Remittance Advice Reason Codes - Workforce Safety · PDF fileRemittance Advice Reason Codes...

Remittance Advice Reason Codes

Reason Code Abbreviated Description Complete Description

Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

1 Liability Determination – Entire Claim Denied

The entire claim for injury has been denied; therefore, WSI is not

liable for payment of any charges relating to this injury. The

charge is the patient's responsibility. Please contact the patient

for payment or for other insurance information.

N Y

2Analyst Liability Determination – Unrelated

Service

This service is unrelated to the patient's work injury. The charge

for this service is the patient's responsibility. Please contact the

patient for payment or for other insurance information.

Y Y

3Liability Determination – No Further Liability

for Condition or no Medical Necessity

WSI previously determined that it has no liability or no medical

necessity for these charges. The charge is the patients’

responsibility. Please contact the patient for other insurance

information.

N Y

4 Third-Party Settlement – Suspended Benefits

Suspended benefits exist as part of a third-party settlement. The

amount approved shown is the patient's responsibility. The

patient cannot be billed for more than the amount approved as

shown in the approved column. Please contact the patient for

payment of the amount approved.

Y Y

5 Date of Service Error – Prior to Injury

This charge is denied because medical documentation indicates

this service was provided prior to the date of the patient's injury.

The charge is the patient’s responsibility. Please contact the

patient for the payment of the allowable amount.

N Y

6Medical Rule Exceeded – Nonreimburseable

Service – Not Billable to Patient

This charge is denied because WSI does not pay for this type of

service or procedure. The patient may not be billed for this

charge.

N Y

7 Funeral – Costs Exceed Maximum Allowed WSI's reimbursement of funeral expenses is exceeded. Y Y

* Effective January 1, 2015, pilot program lengthens the appeal timeframe

to 60 days from the date of the Remittance Advice for designated reason codes.

of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

9 * Duplicate Charge Submitted

This charge is denied as a duplicate charge. To request

reconsideration, complete the provider request for an adjustment

form (M6) and submit to WSI within 30 days from the date of the

remittance advice and provide a statement of why the reduction

or denial is disputed. You may also supply any supporting

documentation. The patient may not be billed for this reduced or

denied charge.

N Y

10 Claim Accepted on Aggravation

This claim has been accepted on an aggravation basis. The

charge is payable at the fee schedule allowable amount on an

aggravation percentage. Balance of the allowed charge is the

patient's responsibility. Please contact the patient for payment or

for other insurance information.

Y Y

11Liability Determination – Service Partially

Unrelated to Claim

This charge has been reduced by 50 percent of the fee schedule

because medical documentation shows services unrelated to the

patient's work injury were provided in addition to services related

to the patient's work injury. The balance of the charge is the



Y Y

12Audit Liability Determination – Unrelated

Service

This service is unrelated to the patient's work injury. The charge

is the patient's responsibility. Please contact the patient for

payment or for other insurance information.

Y Y

13 *Liability Determination – Requested Medical

Records Not Received

This charge is denied because the requested medical records

have not been received and WSI is unable to establish liability for

these charges. To request reconsideration, complete the

provider request for an adjustment form (M6) and submit to WSI

within 30 days from the date of the remittance advice and

provide the appropriate records along with a request for

reconsideration. The patient may not be billed for this charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

14Liability Determination – Unauthorized

Services – No Liability

This charge is denied because the services were not ordered by

the patient's attending doctor and WSI did not approve a change

of the attending doctor for this patient. The patient is responsible

for these charges. Please contact the patient for payment.

Y Y

17Legal Fees and Costs – Exceeded Maximum

Amount Payable

Your fees have been adjusted because the amount submitted

causes you to exceed the maximum amount payable.N Y

18 Legal Fees and Costs – Formal Hearing

Since the injured worker did not prevail at the formal hearing,

your fees and costs have been denied. If you disagree, contact

Legal Services, in writing, within 30 days from the date of the

remittance advice for reconsideration.

N Y

20 Miscellaneous – Zero Amount Submitted

Your charge for this service date was submitted as zero payable.

This notification is provided for your information. If this was billed

in error, please resubmit a corrected billing.

N Y

30 Internal Code – Do Not Deduct Overpayment Do Not Deduct Overpayment. N N

31Miscellaneous – Adjustment to Previous

ChargeAdjustment to Previous Charge. N Y

32Internal Code – Do Not Deduct Overpayment

and Do Not Apply AggravationDo Not Deduct Overpayment and Do Not Apply Aggravation. N N

34Audit Adjustment – Reversed – Original

Decision Overridden

The original recommendation relating to this charge has been

overridden. N Y

37Personal Reimbursement – No Receipts

Submitted

Your request for reimbursement is denied because you did not

provide itemized receipts. Please submit the original receipts if

you have them. If you disagree, you must file a request for

reconsideration, in writing, within 30 days from the date of the

remittance advice and provide appropriate record(s).

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

38Personal Reimbursement – Over One Year

Old

Your request for reimbursement is denied because it was not

filed within one year of incurred expense. If you disagree, you

must file a request for reconsideration, in writing, within 30 days

from the date of the remittance advice and provide a statement of

why the reduction or denial is disputed. You may also supply any

supporting documentation.

N Y

39Liability Determination – Stipulation – WSI

Pay Part or Zero - Patient to be Billed

This charge has been processed according to a settlement with

the patient. The charge is the patient's responsibility. Please

contact the patient for payment or for other insurance

information.

N Y

40Medical Rule Exceeded – Pharmacy – Over-

the-Counter Medication

This charge is denied because medical service rules limit

payment for over-the-counter medication. The charge is the



N Y

41 School Expenses – Allowance Exceeded

This charge is reduced or denied because the school supply

allowance has been exceeded for this school term. Please

contact the student for payment or for other insurance

information.

N Y

42 Legal Fees and Costs – Prior to EntitlementThese fees and costs are for services billed prior to the date you

are entitled to fees and costs. N Y

43Liability Determination – Stipulation – Fee

Schedule Applied.


the patient. The patient may not be billed for this reduced or

denied charge.

N Y

44Liability Determination – Stipulation – Fee

Schedule Not Applied


the patient.N Y

45Personal Reimbursement – Not Enough Miles

in a Month

Your request for reimbursement for mileage is denied because

you did not travel at least 200 miles during the calendar month. If

you disagree, you must file a request for reconsideration, in

writing, within 30 days from the date of the remittance advice

and provide a statement of why the reduction or denial is

disputed. You may also supply any supporting documentation.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

46Medical Rule Exceeded – Nonreimbursable

Service – Billable to Patient

This charge is denied because WSI does not pay for this type of

service or procedure. The charge is the patient's responsibility.

Please contact the patient for payment or for other insurance

information.

Y Y

47Personal Reimbursement – Vocational

Mileage

Reimbursement for mileage is denied because WSI does not

reimburse for mileage related to this vocational service. If you

disagree, you must file a request for reconsideration, in writing,


provide a statement of why the reduction or denial is disputed.

You may also supply any supporting documentation.

N Y

49Manipulations Exceeded – 2 Chiro

Manipulations Per Day

This charge is denied because two or more chiropractic

manipulations per day are allowed only when provided within 72

hours of the original injury date. The patient may not be billed for

this charge.

N Y

51 *Service does not meet WSI’s practice or

treatment guidelines

This charge is denied because this service does not meet WSI’s

practice or treatment guidelines. To request reconsideration,

complete the provider request for an adjustment form (M6) and

submit to WSI within 30 days from the date of the remittance

advice and provide a statement of why the reduction or denial is


The patient may not be billed for this reduced or denied charge.

N Y

52 *

Services Not Provided – Medical

Documentation Doesn’t Support Submitted

Charge

This charge is denied as medical documentation does not

support the submitted charge. To request reconsideration,






N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

53 Chiropractic Modalities Limited to Two

This charge is denied because chiropractic modalities are limited

to two modalities per visit. The patient may not be billed for this

charge.

N Y

54 Fee Schedule Applied

This charge is reduced or denied as required by WSI's Medical

and Hospital Fee Schedule. The patient may not be billed for this

reduced or denied charge.

N Y

55Fee Schedule Not Applied – WSI Approved

Service

This charge has been paid in full because it was a service or

report requested or pre-approved by WSI.N Y

56 *Procedure Code Changed – Medical

Documentation Doesn't Support Code Used

This charge is reduced or denied because the medical

documentation does not support the submitted procedure code.

The procedure code has been changed. To request






denied charge.

N Y

57 *Modifier Changed – Not Appropriate for

Procedure Performed

This charge is reduced or denied because the modifier submitted

is not appropriate for the procedure performed. The modifier was

changed. To request reconsideration, complete the provider

request for an adjustment form (M6) and submit to WSI within 30

days from the date of the remittance advice and provide a

statement of why the reduction or denial is disputed. You may

also supply any supporting documentation. The patient may not

be billed for this reduced or denied charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

58 * UCR Exceeded – Service Charge

This charge is reduced or denied because it does not reflect the

usual, customary, or reasonable reimbursement level for this

service, To request reconsideration, complete the provider






N Y

59 * Modifier 51 – Multiple Procedures Performed

This charge is reduced or denied because multiple procedures

were performed the same day or at the same session. Modifier

51 was added. To request reconsideration, complete the




You may also supply any supporting documentation. The patient

may not be billed for this reduced or denied charge.

N Y

63UR Initial Rec – Service does not meet WSI’s

practice or treatment guidelines

This charge is denied because the initial utilization review

determined the service does not meet WSI’s practice or

treatment guidelines. Notice of decision denying service,

including information on your right to appeal, has been sent to

your facility. The patient may not be billed for this reduced or

denied charge.

N Y

69Internal Code – Pay in Full and Override

AggravationPay in Full and Override Aggravation. N N

70 Rehab – Late Report Penalty

This charge is reduced because a late report penalty has been

applied. To request reconsideration, contact WSI, in writing,

within 30 days. The injured worker may not be billed for the

balance of this reduced charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

71Rehab – Office / Clerical / Copy Charges

Denied

This charge is denied because WSI does not pay for office,

clerical, or copy charges. To request reconsideration, contact

WSI, in writing, within 30 days. The injured worker may not be

billed for this charge.

N Y

72 Rehab – Unauthorized Rehab Services

This charge is denied because the services performed were not

authorized by WSI. To request reconsideration, contact WSI, in

writing, within 30 days. The injured worker may not be billed for

this charge.

N Y

73 Rehab – Report Lacks Earning Capacity

This charge is reduced or denied because the submitted report

lacks information required by the contract. To request

reconsideration, contact WSI, in writing, within 30 days. The

injured worker may not be billed for this reduced or denied

charge.

N Y

74 Rehab – VCR Doesn't Meet Guidelines

This charge is reduced or denied because the submitted VCR

does not meet established WSI guidelines for an acceptable

report. To request reconsideration, contact WSI, in writing,

within 30 days. The injured worker may not be billed for this


N Y

75 Rehab – Unnecessary or Excessive Charges

This charge is reduced or denied because the service performed

was unnecessary or in excess of what was requested. To

request reconsideration, contact WSI, in writing, within 30 days.

The injured worker may not be billed for this reduced or denied

charge.

N Y

76 Rehab – Not Substantiated in Report

This charge is denied because the report is insufficient to support

payment for this service. To request reconsideration, contact

WSI, in writing, within 30 days. The injured worker may not be

billed for this charge.

N Y

77 Rehab – Exceeded Maximum Allowed

This charge exceeds the maximum allowed for the requested

service. To request reconsideration, contact WSI, in writing,

within 30 days. The injured worker may not be billed for this

charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

79UR Initial Rec – Insufficient Information

Received to Complete Review

This charge is denied because insufficient information was

received to complete an initial utilization review. Notice of

decision denying service, including information on your right to

appeal this decision, has been sent to your facility. The patient

may not be billed for this charge.

N Y

80 * UR Required – Service Not Pre-Certified

This charge is denied because the service was not reviewed

through utilization review. To request approval for a retrospective

review, complete the provider request for an adjustment form

(M6) and submit to WSI within 30 days. Please provide on the

form a statement of why it was not known that the injury may

have been a compensable injury. The patient may not be billed

for this charge.

N Y

81Personal Reimbursement – Wage Loss Not

Paid

Wage loss for attending medical examinations is paid only when

WSI has ordered the examination. If you disagree, you must file

a request for reconsideration, in writing, within 30 days from the

date of the remittance advice and provide a statement of why the

reduction or denial is disputed. You may also supply any


N Y

82 Personal Reimbursement – Meals Not Paid

Your request for this meal reimbursement is reduced or denied

because it exceeds the maximum allowed or is not reimbursable

within state guidelines. If you disagree, you must file a request for

reconsideration, in writing, within 30 days from the date of the



documentation.

N Y

83 Miscellaneous – Bill Sent in ErrorThis charge was submitted to WSI in error and is rejected per

your request.N Y

84Liability Determination – Requested Patient

Information Not Received

This charge is denied because information requested from the

patient has not been received. WSI is unable to establish liability

for these charges. The charge is the patient's responsibility.


information.

Y Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

85UR Appeal Rec – Service does not meet

WSI’s practice or treatment guidelines

This charge is denied because utilization review appeal

determined the service does not meet WSI’s practice or

treatment guidelines. Notice of decision denying service,

including information on your right to appeal this decision, has

been sent to your facility. The patient may not be billed for this


N Y

88

UR Initial Rec Retro Review – Service does

not meet WSI’s practice or treatment

guidelines

This charge is denied because an initial retrospective review

determined the service or treatment does not meet WSI’s

practice or treatment guidelines. Notice of decision denying

service, including information on your right to appeal this

decision, has been sent to your facility. The patient may not be

billed for this reduced or denied charge.

N Y

90 *Audit – Treatment Exceeds Medical Rules and

Fee Guidelines

This charge is reduced or denied because medical

documentation indicates that treatment exceeds WSI’s Medical

Rules and Fee Guidelines. To request reconsideration, complete

the provider request for an adjustment form (M6) and submit to

WSI within 30 days from the date of the remittance advice and




N Y

91 *Medical Rule Exceeded – Service Not Pre-

Authorized by WSI

This charge is denied because the service, equipment, or

treatment was not pre-approved by WSI. To request



remittance advice. The patient may not be billed for this charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

93 *Medical Rule Exceeded – Equipment ,

Supplies, Hardware

This charge is reduced or denied because it exceeds the rule of

reimbursement for medical equipment, supplies, and hardware.

To request reconsideration, complete the provider request for an

adjustment form (M6) and submit to WSI within 30 days from the



supporting documentation. The patient may not be billed for this


N Y

94 *Medical Rule Exceeded – Medical Record

Copy Fee for Treatment Prior to Injury

This charge is reduced or denied because it exceeds WSI's rule

of reimbursement for medical records which allows five dollars for

five or fewer pages or five dollars for the first five pages plus

thirty-five cents per page for each page after the fifth. To request



remittance advice. The patient may not be billed for this reduced

or denied charge.

N Y

95 *Medical Rule Exceeded – Medical Record

Copy Fee for Current Treatment

This is not a reimbursable charge because the records requested

are for treatment WSI is covering for the injured employee. To

request reconsideration, complete the provider request for an


date of the remittance advice. The patient may not be billed for

this reduced or denied charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

98 *Modifier NP – Medical Documentation Shows

NP/PA Performed Service


documentation indicates this service was provided by a nurse

practitioner or physician’s assistant. Modifier NP has been

added. To request reconsideration, complete the provider






N Y

99 *Modifier 80 – Medical Documentation Shows

Assistant Surgeon Service


documentation indicates a physician provided assistance to

another physician performing a surgical procedure. Modifier 80

has been added. To request reconsideration, complete the






N Y

100 *Modifier SA – Medical Documentation Shows

Surgical Assistant Service


documentation indicates a non-physician assistant provided

assistance to a physician performing a surgical procedure.

Modifier SA has been added. To request reconsideration,






N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

102 * Modifier 50 – Bilateral Procedure Performed


documentation indicates bilateral procedures were performed.

Modifier 50 has been added. To request reconsideration,






N Y

104 *Modifier 26 – Medical Documentation Shows

Only Professional Component Done


documentation indicates this charge is for the professional

component only. Modifier 26 has been added. To request






denied charge.

N Y

105 *Modifier TC – Medical Documentation Shows

Only Technical Component Done


documentation indicates this charge is for the technical

component only. Modifier TC has been added. To request






denied charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

106 *Procedure Code Changed – Completed

Multiple Repair Same Classification


documentation indicates repair of multiple wounds of the same

classification was completed. The procedure code has been

changed. To request reconsideration, complete the provider






N Y

115

UR Rec Ancillary Service – Primary Service

does not meet WSI’s practice or treatment

guidelines

This charge is denied because utilization review determined the

primary service does not meet WSI’s practice or treatment

guidelines. Notice of decision denying service, including

information on your right to appeal this decision, has been sent to

your facility. The patient may not be billed for this reduced or

denied charge.

N Y

116 Date of Service Error – Changed Date

The date of service has been changed as verification with your

facility indicates a different date of service than previously

submitted.

N Y

117 Tax – State Health Care Tax

The State Health Care Tax is not reimbursable as a separate

charge, but is considered included in your submitted charges for

the service performed. Submitted charges, including this tax, are

subject to the fee schedule allowable when ND has jurisdiction

over the work injury. The patient may not be billed for this tax.

N Y

118Tax – Exempt From North Dakota State Sales

Tax

WSI is a tax exempt agency pursuant to Subsection 6 of Section

57-39.2-04 of the North Dakota Century Code, certificate number

E-2001. No one may be billed for this tax.

N Y

119Medical Rule Exceeded – Eye Care – No

Change in Vision

This charge is denied because WSI does not reimburse eyewear

unless a change in sight attributable to the work injury has

occurred. This charge is the patient's responsibility. Please


information.

Y Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

122 *Medical Rule Exceeded – Assistant Surgeon /

Surgical Assistant – Not Allowed

This charge is not reimbursable because the procedure code

does not support assistant surgeon / surgical assistant services.

To request reconsideration, complete the provider request for an






N Y

127Legal Fees and Costs – Exceeded Hourly

Rate

Your fees have been adjusted because the hourly rate submitted

on your statement exceeds the maximum allowable hourly rate.

To request reconsideration, contact Legal Services, in writing,

within 30 days.

N Y

130 *Units Changed – Medical Documentation

Doesn't Support Submitted Units


documentation does not support the number of units billed. The

number of units has been changed. To request reconsideration,






N Y

132Overpayment – Injured Worker Overpayment

Recovery

The approved amount of this charge has been applied to recover

an overpayment on your claim. Please contact your claims

analyst if you have questions about any overpayment on your

claim.

N Y

133Overpayment – Provider Overpayment

Recovery

The approved amount of this charge has been applied to recover

an overpayment to your facility. Please reference your prior

remittance advice statements for information on which claims

created the overpayment to your facility.

N Y

134 Legal Costs 3rd

Party – 50% Recovery WSI pays 50% of the costs of the action. N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

135Legal Costs 3

rd Party – Less Than 50%

Recovery

The costs of the action are prorated and adjusted on a

percentage of WSI's total subrogation interest recovered to the

total recovery in the action.

N Y

136 Personal Reimbursement – Motel Reduced

Your request for motel reimbursement is reduced because it

exceeds the maximum allowable reimbursement. If you disagree,

you must file a request for reconsideration, in writing, within 30



also supply any supporting documentation.

N Y

137 Personal Reimbursement – Spouse Denied

Your request for reimbursement for expenses incurred by your

spouse or by another person who accompanied you to your

appointment is denied because there are no doctor's orders

indicating the need for accompaniment. Please submit a copy of

the Doctor’s Order which indicates that your medical condition

prevents you from traveling alone. If you disagree, you must file

a request for reconsideration, in writing, within 30 days from the

date of the remittance advice and provide appropriate record(s).

Y Y

138 Personal Reimbursement – Expenses Denied

Your request for reimbursement for expenses incurred due to

your appointment is denied because it was unnecessary for you

to seek medical treatment outside of your local area. If you





Y Y

139 Personal Reimbursement – Intracity Mileage

WSI does not reimburse for intracity mileage. If you disagree,





N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

140Personal Reimbursement – No Appointment

Verified

Your request for reimbursement for these expenses is denied

because WSI has no verification of an appointment on this date.

Please submit verification of the appointment. If you disagree,


days from the date of the remittance advice and provide

appropriate record(s).

N Y

141Legal Fees and Costs – Duplicate Charge

Submitted

This charge is reduced or denied because it is a duplicate

charge. The injured worker may not be billed for this charge. To

request reconsideration, contact Legal Services, in writing,

within 30 days.

N Y

142Legal Fees and Costs – Disallowed Under

NDCC

Payment of attorney fees and costs are not allowed under NDCC

Section 65-02-08. To request reconsideration, contact Legal

Services, in writing, within 30 days.

N Y

143Legal Fees and Costs – Negotiated Fee

Settlement

Contested attorney fees were reduced according to a negotiated

fee settlement.N Y

145 Internal Code – No Claim for Bill Entered This charge is not associated with any claim on file. N N

146 Audit – Split/Replace/Combine Line Item

This line item does not comply with billing methods required by

WSI and has been replaced with an appropriate line item. To







N Y

147 Personal Reimbursement – Mileage Reduced

Your request for mileage reimbursement is reduced because it

exceeds the miles actually and necessarily traveled. If you





N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

148Personal Reimbursement – Nonreimbursable

Expenses

Your request for personal reimbursement is reduced or denied as

these expenses are not reimbursable, have been previously

submitted, or exceeded the amount(s) allowed. . If you disagree,





N Y

149Overpayment – Bill Paid to Wrong Payee /

Repaid to Correct Payee

This line item was paid to your facility in error and has created an

overpayment that must be recovered. This line is provided for

information only and is not included in calculating your total

remittance amount. The paid amount has been or will be

deducted from other payments owed to your facility. If no further

payments are owed to your facility, please send a check for the

total overpayment amount for deposit against the overpayment.

N Y

150Overpayment – Bill Paid to Correct Payee But

Paid in Error

This line item was paid incorrectly to your facility and has created

an overpayment that must be recovered. This line is provided for

information only and is not included in calculating your total

remittance amount. The paid amount has been or will be

deducted from other payments owed to your facility. If no further

payments are owed to your facility, please send a check for the

total overpayment amount for deposit against the overpayment.

N Y

151 Overpayment – Void Check

This line item reflects receipt of a returned check from your

facility. The check has been voided per your request. This line is

provided for information only and is not included in calculating

your total remittance amount. If necessary, you will be notified of

any additional payments through other remittance line item

transactions.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

152 Overpayment – Deposit Check

This line item reflects receipt of a deposit from your facility for an

overpayment. This line is provided for information only and is not

included in calculating your total remittance amount. If

necessary, you will be notified of any additional payments or

overpayments through other remittance line item transactions.

N Y

153Legal Fees and Costs – Reduced Pursuant to

NDCC

Attorney fees have been reduced to 20% of the awarded amount

pursuant to Sections 65-02-08 and 65-02-14, NDCC. If you

disagree, contact Legal Services, in writing, within 30 days for

reconsideration.

N Y

154 Legal Fees – 3rd PartyAttorney fees in connection with third-party actions are paid on a

percentage of the recovery pursuant to Section 65-01-09, NDCC.N Y

155 Personal Reimbursement – Motel Denied

Your request for motel reimbursement is denied because WSI

did not authorize this service. If you disagree, you must file a

request for reconsideration, in writing, within 30 days from the




N Y

158 Time Statements – Erroneously EnteredThis bill was erroneously entered into the system and should not

be paid.N N

159 Post – Rehab Manipulation

This charge is denied because the patient has completed the

Spinal Rehabilitation Program. The patient may not be billed for

these services.

N Y

160Closed Claim – No Further Liability for

Condition

This service is denied, as the claim is presumed closed. The

charge is the patient's responsibility. Please contact the patient

for payment or for other insurance information.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

161Overpayment – Injured Worker Advance

Payment

An advance payment was made to you. Upon completion of your

travel, you must submit a request for reimbursement on a C40a

form along with original receipts. If your actual expenses exceed

the amount of the advance, but do not exceed the maximum

allowable, additional reimbursement will be made to you. If you

do not submit a request for reimbursement, or if your actual

expenses are less than the advance, an overpayment will result.

If an overpayment does result, you will be notified by letter of the

amount you are required to reimburse WSI. If you disagree, you

must file a request for reconsideration, in writing, within 30 days

from the date of the remittance advice and provide a statement of

why the advance overpayment is disputed. You may also supply

any supporting documentation.

N Y

162No Liability for Palliative Chiropractic Care

Services

WSI previously determined that it has no liability for these

charges. The charge is the patient's responsibility. Notice of

decision denying service, including information on your right to

appeal this decision, has been sent to your facility. Please


information.

Y Y

163Personal Reimbursement – Request for

Medical Services Denied

Your request for reimbursement for medical services is denied.

WSI requires all medical providers to submit billings directly to

WSI for payment of services directly related to workers'

compensation claims. Please contact your medical provider and

have them submit a bill to WSI directly. If we determine these

charges are our liability, payment will be made to the provider.

You may then seek reimbursement from the medical provider. If

you disagree, you must file a request for reconsideration, in

writing, within 30 days from the date of the remittance advice

and provide a statement of why the reduction or denial is


Y Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

164Miscellaneous – Injured Worker Returned

Item

Injured worker returned item and reimbursement should not be

provided for this service.N Y

165 Adjustment – Reversed – DecisionThe original recommendation relating to this charge has been

adjusted.N Y

166Adjustment – Reversed – Office of

Independent Review


adjusted.N Y

167Adjustment – Reversed – Binding Dispute

Resolution


adjusted.N Y

168 Adjustment – Reversed – LegalThe original recommendation relating to this charge has been

adjusted.N Y

169Legal Bill Auditing Guidelines Applied –

Administrative/Clerical

This billed line item is reduced or denied as being

clerical/administrative in nature and not payable in accordance

with Legal Services Management and Billing Guidelines for law

firms representing WSI.

N Y


Internal Instructions

This charged line item is reduced or denied as it applies to

giving/receiving instructions for task accomplishment. Only the

fees of the senior party will be paid.

N Y


Internal Conferences

This billed line item is reduced or denied, as WSI will only pay for

conferences, which are not administrative.N Y


Photocopying

This photocopying expense is reduced or denied as excessive

without prior authorization or use of WSI facilities.N Y

173Legal Bill Auditing Guidelines Applied – Block

Billing

This charge is reduced or denied as block billing without

specifically identifying the time for each task within the block is

not payable.

N Y


Overhead

Line item billing for items which are firm overhead and inclusive

within the hourly rate are reduced or denied.N Y


Vagueness

Billing item is reduced or denied as it is vague and an accurate

determination of the services cannot be made.N Y

176Liability Determination – Injured Worker Failed

to See Designated Medical Provider

This charge is denied because the services were not provided by

the employer’s designated medical provider and the injured

worker has failed to select another medical provider prior to being

injured. The patient is responsible for these charges. Please

contact the patient for payment or other insurance information.

Y Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

177 Medical Records ReceivedThis charge has been reviewed again because requested

medical records have now been received.N Y

178 * Global Period Applied

This service is denied as included in global period to initial

procedure. To request reconsideration, complete the provider






N Y

179 * Out-of-State Usual and Customary Applied

This charge is reduced or denied because it does not reflect the

usual, customary, or reasonable rate. To request






denied charge.

N Y

181 * Medical Records Illegible

This charge is denied because medical records received were

illegible. To request reconsideration, complete the provider


days from the date of the remittance advice and provide medical

notes in a typed format along with a request for reconsideration.

The patient may not be billed for this charge.

N Y

183 *Special Request – No Time for Service /

Procedure Submitted

This charge is reduced or denied because time spent on WSI’s

requested service / procedure was not noted in your review. To



date of the remittance advice The patient may not be billed for

this reduced or denied charge..

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

184Return-to-Work Case Management –

Unnecessary or Excessive Charges

This charge is reduced or denied because the service performed

was unnecessary or in excess of what was requested. To

request reconsideration, contact WSI, in writing, within 30 days.

The employee may not be billed for this reduced or denied

charge.

N Y


Unauthorized Disability Management Services

This charge is denied because the services performed were not

authorized by WSI. To request reconsideration, contact WSI, in

writing, within 30 days. The employee cannot be billed for this

charge.

N Y

186Liability Determination – Treatment Plan Not

Received

This charge is denied because no treatment plan has been

received. Per Administrative Rule 92-01-02-30 - Medical

services may be reimbursed only when provided according

to a written treatment plan. A copy of the treatment plan,

signed by the attending medical service provider, must be

provided to WSI within 14 days of beginning the treatment

or within 14 days of learning that the treatment is claimed to

be work related, whichever occurs later . To request

reconsideration, contact WSI, in writing, within 30 days, and

provide the written treatment plan along with a request for

reconsideration. The patient may not be billed for this charge.

N Y


Exceeded Maximum Allowed

This charge exceeds the maximum allowed for the requested

service. To request reconsideration, contact WSI, in writing,

within 30 days from the date of the remittance advice. The

employee may not be billed for this reduced or denied charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

188 * DRG Hospital Payment Formula Applied

This charge is reduced or denied as required by WSI’s Inpatient

Hospital Fee Schedule. To request reconsideration, complete the


within 30 days from the date of remittance advice and provide a




N Y

189 *DRG Outlier Hospital Payment Formula

Applied

This charge is reduced or denied as required by WSI’s Inpatient

Hospital Fee Schedule with an outlier threshold. To request


form (M6) and submit to WSI within 30 days from the date of




denied charge.

N Y

190Liaison Program – Documentation Does Not

Support the Charge

This charge is being denied because the documentation in the

claim file does not reflect a request for the assistance of the

liaison. The patient may not be billed for this charge.

N Y

191 Liaison Program – Duplicate ChargeThis charge has been paid on a previous invoice or is listed twice

on this invoice. The patient may not be billed for this charge.N Y

192Procedure Code Change – Service(s) Beyond

Compensable Work Injury

This code has been changed because medical documentation

shows service(s) beyond what is necessary to treat the

compensable injury were provided in addition to those related to

the work injury. The patient may not be billed for this charge.

Y Y

193 Miscalculated Transcription Fees

This charge has been reduced or increased because it does not

meet SIU’s rule of reimbursement for transcription, which allows

for three dollars and fifty cents ($3.50) per page.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

194 Unauthorized Expense

This charge has been reduced due to SIU being charged for an

expense which SIU does not cover, is exempt from, or SIU did

not authorize.

N Y

195Times Logged on Bill Do Not Coincide With

Times Logged on Report

This charge has been reduced or increased due to a “beginning

time” or an “ending time” on the bill not coinciding with the time

logged on your investigative report for that particular day.

N Y

196 Miscalculation of Travel Time

This charge has been reduced or increased due to a

miscalculation of the travel time. This change was due to one of

the following: 1) the “beginning time” to “ending time” did not

equal “total travel time” for a specific day; 2) the total travel time

for the bill was miscalculated; or, 3) the total travel time multiplied

by the approved rate paid by SIU was miscalculated.

N Y

197 Miscalculation of Sub-totalsThis charge has been reduced or increased due to a

miscalculation of the sub-totals to get the total amount of the bill.N Y

198 Miscalculation of Surveillance Time


miscalculation of the surveillance time. This change was due to

one of the following: 1) the “beginning time” to “ending time” did

not equal “total surveillance time” for a specific day; 2) the total

surveillance time for the bill was miscalculated; or, 3) the total

surveillance time multiplied by the approved rate paid by SIU was

miscalculated.

N Y

199 Miscalculated Mileage


miscalculation of the mileage. This change was due to one of the

following: 1) there was a miscalculation in miles for a given day;

2) there was a miscalculation in adding the “total miles” for the

bill; or 3) the total miles multiplied by the approved rate paid by

SIU was miscalculated.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

200 Claim Withdrawn

The entire claim for this injury has been withdrawn; therefore,

WSI is not liable for payment of any charges relating to this

injury. This charge is the patient’s responsibility. Please contact

the patient for payment or for other insurance information.

Y Y

201Medical Rule Exceeded – Charge Older than

One Year

This charge is denied because the bill was not submitted within

one year of the date of service or within one year of the date WSI

accepted liability for the work injury or condition. The patient may

not be billed for this charge.

N Y

202 Brand Medication Submitted

This charge is reduced because a generic brand must be

dispensed unless the ordering physician has stated “dispense as

written”. The patient is responsible for the difference between

the brand name and generic medication. Please contact the

patient for payment.

Y Y

203 Miscellaneous Addition to the Bill

This charge has been increased due to one of the following: 1)

meals for a given day were inadvertently left off the bill; 2) motel

charges were inadvertently left off the bill; or 3) another expense

was inadvertently left off the bill. Due to one of these changes,

the bill was recalculated and the total was changed.

N Y

204 * Audit Bill Type does not Qualify as Submitted.

This charge is denied as WSI has determined that the bill type

does not qualify as submitted. Please submit the corrected bill

type for services rendered. To request reconsideration, complete

the provider request for an adjustment form (M6) and submit to

WSI within 30 days from the date of the remittance advice and




N Y

205 Outpatient Packaged Services Denied

This charge is denied because WSI does not pay for this

packaged service, as required by WSI’s medical and hospital fee

schedule. The patient may not be billed for this charge.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

206 Home Modifications – Allowance Exceeded

This charge is reduced or denied because the home modification

allowance has been exceeded. The remaining balance is the

responsibility of the injured worker.

Y Y

207 Unauthorized Expense – RTW Services

This charge has been reduced due to RTW Services being

charged for an expense which RTW Services does not cover, is

exempt from, or RTW Services did not authorize.

N Y

209Personal Reimbursement - Request for

Pharmacy Denied

Your request for reimbursement for pharmacy is denied. WSI

requires all pharmacies to submit billings directly to the pharmacy

benefit management company, PBM. Please contact your

pharmacy and have them submit a bill to the PBM. If we

determine these charges are the responsibility of WSI, payment

will be made to the pharmacy. You may then seek

reimbursement from the pharmacy.

Y Y

210 WSI has opted out of the third party litigationWSI has opted out of the third party litigation pursuant to

N.D.C.C. § 65-01-09 and has no further liability for costs or fees.N Y

211 Internal code, ICD-9 adjustment ICD-9 adjustment N N

212 *Liability Determination – Medical records not

received

This charge is denied because the medical records have not

been received and WSI is unable to establish liability for these

charges. To request reconsideration, complete the provider


days from the date of the remittance advice and provide the

appropriate records. The patient may not be billed for this

charge.

N Y

213 * W9 not received

This charge is denied because WSI has not received a W9

(Federal Taxpayer Identification Form). A W9 is necessary

before any payments can be made to your facility. To request


form and submit to WSI within 30 days from the date of the

remittance advice. The patient may not be bill for this charge.

Y Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

215 * Anesthesia modifier missing

This charge is denied because the anesthesia modifier is

missing. To request reconsideration, complete the provider



statement of why the denial is disputed. You may also supply

any supporting documentation. The patient may not be billed for

this reduced or denied charge.

N Y

216Preferred Worker unnecessary or excessive

reduction/denial

Preferred Worker, Unnecessary or Excessive Charges - This

charge is reduced/denied because the service or request was

unnecessary or not allowable.

N Y

217 Preferred Worker, Maximum reduction/denialExceeded Maximum Allowed -- This charge exceeds the

maximum allowed.N Y

218 * Audit - EMG

This charge is reduced or denied because electrodiagnostic

studies, may only be performed by electromyographers who are

certified or eligible for certification by the American Board of

Electrodiagnostic Medicine, American Board of Physical

Medicine and Rehabilitation, or the American Board of Neurology

and Psychiatry’s certification in the specialty of Clinical

Neurophysiology. To request reconsideration, complete the




You may also supply supporting documentation. The patient

may not be bill for this reduced or denied charge.

N Y

219 *UR Required – Services/treatment not done in

a timely matter after approval.

This charge is denied because this service was not done within

authorization time frame. To request approval for a retrospective

review, complete the provider request for an adjustment form

(M6) and submit to WSI within 30 days.

N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

220 *Billed time units – medical documentation

does not support submitted units.

This charge is reduced or denied because the total units billed for

the timed code does not match the documented total time

performed. To request reconsideration, complete the provider




also supply supporting documentation. The patient may not be

bill for this reduced or denied charge.

Y Y

221Pharmacy Reimbursement – submit pharmacy

bill to pharmacy benefit manager.

WSI requires all pharmacy or medication charges to be

submitted directly to the pharmacy benefit management

company, Tmesys (1-800-964.2531). The patient may not be

billed for this denied charge.

Y Y

222 * NCCI Edits, AMA and CPT edits

This charge is reduced or denied because of incorrect coding

combinations. WSI uses the National Correct Coding Initiative,

AMA and CPT edits. To request reconsideration, complete the


within 30 days from the date of the remittance advice. You may



N Y

223 Paradigm Management Services

This charge is denied because WSI has contracted with

Paradigm Management Services to manage, coordinate, and

reimburse for this catastrophic work injury. Please contact

Paradigm Management Services for reimbursement. Telephone

800.676.6777; Fax925.676.2197

N Y

224 * Invalid Code per WSI Guidelines

This charge is denied because the code submitted is invalid per

WSI coding guidelines. Resubmit the charge using the

appropriate code. If you disagree with the denial, you may

complete the provider request for adjustment form (M6) and


advice. You may also supply and supporting documentation.


N Y



of 30

March 2015



Print Notice Non-

Payment to

Injured Worker

Print Line &

Code on

Payee Remit

225 Out of state claim filing

The charge is denied because the patient has filed in another

state and the claim is either pending or accepted in the other

state. Please contact the patient for payment or for other

insurance information.

Y Y

226Managed Care – Service Not Medically

Necessary

The charge is denied because it has been determined the service

is not necessary for treat or diagnoses of the compensable work

injury. Notice of decision denying/reducing service, including

information on your right to appeal, has been sent to your facility.


information.

Y Y

227 Bunch CareSolutions Services

This charge is denied because WSI has contracted with Bunch

CareSolutions to reimburse medical bills for this injury. Please

submit charges to Bunch CareSolutions at Bunch CareSolutions

PO Box 32045, Lakeland, FL 33802 or call 888.853.4735 opt 6

Y Y

228 Medicare Processing

This charge has been processed according to WSI fee schedule.

The charges were initially paid in error by Medicare. WSI has not

accepted any additional liability past the charges paid. The

patient may not be billed for this reduced or denied charge.

N Y

229 Medicare Denial This charge was paid correctly by Medicare N Y

230 DRG - Primary Diagnosis Code not Submitted

This charge is denied because the principal diagnosis code is

missing. Please resubmit the corrected UB 04 for services

rendered with the required information. The patient may not be

billed for this denied charge.

N Y

231 Modifier 50 Incorrect Billing

This charge is denied because modifier 50 was used incorrectly

per WSI guidelines. Please review fee schedule requirements for

billing bilateral procedures on WSI website at

www.workforcesafety.com. Please resubmit the corrected bill for

services rendered. The patient may not be billed for this reduced

or denied charged.

N Y



of 30

March 2015

Remittance Advice Reason Codes - Workforce Safety · PDF fileRemittance Advice Reason Codes...

Documents

Transcript of Remittance Advice Reason Codes - Workforce Safety · PDF fileRemittance Advice Reason Codes...