriate/Deleted Code, Modifier or
Decription 182 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I05 Clm Pend: Invalid/Del Code, Mod or D
Invalid/Inappropriate/Deleted Code, Modifier or
Decription 182 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I14 Clm Pend: invalid/miss Rev Code Invalid/missing Revenue Code 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I06 Clm Pend: Itemized Bill Required Itemized Bill/DOS/Charges/Invoice Required 16 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X06 Clm Pend: itemized bill required Itemized Bill, Date of Service, or Invoice 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I03 Clm Pend: Rept Req for Non-Spec Code
Report Required to Support Non-Specific Code; Please
Refile 16 N350
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I08 Clm Pend:Diag Inv/Missing/Del/4th or5
Diagnosis invalid/missing/deleted/requires 4th or 5th
digit; 146 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J01 Clm prev denied incorrectly as duplicate R129:Claim is not a duplicate 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J04 Clm previously processed for wrong prov R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J33 Clm Proc incorr for penny pricing Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X96 ClmPend: EOB/attach illeg/incomplete EOB attachments were illegible/incomplete 251 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B37 ClmPend:AppModifier and/or time units Resubmit with appropriate modifier and/or 4 N517 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
X08 ClmPend:diag inv/missing/del 4thor5th
Diagnosis Invalid/missing/deleted/requires 4th or 5th
digit 146 M64
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X05 ClmPend:invalid/del code,mod or desc Invalid/inappropriate/deleted code, modifier or 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J43 Clms adj. to deny for clms billed incorr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V42 Clms adj. To deny for clms billed incorr R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMO Co- Surgeon - Different Specialties
Co- Surgeons are only allowed if the providers are in
different 8 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB3 COB Recovery COB Recovery 22 N420 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
614 COB verification required from member
COB verification/documentation is required from the
member to process 22 N197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CJ COB/exceeds fee schedule Coordination of benefits exceeds the fee schedule. 23 N131
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSP Code combination - CC2 Retro
Based on NCCI the specific billed service code combo is
not payable. 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSQ Code Combination Hosp CCR Retro
Hospital OP NCCI the specific billed service code combo
is not payable 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMX Code Combo not payable
Based on NCCI the specific billed service code
combination is not 236
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
457 Code description required Please submit a full description of the services provided 16 N350
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BC Code description required Please submit a full description of the services provided 16 N350
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H34 Code is Incident to Service
This was furnished as an integral, although incidental
part of the Drs 97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z96 CodeNotApproved for ProviderSpecialty
Procedure Code not approved by Medicaid for provider
specialty type 8 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R37 Combined Payment - Mother and Baby Combined Payment - Mother and Baby 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R45 Complete Med Records Req'd Complete Medical Records Required 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZC0 Complete Medical Records Required
Complete Medical Records Required for Consideration -
Refile 163 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZC0 Complete Medical Records Required
Complete Medical Records Required for Consideration -
Refile 163 M127
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZE2 Complete Medical Records Required
Complete Medical Records Required for consideration -
Please re-file; 163 M127
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G39 Component Of Critical Care Service
This health service code was denied as it is considered
to be an integ 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G79 Condition Code Not Appropriate For Bi
The health care codes were denied because the
Condition Code is not ap 16 M44
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V38 Configuration Error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R38 Contracted Fee Contracted Fee 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
944 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
952 Contractual agreement Adjusted - retroactive change to the provider's contract. 45 N419
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G43 Convenience Item - Does Not Meet Defi
Item denied because it is an item of convenience, the
item is not medi 50
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9B9 Corrected claim - add'l payment due Adjusted - corrected claim received 63 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
406 Corrected claim - no add'l payment due
Provider corrected claim but no additional payment is
due. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR4 Corrected claim with diff Prov Tax ID
Corrected claim has different provider tax ID then
original submission 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR4 Corrected claim with diff Prov Tax ID
Corrected claim has different provider tax ID then
original submission 16 N209
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR3 Corrected claim with different Member ID
Corrected claim has different member ID then original
submission 16 N382 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR3 Corrected claim with different Member ID
Corrected claim has different member ID then original
submission 16 N382
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
112 Corrected claim. No payment due.
Corrected claim received, reprocessed claim, but no
additional B13 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
HMN Co-Surgeon not allowed for procedure Co- Surgeons are not allowed for this procedure 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B08 Co-Surgeons Cannot Be Same Subspecia Cosurgeons need to be of different subspecialties. 172
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H62 Co-Surgeons Not Allowed Procedure denied. The procedure code submitted does
not necessitate
54 N450 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 96 N193 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z70 Covered by State; Bill EDS Pharmacy/Supplies covered by the State 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5C0 CPT invalid DOS Procedure code invalid for date of service 181 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G61 Cpt Modifier Is Not Valid
This health service code was denied because the
modifier is invalid. 182 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMN CPT Not Covered by CLIA Certificate Type CPT Not Covered by CLIA Certificate Type B23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G41 CPT Recoded To A CMS Designated Alter
According to CMS guidelines, outpatient hospitals
should bill certain 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H56 CPT Seperate Procedure Policy This procedure/service is not paid separately 97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
407 CPT/HCPCS invalid for rev code billed
The CPT/HCPCS code on the claim is invalid for the
revenue code billed 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CL CPT/HCPCS invalid for rev code billed
The CPT/HCPCS code on the claim is invalid for the
revenue code billed 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD5 Data required is missing in box 32 Address and/or time requirement is missing in box 32 95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH5 Date of Death proceeds the DOS Date of Death proceeds the date of service 13 CMS Coverage Policies
HM1 Date of service is Later Than Date Recd
Date Of Service Is Later Than Date Received Or Future
Date Of Service. 110
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X60 Dates and/or ServicesOutsideRef/Auth Dates and/or Services Outside Authorization/Referral 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R60 Dates and/or Servs Outside Ref/Auth Dates and/or Services Outside Referral/Authorization 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4BM Denial overturned and service is now app
Our denial was overturned and the service is now
approved. This means 64 MA91
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
492 Denied - authorized services exceeded
Services exceed authorized amount/days - member not
liable 198 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CT Denied - authorized services exceeded
Services exceed authorized amount/days - member not
liable 198 N54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
493 Denied - benefit exceeded Denied - benefit exceeded 119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CU Denied - benefit exceeded Denied - benefit exceeded 119 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
497 Denied - no NPI Denied - no NPI 206 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
498 Denied - not on fee schedule Denied - not on fee schedule - member not liable 147
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
499 Denied - not payable - member not liable
Denied - not payable (inclusive, exclusive, unbundled or
not payable B1 M39
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5D1 Denied - payment for donor services
Payment is for donor services and paid under the
recipient's B1
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5D2 Denied - provider billing error Denied - provider billing error 16 N296 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5D3 Denied - resubmit to vision vendor Services need to be billed to the vision vendor. 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5D5 Denied - settlement agreement Date of service included in a settlement agreement. 97 N664
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
489 Denied- altered claim, member not liable
Claim has been altered; member not liable; resubmit
corrected claim 31 MA130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H02 Denied- Duplicate Service on Same Day
The same or a similar procedure code was billed on the
same date of 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS7 Denied in Hospital In/Out
Service is not payable in a Hospital Inpatient or
Outpatient setting 58
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J72 Denied incorrectly, remit correct Claim denied incorrectly in error 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4A2 Denied- NPI incorrect NPI incorrect 208 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4A0 Denied- past reconsideration time period
Claim is past the reconsideration time period. Member
not liable. 29
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AA Denied -updating of payment information
Denied -updating of payment info-SMT claims only-
member not liable 250 MA04
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
Z09 Denied,corrected claim submitted Correction to a prior claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AB Denied-auth servs do not match claim
Service code on claim does not match service code on
authorization- 284 M62
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5D9 Denied-auth servs do not match claim
Service code on claim does not match service code on
authorization- 284
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AE Denied-invalid billing name, addr or TIN
Invalid billing name, address or tin; re-submit claim with
correct 16 N258
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AF Denied-name and address required
Name and address of facility where services were
rendered 16 N256
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AG Denied-no add'l pmt,under original DRG
Re-admission applies under original DRG of primary
admit- 249
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DC Denied-no add'l pmt,under original DRG
Re-admission applies under original DRG of primary
admit- 249
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AJ Denied-remit/billing addr does not match
Remitting/billing address does not match system
records 16 N258
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AK Denied-rendering provider required
Rendering physician / facility required and not
submitted. 16 N289
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H46 Deny due to Interaction with other drug Service denied because potential interactions with
another drug
50 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H72 Deny Item doesn't meet definition of DME
Item denied because it is an item of convenience, item is
not medical 50 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AM Deny-DOS outside statement dates Deny-DOS outside statement dates 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DE Deny-DOS outside statement dates Deny-DOS outside statement dates 16 MA31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
468 Device/equip invoice required An invoice from the vendor supplying the implantable 252 M23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R08 Diag inv/missing/del 4th or 5th Diagnosis invalid/missing/deleted 4th or 5th digit 16 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I09 Diag Inv/Missing/Deleted Req 4th/5/6/7th
Diagnosis Invalid/Missing/Deleted or Requires 4th or 5th
or 6th or 7th 146 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations.
ZK4 Diagnosis Code Invalid Diagnosis Code Invalid 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS1 Diagnosis Codes missing or inval on DOS All Diagnosis codes are invalid on the DOS or requires a 146 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
408 Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BJ Diagnosis ineligible The diagnosis submitted is ineligible for reimbursement. 167
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H64 Diagnosis Invalid for Age The age of the patient does not correlate with the
submitted diagnosis
9 N517 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H15 Diagnosis Invalid For Gender This was denied because the diagnosis is not
appropriate based on the
10 N517 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA2 Did not meet minimum unit requirement Did not meet minimum case rate unit requirement 16 M53
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R67 Discrep w/Level of Care-Appeal Req Discrepancy with Level of Care - Appeal Required 150 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X67 Discrep with Level of Care-AppealReq Discrepancy with Level of Care - Appeal Required 150 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZ0 Documented Service does not support 9929 Documented Service does not support 99292 150 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H21 Doesn't Meet Observation Criteria Observation care code requires minimum of 8 hours. 150 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R97 DOS Cannot be Greater than Received DOS cannot be Greater than Received Date 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X97 DOS Cannot be Greater than Recv Date Date of Service cannot be greater then claim received 110
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
581 DRG change due to DX/discharge
DRG change due to incorrect principal or secondary DX
codes and 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
583 DRG change due to DX/Procedure/discharge
DRG change due to incorrect principal or secondary DX
and procedure 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
584 DRG change due to DX/Procedure/discharge
DRG change due to incorrect principal or secondary DX
and procedure 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
578 DRG change due to incorrect DX
DRG change due to incorrect principal or secondary DX
codes(s) 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
582 DRG change due to proc code/discharge
DRG change due to incorrect principal or secondary
procedure 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
580 DRG change due to procedure code
DRG change due to incorrect principal or secondary
procedure code(s) 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
579 DRG change/payment due to discharge stat DRG change/payment due to incorrect discharge status 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
585 DRG coding review;Denied med record IP DRG coding review; denied for medical records 252 M127
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB5 DRG Doesn't Match The billed DRG does not match the Grouper DRG 16 N208 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R42 DRG Payment DRG Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R39 Dup Claim Prev Pd at Correct Rate/Ca
Duplicate claim previously paid at correct rate or
capitated. B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R41 Dup Clm Previously Denied Appropriate Duplicate Claim Previously Denied Appropriately B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I65 Dup Clm-Prev denied approp Duplicate Claim-previously denied appropriately B13 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X39 DupClaimPrevPd at Correct Rate/Cap
Duplicate claim previously paid at correct rate or
capitated. B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
409 Duplicate bill, previously considered
This is a duplicate claim that has previously been
considered. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
409 Duplicate bill, previously considered
This is a duplicate claim that has previously been
considered. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CM Duplicate bill, previously considered
This is a duplicate claim that has previously been
considered. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CM Duplicate bill, previously considered
This is a duplicate claim that has previously been
considered. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G12 Duplicate Claim Prev Denied appropr Duplicate Claim Previously Denied Appropriately 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
485 Duplicate claim, previously considered
This is a duplicate claim that has previously been
considered. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
485 Duplicate claim, previously considered
This is a duplicate claim that has previously been
considered. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H39 Duplicate Condition 1
Duplicate Logic Condition 1 - Everything the same
except Submitted 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H40 Duplicate Condition 2
Duplicate Logic Condition 2 - Everything the same
except Allowed 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H41 Duplicate Condition 3
Duplicate Logic Condition 3 - Everything the same
except co-pay. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H42 Duplicate Condition 4 Duplicate Logic Condition 3 - Everything the same. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H44 Duplicate of New/Deleted Proc Code.
During the grace period for a new or deleted procedure
code only 16 M84
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMY Duplicate Procedure on Same Day Duplicate Procedure on Same Day 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
954 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
969 Duplicate procedure/payment Adjusted - duplicate procedure or payment. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V03 Duplicate pymt to incorrect provider R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G45 Duplicate Service Within 30 Days
This health service code was denied because an
inclusive same or simil B13 M86
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H43 Duplicate Submission This claim has been previously submitted. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK3 Dx Code Invalid for Inpatient Claim Dx Code Invalid for Inpatient Claim 11 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H09 Dx Code Not Coded to Highest Level
The billed diagnosis code is not coded to the highest
level of 16 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS National Coverage Determinations (NCD) Policy
H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
H19 DX Doesn't Support Procedure Code The procedure code submitted does not support the 11 N657 CMS Coverage Policies
469 Dx invalid for DOS Diagnosis invalid for date of service 146 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BU Dx invalid for DOS Diagnosis invalid for date of service 146 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G47 E & M Level Of Service Recoded
This health service code was changed to one that is
consistent with th B15 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H93 E&M Code level Re-coded
The level of the Evaluation and Management visit has
been recoded 150 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM4 E&M svs. Btwn Global Pre and Post Op Per E&M svs. Btwn Global Pre and Post Op Period 97 N525 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G48 E/M Service Inappropriately Coded
This health service code was denied because it was
inappropriately cod 16 M81
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH8 E/M Service inappropriately coded The health code was denied because it was
inappropriately coded based
11 M64 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J59 EDI issue- incorrect info. mapped R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V57 EDI issue- incorrect info. Mapped R129:Administrative Overturn 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
410 Emergency room report required
The emergency room report is required for
consideration of this claim. 16 N391
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A0 Emergency room report required
The emergency room report is required for
consideration of this claim. 252 N706
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J31 Encounter req change after clm pymt R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BW EOB cannot be read
Please resubmit legible EOB. Original EOB could not be
read. 251 N205
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R11 EOB from prim carrier req Resubmit with EOB from Primary Carrier 16 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J17 EOB in system not applied correctly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V16 EOB in system not applied correctly R129:Retro Authorizations 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J19 EOB in system yet processed as primary R129:Valid EOB on File 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB5 EOB Missing Date Rec or Denial Reas EOB Missing Date Received or Denial Reason 251 N480 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
039 EOB Statement Explanation This explanation will appear on the EOB 23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R96 EOB/Attachmnts were Incomplete/Illeg EOB/Attachments were Incomplete/Illegible 251 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J20 EOB/TPL in system not effective on DOS R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I73 EPSDT Form was Incomplete EPSDT form was incomplete 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X73 EPSDT Form was Incomplete EPSDT Form was Incomplete 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R63 EPSDT Pay Adj-5 /12 year old screeni
EPSDT Payment Adjustment For 5 And 12 Year Old
Health Screen 24
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZ8 ER med record review completed; Denied
ER medical record review completed; records do not
support 216 N109
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT0 Established /New Patient
An Established visit should be billed instead of New
Patient B16
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J36 Ex adj clm by mistake/no chge in outcome R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V34 Ex adj clm by mistake/no chge in outcome R129:Settlement Adjustment 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J49 Examiner overlooked addtlmod/dx Examiner overlooked addtl mod/dx 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
917 Exceeded benefit maximums Adjusted - member maximum benefit was exceeded. 119
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
466 Exceeds allowed units
The units submitted on this claim exceed the daily unit
allowance. 96 N362
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BQ Exceeds allowed units
The units submitted on this claim exceed the daily unit
allowance. 96 N362
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
413 Exceeds approved length of stay
The services rendered exceed the approved length of
stay. 152 M26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,
the frequency
150 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,
the frequency
150 N130 CMS National Coverage Determinations (NCD) Policy
H20 Exceeds Clinical Guidelines Based upon clinical guidelines for this procedure code,
the frequency
150 N130 CMS Coverage Policies
4AN Exceeds contracted rate
Billed charges exceed contracted rate. Member not
liable 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DF Exceeds contracted rate
Billed charges exceed contracted rate. Member not
liable 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
G40 Exceeds Coverage Guidelines
This health service code was denied as this service
exceeds the frequ 151 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD6 Exceeds daily limitation
Exceeds the daily limitation of 1 ER Visit per date of
service 273 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD6 Exceeds daily limitation
Exceeds the daily limitation of 1 ER Visit per date of
service 273 N362
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD8 Exceeds daily limitation
Exceeds the daily limitation of 1 ER Visit per date of
service 273 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD8 Exceeds daily limitation
Exceeds the daily limitation of 1 ER Visit per date of
service 273 N362
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A4 Exceeds DRG reimbursement The services rendered exceed the DRG reimbursement. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B36 Exhaustion of Benefits Exhaustion of Benefits 119 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I26 Exhaustion of Benefits Exhaustion of Benefits 119 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G49 Experimental/Investigational
This health service code was denied because it is
considered experime 55 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF6 External Error - Auth/Ref Req to Config
External Error - Auth/Ref Requirements to Config
Revised/Reversed 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J65 Externally Priced Claims Manual pricing applied for correct payment 45 N442 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE2 Facility Prov not enrolled in Medicaid Facility Prov not enrolled in Medicaid Program 16 N278 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZB Fam Plan Consent Form Rev: Missing Info Family Planning Consent Form reviewed: 251 N228 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZC Fam Plan Consent Form reviewed: payable Family Planning Consent Form Reviewed: Payable 216 N11
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
459 Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BE Fed tax ID invalid/missing/termed Provider tax ID is missing, invalid or termed. 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
601 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XF2 Follow-up Incentive Payment Follow-up Incentive Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMD Gender of Patient Not Consistent w/Code
The Gender Of The Patient Is Not Consistent With
Service Code Billed. 7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Y98 General Claim adjustment from NaviNet General Claim adjustment from NaviNet 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V77 Global maternity code only payable as sc
The Health Plan only considers payment on a global
maternity code as t 22 MA04
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H84 HCPCS Code Not Appropriate According to CMS guidelines, the billed HCPCS code has
been
8 CMS Coverage Policies
G67 HCPCS Code Not Appropriate For Profe
According to CMS guidelines, the billed HCPCS code has
been designate 189 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G42 HCPCS Recoded Based On Gender
The health service code has been changed to correlate
to the appropria 7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G81 HCPCS Recoded Per Health Plan Policy
The billed HCPCS was recoded to another HCPCS code
based on Health Pla 189 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH9 HCPCS recorded based on gender The health service code has been changed to correlate
to the
7 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HDR High Dollar Review Team High Dollar Review Team 133 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J51 High Dollar review, reprocess claim R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V50 High Dollar review, reprocess claim R129:Clm Proc w/o ICD9 surgical code 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZPD HMS - Rebill ER care
HMS identified that ER care should be rebilled at an
appropriate level 150 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM0 HMS Overturn Appeals Process Review Appeal Overturn 216 MA91 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
586 HMS Review no findings pay as billed HMS Review no findings pay as billed 216 N11 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMQ Hosp O/P Specific Billed Serv Code Combo
Hospital Outpatient Based on NCCI. The specific billed
service code is 236
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMB Hosp.Outpt Proc.is Mut.Excl.On Prior Clm
Hosp.Outpt Proc.is Mut.Excl to Prior Clm submisson on
same DOS 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMA Hosp.Outpt Procedure is Mutually Excl.
Hosp Outpt Proc.is Mutally Excl. Two Proc are consid.
Mut Exclusive 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMC Hosp.Outpt.Based on NCCI Proc
Hosp.Outpt.Bsd on NCCI Proc Mut Excl.Non payable
code was Pd 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M72 I/P Billed as OBSV
Claim was billed as Inpatient but was authorized as
Inpatient 186 N54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
Z86 I/P Billed as OBSV
Claim was billed as Inpatient but was authorized as
Inpatient 60
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V65 ICD-9 surgical code needed on claim R129: Prior Processing Information Appears Incorrect 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J50 ICD-9 surgical code needed on claims R129:Clm Proc w/o ICD9 surgical code 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V48 ICD-9 surgical code needed on claims R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Y99 ICM claims adjustment for CDPS process
Intensive case management process - claim adjustment
for CDPS process 45 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
190 If A0999 is billed over 30 units submit
If A0999 is billed over 30 units, please submit supporting
documents 252 N706
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V17 IIIegible/incomplete EOB attached R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZE3 Illegible Records Submitted
Illegible records submitted Please re-file legible
records; Program 251 N237
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J21 Illegible/incomplete EOB attached Illegible/incomplete EOB Attached 251 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IRR Implant In Review Implant In Review 163 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IA2 Implant included in DRG reimb Implant included in DRG reimbursement line item 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IR1 Implant Invoice Required Implant Invoice Required 163 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IA1 Implant payment based on clin rev
Implant payment based on clinical review line item
explan 50 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B09 Implant Procedure Requires Implant De
This implant procedure code was denied because the
associated implant 16 N354
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R91 Inappropriate Coding for Contract/Agr Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H92 Inappropriate Place of Service The Place of Service indicated on the claim is not
appropriate for
58 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H92 Inappropriate Place of Service The Place of Service indicated on the claim is not
appropriate for
58 CMS National Coverage Determinations (NCD) Policy
H92 Inappropriate Place of Service The Place of Service indicated on the claim is not
appropriate for
58 CMS Coverage Policies
HS6 Incidental Phys Service Item or Service is incidental to the Physician's Service 234 N390
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G54 Include in Monthly Rental Fee
This health service code was denied because it is
considered to be inc 108 N370
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G83 Included In Blood/Blood Product Reve
The Revenue code was denied as it is a part of the
Blood/Blood Product 97 N19
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
416 Included in contracted rate
The services rendered are included in the contracted
rate. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A6 Included in contracted rate
The services rendered are included in the contracted
rate. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS5 Included in E&M Procedure is included in E&M Code 97 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H03 Included in E&M Service This service is included in the billed Evaluation and
Management code
97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H24 Included in Global Fee This code is included in the global fee for another
procedure.
97 N19 National Correct Coding Manual Policy
H24 Included in Global Fee This code is included in the global fee for another
procedure.
97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A7 Included in inpatient per diem
The services rendered are included in the inpatient per
diem. 45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A7 Included in inpatient per diem
The services rendered are included in the inpatient per
diem. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
MBC Included in Mom/Baby Case Rate Payment is included in Mom and Baby Case Rate 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMB Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMC Included in Mom/Baby Case Rate Well baby is included in Mom Claim Payment 128 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G55 Included In Other Code
This procedure has been included as part of another
procedure. 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G53 Included In Physical Medicine Service
This health service code was denied because it is
considered to be an 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
H01 Included in Primary Procedure This procedure has been included in the primary
procedure.
97 N19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H01 Included in Primary Procedure This procedure has been included in the primary
procedure.
97 N19 National Correct Coding Initiative Policy
H01 Included in Primary Procedure This procedure has been included in the primary
procedure.
97 N19 National Correct Coding Initiative Supplemental Policy
H01 Included in Primary Procedure This procedure has been included in the primary
procedure.
97 N19 CMS National Coverage Determinations (NCD) Policy
H01 Included in Primary Procedure This procedure has been included in the primary
procedure.
97 N19 National Correct Coding Manual Policy
H22 Included in Radiation TX Mgt Svc.
These services are included in the weekly radiation
treatment 97 N19
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B66 Included in Settlement Payment Included in Settlement Payment 97 N45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X25 Included in Settlement payment Included in Settlement payment 45 N664 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V06 Incorr. Prov info loaded/att to incor ag R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J06 Incorr. Prov info loaded/att to wrg agrm R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V12 Incorrect Auth/Referral applied to claim R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
957 Incorrect charge Adjusted - incorrect charge. 16 M54 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
958 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
971 Incorrect claim data Adjusted - incorrect claim data. 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B40 Incorrect Contract Amount Prev Paid Incorrect Contract AMount Previously Paid 129 MA130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
959 Incorrect date of service Adjusted - incorrect date of service. 16 MA31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
960 Incorrect diagnosis code Adjusted - incorrect diagnosis code. 146 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G24 Incorrect Diagnosis Code Entered Incorrect Diagnosis Code Entered on Previous Claim 146 M64
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I32 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X65 Incorrect form type for svc submitted Incorrect form type for services submitted 16 N34 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
961 Incorrect member/patient
Adjusted - incorrect member/patient selected on
original claim 16 MA36
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
972 Incorrect member/patient
Adjusted - incorrect member/patient selected on
original claim 16 MA36
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
419 Incorrect modifier
The service submitted has been reported with an
incorrect modifier. 4
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5A9 Incorrect modifier
The service submitted has been reported with an
incorrect modifier. 4
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
962 Incorrect number of units Adjusted - incorrect number of units. 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
973 Incorrect payee Adjusted - paid to incorrect payee. 16 N279 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G13 Incorrect Place of Service Incorrect Place of Service on Previous Claim 5 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I34 Incorrect proc/diag for EPSDT payment Incorrect procedure/Diagnosis for EPSDT payment 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
964 Incorrect procedure code Adjusted - incorrect procedure code. 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V66 Incorrect provider paid Incorrect provider paid B7 N570 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA3 Incorrect Provider/TIN ID # submitted Incorrect Provider/TIN ID # submitted 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z76 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA6 Incorrect Provider/TIN ID Submitted Incorrect Provider/TIN Identification Number Submitted 16 N209
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
420 Incorrect revenue code / resubmit The revenue codes that has been submitted is incorrect. 16 M50
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G09 Incorrect Secondary Liability Incorrect Secondary Liability 252 MA64 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J24 Incorrect TPL info supplied by state R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V22 Incorrect TPL info supplied by state R129:Secondary EOB req 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
462 Incorrect/missing pos
The claim has been submitted with an incorrect or
missing place of 16 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J53 Inpatient downgrded to lower lvl of care R129:inpt downgrd to lower level of care 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
K51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V51 Inpatient downgrded to lower lvl of care R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J54 Interest paid in error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V53 Interest paid in error R129:inpt downgrd to lower level of care 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
975 Interest paid incorrectly Adjusted - interest paid incorrectly. A7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
R64 Interim Bill 1st Cycle Payment Interim Bill 1st Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R65 Interim Bill 2nd Cycle Payment Interim Bill 2nd Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R66 Interim Bill Final Cycle Payment Interim Bill Final Cycle Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R43 Interim Bill Payment Interim Bill Payment 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X33 Interim Bill Resubmit Final Bill Interim Bill Resubmit Final Bill 135 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
421 Interim bill, submit clm for entire stay
This is an interim bill. Please submit claim for the entire
stay. 16 MA31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF8 Internal Delay - Auth/Ref not on file
Internal Delay - Auth/Referral not on file During initial
Processing 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J07 Internal enrollment error R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF2 Internal Error - Incomp/Inaccurate Req
Internal Error - Incomplete/Inaccurate Requirements
Provided to Config 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA8 Invalid Admission DX Eff Date Invalid Admission Diagnosis Effective Date 146 MA65 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA5 Invalid Bill Type Invalid Bill Type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I93 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z90 Invalid Billing Invalid Billing 95 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA4 Invalid CPT/HCPCS Code Invalid CPT/HCPCS Code 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H32 Invalid Diagnosis Code The diagnosis code listed on the claim is invalid. 146 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB6 Invalid Discharge Status Invalid Discharge Status 16 N50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J71 Invalid Gender for DX Invalid Gender for DX 10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMJ Invalid Gender for DX Invalid Gender for DX 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R32 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X99 Invalid Gender for Procedure Member's Sex Not Valid Procedure Code 7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
185 Invalid Member Date of Birth
Members Date of Birth on Claim does not match DOB in
FACETS 16 N329
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
184 Invalid Member Name
Member Name on claim does not match Name in
FACETS 16 MA36
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
422 Invalid member number submitted
The claim has been submitted with an invalid member
number. 31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AB Invalid member number submitted
The claim has been submitted with an invalid member
number. 31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZHA Invalid Modifier
Invalid Modifier used. Submit claim without modifier or
appropriate 182 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZHA Invalid Modifier
Invalid Modifier used. Submit claim without modifier or
appropriate 182 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB1 Invalid NPI Invalid NPI 207 N257 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB5 Invalid or Multiple Evidence Based Progr
Invalid or Multiple Evidence Based Program Indicators
on Claim 95 N182
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE7 Invalid ORP Ordering prov type Invalid ORP Ordering Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEH Invalid ORP Referring and Ordering Prov Invalid ORP Referring and Ordering Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE8 Invalid ORP Referring Prov type Invalid ORP Referring Prov type 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA7 Invalid Patient Status for Bill Type Invalid Patient Status for Bill Type 16 MA43 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I68 Invalid place of service for procedure Invalid Plance of Service for Procedure 5 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Q55 Invalid Procedure Code Procedure is invalid for this date of service 181 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ISR Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IST Invalid Sex for Diagnosis Member's Sex Not Valid Diagnosis Code 10 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ISU Invalid Sex for Diagnosis Member Sex Invalid for Diagnosis Code 10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA3 Invalid Units Invalid Units 16 M53 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK1 Invalid/Deleted Code, Modifier, or Descr Invalid/Deleted Code, Modifier, or Description 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AW Invalid/missing bill type The submitted bill type is invalid or missing. 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DP Invalid/missing code - CPT, HCPCS or mod
The submitted procedure code or modifier is missing or
invalid. 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DW Invalid/missing diagnosis code The submitted diagnosis is invalid or missing. 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Submitted Claim 16 M50
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R86 Invalid/Missing Rev Code on Claim Invalid/Missing Revenue Code on Claim 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
458 Invoice pricing Pricing based on submitted invoice. 45 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
5BD Invoice pricing Pricing based on submitted invoice. 45 N649 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
424 Invoice required The invoice is required. 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AD Invoice required The invoice is required. 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R57 IP stay if <24 hrs IP stay if<24 hrs, resubmit as observation 150 N640 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZF0 IS Processing Error IS Processing Error 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J68 Itemized bill/invoice/med rec rec'd Itemized bill/invoice/med rec rec'd 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X75 JCode ident as med exp instead pharm
J Code identified as medical expense instead of
pharmacy 96 N448
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V36 KMHP had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H80 Lab compnt price exceeds lab panel price Price of Lab Panel components exceed lab panel price 45 N70 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
478 Late charge ineligible
Late charge claim cannot be accepted. Combine original
claim and late 16 MA30
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5C7 Late charge ineligible
Late charge claim cannot be accepted. Combine original
claim and late A1 MA30
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J73 Late charges applied Late charges applied 45 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB7 LCD - Procedure vs Diagnosis
Billed DIagnosis does not support Medical Necessity -
refer to LCD 11 N115
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB8 LCD - Procedure vs Diagnosis
Billed DIagnosis does not support Medical Necessity -
refer to LCD 11 N115
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
217 Line Received with Zero Billed Charge Line Received with Zero Billed Charge, Nothing is Due.
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
MA1 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
MA2 MA based SPU Overpayment MA based SPU Overpayment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J69 Mat Kick payment applied Mat Kick payment applied 131 N442 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B46 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I23 Mbr sex & age invalid both proc & dx Member sex and age is invalid both procedure and dx 7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J81 McKesson historical clinical edit Correction to a prior claim 129 N377 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z25 Medicaid Fee for Service Medicaid Fee for Service 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I99 Medicaid Prov # Missing or Invalid Medicaid provider number is missing or invalid 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZE0 Medical Record Review Complete
Medical Record Review Complete; documentation does
not support 96 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZE1 Medical Record Review Complete
Medical Record Review Complete; documentation does
not support 96 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZE Medicare A unavailable submit Part B EOB Medicare A unavailable submit Part B EOB 16 N479 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
MCO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XMO Medicare Contractual Obligation Medicare Contractual Obligation 45 N6 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9BP Medicare Primary Care Physician Bonus Medicare Primary Care Physician Bonus Payment 161 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R87 Medicare/Medicaid Sanctioned Provider Medicare/Medicaid Sanctioned Provider 184 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 24 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X88 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XC7 Medicare/Third Party Denial on File Medicare/Third Party Denial on File 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M74 Member has Multiple Insurances
Member has multiple insurances. Submit EOB from
other carrier 16 MA64
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z75 Member has Multiple Insurances
Member has multiple insurances. Submit EOB from
other carrier 22 MA64
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
TRI Member is tri-eligible; Submit EOBs
Member is tri-eligible; Submit EOBs from all insurance
carriers 169 N23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS2 Member not Eligible at Time of Service Member was not Eligible at Time of Service 200 N650 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB3 Member not enrolled in Evidence Based Pr Member not enrolled in Evidence Based Program 272
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I39 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X55 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZH2 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZH3 Members Age not valid for diagnos code Members Age not valid for diagnosis code 9 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B21 Members Age not valid for procedu code Members Age not valid for procedure code 6 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
A54 Met Monitoring Incentive Metabolic Monitoring Incentive 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
V55 Mgmt decision to waive business rule R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB4 Missing CC/MCC Diagnosis
The Provider's billed DRG indicates a
complication/comorbidity that 16 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMK Missing CLIA Number on Claim Missing CLIA Number on Claim 16 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB2 Missing Discharge Hour for Disc Bill Typ Missing Discharge Hour for Discharge Bill Type 16 N317 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
130 Missing DX for Intensive Case Mgmt Progr Missing Dx for Intensive Case Mgmt Program 16 M76 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA1 Missing HCPCS Code for Bill Type Missing HCPCS Code for Bill Type 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I97 Missing/Illegible Charge Billed Missing or Illegible Charge Billed 16 M79 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z41 Missing/Illegible CPT,HCPCS or ICD-9 Missing/Illegible ICD-9 procedure code submitted 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 CMS Coverage Policies
IH1 Missing/incomplete/invalid Revenue code MISSING/INCOMPLETE/INVALID REVENUE CODES(S). 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZJ9 Missing/Incomplete/Invalid Revenue Code Missing/Incomplete/Invalid Revenue Code 16 M50
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS9 Mod 26/TC Not allowed for Service
Modifiers 26 or TC are not allowed for Professional or
Technical 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H76 Mod Inappropriate/Req/Inval for Service Modifier Inappropriate/Required/Invalid for Service 4 N657 CMS National Coverage Determinations (NCD) Policy
HMU Mod QW required
Per CLIA Requirements a modifier QW is required for
this procedure 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSA Mod TC not allowed for this Service Code Modifier TC is not allowed for this Service Code 4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H27 Modifier Adjustment The recommended percentage for this procedure has
been adjusted based
4 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZK2 Modifier Combination Invalid Modifier Combination Invalid 4 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G64 Modifier Inappropriate For Place Of Se Modifier Inappropriate For Place Of Service 5 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a
modifier that
4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H77 Modifier Inappropriate for Procedure This procedure was denied because it was billed with a
modifier that
4 N519 CMS Coverage Policies
G63 Modifier Inappropriate For Provider Ty N/A 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G60 Modifier Inappropriately Coded
The modifier for this service has been changed to reflect
appropriate 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H82 Modifier Inappropriately Coded The modifier for this service has been changed to reflect
appropriate
4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSX Modifier not Applicable
Per Plan Requirements, the service code and modifier
cannot be billed 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H57 Modifier removed on Termed Proc Code Modifier removed. Terminated procedure can not be
billed bilaterally
4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H65 Modifiers Re-Ordered
The modifiers on the claim line were reordered based on
the 182 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H96 More Than 1 Asst Surgeon Not Allowed Only one assistant surgeon is allowed for the procedure
submitted.
54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS0 More than one Interp and Reading perfrmd
More than one interpretation and reading being
performed for the same 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X83 Mother's Bill not Received; Refile Mother's Bill not Received; Refile 16 N182 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X12 Motor Vehicle Accident - Auto Primary Motor Vehicle Accident-Auto Carrier Primary 20 MA04 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD4 MSRP is missing MSRP is missing and is required with the claim 252 M23 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSC MUE for DME Medically Unlikely Edits for DME 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSD MUE For Hospitals Medically Unlikely Edits for Hospitals 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSB MUE for Physicians Medicallly Unlikely Edits for Physicians 151 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RB1 Multiple Corrected Claims Submitted
Multiple Corrected Claims Submitted. Last submission
will be used. 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RB1 Multiple Corrected Claims Submitted
Multiple Corrected Claims Submitted. Last submission
will be used. 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H26 Multiple Endoscopy Review Multiple endoscopy, modifier 51 has been removed. 97 N20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
G32 Multiple Endoscopy Rules
The claim has been processed using the Multiple
Endoscopy methodology. 59 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G66 Multiple Nuclear Medicine Studies N/A 59 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT2 Multiple Paymnt Reduction Imaging
Multiple Procedure Payment Reduction on the Technical
Component 59
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT1 Multiple Proc Reduction - Imaging
Multiple Procedure Payment Reduction on the Technical
Component 59
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G80 Multiple Procedure Reduction for Radi The technical component of this service code was
reduced because more
59 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H28 Multiple Procedure Review
This code is subjected to a multiple procedure reduction
when more 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DZ Multiple same day surgery reductions
The allowable amount for this service has been reduced
according to 59 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R44 Multiple Surgical Reduction Multiple Surgical Reduction 59 N670 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H58 Mutually Exclusive of Another Proc This code should not be reported since a similar
procedure was
97 N20 National Correct Coding Manual Policy
H58 Mutually Exclusive of Another Proc This code should not be reported since a similar
procedure was
97 N20 National Correct Coding Initiative Supplemental Policy
H58 Mutually Exclusive of Another Proc This code should not be reported since a similar
procedure was
97 N20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M73 Name/DOS on case notes do not match Member name/DOS on case notes do not match claim 250 N206
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z74 Name/DOS on case notes do not match Member name /DOS on case notes do not match claim 16 N329
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X91 nappropriateCoding ForContract/Agree Inappropriate Coding for Contract/Agreement 256 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G38 National Correct Coding Policy Manual
This health service code was denied based on correct
coding guidelines 16 M81
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
425 Nbr of units dont correspond w/date span
The number of units billed does not correspond with the
date span 16 M23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AE Nbr of units dont correspond w/date span
The number of units billed does not correspond with the
date span 16 N345
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT8 NCCI Column 1 denied,Column II paid prev
NCCI Column I and Column II codes billed out of
sequence for same date 234 M80 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT8 NCCI Column 1 denied,Column II paid prev
NCCI Column I and Column II codes billed out of
sequence for same date 234 M80
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H17 NCCI Denial- Mutually Exclusive This health service code was denied as mutually
exclusive of another
231 National Correct Coding Initiative Policy
H18 NCCI Denial-Comprehensive/Component This health service code was denied as a component of a
comprehensive
97 N19 National Correct Coding Initiative Policy
5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BX NDC number required Denied - NDC number required; resubmit with NDC 16 M119
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I38 Need Newborn Number Need Newborn Number 32 N15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G69 New Patient Visit Allowed Once Per 3 N/A B16 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZB0 Newborn Birth Weight Required Newborn Birth Weight Required 16 M49 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA7 Newborn Inpt > 30 days require Auth
Newborn Inpt > 30 days require Auth/submit itemized
bill 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA8 Newborn Inpt >30 day/pymt reduced no aut Newborn inpt>30 days/payment reduced for no auth 210
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
A50 Newborn inpt >30 days requires
Newborn inpt > 30 days requires auth/submit itemized
bill 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
A51 Newborn inpt>30 day/pymt reduce Newborn inpt > 30 days/payment reduced for no auth 210
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZB6 NIA Multiple Procedure Discount Applied NIA Multiple Procedure Discount Applied 59 M75 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H06 No Assist Needed For This Procedure Procedure Denied. The procedure code billed does not
require the
54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE6 No Attending NPI Submitted No Attending NPI Submitted 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V15 No auth existed at time of processing R129:Authorization/Referral Updated 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
R24 No Benefit. OIC Pymt Equals/Exceeds L
No Benefit Due. Other Carrier Payment Equals/Exceeds
our Liability 23 N9
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZMM No CLIA Number on our File No CLIA Number on our File 16 MA120 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X89 No MAID on File No MAID number on file. Contact Provider Services. 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZJ7 No MAID on file No MAID on file 183 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M97 No Medicaid Allowable, paid at 30% No Medicaid Allowable, paid at 30% 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R27 No PCP Required for PE Member No PCP Required for Presumptive Eligibility Member 24
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z07 No Pre CertAuthorization/ or Referral Authorization/Referral not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R01 No Precert/Authorization or Referral
Precert/Auth/Notification not obtained, denied or
invalid 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD4 No referring or ordering NPI submitted No referring or ordering NPI submitted on claim 16 N265 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z58 No supporting doc or ambul run sheet
No supporting documents or ambulance run sheet
received 252 N745
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B62 No supporting documents received No supporting documents received 16 N29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B38 Non contracted level of care Non contracted level of care 96 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH3 Non Covered Charges Non covered charges 96 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSE Non covered member SIU has never received eligibility for this member 31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSF Non Covered member/plan Member benefits are not payable through this plan 31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HB9 Non -Covered Revenue Code Not a covered revenue code Healthcare 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H51 Not a Covered Procedure Certain procedures are not covered as deemed by the
plan.
96 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H51 Not a Covered Procedure Certain procedures are not covered as deemed by the
plan.
96 N130 CMS Coverage Policies
H51 Not a Covered Procedure Certain procedures are not covered as deemed by the
plan.
96 N130 CMS National Coverage Determinations (NCD) Policy
HSG Not a Covered Service Not a Covered Service 96 N643 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM3 Not Appr to Bill Ext DX code in 1st pos
Not Appr to Bill External Cause DX in the First ICD
Position 167 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM2 Not Appr to Bill Ext DX W/O another DX
Not Appropriate To Bill An External Cause Diagnosis
W/O another 167
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G72 Not considered safe and/or effective.
This service was denied because it is not considered safe
and/or effec 56
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G68 Not Covered For Diagnosis Indicated
This health service code was denied as it is not a
covered service whe 16 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H74 Not Covered for Diagnosis Indicated This health service code was denied as it is not a
covered service
11 N657 CMS National Coverage Determinations (NCD) Policy
H99 Not Covered for Provider Specialty Certain procedures are not covered for specific
specialties as deemed
185 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H99 Not Covered for Provider Specialty Certain procedures are not covered for specific
specialties as deemed
185 N95 CMS Coverage Policies
G70 Not covered when performed by this pr
Payment for services is denied when performed by this
specialty/provid 184 N808
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AY Not cvrd/prv agreement This service is not covered per your provider agreement. 170
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5E0 Not cvrd/prv agreement This service is not covered per your provider agreement. 170
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V84 Not enrolled on date of service Not enrolled on date of service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X10 Not Enrolled on Date of Service Not Enrolled on Date of Service 31 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G71 Not Included In Opps
This health service code was denied because it is not
recognized under 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BN Notes required
Please submit corresponding operative, radiology or
office notes. 252 N710
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B26 Nursing Home Confined > 30 Days - Dis
Nursing Home Confined Greater than 30 days-Member
Disenrolled 27 N30
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
X93 NursingHomeConfined >30 Days - Disenr
Nursing Home Confined Greater then 30 days-Member
Disenrolled 27 N30
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J70 Observation < 24 hrs Observation < 24 hrs 186 M25 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M71 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 186 N54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z72 OBSV Billed as IP Claim was billed as OBSV but was authorized as IP 60 N676
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H95 Only 1 E&M Code Allowed Per Day This E&M service was denied because only 1 E&M
service is allowed for
B14 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H29 Only 1 Service Allowed per Treatment The allowed course of treatment for this procedure code
has been
151 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G65 Only One Anesthesia Service Per Opera
This procedure was denied because only the anesthesia
service which ha 59 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMZ Only one visit allowed per day Only one visit allowed per day B14 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE3 Operating Prov not enrolled in Medicaid Operating Prov not enrolled in Medicaid Program 16 N262
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AP Operative report required
Claim should be re-submitted with copy of operative
report 163 M29
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DG Operative report required
Claim should be re-submitted with copy of operative
report 252 M29
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEM Ordering and Referring Prov NPI is a non
Ordering and Referring Prov NPI is a non-individual per
NPPES Registry 16 N265
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD6 Ordering not enrolled in Medicaid Progra Ordering not enrolled in Medicaid Program 184 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEC Ordering NPI is not enrolled with state
Ordering NPI is not enrolled with state as provider type
31- physician 16 N265
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XED Ordering Provider NPI is a non-individua
Ordering Provider NPI is a non-individual per NPPES
Registry 16 N265
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZB5 Orgl clm processed submit corrected clm
The Original claim has been processed submit a
corrected claim 16 N152
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V13 Original auth updated w/add'l info R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GA9 Original Claim Number missing or invalid Original Claim Number missing or invalid 16 N152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE0 ORP Provider not enrolled in Medicaid
Ordering, Referring, Prescribing Provider not enrolled in
Medicaid 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE9 ORP Provider not submitted Ordering, Referring, Prescribing Provider not submitted 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
920 Other COB
Payment adjusted as the result of coordination of
benefits. 22 N4
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G18 Other Insurance not Effective on DOS Other insurance was not effective on Date of Service 23 MA17
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE4 Other operating prov not enrolled in Med Other operating prov not enrolled in Medicaid Program 16 N262
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limited 119 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X46 Over Max Procedure/Benefit Limit Over Maximum Procedure/Benefit Limit 119 N362 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J47 Overpayment of physician services R129Total Comp Phy svs incl in Fac paymt 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V46 Overpayment of Physician Services R129:Non-covered svs paid incorrectly 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J48 Overpayment on SPU R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V47 Overpayment on SPU R129Total Comp Phy svs incl in Fac paymt 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V63 Overpayments identified by Concentra R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J46 Overpaymt due to non cover svs pd incorr R129:Non-covered svs paid incorrectly 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V45 Overpymt due to non cover svs pd incorr R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H98 Packaged Incidental Service Payment is included in the allowance for another
service/procedure
97 N20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J35 PAD- Passport advantage Lob 1300 R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R83 Paid at Average Wholesale Price Paid at Average Wholesale Price 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7A1 Paid by auto insurance The claim has been paid by auto insurance. 21 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J58 Panel transfer R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G76 Partial Hospitalization Not Indicate
This health service code was denied because condition
code 41 (Partial 16 M44
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G52 Partial Hospitalization Requires Men
This health service code was denied because a partial
hospitalization 135 MA93
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
HSL Partial Payment Hold - DOS Partial Payment Hold Based on Date of Service 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSK Partial Payment Hold - Rec'd Date Partial Payment Hold based on Received Date 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H55 Payable Only W/ Active Intervention
Procedure requires active intervention and is not
payable when 107 N674
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH4 Payment adj invalid place of service Payment Adj- treatment deemed rendered in inapp POS 16 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
MAT Payment Adj Maternity Kick Payment Payment adjustment for Maternity Kick Payment 144 N422 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH7 Payment denied when performed by provide Payment is denied when performed /billed by provider
type in type of
170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HA2 Payment for this service/item is bundled Payment for this service/item is bundled 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSI Payment Hold - Rec'd Date Payment hold based on Received Date 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSJ Payment Hold - DOS Payment hold based on Date of Service 133 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
181 Payment included in DRG Payment included in DRG 97 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R00 Payment Included in Other Billed Serv Payment Included in Other Billed Service 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X00 Payment Included in Other Billed Serv Payment Included in Other Billed Services 97 M15 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZRD Payment Reduced Incomplete PASRR Payment Reduced Due to Incomplete PASRR 272 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I46 Payment reflects combined DRG payment Payment reflects combined DRG payment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HME Phys.Ther Svs not payble in Hosp.Setting
Physical Therapy Service Is Not Payable In A Hospital
Inpatient 5 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT3 Place of Service Facility
Place of Service for this procedure is invalid or not
normally 58
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J37 Plan had update info - but loaded late R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R84 Please Obtain Individual Provider ID# Resubmit w/Individual Provider Name/Number 16 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
519 Please resub family planning related
Please resubmit family planning related charges to
IUMG 109 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AJ Please submit charges to Medicare Please submit charges to Medicare. 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AK Please submit other carrier's info. Please submit other carrier's information. 16 N4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR2 Please submit the correct original claim
Please submit the correct original claim number for
consideration 95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZR2 Please submit the correct original claim
Please submit the correct original claim number for
consideration 95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZQ1 Please Submit to Coastal Care Services 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X84 PleaseObtain Individual Provider ID # Please Obtain Individaul Provider Identification Number 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I47 Pmt based on DRG transfer policy
Payment is based on DRG transfer policy, DRG discharge
formula 45 N381
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4B3 POA required Present on admission indicator is required 16 N434 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSM POS - Non Facility
POS for this Procedure is invalid or not normally
performed in this 5 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSO POS Plan Specific Service Code
Per Plan requirements service code cannot be billed
with the POS 5 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSN POS Plan Specific/Service Code
Per Plan requirements specific place of service(s) are
required when 5 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H04 Post-Op Follow Up Incl in Global Fee The procedure is included in the global surgical fee for a
procedure
97 M144 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RA9 PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZD PPC/HCAC considered in the processing PPC/HCAC considered in the processing of this claim B22 N109
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSW Pre Admit Service included in Hospitaliz
3 Day window OP Serv s/b included in IP Stay. Non
Payable Code pd 60 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R48 Pre-Adm Testing Included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X48 Pre-Adm Testing included with SPU/Adm Pre-Admission Testing included with SPU/Admission 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z42 Pregnancy Risk Assessment Form Req'd Completed Pregnancy Risk Assessment Form Required 252 N80
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA9 Pregnancy Risk Assessment Form Required Completed Pregnancy Risk Assessment Form Required 252 N80
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
H50 Prev Proc/Paid to Same/Diff Provider Same procedure has been paid or processed to the
same or different
97 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R49 Previous Payments = to Purchase Pric Previous Payments Equal to Purchase Price B13 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X49 PreviousPayments = to Purchase Price Previous Payments Equal to Purchase Price 119 M7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G57 Price of Lab Panel Components Exceed
The price of the individual lab panel components have
exceeded the pri 97 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V25 Prim ins listed in Facets(Non Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J27 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V26 Primary ins listed in Facets(Medicare) R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J26 Primary ins listed in Facets/Non Medicar R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H12 Primary Procedure Must be Billed The procedure was denied because it requires an
accompanying procedure
107 MA66 CMS Coverage Policies
H12 Primary Procedure Must be Billed The procedure was denied because it requires an
accompanying procedure
107 MA66 CMS National Coverage Determinations (NCD) Policy
H12 Primary Procedure Must be Billed The procedure was denied because it requires an
accompanying procedure
107 MA66 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
A52 Primary/Sec Diagnosis POA Error Primary/Sec Diagnosis POA Missing/Invalid 167 N607 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z67 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z68 Primary/Sec Diagnosis POA Error Primary/Secondary Diagnosis POA Missing/Invalid 16 M76
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G46 Principal Diagnosis Inappropriately C
The principal diagnosis has been inappropriately coded
based upon ICD- 11 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G75 Principal Diagnosis Invalid
This health service code was denied because it was
submitted with an i 11 MA63
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZC8 Principal Surg Code is missing/invalid Principal Surgical Procedure is missing or invalid 16 MA66 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H66 Principle Diagnosis incorrectly utilized Missing/Incomplete/Invalid Principle Diagnosis 16 MA63 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
IH2 Proc Code and Mod inval of DOS Payment adjustment because the procedure and
Modifier invl on DOS
182 N657 CMS Coverage Policies
IH6 Proc code changed to acc desc svs Procedure code changed to accurately desc. The
services rendered
189 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V76 Proc Code isnt payable w T1015 Procedure Code isnt payable w T1015 236 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V75 Proc Code required with T1015 Procedure Code required with T1015 16 M51 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
461 Proc processed on separate claim id This claim has been processed under a separate claim id. B13
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM8 Proc. is Mut. Excl, Non Pay Cd pd prior
Mutually Excl.Proc is listed on Prior claims run For the
same DOS. 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
433 Procedural modifier(s) required The service submitted requires a procedural modifier. 4
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AN Procedural modifier(s) required The service submitted requires a procedural modifier. 4
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H31 Procedure Bilateral in Nature This procedure was adjusted because the service is
bilateral in nature
4 N644 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB4 Procedure Billed not part of Members Evi
Procedure Billed not part of Members Evidence Based
Program 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B15 Procedure code billed is not correct
Procedure code billed is not correct/valid or the date of
service bill 16 N56
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G29 Procedure Code Definition
This health service code was denied because it is
included in the CPT 97 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G30 Procedure Code Guideline
This service code was denied because it is
inappropriately coded based 4 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H16 Procedure Code Inapp. for Age The age of the patient does not correlate with the
submitted procedure
6 N129 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H71 Procedure Code Inappropriately Coded This service was denied because it is inappropriately
coded based on
189 N657 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more
appropriate
16 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
H91 Procedure Code Inappropriately Coded This code has been changed or denied to reflect a more
appropriate
16 M81 CMS Coverage Policies
H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the
circumstances in
16 M81 National Correct Coding Manual Policy
H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the
circumstances in
16 M81 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the
circumstances in
16 M81 National Correct Coding Initiative Supplemental Policy
H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the
circumstances in
16 M81 CMS Coverage Policies
H97 Procedure Code Inappropriately Coded This procedure code has been denied based on the
circumstances in
16 M81 CMS National Coverage Determinations (NCD) Policy
434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
434 Procedure code incorrect The procedure code submitted in not correct. 181 N56 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AP Procedure code incorrect The procedure code submitted is not correct. 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H14 Procedure Code Incorrect For Gender The gender of the patient does not correlate with the
submitted
7 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V78 Procedure code is age restricted
Members age is not within the coverage range for this
procedure code 6 N129
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMR Procedure code is missing or invalid
The Procedure code is missing or invalid at Time of
Service 16 M20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
435 Procedure code not eligible for reimburs
The submitted procedure code is not eligible for
reimbursement. 181 N56
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AQ Procedure code not eligible for reimburs
The submitted procedure code is not eligible for
reimbursement. 16 M20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H13 Procedure Code Not Valid for DOS The submitted procedure code is no longer valid. Please
resubmit
181 N517 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
550 Procedure does not require team surg Procedure does not require team surgery 54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G77 Procedure Included With E/M Service
This health service code was denied because it is
included as part of 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G78 Procedure Invalid For Medicare Purpos
This health service code was recoded to a valid code for
Medicare. 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM7 Procedure is Mutually Exclusive
Procedure is Mutually Ex. Not Poss.For both Proc.to
Occur at same time 231
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H63 Procedure Recoded Based on Age The procedure code has been recoded based on the age
of the patient.
6 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G73 Procedure Recoded To Delivery Only Se
This health service code was changed to reflect that the
provider did 169 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H83 Procedure Recoded To Delivery Only Servi
Code was changed to reflect that the provider did not
provide the 45 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMJ Procedure should be bundled
Procedure should be bundled in an All Inclusive
Procedure 234 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
436 Processed according to negotiated rate.
The claim has been processed according to a negotiated
rate. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AR Processed according to negotiated rate.
The claim has been processed according to a negotiated
rate. 45
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J55 Processin rules(OLH) incorr/ not updated R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V54 Processing rules(OLH) incorr/ not update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G74 Professional Component Not Payable Fo
This procedure was either billed as a professional
component or it was 16 N184
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V64 Prov rec'd pymnt from pri/no reimb rec'd R129: Prior Processing Information Appears Incorrect 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V40 Prov req recovery via corr/phone Prov req recovery via corr/phone 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R94 Prov#Submitted via EDI Incorrect/Ter Provider# Submitted EDI Incorrect/Termed 16 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X94 Prov#Submitted viaEDI Incorrect/Termd
Provider Number Submitted via EDI
Incorrect/Terminated 16 N77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G21 Provider Adjustment Provider Adjustment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB1 Provider and Member not enrolled in Evid
Provider and Member not enrolled in Evidence Based
Program 272
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
438 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5AT Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
620 Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7AE Provider is ineligible for reimbursement The provider is ineligible for reimbursement. 170 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZJ8 Provider Not Active in Facets Provider Not Active in Facets 16 N253 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
439 Provider not certified for service The provider is not certified for the service provided. B7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EB2 Provider not enrolled in Evidence Based Provider not enrolled in Evidence Based Program 272
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XB2 Provider on Payment Suspension Provider on Payment Suspension 133 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9C2 Provider payment adjustment Copay extension, provider payment adjusted 45 N419 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
472 Provider terminated Billed after providers termination date with plan. B7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BZ Provider terminated Billed after providers termination date with plan. 147
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X77 Provider TIN ID is missing or invalid Provider Tax Identification Number is Missing or Invalid 16 N209
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT5 Provider Type Billed Services
The Provider's Specialty Type has a limitation of service
codes 8 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT4 Provider Type/Service not allowed
The Specialty of the provider performing this service is
not allowed 170 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HT6 Provider Type/Service Specialized
This Service Code can only be billed by Certain Provider
Types. 8 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R72 Provider was Not Member's PCP Provider was not the members PMP 242 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B43 Provider was not members PMP Provider was not the members PMP 184 N808 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R74 Pru Layperson Review Completed; Emer
Prudent Layperson Review Completed; Emergent rate
paid 16 N78
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J67 Prudent lay review complete Prudent lay review complete 45 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
111 Prudent lay review completed;nonemerg Prudent lay review completed; nonemergent 40 N627 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
099 Prudent Layperson Rev Comp: Prudent Layperson Rev Comp: 1st Level Screening Paid 216 N115
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
096 Prudent Layperson Rev Comp 1st Level Prudent Layperson Rev Comp: 1st Level Screening Paid 150 N115
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B44 Prudent Layperson Review Completed;E
Prudent Layperson Review Completed: Emergent rate
paid 216 N115
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J60 Prvdr billed proc units > than allowed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V59 Prvdr billed proc units > than allowed. R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J42 Prvdr req. retraction via correspondence R129:Provider Requested Recoupment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J34 Prvdr settlmt- settlmt adjustment R129:Settlement Adjustment 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V32 Prvdr settlmt- settlmt adjustment R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M01 Pymt $150,000 or over may be audited
Any payment of $150,000 or over may be subject to
audit 133 N26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H33 Pymt Includes Svcs for Pre/Intra Op Each provider is reimbursed according to the portion of
surgical
B20 N22 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EAO Pymt reflects COB for QMB Plus member
Payment reflects Coordination of Benefits for a QMB
Plus member 23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EA0 Pymt reflects COB for QMB Plus membr
Payment reflects Coordination of Benefits for QMB Plus
member 23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J82 Pymt reflects COB for QMB Plus membr
Payment reflects Coordination of Benefits for QMB Plus
member 23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R47 Pymt reflects COB, if $0, max liab me
Payment reflects Coordination of Benefits, if $0, max
liability met 23 N9
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B60 Pymt reflects COB,if $0, max liab met
Payment reflects Coordination of Benefits, if $0, max
liability met 23 N23
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC6 Qty Exceeds Max - Specified Rolling(Deny
Per Plan Guidelines, the quantity maximum for specified
time period 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
HC2 Qty Exceeds Max - Unspecified(Roll/Deny)
Per Plan guidelines, the Quantity Maximum for Specified
time period 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC5 Qty Exceeds Max Specified Calendar(Deny)
Per Plan Guidelines, the quantity maximum for specified
time period 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC4 Qty Exceeds Max -Specified Fiscal
Per Plan Guidelines, the quantity maximum for specified
time period 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC3 Qty Exceeds Max- Unspecified
Per Plan Guidelines, the quantity maximum for specified
time period 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC7 Qty Exceeds Max-Time Span Rule/One Day
Per Plan Guidelines, the quantity maximum for specified
time pd has 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B07 Quality Review Processing Quality Review Processing 133 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC9 Quantity Invalid Quantity of service exceeds the payor specified limit 119 N640
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HC8 Quantity Payor Specific Quantity of service exceeds the payor specified limit 119 N362
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J39 RCA R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J41 RCC-use this code on Orig. claim R129: Revd Corrected Claim from Prvdr 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9D1 Rebundled to current/historical claim
Adjustment-Current or added procedure has been
rebundled to a global 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R07 Received after Timely Filing Limit Received after Timely Filing Limit 29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H90 Recoded Procedure Code
The billed procedure was recoded to a more appropriate
procedure code 181 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H25 Recoded to Complete Procedure Code Based on the other procedures billed for this service
date, this code
181 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G58 Recoded To The Least Costly Alternat
The procedure has been recoded to a procedure code
representing the le 189 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H75 Recoded to the least Costly Alternative The Procedure has been recoded to a procedure code 181 N22
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G25 Recover Review Recovery Review 133 N421 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X58 RecoveryForwardedToState per Contract Recovery Forwarded to State per Contract Agreement 129 MA67
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H23 Reduction for Ionic Contrast Media
When non-ionic contrast media is submitted a reduction
will be taken 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
982 Reduction for multiple surgical proc Adjusted - reduction for multiple surgical procedures. 59 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD7 Referring & Ordering not enrolled in Med
Referring and Ordering not enrolled in Medicaid
Program. 183 N767
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XD5 Referring not enrolled in Medicaid Progr Referring not enrolled in Medicaid Program 183 N767 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEE Referring NPI is not enrolled with state
Referring NPI is not enrolled with state as provider type
31-physician 16 N286
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEF Referring Provider NPI is a non-individu
Referring Provider NPI is a non-individual per NPPES
Registry 16 N286
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EQ1 Reimbursement exceeds $50K resubmit with
Anticipated reimbursement exceeds $50K resubmit with
Itemized Bill 252 N26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M75 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z84 Related Claim Previously Paid Related Claim Previously Paid 18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
183 Rendering NPI not for Provider ID Box 31 Rendering NPI not for Provider ID in Box 31 208 N77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEJ Rendering Prov does not have an active
Rendering Prov does not have an active license on claim
DOS B7 M143
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XE5 Rendering prov not enrolled in Medicaid Rendering prov not enrolled in Medicaid Program 16 N290
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM1 Rendering prov NPI missing or illegible Rendering provider NPI is missing or illegible in 24J 206 N290
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G37 Rental Cap Exceeded
The billed equipment was denied because the maximum
number of rentals 108 N370
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H73 Rental Cap Exceeded The billed equipment was denied because the maximum
number
108 N370 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R62 Reprocessed - Claim Subject to Intere Reprocessed - Claim Subject to Interest 225 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
I28 Reprocessed-claim subject to interest Reprocessed-claim subject to interest 225 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B25 Req'd Prescrip. from MD not Attach/Va Required Prescription from MD not Valid/Attached 16 N31
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X92 Req'dPrescrip. fromMDnot Attach/Valid Required Presciption from MD not Attached/Valid 175
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4B1 Request info not recd from pvdr Requested information not received from provider 226 N517
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R09 Requested Hosp Documents not Rec'd Requested Hospital Documents not Received 252 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AT Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5DK Required auth was not obtained Required auth was not obtained 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZD3 Required Medicaid Elements Missing Required Medicaid Encounter Data Elements Missing 16 N350
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HS8 Required Modifier Missing
This service was billed without the plan required
modifier 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XA8 Required Service not performed/reported Required Service not performed/reported 16 N149 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA4 Restricted Member Auth Required Restricted Member Auth Required 243 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
182 Restricted Member-Auth Required Restricted Member-Auth Required 197 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I48 Resub Primary Carrier/Appeal Process Resubmit to Primary Carrier for Appeals Process 22 N36 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZA5 Resub Primary Carrier/Appeals Process Resubmit to Primary Carrier for appeals processing 22 N598
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B16 Resub w/ ICD prin proc, HCPC or CPT
Resubmit with ICD9 pinciple procedure code or valid
HCPCS or CPT Code 16 M20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I69 Resub w/ICD prin proc, HCPC or CPT
Resubmit with ICD9 principle procedure code or valid
HCPCS or CPT Code 16 MA66
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
460 Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5BF Resubmit correct bill type Resubmit claim with correct bill type 16 MA30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4AX Resubmit on ub04 Please resubmit these charges on a ub04 claim form. 16 N34
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
A85 Resubmit to Behavioral Health Contractor Resubmit to Behavioral Health Contractor 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZC7 Resubmit to MCNA
Dental Claims for members under 21 should be
submitted to MCNA 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZC7 Resubmit to MCNA
Dental Claims for members under 21 should be
submitted to MCNA 109
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I37 Resubmit w/ Approp. Modifier and/or U Resubmit with Appropriate Modifier and/or Units 4 N517
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 181 N56
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X44 Resubmit w/ICD/9 princ proc code/date Resubmit with ICD/9 principle procedure code/date 16 MA66
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
180 Resubmit w/Registered Billing Provider Resubmit w/Registered Billing Provider 170 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G50 Resubmit With Appropriate G Code
This health service code was denied because it was not
reported with t 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB6 Resubmit with breakdown of pri ins pymt Resubmit with breakdown of primary ins payment 251 N480
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
575 Resubmit with Medicaid RID, Former PE Resubmit with Medicaid RID, Former PE 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B22 Resubmit with NDC# Resubmit with Valid NDC# 16 M119 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G31 Resubmit With Supporting Documentati
Supporting documentation is needed in order to
adjudicate this claim. 151 N435
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HA1 Resubmit with Supporting Documentation Resubmit with Supporting Documentation 16 M127 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B34 Resubmit with visit codes & charges Resubmit with visit codes & charges 16 M49 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
Z48 ResubPrimaryCarrier/Appeals Process Resubmit to primary carrier for appeals processing 22 N598
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R05 ResubtoPassport Advantage(primary)
Please submit to Passport Advantage (primary carrier)
for processing 109 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J30 Retro Benefit change former PE Mbr R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G26 Retro benefit Change Former PE Memb Retro Benefit change-Former Presumptive Eligibility 96 N30
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V29 Retro Benefit change former PE member R129:Work Comp is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
984 Retro change to the provider's contract Adjusted - retroactive change to the provider's contract. 45 N419
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
J09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V09 Retro enrollment updates recd R129:Retro Eligibility Updated 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J38 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V37 Retro Rate Adj and contract update R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M96 Retro Review/Continued Stay Project Retro Review and Continued Stay Project 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G82 Return To OR Payment Adjustment
This health service code was adjusted to reflect that the
billed servi 172
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMV Rev Code cannot be billed w othr Rev Cod
Revenue Code cannot be billed with other billed
Revenue Code 16 M50
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMT Rev Code requires a Procedure Code This Revenue Code Requires a Procedure Code 16 M20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
444 Revenue code requires CPT/HCPCS code
The revenue code submitted requires a CPT/HCPCS
code. 16 M51
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
925 Reviewed v no additional payment made Reviewed v no additional payment made 193 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J56 RHC(Rural Health Center) not applied R129:RHC (Rural Health Center) Not App. 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
EQ2 Rmbrsmnt amnt determined by Equian Reimbursement amount determined by Equian 45 N10 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZPC Same day dschrg, rsbmt as optnt Same day discharge, resubmit as outpatient 152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J44 Same proc. pd to different prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V43 Same Proc. Pd to different Prvdr Id's R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V02 Same procedure paid multiple times R129:Dup Pymt for Proc Code 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B20 M86 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X50 Same Procedure Pd to Different Prov Same Procedure Paid to a Different Provider B13 N472 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure
code has been
18 N702 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure
code has been
18 N702 CMS National Coverage Determinations (NCD) Policy
H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure
code has been
18 N702 National Correct Coding Manual Policy
H52 Same/Similar Procedure Done Recently Patient history indicates that this service/procedure
code has been
18 N702 CMS Coverage Policies
J22 Secondary coverage listed,no EOB on file R129:Secondary EOB req 16 MA64 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H81 Secondary Diagnosis Missing Or Invalid This health service code was denied because a required
secondary
16 M76 CMS National Coverage Determinations (NCD) Policy
V21 Secondary ins listed, no EOB on file R129:Illegible/incomplete EOB Attached 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M02 Send itemized bill to MDHA Send itemized bill to: MDHA 5604 Fortune Circle S, 133 N26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G85 Separate Payment For Services Not Pro
The billed services were denied because services on the
Separate Payme 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G56 Separate Procedures Not Separately Pa This procedure was denied because procedures
designated as inpatient o
97 M2 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G84 Service Denied Because Of Potential I
The drug was denied because another drug was billed
recently that coul 18 N702
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B47 Service Exceeds Lifetime Limitation Service Exceeds Lifetime Limitation 149 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 N587 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X30 Service exceeds lifetime limitation Service exceeds lifetime limitation 149 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R51 Service Not Covered Service Not Covered 96 N30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X51 Service Not Covered Services Not Covered 96 N30 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
GB7 Service not in Provider's Profile Service not in Provider's Profile B7 N570 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
449 Service not payable in this specialty The service provided is not payable in this specialty. B7 N95
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R04 Service Not payable with other serv
Service not payable with other service rendered on the
same date 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5B5 Service performed by another provider
The service submitted was performed by another
provider. B20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G35 Service Processed As A Bilateral Pro
This health service code was adjusted to reflect the
allowed amount fo 59 N644
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
451 Service rendered by ineligible provider The service rendered was by an ineligible provider. B7
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
4BN Service was adjusted due to fee schedule Service was adjusted due to fee schedule update 169 N10
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
RA4 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
RA5 Service will be Processed on a sep claim Split Claim services processed on separate claims(s) B13 MA15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
906 Services after policy expiration date
Adjusted - expenses incurred after coverage
termination. 27
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R76 Services Denied Telephonically Services Denied Telephonically at Time of Service 39
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
483 Services disallowed by UM Services were disallowed by Utilization Management. 96 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CD Services disallowed by UM Services were disallowed by Utilization Management. 96 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9A5 Services included in primary procedure Adjusted - services included in primary procedure. 97 N19
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
988 Services not authorized Adjusted - required authorization was not obtained. 16 M62
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9C9 Services not authorized Adjusted - required authorization was not obtained. 197
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
929 Services not cov'rd per benefit package Adjusted - services are not covered per benefit package. 204 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B31 Services not medically necessary Services not medically necessary 50 N372 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
B57 Services not medically necessary Services not medically necessary 50 N661 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
990 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9A7 Services not rendered Adjusted - services not rendered. 96 N32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
991 Services performed by another provider Adjusted - services performed by another provider. B20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9C5 Services performed by another provider Services performed by another provider B20 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
909 Services prior to policy effective date
Adjusted - expenses incurred before coverage effective
date. 26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
930 Services prior to policy effective date
Adjusted - expenses incurred before coverage effective
date. 26
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
179 Services to be paid on separate remit Services to be paid on separate remit B11 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R53 Services were not Provided Services were not Provided 112 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X53 Services were not Provided Services were not Provided 16 N99 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZM2 Servicing prov NPI missing or illegible Servicing provider NPI is missing or illegible in 32a 16 N270
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZI3 Servicing Provider Taxonomy not match
Servicing Provider Taxonomy does not match with the
Taxonomy on file 16 N94 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZI3 Servicing Provider Taxonomy not match
Servicing Provider Taxonomy does not match with the
Taxonomy on file 16 N94
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZI4 Servicing Provider Taxonomy not present
Servicing Provider Taxonomy not present on Submitted
Claim 16 N94 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZI4 Servicing Provider Taxonomy not present
Servicing Provider Taxonomy not present on Submitted
Claim 16 N94
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G59 Site Of Service Differential
The payment for this procedure was reduced because it
was performed at 5 M77
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZG0 SIU Adjustment SIU Adjustment-Program Integrity 216 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZG1 SIU Overpayment Settlement SIU Overpayment Settlement-Program Integrity 216 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
080 SIU Settlement Adjustment
Settlement Adjustment/no change in outcome-Program
Integrity 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZG2 SIU Settlement Adjustment
Settlement Adjustment/no change in outcome-Program
Integrity 216 N35
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMP Spec Billed Serv Code combo not payable
Based on NCCI, the Specific billed service code combo is
not payable. 236
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R79 Special Project-Adjustment Special Project-Adjustment 45 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X79 Special Project-Adjustment Special Project-Adjustment 45 N381 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSR State Code Combination
Per State Regulations the specific Billed Service code
Combination is 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
HSS State Code Combination - Hospital
Hospital Outpatient - Per State Regulations the specfic
billed service 199 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J32 State Encounter error received R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V30 State Encounter error received R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XA4 Sub. itemized bill does not match UB/CMS
Submitted itemized bill does not match UB/CMS Please
resubmit 16 N232
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
BEH Submit claim to Magellan Behav Healt Submit claim to Magellan Behavioral Health 109 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X71 Submit Claim to Molina Claim is not payable at ACLA Submit to Molina 109 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZA Submit Consent Form Submit Consent Form 252 N3 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
454 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5B9 Submit itemized Please submit itemization of services. 252 N26 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5B7 Submit original billed amount Please submit claim with the original billed amount. 16 M54
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
XEI Supervising provider not enrolled in Med Supervising provider not enrolled in Medicaid Program 16 N253
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZ1 Supporting documentation missing/invalid
Speciifc documentation required for payment is missing
/illegible/dupl 252 N729
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZZ2 Supporting documentation missing/invalid
Speciifc documentation required for payment is missing
/illegible/dupl 252 N729
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
482 Supporting documentation required Supporting documentation required 16 N29 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5CC Supporting documentation required Supporting documentation or medical records required 252 M127
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H94 Surg & Asst Surg Can't Be The Same This code can not be paid as a Surgical assist when the
same provider
54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM5 Surgical Proc Rptd after E&M Payment
Surgical Proc Rptd after pymt of E&M. E&M Svs are
Between The Global 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HM6 Surgical Proc Rptd after E&M Payment
Surg. Proc Rptd after pymt of E&M. Svs. E&M Svs is
between the Global. 97 M15
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
640 Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7AT Svc not covered per benefit plan The services rendered are not covered under your plan. 204 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
932 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
993 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9B0 Svcs do not meet coverage requirements Adjusted - services do not meet coverage requirements. 96 N130
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V74 T1015 cant be billed for your prv type T1015 cant be billed for your provider type 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V73 T1015 must be billed for your prv type T1015 must be billed for your prv type 8 N95 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSV Team Surgeons not allowed Team Surgeons not allowed for this procedure 54 N646 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H54 Technical Service Not Payable for POS This procedure is billed as a technical component and is
not payable
5 M77 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G87 Technical/ Professional Service Inapp
The technical and professsional components of the
procedure were inapp 16 N184
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G86 Terminated Procedure Cannot Be Billed
The procedure was denied because, it is inappropriate
to bill a proced 181 N56
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G62 The Service Code Is Inconsistent With
This health service code was either denied or modified
because it is n 4 M20
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMM This is a Bilateral Code
This is a Bilat code. Modifier LT, RT, 50 or Qty 2 not
applicable. 4 N519
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMF This Procedure is an Add On Code
This Procedure is an Add on Code and must be billed
with the 234 N122
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMG This Procedure is an Add On Code
This Procedure is an Add On Code and must be billed
with the 234 N122
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020
Explanation of Benefits (EOB) Matrix
Explanation
Code Short Description Long Description
Claim Adjustment
Reason Code
Remittance Advice
Reason Code Source
HMS This Revenue code is invalid This Revenue code is invalid 16 M50 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
I81 Time not Validated on Medical Record Time not Validated on Medical Records B12 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HSU Time of Filing - 1 year
Date of Procedure in Excess of 1 year prior to receipt of
claim 29
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J10 Timely filing inappr or paid incorr. R129:Timely Filing Incorrectly Applied 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
M98 Total Amt Still Under Consideration Total Billed Amount Still Under Consideration 133 N372 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V62 TPL identified by PCG R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J23 TPL information input incorrectly R129:Correction to a Prior Claim 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V61 TPL information input incorrectly R129: Prior Processing Information Appears Incorrect 129 N48
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V24 TPL received/updated after clm proces'd R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J25 TPL received/updated after clm processed R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
R17 Under Review for COB processing Under Review for COB processing 133 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
0UN Ungroupable DRG
Claim data is missing, incomplete or invalid. No DRG
found. A8 N208
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
H30 Units Adjusted Exceeds Allowed Amt
The units for the billed procedure code have been
adjusted to reflect 151 CMS National Coverage Determinations (NCD) Policy
H30 Units Adjusted Exceeds Allowed Amt
The units for the billed procedure code have been
adjusted to reflect 152 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
655 Units exceed UM authorization Units exceed a utilization management authorization 222
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7B7 Units exceed UM authorization Units exceed a utilization management authorization 222 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
7B7 Units exceed UM authorization Units exceed a utilization management authorization 222
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZB9 Units reduced by NIA authorization Units reduced by NIA authorization 39 N35 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
658 Unlisted procedure code
The submitted code is disallowed because the
procedure code is 189 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
659 Unlisted procedure code
The submitted code is disallowed because the
procedure code is 189 N657
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G15 Valid EOB on File Valid EOB on File 23 M32 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
G14 Valid Referral/Authorization on File Reprocessed Claim-Valid Referral/Authorization 198 N758 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZH7 VBP Payment-FBMH
Value Based Purchasing Payment-Family Based Mental
Health 144 N422
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
ZH8 VBP Payment-FBMH
Value Based Purchasing Payment-Family Based Mental
Health 144 N422
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
HMW Verfiy Benefits and Elig
Verfiy Benefits and Eligibility for Services Provided in a
State 58
ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
9E1 Void/cancel of prior claim Adjusted - void/cancel of prior claim 16 N798 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J76 Voided claim received Voided claim received 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J29 Workers Comp is Primary R129:Work Comp is Primary 19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
V28 Workers Comp is Primary R129:Auto is Primary 129 N48 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
X13 Workers Comp Primary Carrier Workers Compensation Primary Carrier 19 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
5C3 Wrong CPT-modifier combo Inappropriate procedure-modifier combination 4 N519 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
J08 Wrong info received from state R129:Correction to a Prior Claim 129 MA67 ACLA Plan Policy in alignment with Louisiana Medicaid program requirements/policies and limitations
As of 5/18/2020