VFC VFC DESC PROV TXT MEM TXT LENGTH OF 0001 SVCS … · 2020. 10. 1. · VFC VFC_DESC PROV_TXT...

VFC VFC_DESC PROV_TXT MEM_TXT LENGTH OF MEMBER TEXT

0000 $15.00 + 30% NPAR COPAY A $15 and 30% coinsurance applied for nonparticipating provider 63

0001 SVCS PRIOR TO ENROLLMENT THESE SERVICES RENDERED PRIOR TO SUBSCRIBER'S ENROLLMENT FOR COVERAGE.

Payment is not available as the service was provided when the individual was not an active member under this customer ID number

127

0002 INVALID CN-TYPE FOR MEMBER PATIENT IS NOT COVERED UNDER SUBSCRIBER'S CONTRACT

You are not covered under the insured's contract 48

0003 SVC UNDER PRIOR ENROLLMENT SERVICES RENDERED DURING ENROLLMENT UNDER A PREVIOUS GROUP

Services rendered during your enrollment with a previous group 62

0004 NOT ENROLL 2ND DEPENDENT SECOND DEPENDENT CANNOT BE ENROLLED UNDER THIS COVERAGE

Just one dependent is covered under your contract 49

0005 NOT ENROLL SPOUSE/3RD DEP SPOUSE OR THIRD DEPENDENT CANNOT BE ENROLLED UNDER THIS COVERAGE

Spouse or third dependent is not covered by this contract 57

0006 ENROLLED DEP OVER AGE PATIENT OVER AGE LIMIT FOR TYPE OF CONTRACT WHEN SERVICE WAS RENDERED

Over age limit for type of contract when service rendered 57

0007 LINE ITEM SVC AFTER GRACE THIS SERVICE WAS RENDERED AFTER SUBSCRIBER'S COVERAGE EXPIRED


127

0008 NO CN COVERS LINE ITEM SVC THIS SERVICE IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT

This service is not covered under your contract 47

0009 SVC DURING GAP GRP ENROLL THIS SERVICE WAS RENDERED DURING A GAP IN GROUP ENROLLMENT


127

0010 NOT ENROLL OVER AGE DEP PATIENT IS OVER THE AGE TO BE ENROLLED UNDER THIS COVERAGE

You are over the age to be enrolled under this coverage 55

0011 SVC DURING GAP ENROLLMENT THIS SERVICE WAS RENDERED DURING A GAP IN THE SUBSCRIBER'S ENROLLMENT


127

0012 SVC CANNOT SELECT CONTRACT PATIENT NOT COVERED FOR THIS SERVICE UNDER THE SUBSCRIBER'S CONTRACT

Your contract does not cover these services 43

0013 RETRO DENIAL THIS SERVICE WAS RENDERED AFTER MEMBER'S COVERAGE EXPIRED.

Your contract does not cover these services 43

0014 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430015 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430016 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430017 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430018 ALCOH DETOX BENE EXCEEDED BENEFITS FOR THIS SERVICE HAVE BEEN EXCEEDED Benefits for this service have been exceeded 440019 N/C INJECTABLE THIS PARTICULAR INJECTABLE IS NOT COVERED This particular injectable is not covered 410020 LIMIT 30 SVCS PER CAL-YR SERVICES ARE LIMITED TO 30 DAYS PER CALENDAR YEAR

(JAN TO DEC)Services are limited to 30 days per calendar year (Jan to Dec) 62

0021 $400 MAX PER CAL-YEAR THE $400 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET

The $400 yearly allowance for these services has been met 57





0024 $1000 LIFETIME MAX THE $1000 LIFETIME ALLOWANCE FOR THESE SERVICES HAS BEEN MET

The $1000 lifetime allowance for these services has been met 60



0026 ORTHODONTIC PRICING ORTHODONTIC SERVICES ALLOWED TO PREAPPROVED PAYMENT SCHEDULE

Priced according to orthodontic monthly payment schedule 56

0027 $2000 LIFETIME MAX $2000 IS MAXIMUM LIFETIME ALLOWANCE FOR THESE SERVICES

$2000 is maximum lifetime allowance for these services 54

0028 $1500 MAX PER CAL-YEAR $1500 IS MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THESE SERVICES

$1500 is maximum allowance per calendar year for these services 63

0029 OVER USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE

This amount is the maximum allowed for this service 51

0030 SVCS FILED PREVIOUS These services have been previously paid or denied This is a duplicate claim. A claim for these services has been previously submitted and processed

98

0031 DENTAL OCL REDUCTION OUR ALLOWANCE REDUCED BY THE OTHER INSURANCE CARRIER'S PAYMENT

Our allowance reduced by the other insurance carrier's payment 62

0032 $50I/$150F CAL-YR DED $50 INDIVIDUAL/$150 FAMILY CALENDAR YEAR DEDUCTIBLE TAKEN

$50 individual/$150 family calendar year deductible taken 57

0033 $1700 MAX PER CAL-YR $1700 IS MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THESE SERVICES

$1700 is maximum allowance per calendar year for these services 63

0034 OVER AGE FOR SERVICE PATIENT'S AGE IS BEYOND THE AGE LIMIT FOR THIS SERVICE

Patient's age is beyond the age limit for this service 54

0035 PRICE AT CHARGE PRICED AT CHARGE Priced at charge 160036 MODE PRICING/NON PAR AMOUNT IS MAXIMUM ALLOWED FOR NON-PARTICIPATING

PROVIDERAmount is maximum allowed for non-participating provider 56

0037 20% COPAY 20% PATIENT COPAYMENT APPLIED TO THIS SERVICE This amount represents your coinsurance. You are responsible to pay your provider directly

91

0038 30% COPAY 30% PATIENT COPAYMENT APPLIED TO THIS SERVICE 30% copayment applied to this service is your responsibility 600039 40% COPAY 40% PATIENT COPAYMENT APPLIED TO THIS SERVICE 40% copayment applied to this service is your responsibility 600040 N/C NON-AFFIL OF LIFESPAN THIS IS A NONCOVERED BENEFIT BECAUSE THE SERVICE

WAS RENDERED BY A PROVIDER WHO IS NOT AFFILIATED WITH LIFESPAN

This is a noncovered benefit because the service was rendered by a provider who is not affiliated with Lifespan

111

0041 $500 MAX PER BEN-YR $500 IS THE MAXIMUM ALLOWANCE PER BENEFIT YEAR FOR THIS SERVICE

$500 is the maximum allowance per benefit year for these services 65

0042 $850 MAX PER CAL-YR $850 IS THE MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THIS SERVICE

$850 is the maximum allowance per calendar year for these services

66


$850 is maximum lifetime allowance for orthodontic services 59

0044 OVER USUAL/CUSTOMARY SERVICE OVER USUAL/CUSTOMARY Service over usual/customary 280045 50% COPAY 50% PATIENT COPAYMENT APPLIED TO THIS SERVICE 50% copayment for this service is your responsibility 530046 40% USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS

SERVICEThis amount is the maximum allowed for this service 51

0047 40% USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE


0048 40% MODE PRICE/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE


0049 OVER CUSTOMARY/N PAR THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWED PAYMENT FOR THIS SERVICE

Priced according to orthodontic monthly payment schedule 56

0050 TIMELY FILING SERVICE WAS FILED AFTER THE ACCEPTABLE TIME LIMIT Payment for this service is not available as the claim was not filed within the required timeframe

98

0051 WORKERS COMP SAVINGS PATIENT'S CONTRACT DOES NOT COVER WORK-RELATED INJURIES

Payment is not available for this service because the claim was reported as a potential work-related injury

107

0052 UNDER AGE FOR SVC PATIENT'S AGE IS UNDER THE AGE LIMIT FOR THIS SERVICE Patient's age is under the age limit for this service 53

0053 FMF/DOLLAR INDEMNITY THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE


0054 DENTAL OCL PAID IN FULL ALLOWANCE REDUCED BY THE OTHER INSURANCE CARRIER'S PAYMENT

Allowance reduced by the other insurance carrier's payment 58


$1700 is maximum lifetime allowance for orthodontic services 60

0056 $800 MAX PER CAL-YR $800 PER CALENDAR YEAR MAXIMUM FOR THESE SERVICES MET

$800 per calendar year maximum for periodontal services met 59

0057 SVC NEVER PERFORMED RECORDS DID NOT INDICATE THAT SERVICE WAS PERFORMED

Records did not indicate that service was performed 51





0060 $750 MAX PER CAL-YR THE $750 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET


0061 $1200 MAX PER CAL-YR THE $1200 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET




0063 INTERSCHOLASTIC SPORTS INTERSCHOLASTIC/INTERCOLLEGIATE SPORTS INJURIES ARE NOT COVERED

Interscholastic/intercollegiate sports injuries are not covered 63

0064 ADMIN PURPOSE EXAMS N/C MEDICAL EXAMINATIONS FOR ADMINISTRATIVE PURPOSES ARE NOT COVERED.

Medical examinations for administrative purposes are not covered

69

0065 INFIRMARY SERVICE N/C INFIRMARY CHARGES ARE NOT COVERED UNDER PATIENT'S CONTRACT

Infirmary charges are not covered under your contract 53

0066 NON-ACC PROV SPECIFIC SVC PROVIDER'S CREDENTIALS DO NOT MEET OUR REQUIREMENTS FOR THIS SPECIFIC SERVICE.

This service has been denied. The provider is not authorized to perform this type of service. You are not responsible for the denied service

140

0067 CUSTODIAL CARE N/C PATIENT'S CONTRACT DOES NOT INCLUDE CUSTODIAL CARE

Your contract does not include custodial care 45

0068 ROUTINE DIAGNOSIS N/C ROUTINE PHYSICALS ARE NOT A COVERED SERVICE Routine physicals are not a covered service 430069 HOME NO ALLOWANCE-INST0070 NONCOVERED HOSPITAL LAB LABORATORY CONSULTATIONS OR INTERPRETATIONS ARE

NOT COVEREDLaboratory consultations or interpretations are not covered 59

0071 NONCOVERED POSTMORTEM SVC THIS POSTMORTEM SERVICE IS NOT COVERED This postmortem service is not covered 380072 HOME NO ALLOWANCE-PPO/POS0073 HOME NO ALLOWANCE-CAP0074 STAFF PHYSICIAN N/C SERVICE BY A PHYSICIAN ON THE STAFF OF A HOSPITAL IS

NOT COVEREDService by a physician on the staff of a hospital is not covered 64

0075 ASSOCIATED ROOM CHARGE N/C ASSOCIATED CHARGES DENIED WHEN FACILITY CHARGE HAS BEEN DENIED

Associated charges denied when facility charge has been denied 62

0076 SVC N/C IF NOT BY THE PCP THIS SERVICE IS ONLY COVERED WHEN RENDERED BY THE PRIMARY CARE PHYSICIAN

This service is only covered when rendered by your primary care physician

73

0077 ALT BIRTH CTR N/C PROV ONLY SERVICES BY AN APPROVED BIRTHING CENTER CAN BE REIMBURSED

Only services from an approved birthing center can be reimbursed 64

0078 ACTS OF WAR N/C SERVICES FOR CONDITIONS RESULTING FROM ACTS OF WAR NOT COVERED

Services for conditions resulting from acts of war not covered 62

0079 INSUFF INFO TO DET ER COV INSUFFICIENT INFORMATION TO DETERMINE COVERAGE FOR EMERGENCY ROOM SERVICE; PLEASE PROVIDE MEDICAL RECORDS

Insufficient information to determine coverage for emergency room service

73

0080 90% MDR PRICING THIS IS THE MAXIMUM ALLOWED AMOUNT FOR THIS SERVICE

This is the maximum allowed amount for this service 51

0081 INV DIAG FOR LABOR RM MATERNITY-RELATED DIAGNOSIS IS REQUIRED TO ALLOW LABOR ROOM

Maternity-related diagnosis is required to allow labor room 59

0082 DENTAL CARE NOT COVERED THIS DENTAL CARE IS NOT A COVERED SERVICE This dental care is not a covered service 410083 THERAPY N/C BT AGE 3 - 21 THERAPY BETWEEN AGES 3 AND 21 IS RESPONSIBILITY OF

CITY OR TOWNTherapy between ages 3 and 21 is responsibility of city or town 63

0084 SERVICE NOT COVERED THIS SERVICE IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT

This service is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents

119

0085 N/C PRE ADMIN TEST B/C PRE-ADMISSION TESTING IS NOT COVERED UNDER PATIENT'S CONTRACT

Pre-admission testing is not covered under your contract 56

0086 N/C OPERATING ROOM B/C SERVICE DID NOT MEET CRITERIA FOR COVERED OUTPATIENT SURGERY

This service was denied as it is not covered as outpatient surgery 66

0087 NONCOVERED BLOOD CHARGE THESE BLOOD CHARGES ARE NOT COVERED UNDER PATIENT'S CONTRACT

These blood charges are not covered under your contract 55

0088 FLEX COINSURANCE APPLIED A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.

A flex coinsurance has been applied to this service 51

0089 INV DIAG FOR CHEMOTHERAPY THIS SERVICE IS NOT COVERED FOR THE CONDITION REPORTED

Chemotherapy covered only for treatment of cancer 49

0090 CHEMO ANCILL DENIED CHEMOTHERAPY ANCILLARY DENIED BECAUSE CHEMOTHERAPY ADMINISTRATION IS DENIED.

Chemotherapy ancillary denied because chemotherapy administration is denied

75

0091 BENEFITS EXHAUSTED The maximum benefits for these services have been previously used

Payment is not available because you have exceeded the benefitlimit for this type of service

92

0092 FLEX COPAY HAS BEEN MET0093 SVC NOT MED NECESSARY SERVICES ARE CONSIDERED NOT MEDICALLY NECESSARY This service was denied as it is considered not medically necessary 67

0094 FLEX DEDUCTIBLE APPLIED A FLEX PLAN DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE.

This amount was applied toward your Flex Plan deductible 56

0095 NURSERY W/O MOTHER FLE SEP NURSERY NOT COVERED IF MOTHER'S ROOM AND BOARD CHARGES NOT FILED

Nursery not covered if mother's room and board charges not filed 64

0096 INPATIENT DEDUCT APPLIED AN INPATIENT DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE

An inpatient deductible has been applied to this service 56

0097 NONCOVERED HOME CARE THIS HOME CARE SERVICE IS NOT COVERED UNDER YOUR CONTRACT

This home care service is not covered under your plan 53

0098 FILE WITH MH VENDOR MENTAL HEALTH/SUBSTANCE ABUSE SERVICES SHOULD BE FILED DIRECTLY WITH THE MENTAL HEALTH VENDOR

Mental health/substance abuse services should be filed directly with the mental health vendor

93

0099 N/C TRANSPLANT SERVICE THIS TRANSPLANT SERVICE IS NOT COVERED UNDER PATIENT'S CONTRACT

This transplant service is not covered under your contract 58

0100 ONE EXAM/VISIT PER YEAR THE LIMIT OF ONE VISIT PER YEAR HAS BEEN PAID The limit of one visit per year has been paid 45

0101 I/P DEDUCTIBLE APPLIED INPATIENT DEDUCTIBLE APPLIED. Inpatient Deductible applied 280102 BENE EXHAUSTED FOR CAL YR MAXIMUM CALENDAR YEAR BENEFITS FOR THIS SERVICE

HAVE BEEN METMaximum calendar year benefits for this service have been met 61

0103 $50 DED PER ADMISSION A $50 DEDUCTIBLE HAS BEEN APPLIED TO THIS ADMISSION A $50 deductible has been applied to this admission 51

0104 WITHHOLD APPLIED0105 REDUCE TO ZERO, CAPITATION Capitated service0106 LIMIT 30 HRS PER CALYR MAXIMUM OF 30 HOURS PER CALENDAR YEAR HAS BEEN

PREVIOUSLY PAIDMaximum of 30 hours per calendar year has been previously paid 62

0107 HOST MED ADV CLM IN PROC THIS CLAIM HAS BEEN ROUTED TO THE MEMBERS BLUE CROSS PLAN FOR PROCESSING. PAYMENT TO THE PROVIDER WILL BE MADE ON A FUTURE SETTLEMENT

0108 N/C RADIOLOGY SERVICES DENTAL X-RAYS COVERED ONLY IF RELATED TO AN ACCIDENT

Dental X-rays covered only if related to an accident 52

0109 APPROVED UNITS EXCEEDED ADDITIONAL REIMBURSEMENT MAY BE AVAILABLE. PLEASE CONTACT THE MENTAL HEALTH VENDOR.

Additional reimbursement may be available. Please contact the mental health vendor

82

0110 NONCOVERED MACHINE TEST THIS MACHINE TEST IS NOT COVERED This machine test is not covered 320111 N/C MAINTENANCE THERAPY THESE MAINTENANCE THERAPY SERVICES ARE NOT

COVEREDThese maintenance therapy services are not covered 50

0112 EXCEEDS 3 VISITS PER WEEK THE MAXIMUM OF 3 VISITS PER WEEK HAS ALREADY BEEN REIMBURSED

The maximum of 3 visits per week has already been reimbursed 60

0113 INVALD DX FOR BENEFIT CONT THIS SERVICE IS NOT COVERED FOR THE CONDITION REPORTED

This service is not covered for the condition reported 54

0114 ECHO PREV PAID SAME PROV THIS SERVICE HAS BEEN PAID PREVIOUSLY TO THE SAME PROVIDER

This service has been paid previously to the same provider 58

0115 ECHO PREV PAID DIFF PROV SAME SERVICE WAS PAID PREVIOUSLY TO A DIFFERENT PROVIDER

Same service was paid previously to a different provider 56

0116 ECHO PARTS PRV PD SAME PRV PAYMENT REDUCED BECAUSE PART OF SERVICE HAS BEEN PREVIOUSLY PAID

Payment reduced because part of service has been previously paid 64

0117 ECHO PARTS PRV PD DIFF PRV SERVICE INCLUDED IN CLAIM PREVIOUSLY PAID TO ANOTHER PROVIDER

Service included in claim previously paid to another provider 61

0118 PLACE OF SERV NOT APPROVED SERVICE NOT COVERED IN THE PLACE WHERE IT WAS PERFORMED

Service not covered in the place where it was performed 55

0119 LIMITED TO 45 DAYS/CAL YR AMOUNT EXCEEDS CALENDAR YEAR MAXIMUM FOR MENTAL HEALTH SERVICES

Amount exceeds calendar year maximum for mental health services 63

0120 LIMITED TO 60 SVCS/LIFETIM THE LIMIT OF 60 SERVICES PER LIFETIME HAS BEEN PREVIOUSLY PAID

The limit of 60 services per lifetime has been previously paid 62

0121 DAY HOSP ADMISSION DENIED MENTAL HEALTH SERVICE DENIED WHEN DAY HOSPITAL STAY IS DENIED

Mental health service denied when day hospital stay is denied 61

0122 ACCOMODATIONS MAX EXCEEDED SERVICES NOT ALLOWED BECAUSE ROOM AND BOARD LIMIT HAS BEEN EXCEEDED

Services not allowed because room & board limit has been exceeded

65

0123 XRAY INCL IN PREV PD PROC THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470124 XRAY PREV PAID DIFF PROV PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY TO

ANOTHER PROVIDERPayment reduced by amount paid previously to another provider 61

0125 XRAY PTS PRV PAID SAME PRV PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY TO THE SAME PROVIDER

Payment reduced by amount paid previously to the same provider 62

0126 TOT LIAB PD TO ANOTHER PHY THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470127 INV PROV FOR HEMODIALYSIS PROVIDER IS NOT APPROVED FOR PAYMENT OF

HEMODIALYSIS SERVICESProvider is not approved for payment of hemodialysis services 61

0128 NEW/EXPER SVC NOT APPROVED NEW AND INVESTIGATIONAL PROCEDURES ARE NOT COVERED

New/experimental services not covered. Please refer to the exclusions section of your benefit documents

103

0129 NONCOVERED PSYCH SERVICE THIS SERVICE IS NOT COVERED BY PATIENT'S CONTRACT This service is not covered by your contract 44

0130 INVALID POS OR PROVIDER PROVIDER OR FACILITY IS NOT APPROVED FOR THIS SERVICE

Provider or facility is not approved for this service 53

0131 NO DAY HOSP ADM ON HIST SERVICE NOT COVERED IN THE PLACE WHERE IT WAS PERFORMED

Service not covered in the place where it was performed 55

0132 MULT PSYCH/MED SAME DAY MAXIMUM OF 1 MEDICAL AND/OR MENTAL HEALTH DAILY VISIT WAS PAID

Maximum of 1 medical and/or mental health daily visit was paid 62

0133 120 MAX DAYS/SVCS EXCEEDED Annual MAXIMUM OF 120 DAYS HAS BEEN EXCEEDED Annual maximum of 120 days has been exceeded 440134 PROV IDENT BILLING ERROR PROVIIDER REQUESTED RETRACTION OF CLAIM Provider indicated this claim was billed in error 490135 BRADLEY ADM NOT PD/DENIED BRADLEY HOSP MENTAL HEALTH SERVICES DENIED IF

ADMISSION NOT PAIDBradley Hosp mental health services denied if admission not paid 64

0136 ECT SVC PAID - DENY PSYCH ONLY 1 THERAPY PER DAY COVERED AND VISITS NOT COVERED ON SAME DAY

Only 1 therapy covered per day. Visits not covered on same day 62

0137 OTHER ECT,MED,PSYCH PAID MAXIMUM OF 1 THERAPY SERVICE HAS ALREADY BEEN PAID FOR THIS DATE

Maximum of 1 therapy service has already been paid for this date 64

0138 25% COPAY UP TO $1000 BENEFITS REDUCED BY 25% COPAY UP TO $1000 Benefits reduced by 25% copay up to $1000 410139 DENY SERVICE BY PAR ANESTH0140 $150IND/$300FAM CAL-YR CP PAYMENT HAS BEEN REDUCED BY CONTRACT COPAY

AMOUNTPayment has been reduced by contract copay amount 49

0141 NONCOVERED SUPPLIES CRUTCHES, CANES, AND COLLARS ARE NONCOVERED SUPPLIES

Crutches, canes, and collars are noncovered supplies 52

0142 DENY PSYCH/MED-CONSULTN PD A CONSULTATION SERVICE HAS BEEN PAID PREVIOUSLY A consultation service has been paid previously 47

0143 $250 DED PER ADMISSION A $250 DEDUCTIBLE IS APPLIED TO EACH ADMISSION A $250 deductible is applied to each admission 460144 PAY AVG SEMI-PVT RM RATE PAYMENT FOR PRIVATE ROOM BASED ON ALLOWANCE FOR

SEMI-PRIVATE ROOMPayment for private room based on allowance for semi-private room 65

0145 N/C UNQUAL/SPECIAL RM&BD NO PAYMENT FOR SPECIAL ROOM AND BOARD CHARGES No payment for special room and board services 46

0146 DENY 1ST 10 PT/OT CAL YR0147 INST/FLEX COINS APPLIED AN INPATIENT/OUTPATIENT INSTITUTIONAL DEDUCTIBLE

AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.

An inpatient/outpatient institutional deductible and a flex coinsurance has been applied to this service

104

0148 TREATMENT FEE ALL INCLUSIV THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470149 UTILIZATION REVIEW DENIAL THESE SERVICES WERE REVIEWED AND DENIED AS

NONCOVEREDThese services were reviewed and denied as noncovered 53

0150 XRAY PARTS PAID SM/DIF PRV REDUCED BY AMOUNT PAID PREVIOUSLY TO SAME OR DIFFERENT PROVIDER

Reduced by amount paid previously to same or different provider 63

0151 DIAG NOT URGENT CARE THE CONDITION REPORTED DOES NOT MEET CRITERIA OF URGENT CARE

The condition reported does not meet criteria of urgent care 60

0152 MACHINE TEST PAID SM PROV PAYMENT FOR THIS SERVICE WAS MADE PREVIOUSLY TO SAME PROVIDER

Payment for this service was made previously to same provider 61

0153 MACH TESTS PD SM/DIFF PRV PAYMENT MADE PREVIOUSLY TO THE SAME OR DIFFERENT PROVIDER

Payment made previously to the same or different provider 57

0154 MACHINE TEST PD DIFF PROV SERVICE INCLUDED IN CLAIM PAID PREVIOUSLY TO DIFFERENT PROVIDER

Service included in claim paid previously to different provider 63

0155 ECHO PARTS PD SM/DIFF PROV REDUCED BY AMOUNT PAID PREVIOUSLY TO SAME OR DIFFERENT PROVIDER

Reduced by amount paid previously to same or different provider 63

0156 LIMIT 70 DAYS/CAL YR BENEFITS LIMITED TO 70 DAYS PER CALENDAR YEAR Benefits limited to 70 days per calendar year 450157 LIMIT 365 DAYS/CAL YR BENEFITS LIMITED TO 365 DAYS PER CALENDAR YEAR Benefits limited to 365 days per calendar year 460158 LIMIT 730 DAYS/CAL YR BENEFITS LIMITED TO 730 DAYS PER ADMISSION Benefits limited to 730 days per admission 420159 NO 2ND OP OR PREAUTH COPAYMENT APPLIED BECAUSE MANAGED BENEFITS

PROCEDURE WAS NOT FOLLOWEDCopayment applied because Managed Benefit procedures not followed

65

0160 $150 INDEMNITY CONTRACT PAYMENT BASED ON THE DOLLAR LIMIT DEFINED IN SUBSCRIBER'S CONTRACT

Payment was based on the dollar limit defined in your contract 62

0161 N/C HOSPICE ROOM AND BOARD HOSPICE ROOM & BOARD CHARGES ARE NOT COVERED Hospice room & board charges are not covered 440162 NO ABORTION COVERAGE SERVICE EXCLUDED BY THE EMPLOYER'S CONTRACT Service excluded by your employer's contract 440163 $150 MATERNITY MAXIMUM PAYMENT BASED ON THE DOLLAR LIMIT DEFINED IN

SUBSCRIBER'S CONTRACTPayment was based on the dollar limit defined in your contract 62

0164 NO COVERAGE FOR THIS SVC THESE SERVICES ARE NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT


119

0165 OTHER COM CARRIER PD PORTN PAYMENT REDUCED BY AMOUNT PAID BY OTHER HEALTH CARE COVERAGE

This is the amount paid by your primary coverage 48

0166 MEDICARE PD PORTION ALLOWANCE AFTER MEDICARE This is the amount paid by Medicare 350167 OTHER BLUE PD PORTION ALLOWANCE AFTER OTHER BLUE CROSS PLAN Allowance after other Blue Cross plan 370168 BILL OTHER CARRIER FIRST SUBSCRIBER'S OTHER INSURANCE COVERAGE SHOULD

PAY FIRSTThis claim needs to be processed by your other insurer before additional benefits under this coverage can be considered.

120

0169 SUBMIT TO MEDICARE FIRST FILE CLAIM WITH MEDICARE FIRST This claim needs to be processed by Medicare before additionalbenefits under this coverage can be considered.

109

0170 NO 2ND OP; PENALTY APPLIED PAYMENT REDUCED BECAUSE A SECOND OPINION WAS NOT OBTAINED

Payment reduced because a second opinion was not obtained 57

0171 INST COINS APPLIED AN INPATIENT/OUTPATIENT INSTITUTIONAL DEDUCTIBLE HAS BEEN APPLIED

An inpatient/outpatient institutional deductible has been applied 65

0172 EXCD 245 ADD MED/PSYCH DYS BENEFITS LIMITED TO 365 DAYS Benefits limited to 365 days 280173 UNLISTED PROCEDURE DENIED ADDITIONAL DOCUMENTATION NEEDED TO DETERMINE

COVERAGE FOR UNLISTED PROCEDURES.ADDITIONAL DOCUMENTATION NEEDED TO DETERMINE COVERAGE FOR UN- LISTED PROCEDURES

79

0174 EXCD 610 ADD MED/PSYCH DYS THE MAXIMUM NUMBER OF ALLOWED DAYS HAS BEEN EXCEEDED

The maximum number of allowed days has been exceeded 52

0175 $30 AND INST COINS APPLIED A $30 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE HAS BEEN APPLIED

A $30 copay and an inpatient/outpatient deductible has been applied

67

0176 EXCD 25 ADD PSY DY,SM ADM BENEFITS LIMITED TO 70 DAYS Benefits limited to 70 days 270177 $20 AND INST COINS APPLIED A $20 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE

HAS BEEN APPLIEDA $20 copay and an inpatient/outpatient deductible has been applied

67

0178 HEMO /MEDICAL SAME DAY MEDICAL CARE IS NOT COVERED ON SAME DAY AS HEMODIALYSIS

Medical care is not covered on same day as hemodialysis 55

0179 EXCD 75 ADD PSY DY,SM ADM BENEFITS LIMITED TO 120 DAYS Benefits limited to 120 days 280180 20% AND INST COINS APPLIED A 20% COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE

HAS BEEN APPLIED TOTHIS SERVICE0181 WHOLE MACH TEST PD SM PROV THIS SERVICE PREVIOUSLY BILLED BY AND PAID TO SAME

PROVIDERThis service previously billed by and paid to same provider 59

0182 WHOLE MACH TST PD DIFF PRV THIS SERVICE PREVIOUSLY BILLED BY AND PAID TO DIFFERENT PROVIDER

This service previously billed by and paid to different provider 64

0183 ROUTINE GENETIC SCREEN N/C ROUTINE GENETIC SCREENING IS NOT A COVERED SERVICE

Routine genetic screening is not a covered service 50

0184 NO INPAT STAY W/IN TIME RQ THERAPY NOT COVERED IF PATIENT WAS NOT HOSPITALIZED

Therapy not covered if patient was not hospitalized 51

0185 MEMBER NOT ELIGIBLE MEMBER IS NOT ELIGIBLE FOR SERVICE. Member is not eligible for service 340186 $30/INST/FLEX COINS APPL A $30 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE

AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE

A $30 copay and an inpatient/outpatient deductible and a flex coinsurance has been applied to this service

106

0187 $125 INDEMNITY CONTRACT BENEFITS LIMITED TO $125 PER DAY FOR ROOM AND BOARD

Benefits limited to $125 per day for room and board 51

0188 BLUECHIP PD PORTION ALLOWANCE AFTER BLUECHIP Allowance after BlueCHiP 240189 BOB-PRI PD PORTION ALLOWANCE AFTER PRIMARY COVERAGE This is the amount paid by your primary coverage. 490190 OTHER GOVT AGENCY PD ALLOWANCE AFTER GOVERNMENT AGENCY OTHER THAN

MEDICAREAllowance after government agency other than Medicare 53

0191 OTHER HMO PD PORTION ALLOWANCE AFTER HMO COVERAGE Allowance after HMO coverage 280192 $20/INST/FLEX COINS APPL A $20 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE

AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE

A $20 copay and an inpatient/outpatient deductible ans a flex coinsurance has been applied to this service

106

0193 20%/INST/FLEX COINS APPL A 20% COINSURANCE AND AN INPATIENT/OUTPATIENT DEDUCTIBLE AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.

A 20% coinsurance and an inpatient/outpatient deductible and a flex coinsurance has been applied to this service

112

0194 FILE WITH BLUE CHIP CHARGES MUST FIRST BE FILED WITH BLUE CHIP Charges must first be filed with Blue CHiP 420195 FILE WITH HMO CHARGES MUST FIRST BE FILED WITH PATIENT'S PRIMARY

HMO COVERAGEThis claim need to be processed by the other insurer before additional benefits can be considered.

98

0196 FILE WITH OT BC PLAN CHARGES MUST FIRST BE FILED WITH PATIENT'S OTHER BLUE CROSS PLAN

This claim need to be processed by your other insurer before additional benefits can be considered.

99

0197 FILE WITH OT GOVT AGENCY CHARGES MUST FIRST BE FILED WITH THE FEDERAL AGENCY COVERING PATIENT

Charges must first be filed with the federal agency covering you 64

0198 N/C DUE TO WEEKEND ADMISSI PATIENT'S CONTRACT EXCLUDES ADMISSIONS OCCURRING ON THE WEEKEND

Your contract excludes admissions occurring on the weekend 58

0199 REDUCED BY PREV BENE ALLOW REDUCED BY AMOUNT PREVIOUSLY PAID Reduced by amount previously paid 330200 CHARGE 100% GT RI U/C BLUE CROSS/BLUE SHIELD MAXIMUM ALLOWANCE FOR

THIS SERVICEBlue Cross/Blue Shield maximum allowance for this service 57

0201 MAJOR MEDICAL LIABILITY SERVICES ARE BEING PROCESSED UNDER YOUR MAJOR MEDICAL CONTRACT

Services are being processed under your Major Medical contract 62

0202 ONE NEWBORN VISIT/LIFETIME ONLY ONE INITIAL NEWBORN EXAM IS ALLOWED IN PATIENT'S LIFETIME

Only one initial newborn exam is allowed in patient's lifetime 62

0203 N/C SERVICE FOR CONTRACT THIS SERVICE IS NOT A COVERED BENEFIT UNDER PATIENT'S CONTRACT


119

0204 ONE SERV ALLOWED PER DAY ONLY ONE OF THESE RADIOLOGY SERVICES IS ALLOWED PER DAY

Only one of these radiology services is allowed per day 55

0205 ONE SERV ALLOWED PER 7 DAY ONLY ONE OF THESE SERVICES COVERED DURING A SEVEN DAY PERIOD

Only one of these services covered during a seven day period 60

0206 ROUTINE SERVICES NON-COV BENEFITS NOT PROVIDED FOR ROUTINE SERVICES Benefits not provided for routine services 420207 PROV NOT AUTH FOR PROCEDUR THE PROVIDER IS NOT AUTHORIZED TO PERFORM THIS

SERVICEThis service has been denied. The provider is not authorized to perform this type of service. You are not responsible for the denied service

140

0208 TOTAL SVC PREVIOUSLY PAID THIS SERVICE WAS PREVIOUSLY PAID IN FULL This service was previously paid in full 400209 TOTAL SVC PAID DIFF PROV THIS SERVICE WAS PAID PREVIOUSLY TO A DIFFERENT

PROVIDERThis service was paid previously to a different provider 56

0210 MULT SVCS - PRICE REDUCED THIS IS THE MAXIMUM ALLOWANCE FOR SERVICES RENDERED

This is the maximum allowance for services rendered 51

0211 SUB NOT AUTH FOR HOME CARE PATIENT DOES NOT QUALIFY FOR MATERNITY HOME CARE Patient does not qualify for maternity home care 48

0212 ONE SVC ALLOWED/LIFETIME ONLY ONE SERVICE OF THIS TYPE IS ALLOWED IN PATIENT'S LIFETIME

Only one service of this type is allowed in patient's lifetime 62

0213 $20 AND FLEX COINS APPLIED A $20 COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS

A $20 copay and a flex coinsurance has been applied to this 59

0214 SURGERY INCL CONSULT FEE SURGEON'S CONSULTATION IS INCLUDED IN OUR ALLOWANCE FOR SURGERY

Surgeon's consultation is included in our allowance for surgery 63

0215 MULT CONSUL MUST BE OFFICE 2ND & 3RD OPINION CONSULTS ALLOWED WHEN PERFORMED IN MD'S OFFICE

2nd & 3rd opinion consults allowed when performed in MD's office 64

0216 MULT OPINION/SAME PROVIDER PAYMENT WILL BE MADE FOR ONLY ONE SECOND OPINION VISIT PER DOCTOR

Payment will be made for only one second opinion visit per doctor 65

0217 LIMIT 2 OPINIONS EXCEEDED CONTRACT COVERS 2 SECOND/THIRD OPINION CONSULTS WITHIN 6 MONTHS

Contract covers 2 second/third opinion consults within 6 months 63

0218 MUST BE SMOKE-FREE 1 YEAR PATIENT MUST BE SMOKE-FREE FOR AT LEAST ONE YEAR Patient must be smoke-free for at least one year 48

0219 CONSULT MUST BE INPATIENT OFFICE OR OUTPATIENT HOSPITAL CONSULTATIONS NOT COVERED

Office or outpatient hospital consultations not covered 55

0220 1 CONSULT PER SPECIALTY CONSULTATIONS LIMITED TO ONE PER PROVIDER SPECIALTY, PER ADMISSION

Consultations limited to one per provider specialty, per admission 66

0221 TREATMENT NOT W/IN 72 HRS TREATMENT MUST BE RECEIVED WITHIN 72 HOURS OF ACCIDENT

Treatment must be received within 72 hours of accident 54

0222 DIAG NOT TRAUMA RELATED SERVICE NOT COVERED WHEN CONDITION IS NOT RESULT OF TRAUMA

Service not covered when condition is not result of trauma 58

0223 SURGERY PAID - SAME CONDIT NONCOVERED SERVICE WHEN SURGERY PERFORMED BY SAME DOCTOR SAME DAY

Noncovered service when surgery performed by same doctor same day

65

0224 RELATED MED EMERGENCY PAID ONLY 1 RELATED MEDICAL EMERGENCY SERVICE IS COVERED ON SAME DAY

Only 1 related medical emergency service is covered on same day 63

0225 $30 AND FLEX COINS APPLIED A $30 COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS

A $30 copay and a flex coinsurance has been applied to this 59

0226 CONTRACEPTIVE SVC N/C CONTRACEPTIVE MANAGEMENT IS A NONCOVERED SERVICE

Contraceptive management is a noncovered service 48

0227 1 SVC PER 12 DAYS ONLY ONE OF THIS TYPE OF SERVICE COVERED DURING 12 DAY PERIOD

Only one of this type of service covered during 12 day period 61

0228 $100.00 DEDUCTIBLE APPLIED THIS AMOUNT WAS APPLIED TOWARD YOUR $100 DEDUCTIBLE

This amount was applied toward your $100 deductible 51

0229 NOT REFERRED BY VNA COLLECTION FEES FOR LABORATORY TESTS ARE NOT COVERED

Collection fees for laboratory tests are not covered 52

0230 GTT PREVIOUSLY PAID THIS SERVICE WAS INCLUDED IN A PREVIOUSLY PAID CLAIM

This service was included in a previously paid claim 52

0231 GLUCOSE PREVIOUSLY PAID PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY FOR RELATED TEST

Payment reduced by amount paid previously for related test 58

0232 NOT MED NECESSARY CONDIT THIS SERVICE IS NOT MEDICALLY NECESSARY FOR THE CONDITION REPORTED

This service is not medically necessary for the condition reported 66

0233 MORE THAN 4 SVCS SAME DOS EXCEEDS THE MAXIMUM OF 4 SERVICES PER DATE OF SERVICE

Exceeds the maximum of 4 services per date of service 53

0234 20% COPAY/FLEX COINS APP A 20% COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS

A 20% copay and a flex coinsurance has been applied to this 59

0235 HEMO/SURGERY ON SAME DAY HEMODIALYSIS NOT COVERED WHEN SURGERY PERFORMED ON SAME DAY

Hemodialysis not covered when surgery performed on same day 59

0236 DENTAL CONSULTANT DENIAL THIS SERVICE WAS REVIEWED AND DENIED This service was reviewed and denied 360237 > 10 VISITS UNDER AGE 3 EXCEEDS THE 10 PEDIATRIC PREVENTIVE VISITS ALLOWED

UNDER AGE 3Exceeds the 10 pediatric preventive visits allowed under age 3 62

0238 PART OF XRAY PROCEDURE SERVICES INCLUDED IN THE RELATED X-RAY PROCEDURE Services included in the related X-ray procedure 48

0239 NO LACERATION REP PERFORMD SERVICE REQUIRES RECORD OF LACERATION REPAIR Service requires record of laceration repair 440240 REMOVE SUTURES SAME PROV ALLOWANCE INCLUDES PLACING AND REMOVAL OF

STITCHESAllowance includes placing and removal of stitches 50

0241 MULT PROC SAME OPER FIELD ONLY ONE RELATED SURGICAL SERVICE IS COVERED ON THE SAME DAY.

Only one related surgical service is covered on the same day 60

0242 DIAG SURG PRIOR REL SURG DIAGNOSTIC SURGERY NOT COVERED WHEN SAME DAY AS MAJOR SURGERY

Diagnostic surgery not covered when same day as major surgery 61

0243 PER DIEM/CAP/FIXED FEE THE DOLLAR MAXIMUM FOR THIS SERVICE HAS BEEN MET This amount represents the maximum allowance for this type of service.

70

0244 its n/c anes per sub cont This procedure does not warrant services by an anesthesiologist per the subscribers contract.

0245 its no student cert There is no student certification on file for this member.0246 its predeterm req by prov Claim closed until predetermination has been obtained by the

Provider.0247 INCLUDED IN FRACTURE CARE ALLOWANCE FOR THIS SERVICE INCLUDED IN PAYMENT

FOR FRACTURE CAREAllowance for this service included in payment for fracture care 64

0248 its mat cov sub/spouse ITS - MATERNITY SERVICES ARE COVERED FOR THE SUBSCRIBER OR SPOUSE ONLY.

0249 DENY FRACTURE CARE NONCOVERED BECAUSE FRACTURE CARE PROVIDED WITHIN LAST 7 DAYS

Noncovered because fracture care provided within last 7 days 60

0250 its dental coverage only This subscriber has dental coverage only.0251 NOT BY ANESTHESIOLOGIST ANESTHESIA COVERED ONLY WHEN ADMINISTERED BY AN

ANESTHESIOLOGISTAnesthesia covered only when administered by an anesthesiologist 64

0252 its blue shield cov only This subscriber has Blue Shield coverage only.0253 ANESTHESIA SAME DAY PAYMENT FOR ANESTHESIA INCLUDES THIS SERVICE Payment for anesthesia includes this service 440254 its blue cross cov only This subscriber has Blue Cross coverage only.0255 UNITS EXCEEDED DOC REQ ADDITIONAL MEDICAL DOCUMENTATION IS NEEDED TO

ADJUDICATE THIS SERVICE.Additional medical documentation is needed to adjudicate this service.

70

0256 MEDICAL CARE IN HISTORY THIS SERVICE IS NOT COVERED IF MEDICAL CARE PAID ON SAME DAY

This service is not covered if medical care paid on same day 60

0257 ANCILLARY SERVICES DENIED CHARGES ASSOCIATED WITH NONCOVERED ROOM CHARGE ARE ALSO NONCOVERED

Charges associated with noncovered room charge are also noncovered

66

0258 DOC REVIEWED DENY APPROVED UNITS HAVE BEEN DETERMINED BASED ON SUBMITTED DOCUMENTATION.

Approved units have been determined based on submitted documentation

75

0259 ITS HOST - ANNUAL MAX MET MAXIMUM CALENDAR YEAR BENEFITS FOR THIS SERVICE HAVE BEEN MET.

Maximum calendar year benefits for this service have been met 61

0260 PROSTHESES ANCILL DENIED BENEFITS LIMITED TO INITIAL PROSTHESIS ONLY Benefits limited to initial prosthesis only 430261 PROVIDER NOT PEDIATRICIAN PHYSICIAN MUST BE PEDIATRICIAN TO PERFORM THIS

SERVICEPhysician must be pediatrician to perform this service 54

0262 ITS HOST - LIFETIME MAX EXCEEDS THE LIFETIME MAXIMUM FOR THESE SERVICES Exceeds the lifetime maximum for these services 47

0263 ITS HOST - PAYMENT MAX THE MAXIMUM BENEFITS HAVE BEEN PREVIOUSLY USED The maximum benefits have been previously used 46

0264 $300 DED PER ADMISSION PAYMENT REDUCED BY CONTRACT DEDUCTIBLE Payment reduced by contract deductible 380265 MORE THAN 1 INTL SNF VISIT ONLY 1 INITIAL VISIT BY PHYSICIAN PER ADMISSION TO

THIS FACILITYOnly 1 initial visit by physician per admission to this facility 64

0266 MORE THAN 2 SNF VISITS/WK MAXIMUM OF TWO SKILLED NURSING VISITS PER WEEK HAS BEEN PAID

Maximum of two visits per week has been paid 44

0267 EXCEEDED 30 DAYS SAME ADM BENEFITS LIMITED TO 30 DAYS FOR THE SAME ADMISSION Benefits limited to 30 days for the same admission 50

0268 DENY SNF;SURG SAME PRV,DAY VISIT IS INCLUDED IN THE SURGICAL ALLOWANCE Visit is included in the surgical allowance 430269 $35 DOLLAR COPAY A $35 DOLLAR COPAY HAS BEEN APPLIED TO THIS SERVICE. A $35 dollar copay has been applied to this service 51

0270 MORE THAN 1 INTL MED VISIT ONLY 1 INITIAL VISIT IS COVERED FOR EACH HOSPITAL ADMISSION

Only 1 initial visit is covered for each hospital admission 59

0271 1 FLLWUP MED VST ALLWD/DAY BENEFITS LIMITED TO ONE FOLLOW-UP VISIT PER DAY Benefits limited to one follow-up visit per day 470272 WAIVE $3 CP FRESHMAN CLASS Copay waived - Blueprint for Life - The Freshman class 540273 DENY MED SVC;ECT CVRD SMDY DOCTOR'S VISIT NONCOVERED IF ELECTROCONVULSIVE

THERAPY SAME DAYDoctor's visit noncovered if electroconvulsive therapy same day 63

0274 MED SVC PART OF DIAG SURG PAYMENT FOR DIAGNOSTIC SURGERY INCLUDES THESE MEDICAL VISITS

Payment for diagnostic surgery includes these medical visits 60

0275 DENY MED SVC;HEMO CVRD PAYMENT FOR HEMODIALYSIS INCLUDES THESE MEDICAL VISITS.

Payment for hemodialysis includes these medical visits 54

0276 DENY MED CARE WITH SURGERY PAYMENT FOR SURGERY INCLUDES THESE MEDICAL VISITS.

Payment for surgery includes these medical visits 49

0277 DENY MED;HM.SNF OR PSY CVR MEMBERSHIP DOES NOT PROVIDE BENEFITS FOR THIS PHYSICIAN'S HOSPITAL VISIT SINCE OTHER HOME CARE, MENTAL HEALTH CARE OR SKILLED NURSING FACILITY CARE WERE RENDERED TO THE PATIENT ON THE SAME DAY

Benefit limited to 1 visit per day 34

0278 FILE WITH MAJOR MEDICAL FILE WITH MAJOR MEDICAL Submit charges to Major Medical 310279 DENY MED-CONSULTATION CVRD BENEFITS NOT PROVIDED FOR THE PHYSICIAN'S FOLLOW-

UP VISITS TO THE HOSPITAL WHEN THE SAME PHYSICIAN FILED AND WAS PAID FOR CONSULTATION SERVICES DURING THE SAME PERIOD OF HOSPITALIZATION

Follow-up hospital visits by the consulting physician not covered 65

0280 NOT APPV MULTIPLE OPINION CRITERIA FOR SECOND OR THIRD OPINION CONSULTATION NOT MET

Criteria for second or third opinion consultation not met 57

0281 EXCEEDED 45 DAYS SAME ADM BENEFITS LIMITED TO 45 DAYS PER SAME ADMISSION Benefit limited to 45 days per same admission 450282 EXCEEDED 45 DAYS SAME CY BENEFITS LIMITED TO 45 DAYS PER CALENDAR YEAR Benefits limited to 45 days per calendar year 450283 WAIVE $5 CP FRESHMAN CLASS Copay waived - Blueprint for Life - The Freshman Class 540284 WAIVE $10 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540285 COSMETIC N/C BENEFITS ARE NOT PROVIDED FOR COSMETIC SERVICES Benefits are not provided for cosmetic services 47

0286 WAIVE $15 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540287 WAIVE $20 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540288 N/C SEX TRANS/DYSFUN/INADJ SEXUAL DYSFUNCTION OR SEX CHANGE PROCEDURES ARE

NOT COVEREDSexual dysfunction or sex change procedures are not covered 59

0289 INP ALCOHOL DETOX-DENY SVC THE BENEFIT MAXIMUM OF 21 DAYS HAS BEEN PREVIOUSLY USED

The benefit maximum of 21 days has been previously used 55

0290 INP ALC REHAB 30 DAY MAX 30 DAY CALENDAR YEAR MAXIMUM FOR REHABILITATION HAS BEEN MET

30 day calendar year maximum for rehabilitation has been met 60

0291 OUT OF STATE PROVIDER N/C PROVIDER IS NOT APPROVED BY THE CORPORATION FOR COVERAGE

Provider is not approved by the Corporation for coverage 56

0292 WAIVE 20% CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540293 HOME CARE N/C SAME DAY MED HOME CARE IS NOT COVERED WHEN PATIENT IS IN

HOSPITAL ON SAME DAYHome care is not covered when patient is in hospital on same day 64

0294 LIMITED TO 6 SVCS PER 30DY THE MAXIMUM OF 6 VISITS PER 30 DAYS HAS BEEN MET The maximum of 6 visits per 30 days has been met 480295 PREEXISTING CONDITION CONDITIONS WHICH EXISTED PRIOR TO ENROLLMENT ARE

NOT COVEREDConditions which existed prior to enrollment are not covered 60

0296 $50 DED FOR MAT SVC A $50 DEDUCTIBLE IS APPLIED TO THESE MATERNITY SERVICES

A $50 deductible is applied to these maternity services 55

0297 90% CHARGE THIS IS THE MAXIMUM ALLOWANCE FOR THIS SERVICE This is the maximum allowance for this service 460298 SINGLE OB, NOT COVERED THESE MATERNITY BENEFITS ARE NOT PROVIDED UNDER

PATIENT'S CONTRACTThese maternity benefits are not provided under your contract 61

0299 ALC REHAB 90DAY LIFE MAX THE MAXIMUM OF 90 DAYS PER LIFETIME HAS BEEN MET The maximum of 90 days per lifetime has been met 48

0300 SVC N/C DUE TO LATE DUES WHEN THESE SERVICES WERE RENDERED, THERE WAS A LAPSE IN THE SUBSCRIBER'S COVERAGE; THEREFORE, THE SERVICES WERE DENIED. PLEASE HAVE THE SUBSCRIBER CONTACT OUR OFFICE

Services noncovered because your payment for coverage was overdue

65

0301 SIU REVIEW; NON-COV SVCS BASED ON INFORMATION PROVIDED, SERVICE DETERMINED TO BE NON-COVERED

Based on information provided, service determined to be non-covered

73

0302 DENY CRITCARE;MED RVW DONE THIS CRITICAL CARE WAS REVIEWED AND IS NOT COVERED This critical care was reviewed and is not covered 50

0303 NOT COVERED FOR PROVIDER SERVICE NOT COVERED FOR PROVIDER. Payment for this service is not available when billed by this type of provider

78

0304 BENEFIT NOT APPROVED SERVICE HAS NOT BEEN APPROVED FOR COVERAGE BY THE CORPORATION

Service has not been approved for coverage by the Corporation 61

0305 BENEFIT NOT COVERED BENEFITS FOR THIS SERVICE ARE NOT COVERED Benefits for this service are not covered 410306 20% CP $10 WAIVED FROSH Out of network COPAY applied - dollar COPAY waived -

Blueprintfor Life - the Freshman Class91

0307 20%CP APP $15 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of network COPAY applied - dollar COPAY waived - Blueprint for Life - the Freshman class

92

0308 20%CP APP $5 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived - Blueprint for Life - the Freshman class

92

0309 30%CP APP $15 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived - Blieprint for Life - the Freshman class

92

0310 DENY CONSULT PSYCH PAID THIS CONSULTATION WAS REVIEWED AND DENIED This consultation was reviewed and denied 410311 CLINIC/OV SAME DOS CLINIC VISIT NOT COVERED WHEN OFFICE VISIT PAID FOR

SAME DATEClinic visit not covered when office visit paid for same date 61

0312 PRICE AT 60% OF CHARGE Amount is the maximum allowed for a non-participating provider 620313 35%CP APP $20 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived -

Blueprintfor Life - the Freahman class91

0314 PROV N/C FOR CHEMO DAY SVC PROVIDER IS NOT APPROVED FOR THIS SERVICE Provider is not approved for this service 410315 POS N/C FOR CHEMO DAY SVC CHEMOTHERAPY DAY HOSPITAL CARE MUST BE DONE ON

OUTPATIENT BASISChemotherapy day hospital care must be done on outpatient basis 63

0316 CHEMO DAY HOSP SVC NOT APP DOCTOR'S CHARGE NOT COVERED IF OUTPATIENT HOSPITAL CHARGES DENIED

Doctor's charge not covered if outpatient hospital charges denied 65

0317 DIAG N/C FOR CONSULTATIONS NEWBORN WELL-BABY CARE CONSULTATIONS ARE NOT COVERED

Newborn well-baby care consultations are not covered 52

0318 PRICE AT 93% OF CHARGE THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE


0319 NOT COV FOR SPECIALTY CODE SERVICES NOT COVERED WHEN PROVIDER HAS THIS TYPE OF SPECIALTY

Services not covered when provider has this type of specialty 61

0320 0% COPAY - SYSTEM USE ONLY0321 place of svc not appro THESE SUPPLIES WERE DENIED AS THEY WERE NOT USED

IN THE APPROPRIATE SETTINGThese supplies were denied as they were not used in the appropriate setting

75

0322 ROUTINE FOOT CARE N/C SVC ROUTINE FOOT CARE IS NOT COVERED UNDER SUBSCRIBER'S CONTRACT

This service was denied as routine foot care is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents

151

0323 BASIC PAID-COVER REDUCE NO ADDITIONAL BENEFITS PROVIDED BEYOND THOSE UNDER BASIC CONTRACT

This amount is the maximum payment under your Basic coverage. The balance has been processed under your Major Medical coverage

127

0324 SUBSTANCE ABUSE LIFE MAX THE LIFETIME MAXIMUM FOR THESE SERVICES HAS BEEN EXCEEDED

The lifetime maximum for these services has been exceeded 57

0325 TREATMENT ORDER REQUIRED SERVICES NONCOVERED AS TREATMENT ORDER NOT SUBMITTED BY PROVIDER

Services noncovered as treatment order not submitted by provider 64

0326 LIMIT 1 PER 3 CAL YRS LIMIT 1 GLUCOSE MONITOR PER 3 CAL YRS Limit 1 Glucose Monitor per 3 cal yrs 370327 NON-COVERED NURSING SVC NURSING CARE MUST BE PROVIDED BY A REGISTERED OR

LICENSED PRACTICAL NURSE.Nursing care must be provided by a registered or licensed practical nurse

77

0328 7 SVCS PER CALENDAR YEAR MAXIMUM OF 7 INTENSIVE MENTAL HEALTH SESSIONS PER ADMISSION

Maximum of 7 intensive mental health sessions per admission 59

0329 16 SVCS PER CALENDAR YEAR MAXIMUM OF 16 MODERATE MENTAL HEALTH SESSIONS PER ADMISSION

Maximum of 16 moderate mental health sessions per admission 59

0330 N/C SAME DAY CHEMOTHERAPY EMERGENCY MEDICAL SERVICES NONCOVERED SAME DAY AS CHEMOTHERAPY

Emergency medical services noncovered same day as chemotherapy

62

0331 $8 INDEMNITY CONTRACT AMOUNT REFLECTS THE CONTRACT MAXIMUM BENEFIT OF $8 PER DAY

Amount reflects the contract maximum benefit of $8 per day 58







0335 N/C SERVICE THIS SERVICE IS NOT COVERED This service is not covered 270336 20% + $15 NPAR/AFFIL COPAY A 20% AND $15 COPAY FOR NON-PARTICIPATING OR

AFFILIATE PROVIDERA 20% and $15 copay for non-participating or affiliate provider 63

0337 $700 MAX PER CAL-YR OUTPATIENT MENTAL HEALTH LIMITED TO $700 PER CALENDAR YEAR

Outpatient mental health limited to $700 per calendar year 58

0338 N/C ELECTRO-SHOCK THERAPY ELECTROCONVULSIVE THERAPY REVIEWED AND DETERMINED TO BE NONCOVERED

Electroconvulsive therapy reviewed and determined to be noncovered

66

0339 INVALID PROVIDER FOR HSC PROVIDER NOT APPROVED BY THE CORPORATION FOR THIS SERVICE

Provider not approved by the Corporation for this service 57

0340 1 ROUTINE VISIT PER YEAR ONLY 1 PEDIATRIC CARE ROUTINE VISIT ALLOWED PER CALENDAR YEAR

Only 1 pediatric care routine visit allowed per calendar year 61

0341 PREEMPLOYMENT SVC N/C PRE-EMPLOYMENT SCREENING IS NOT A COVERED SERVICE

Pre-employment screening is not a covered service 49

0342 INC IN SURG ALLOWANCE THIS SERVICE WAS INCLUDED IN THE SURGICAL ALLOWANCE

This service was included in the surgical allowance 51

0343 INCL IN DELIVERY ALLOW THESE CHARGES ARE INCLUDED IN THE ALLOWANCE FOR THE DELIVERY

These charges are included in the allowance for the delivery 60

0344 ONLY MDS + DOS COVERED A MEDICAL OR OSTEOPATHIC DOCTOR MUST PERFORM THESE SERVICES

A medical or osteopathic doctor must perform these services 59

0345 NOT VALID PLACE OF SERVICE SERVICE MUST BE PERFORMED IN HOME, OFFICE OR OUTPATIENT HOSPITAL

Service must be performed in home, office or outpatient hospital 64

0346 MEDICARE ASSIGNED CLAIM MEDICARE ASSIGNED CLAIM Medicare assigned claim 230347 $25 DEDUCTIBLE PER ADM THIS SERVICE REQUIRES A $25 DEDUCTIBLE PER

ADMISSION.This service requires a $25 deductible per admission 52

0348 FILE W/HOME MHSA VENDOR NOT CURRENTLY ASSIGNED Provider will file claim directly to MHSA vendor 480349 NON-PAR PROVIDER N/C No coverage is provided as the services were rendered by a non-

participating provider without prior authorization113

0350 20% NON-PAR/NON-NTWK COPAY This amount represents your out-of-network coinsurance. You are responsible to pay your provider directly

106

0351 INELIGIBLE DEPENDENT PATIENT IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT

You are not covered under the subscriber's contract 51

0352 NO BIOPSY IN HISTORY THIS SERVICE REQUIRES A NEEDLE BIOPSY. This service requires a needle biopsy. 380353 PROVIDER MUST SUBMIT CLAIM Provider must submit this claim for reimbursement 490354 EXCEEDED 30 DAYS SAME YR BENEFIT MAXIMUM OF 30 SERVICES PER YEAR HAS BEEN

EXHAUSTEDBenefit maximum of 30 services per year has been exhausted 58

0355 FEE REDUCTION APPLIED FEE REDUCTION APPLIED FOR N/I NON-RISK PROVIDER0356 N/C SVC WHEN WITH N/C SURG SERVICE NOT COVERED WHEN PERFORMED WITH A

NONCOVERED SURGERYService not covered when performed with a noncovered surgery 60

0357 ADJUSTMENT BY VENDOR ADJUSTMENT BY VENDOR Adjustment by vendor 200358 $20,000 PSYCH LIFETIME MAX LIFETIME MENTAL HEALTH MAXIMUM OF $20,000 HAS BEEN

METLifetime mental health maximum of $20,000 has been met 54

0359 DENIED BY VENDOR DENIED BY VENDOR Denied by vendor 160360 TOTAL PURCHASE PRICE PAID THE TOTAL PURCHASE PRICE HAS BEEN PAID The total purchase price has been paid 380361 MANUAL DENY CLAIM NOT PROCESSED THROUGH AUTOMATED SYSTEM

WAS MANUALLY DENIEDClaim not processed through automated system was manually denied

64

0362 RI MAXIMUM ALLOWANCE THIS IS THE RI MAXIMUM ALLOWANCE This is the RI maximum allowance 320363 PAYMENT BY VENDOR PAYMENT BY VENDOR Payment by vendor 170364 INVALID POS FOR HSC SERVICE NOT COVERED IN THE PLACE WHERE IT WAS

PERFORMEDService not covered in the place where it was performed 55

0365 FILED UNDER INCORRECT CODE PROVIDER MUST FILE SERVICE UNDER CORRECT HEALTH SERVICE CODE

Your provider must re-file this claim using the correct billing code(s) 71

0366 TUBAL/DELIVERY REDUCTION REDUCED IF TUBAL LIGATION DONE ON SAME DAY AS DELIVERY

Reduced if tubal ligation done on same day as delivery 54

0367 SWAN GANTZ/ANEST REDUCTN ANESTHESIA ALLOWED IN FULL; SWAN GANTZ PROCEDURE ALLOWED AT 50%

This is the maximum allowance for services rendered 51

0368 PEDI PILOT PGM DISCONTINUE AFTER HOURS VISITS ARE NO LONGER COVERED After hours visits are no longer covered 400369 THORACIC HERNIA/GB/VAG RED REDUCED IF VAGINAL/GALLBLADDER SURGERY SAME DAY

AS HERNIA REPAIR.This service was included in the surgical allowance 51

0370 GASTRIC SURG REDUCTION REDUCED IF GASTROINTESTINAL SURGERY ON SAME DAY AS STOMACH OPERATION.


0371 SURG-ADM REDUCE / DENY REDUCED/DENIED IF MULTIPLE SURGICAL PROCEDURES AT SAME BODY SITE


0372 TREATMENT NOT W/IN 24 HRS TREATMENT RECEIVED MORE THAN 24 HOURS FROM ONSET OF CONDITION

Treatment received more than 24 hours from onset of condition 61

0373 REDUCED BY SVC PREV PD PAYMENT REDUCED BY AMOUNT PREVIOUSLY PAID Payment reduced by amount previously paid 410374 INCLUDED IN SVC PREV PD THIS SERVICE WAS INCLUDED IN A PREVIOUSLY PAID

SERVICEPayment to the provider for this amount is included in another charge

69

0375 $3.00 COPAY A $3 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES A $3 copayment has been applied to these services 49

0376 $5.00 COPAY A $5 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES This amount represents your $5 copayment. You are responsible to pay you provider directly

91

0377 $10.00 COPAY A $10 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES This amount represents your $10 copayment. You are responsible to pay your provider directly

93

0378 DEPENDENT NOT COV FOR SVC DEPENDENT NOT COVERED FOR THIS SERVICE UNDER THIS CONTRACT

Dependent not covered for this service under this contract 58

0379 1 ROUTINE PAP SMR / CAL-YR LIMIT OF 1 ROUTINE PAP SMEAR PER YEAR HAS BEEN PREVIOUSLY PAID

Limit of 1 routine pap smear per year has been previously paid 62

0380 SUB MUST SUBMIT CLAIM SUBSCRIBER MUST SUBMIT THIS CLAIM FOR REIMBURSEMENT

Subscriber must submit this claim for reimbursement 51

0381 N/C PLAN65 BENEFIT BENEFITS FOR SERVICES NOT PROVIDED UNDER YOUR PLAN 65 CONTRACT

Benefits for services not provided under your Plan 65 contract 62

0382 COPAY APPLIED COPAY APPLIED Copay applied 130383 ONLY IP DENTAL COVERED OUTPATIENT DENTAL SERVICES ARE NOT COVERED UNDER

THIS CONTRACTOutpatient dental services are not covered under this contract 62

0384 EXCEED 365 DYS/SVCS SM ADM BENEFIT MAXIMUM OF 365 DAYS PER ADMISSION HAS BEEN MET

Benefit maximum of 365 days per admission has been met 54

0385 PRICE AT FEE SCHEDULE PRICE AT FEE SCHEDULE Price at Fee schedule 210386 EXCEEDED 60 DAYS SAME ADM BENEFIT MAXIMUM OF 60 DAYS PER ADMISSION HAS BEEN

METBenefit maximum of 60 days per admission has been met 53

0387 EXCEED 60 DAYS SAME CAL-YR BENEFIT MAXIMUM OF 60 DAYS PER CALENDAR YEAR HAS BEEN MET

Benefit maximum of 60 days per calendar year has been met 57

0388 DETERMINED FRAUD & ABUSE AFTER REVIEW, THIS CLAIM HAS BEEN DETERMINED TO BE NON-COVERED DUE TO FRAUD/ABUSE.

After review, this claim has been determined to be non-covereddue to fraud/abuse

80

0389 LIMIT 21 SVCS PER CAL-YR MAXIMUM OF 21 SERVICES PER CALENDAR YEAR HAS BEEN MET.

Maximum of 21 services per calendar year has been met 53

0390 $25 DEDUCT PER CAL-YR THIS AMOUNT REDUCED BY $25 CALENDAR YEAR DEDUCTIBLE

This amount reduced by $25 calendar year deductible 51

0391 RI MAX ALLOW THIS IS THE RI MAXIMUM ALLOWANCE This is the RI maximum allowance 320392 DEDUCTIBLE APPLIED PAYMENT APPLIED OR REDUCED TOWARDS PLAN YEAR

DEDUCTIBLEPayment applied or reduced towards plan year deductible 55

0393 $200 DEDUCT PER ADMISSION A $200 DEDUCTIBLE IS APPLIED PER ADMISSION A $200 deductible is applied per admission 420394 $150 CAL-YEAR MAXIMUM AMOUNT REFLECTS THE $150 CALENDAR YEAR BENEFIT

MAXIMUMAmount reflects the $150 calendar year benefit maximum 54

0395 $200 PENALTY FOR NO PAT COPAYMENT APPLIED BECAUSE PRE-ADMISSION TESTING WAS NOT PERFORMED

Copayment applied because pre-admission testing was not performed

65

0396 DEDUCT APPLIED BY VENDOR DEDUCT APPLIED BY VENDOR Deduct applied by vendor 240397 $550 MAX CAL-YR PSYCH DAY AMOUNT REFLECTS THE $550 CALENDAR YEAR BENEFIT

MAXIMUMAmount reflects the $550 calendar year benefit maximum 54

0398 MULTIPLE ECT ON SAME DAY MORE THAN 1 ELECTROCONVULSIVE THERAPY SESSION ON SAME DAY DENIED

More than 1 electroconvulsive therapy session on same day denied 64

0399 HOME RECIP CLAIM PAID CLAIM PAID BY RECIPROCAL AGREEMENT WITH ANOTHER BLUE CROSS PLAN

Claim paid by reciprocal agreement with another Blue Cross plan 63

0400 TREATMENT NOT W/IN 48 HRS TREATMENT RECEIVED MORE THAN 48 HOURS FROM ONSET OF CONDITION

Treatment received more than 48 hours from onset of condition 61

0401 $100 MAX PER 12 MONTHS BENEFITS LIMITED TO $100 FOR LESIONS, WARTS AND JOINT INJECTIONS

Benefits limited to $100 for lesions, warts and joint injections 64

0402 ER TRIAGE PAYMENT IN FULL RITE CARE ER TRIAGE - PAYMENT IN FULL ER triage payment in full 250403 $1000 DEDUCTIBLE APPLIED PAYMENT REDUCED BY THE $1000 DEDUCTIBLE AMOUNT Payment reduced by the $1000 deductible amount 46

0404 $15,000 PSYCH LIFETIME MAX AMOUNT REFLECTS THE $15,000 LIFETIME BENEFIT MAXIMUM

Amount reflects the $15,000 lifetime benefit maximum 52

0405 $100I/$200F CAL YR DED PAYMENT REDUCED BY CALENDAR YEAR DEDUCTIBLE Payment reduced by calendar year deductible 430406 SVC PREV PAID TO INST PROV PHYSICIAN PAYMENT FOR HEMODIALYSIS INCLUDED IN

FACILITY PAYMENTPhysician service for hemodialysis included in facility payment 63

0407 PENALTY: NO PRECERT & PAT BENEFITS REDUCED BECAUSE MANAGED BENEFITS REQUIREMENTS NOT MET

Benefits reduced because Managed Benefits requirements not met 62

0408 $546 MAX PER CAL YR AMOUNT REFLECTS THE CALENDAR YEAR MAXIMUM OF $546 FOR HEMODIALYSIS

Amount reflects the calendar year maximum of $546 for hemodialysis

66

0409 NOT SEP REIMBURSED THIS SERVICE IS NOT A SEPARATELY REIMBURSED SERVICE WHEN RENDERED BY A PARTICIPATING PROVIDER

Payment to the provider for this amount is included in another charge

69

0410 $25 DEDUCT PER E.R. VISIT PAYMENT REDUCED BY $25 COPAYMENT FOR EMERGENCY ROOM VISIT

Payment reduced by $25 copayment for emergency room visit 57

0411 $3 CP NO GENERIC AVAILABLE A $3 COPAY IS APPLIED BECAUSE THE GENERIC DRUG WAS NOT AVAILABLE

A $3 copay is applied because the generic drug was not available 64

0412 25% COPAY THE 25% COPAYMENT FOR THIS SERVICE IS PATIENT'S RESPONSIBILITY

The 25% copayment for this service is your responsibility 57

0413 1ST YEAR ENROLLED N/C THIS ILLNESS/INJURY IS NON-COVERED SINCE IT OCCURRED PRIOR TO MEMBER'SEFFECTIVE DATE AND THE WAITING PERIOD HAS NOT BEEN MET.

0414 $1000 MAX HAS BEEN MET AMOUNT REFLECTS THE $1000 MAXIMUM BENEFIT FOR THESE SERVICES

Amount reflects the $1000 maximum benefit for these services 60

0415 FILED TRADITIONAL S/B POS CLAIM WAS SUBMITTED UNDER TRADITIONAL BLUECARD PROCESSING, BUT SHOULD BE SUBMITTED UNDER BLUECARD POINT OF SERVICE PROCESSING.

0416 $374 MAX PER CAL YR AMOUNT REFLECTS THE MAXIMUM BENEFIT OF $374 FOR DIALYSIS

Amount reflects the maximum benefit of $374 for dialysis 56

0417 WEEKEND ADM REDUCTION WEEKEND ADMISSION TO HOSPITAL IS REDUCED UNDER THIS CONTRACT

Weekend admission to hospital is reduced under your contract 60

0418 FILED POS MBR NOT ENROLLED CLAIM WAS SUBMITTED UNDER BLUECARD POINT OF SERVICE PROCESSING, BUT MEMBER IS NOT ENROLLED UNDER THAT NETWORK.

0419 INCLUDE IN ANESTHESIA THIS SERVICE IS INCLUDED IN THE ANESTHESIA PAYMENT AND IS NON-BILLABLE TO THE SUBSCRIBER

This service is included the anesthesia payment 47

0420 30% NPAR COPAY A 30% NON-PARTICIPATING PROVIDER COPAY HAS BEEN APPLIED

A 30% non-participating provider copay has been applied 55

0421 TRAUMA SAME DAY INITIAL ACCIDENT ROOM VISIT WAS PAID; FOLLOW-UP VISITS NOT COVERED

Initial accident room visit was paid; follow-up visits not covered 66

0422 INSUFF INFO TO DET ER COV INSUFFICIENT INFORMATION TO DETERMINE COVERAGE FOR EMERGENCY ROOM SERVICE

Insufficient information to determine coverage for emergency room service

73

0423 NOT WITHIN PEDI TIMEFRAME THIS SERVICE WAS NOT PERFORMED WITHIN THE DESIGNATED HOURS

This service was not performed within the designated hours 58

0424 PART OF TRANSPLANT NETWORK CLAIM SHOULD BE SUBMITTED UNDER THE EXISTING TRANSPLANT NETWORK.

0425 CLAIMS DIRECTOR DENIAL SERVICE IS A NONCOVERED THERAPY FOR PLACE OF SERVICE

Service is a noncovered therapy for place of service 52

0426 TOTAL LIAB MET BY MASS BC TOTAL PAYMENT FOR THESE CHARGES MADE BY BC/BS OF MASSACHUSETTS

Total payment for these charges made by BC/BS of Massachusetts 62

0427 MXC 193 PLUS CONTRACT RED THE TOTAL NUMBER OF INPATIENT DAYS EXHAUSTED UNDER YOUR CONTRACT

The total number of inpatient days exhausted under your contract 64

0428 CAROTID SURG REQ/DIAG NC DIAGNOSIS IS NOT COVERED OR CAROTID SURGERY NOT FILED PREVIOUSLY

Diagnosis is not covered or carotid surgery not filed previously 64

0429 ASSISTANT SURGEON N/C ASSISTANT SURGEON SERVICES NOT WARRANTED FOR THIS PROCEDURE.

0430 WRONG PROVIDER PAID (ADJ) Original payment sent to incorrect provider This is a claim adjustment. The original claim payment was not sent to the appropriate provider

96

0431 $50 CAL YR DED A $50 CALENDAR YEAR DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE

A $50 calendar year deductible has been applied to this service 63

0432 NO LEGAL OBLIGATION PATIENT IS UNDER NO LEGAL OBLIGATION FOR THIS SERVICE

Patient is under no legal obligation for this service 53

0433 NON-BILLABLE LAB SVC THE LAB SERVICE RENDERED IS NON-BILLABLE AND THE PATIENT IS NOT RESPONSIBLE FOR THE CHARGE.

Payment to the provider for this amount is included in another charge

69

0434 1 PAIR LENSES PER YEAR MAXIMUM OF 1 PAIR OF LENSES PER YEAR HAS BEEN PAID PREVIOUSLY

This pair of lenses was denied as you exceeded your benefit limit of 1 service per calendar year

96

0435 ORTHOPEDIC SHOES N/C ORTHOPEDIC SHOES ARE NOT COVERED UNDER YOUR CONTRACT

Orthopedic shoes are not covered under your contract 52

0436 ONLY OPTH/OPT COV ONLY OPTHALMOLOGISTS AND OPTOMETRISTS ARE PAID FOR THIS SERVICE

Only opthalmologists and optometrists are paid for this service 63

0437 $4 COPAY APPLIED A $4 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES A $4 copayment has been applied to these services 49

0438 DATABASE RETRY ERROR0439 NONCOVERED HEMODIALYSIS THIS PARTICULAR HEMODIALYSIS SERVICE IS NOT

COVERED BY YOUR PLANThis particular hemodialysis service is not covered by your plan 64

0440 MEDISPAN FILE ERROR0441 SVC NOT W/IN PROV CONTRACT THIS SERVICE DOES NOT MEET THE CONTRACTUAL

GUIDELINES AND THE PATIENT IS NOT RESPONSIBLE FOR THE CHARGE.

Payment to the provider for this amount is included in anothercharge. You are not responsible for the charge

109

0442 COMBINED W/SUBSEQUENT LINE PAYMENT FOR OTHER SERVICES INCLUDES PAYMENT FOR THIS SERVICE

Payment for other services includes payment for this service 60

0443 DISPENSING FEE NOT COVERED THE DISPENSING FEE IS A NONCOVERED SERVICE The dispensing fee is your responsibility 410444 IC PRICING AMOUNT REFLECTS THE MAXIMUM ALLOWANCE AFTER

INDIVIDUAL REVIEWAmount reflects the maximum allowance after individual review 61

0445 N/C STATE OF RI THE STATE CONTRACT HAS EXCLUDED COVERAGE FOR THIS SERVICE

The State contract has excluded coverage for this service 57

0446 SPECIAL FEATURES N/C LENSES AND/OR SPECIAL FEATURES ADDED TO GLASSES ARE NOT COVERED

Lenses and/or special features added to glasses are not covered 63

0447 NON-PPO VISION MAX ALLOW AMOUNT REFLECTS MAXIMUM ALLOWANCE FOR NON-PARTICIPATING PROVIDER

Amount reflects maximum allowance for non-participating provider 64

0448 VISION PPO MAX ALLOWANCE AMOUNT REFLECTS MAXIMUM ALLOWANCE COVERED BY THE CONTRACT

Amount reflects maximum allowance covered by the contract 57

0449 MEMBER ELIG. DENIAL MEMBER ELIG. DENIAL Member eligibility denial 250450 INCLUSIVE CODE IN HISTORY PAYMENT FOR THIS SERVICE IS INCLUDED IN A PREVIOUS

CLAIMA claim for these services has been previously submitted and processed

70

0451 SVC REQ SAME DAY ER/ACC RM SERVICES MUST BE PERFORMED ON SAME DAY AS EMERGENCY ROOM CHARGES

Services must be performed on same day as emergency room charges

64

0452 DATABASE RETRY ERROR0453 MEDISPAN FILE ERROR0454 DATE CONVERSION ERROR0455 20% COPAY 20% PATIENT COPAYMENT APPLIED TO THIS SERVICE This amount represents your coinsurance. You are responsible to

pay your provider directly90

0456 DME N/C AFTER 3 MONTHS RENTAL OF NERVE STIMULATORS LIMITED TO 3 MONTHS Rental of nerve stimulators limited to 3 months 470457 SUBMIT TO MEDICARE (DIS) PLEASE FILE DISABILITY ACCOUNTS WITH MEDICARE FIRST Please file disability accounts with Medicare first 51

0458 $500 DED/NO CONS. IN HIST A $500 COPAYMENT APPLIED IF INITIAL CONSULTATION WAS NOT OBTAINED

A $500 copayment applied if initial consultation was not obtained 65

0459 NO BIOPSY IN HIST/DIAG N/C THIS DIAGNOSIS IS NOT APPROVED OR THERE IS NO BIOPSY IN HISTORY

This diagnosis is not approved or there is no biopsy in hist 60

0460 NOT USED SUBROGATION SAVGS NOT CURRENTLY ASSIGNED Not currently assigned 220461 SUBROGATION RECOVERY SUBROGATION RECOVERY Subrogation Recovery 200462 MULT PROV SAME DAY SURG N/ MULTIPLE SURGERIES BY DIFFERENT PROVIDERS ON SAME

DAY NONCOVEREDMultiple surgeries by different providers on same day noncovered 64

0463 INV DIAG FOR THIS SVC SERVICE IS NOT COVERED FOR THE CONDITION REPORTED Service is not covered for the condition reported 49

0464 PRICE AT 80% OF CHARGE NON-PARTICIPATING FACILITY PAID AT 80% OF MAXIMUM ALLOWANCE

Non-participating facility paid at 80% of maximum allowance 59

0465 DATE CONVERSION ERROR0466 VOID ADJUSTMENT-WRONG ADDR ORIGINAL PAYMENT WAS VOIDED BECAUSE WRONG

ADDRESS WAS USEDOriginal payment was voided because wrong address was used 58

0467 ITS AUTO ADJ CLM INCORR ORIGINAL CLAIM PROCESSED INCORRECTLY ITS auto adjust claim incorrect 310468 1 MAMMO PER DOS MAXIMUM OF 1 ROUTINE MAMMOGRAM PER DATE OF

SERVICEMaximum of 1 routine mammogram per date of service 50

0469 1 MAMMO PER 2 YRS 40-49 MAXIMUM OF 1 ROUTINE MAMMOGRAM EVERY TWO YEARS (AGES 40-49) PAID

Maximum of 1 routine mammogram every two years (ages 40-49) paid

64

0470 ROUTINE MAMMO N/C UNDER 35 ROUTINE MAMMOGRAM UNDER AGE 35 NOT COVERED Routine mammogram for women under age 35 is not covered 550471 SVC REQ ASSOC ROOM CHARGE CHARGES ALLOWED ONLY IF ROOM CHARGES ALLOWED

FOR THE SAME DATE(S)Charges allowed only if room charges allowed for the same date(s) 65

0472 CLINIC VISIT NOT CVD BENEFITS FOR CLINIC VISITS NOT PROVIDED UNDER SUBSCRIBER'S COVERAGE

Benefits for these clinic visits not provided under your coverage 65

0473 $35 & 20% COPAY $35 & 20% COPAY $35 & 20% COPAY 150474 ITS HOST - MAX BENEFITS THE MAXIMUM BENEFITS HAVE BEEN PREVIOUSLY USED. The maximum benefits have been previously used 46

0475 PROV RISK; RED NOT APPLIED

0476 >9 ROUT VISITS UNDER AGE 3 BENEFITS LIMITED TO 9 ROUTINE PREVENTIVE VISITS UNDER AGE OF THREE

Benefits limited to 9 routine preventive visits under age of three 66

0477 DATABASE RETRY ERROR0478 5 SVCS PER LIFETIME FIVE DIPTHERIA, TETANUS, PERTUSSIS OR POLIO

VACCINES PER LIFETIMEFive diptheria, tetanus, pertussis or polio vaccines per lifetime 65

0479 4 SVCS PER LIFETIME BENEFITS LIMITED TO FOUR SERVICES PER LIFETIME Benefits limited to 4 services per lifetime 430480 > 1 MAMMO BT AGES 35-40 ONE ROUTINE MAMMOGRAM ALLOWED BETWEEN THE

AGES OF 35 AND 40One routine mammogram allowed between the ages of 35 and 39 59

0481 BENE EXCL; RED NOT APPLIED0482 REQUIRED DME DOC NOT RECVD REQUIRED DURABLE MEDICAL EQUIPMENT

DOCUMENTATION NOT RECEIVEDRequired durable medical equipment documentation not received 61

0483 THERAPEUTIC FILE ERROR0484 > ONE SVC SAME DAY ONLY ONE SERVICE OF THIS TYPE IS ALLOWED ON THE

SAME DAYOnly one service of this type allowed on the same day 53

0485 DATABASE RETRY ERROR0486 THERAPEUTIC FILE ERROR0487 NON-COVERED ABORTION ELECTIVE ABORTIONS REQUIRE DOCUMENTATION OF

MEDICAL NECESSITYElective abortions require documentation of medical necessity 61

0488 WELL BABY NON-COVERED THIS WELL BABY SERVICE IS NOT COVERED This well baby service is not covered 370489 UR DENIAL FOR DME DURABLE MEDICAL EQUIPMENT This claim for durable medical equipment was reviewed and denied 64

0490 NON COVERED HOSPICE THESE HOSPICE CHARGES ARE NOT COVERED These hospice charges are not covered 370491 DENY CONSULT-MED CARE PAID CONSULTATION NOT ALLOWED WHEN MEDICAL CARE PAID

TO SAME PROVIDERConsultation not allowed when medical care paid to same provider 64

0492 PRO FEE NON BILL/TRIAGE RITE CARE TRIAGE, PROFESSIONAL FEE IS NON BILLABLE. Rite Care triage, professional fee is non billable. 51

0493 $300 CALENDAR YEAR MAX THE $300 CALENDAR YEAR MAXIMUM HAS BEEN EXHAUSTED

The $300 calendar year maximum has been exhausted 49

0494 DATE CONVERSION ERROR0495 DATE CONVERSION ERROR0496 CARDI > 6 MOS/INVALID DIAG LIMIT FOR THIS SERVICE HAS BEEN EXCEEDED Limit for this service has been exceeded 400497 CARDIAC REHAB EXCEED 12 MO SERVICES EXCEED THE TWELVE MONTH LIMIT FOR

BENEFITSServices exceed the twelve month limit for benefits 51

0498 EXCEED 36 VISITS IN 6 MOS BENEFITS LIMITED TO 36 VISITS IN A SIX MONTH PERIOD Benefits limited to 36 visits in a six month period 510499 BASIC PAID-MAX REDUCE CHARGES CONSIDERED PREVIOUSLY UNDER BASIC

CONTRACT COVERAGECharges considered previously under Basic contract coverage 59

0500 Mult SG MOD;billing error Denied Provider Billing Error; Multiple SG Modifers Services filed on the same day. Please Resubmit

Claim Denied and Sent Back To Provider, Multiple SG Modifers Services filed on the same day

101

0501 1 SVC PER CAL-YR SERVICE ALLOWED ONCE PER CALENDAR YEAR This service was denied as you exceeded your benefit limit of 1 service per calendar year

89

0502 2 SVCS PER CAL-YR SERVICE ALLOWED TWICE PER CALENDAR YEAR This service was denied as you exceeded your benefit limit of 2 services per calendar year

90

0503 1 SVC PER 3 CAL-YRS SERVICE ALLOWED ONCE IN THREE CONSECUTIVE YEARS Service allowed once in three consecutive years 47

0504 3 SVCS PER CAL-YR SERVICE ALLOWED THREE TIMES PER CALENDAR YEAR Service allowed three times per calendar year 450505 1 SVC PER 12 MONTHS SERVICE ALLOWED ONCE IN TWELVE MONTHS Service allowed once in twelve month period 430506 1 SVC PER 5 YRS SERVICE ALLOWED ONCE IN A FIVE YEAR PERIOD Service allowed once in five year period 400507 DOCUMNTATION NOT SUBMITTED CHARGES WERE DENIED AS DOCUMENTATION WAS NOT

SUBMITTEDCharges were denied as documentation was not submitted 54

0508 CONS RED/DNY SUB RES CONSULTANT REDUCED/DENIED BASED ON OUR DENTAL NECESSITY CRITERIA. PATIENT IS RESPONSIBLE FOR BALANCE.

Consultant reduced/denied based on our dental necessity criteria. Patient is responsible for balance

100

0509 CONS RED/DNY PRV RES CONSULTANT REDUCED/DENIED BASED ON OUR DENTAL NECESSITY CRITERIA. REPRESENTS FULL PAYMENT.

Consultant reduced/denied based on our dental necessity criteria. Represents full payment

89

0510 ASF PROV FILING ERROR SERVICE DENIED; CLAIM MUST BE SUBMITTED WITH THE APPROPRIATE REV CODE

Service denied; claim must be submitted with the appropriate rev code

69

0511 CC RED/DNY SUB RESP CLAIMS COMMITTEE REDUCED/DENIED. PATIENT RESPONSIBLE FOR BALANCE

Claims Committee reduced/denied. Patient responsible for balance 64

0512 CC RED/DNY PROV RESP CLAIMS COMMITTEE REDUCED/DENIED. REPRESENTS FULL PAYMENT

Claims Committee reduced/denied. Represents full payment 56

0513 DOUBLE COVERAGE RED PATIENT HAS DUPLICATE BCD COVERAGE. PAYMENT IS BEING APPLIED ACCORDINGLY.

Duplicate coverage; payment has been made accordingly 53

0514 ADMN RED/DNY SUB RES REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT PAYS BALANCE

Reduced/denied per limitation/policy. Patient pays balance 58

0515 ADMN RED/DNY PRV RES REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. REPRESENTS FULL PAYMENT

Reduced/denied per limitation/policy. Represents full payment 61

0516 PRICE EQ TO PERIODIC EXAM THIS AMOUNT REFLECTS THE MAXIMUM ALLOWED PAYMENT FOR THIS SERVICE

This amount reflects the maximum allowed payment for this service 65

0517 AMALGAM ALLOWANCE ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST

Amalgam (silver) filling allowance. Patient pays balance 56

0518 BET/ACC 8 = 2150 ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST






0521 FULL-CAST ALLOWANCE REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.


0522 BET/ACC 12 = 6791 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.










0527 PRICE EQ ANTERIOR RTCNL FOR MULTI-CANAL RCT'S UNDER BENEFIT GROUP 1, AN ALLOWANCE FOR AN ANTERIOR RCT IS MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST

Contract provides benefits for anterior root canals only 56

0528 BET/ACC 18 = 33110529 PRICE EQ TO ADDTNL EXTRACT THIS AMOUNT REFLECTS THE MAXIMUM ALLOWED

PAYMENT FOR THIS SERVICEThis amount reflects the maximum allowed payment for this service 65

0530 PRICE EQ TO SINGLE EXTRACT FOR SURGICAL EXTRACTIONS UNDER BENEFIT GROUP 1, AN ALLOWANCE FOR A SIMPLE EXTRACTION IS MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST

Contract provides benefits for simple extraction only 53

0531 1 SVC PER 6 MONTHS SERVICE ALLOWED ONCE PER SIX MONTH PERIOD Service allowed once per six month period 410532 DATE CONVERSION ERROR0533 SPECIALTY EXAMS N/C SPECIALTY EXAMS ARE LIMITED IN SCOPE AND ARE NOT

CONSIDERED A COVERED BENEFITThis type of exam was denied as it is not a covered benefit under your plan. Please refer to your benefit documents

115

0534 SURF ONCE PER 12 MOS SAME TOOTH SURFACE(S) FILLED WITHIN 12 MONTHS. PATIENT CANNOT BE BILLED FOR BALANCE

Tooth surface filled within twelve months. Represents full payment 66

0535 N/C PER DOC SUB RESP SERVICE RENDERED DOES NOT QUALIFY AS A PALLIATIVE TREATMENT TO RE- LIEVE PAIN. PATIENT IS RESPONSIBLE FOR PAYMENT

Service is not covered. Patient is responsible for payment 58

0536 1 EVAL PER COURSE OF TRMT 1 EVALUATION PER COURSE OF TREAMENT (180 DAYS) 1 Evaluation per course of treatment(180 days) 460537 N/C PER DOC PROV RES0538 PRICE EQ TO PER EXAM, NPAR0539 1 SVC PER 2 CAL-YRS SERVICE ALLOWED ONCE IN TWO CONSECUTIVE YEARS Service allowed once in two consecutive years 450540 N/C W/IN 30 DAYS OF R C THIS SERVICE IS INCLUSIVE WITH ROOT CANAL

PERFORMED PREVIOUSLYThis service is inclusive with root canal performed previously 62

0541 RESTOR SAME PROV N/C This service is inclusive with the filling performed previously 630542 CONS N/C BY ATTD DEN Consultations not covered when rendered by the attending dentist 64

0543 APICO NC SAME DAY RC APICOECTOMY IS CONSIDERED INCLUSIVE WITH THE ROOT CANAL WHEN PER- FORMED ON THE SAME DAY

Reduced/denied per limitation/policy. Represents full payment 61

0544 IC RED/DENY PROV RESP INDIVIDUAL CONSIDERATION REDUCED/DENIED. REPRESENTS FULL PAYMENT.

Individual consideration reduced/denied. Represents full payment 64

0545 N/C SAME DAY AS SURG MEDICAL EMERGENCY SERVICES ARE NOT COVERED ON SAME DAY AS SURGERY

This service is not covered with surgery performed on same day 62

0546 IC RED/DENY SUB RESP INDIVIDUAL CONSIDERATION REDUCED/DENIED. PATIENT PAYS BALANCE.

Individual consideration reduced/denied. Patient pays balance 61

0547 1 SVC PER 2 CAL YRS SERVICE ALLOWED ONCE PER EVERY TWO CALENDAR YEARS

Service allowed once per every two calendar years 49

0548 1 RELINE PER 5 YEARS SERVICE ALLOWED ONCE IN A FIVE YEAR PERIOD Service allowed once in five year period 400549 DATE CONVERSION ERROR0550 1 SVC PER 36 MONTHS SERVICE ALLOWED ONCE PER 36 MONTH PERIOD Service allowed once per 36 month period 400551 N/C INDIVIDUAL ACCTS INDIVIDUAL ACCOUNTS DO NOT COVER THIS SERVICE Individual accounts do not cover this service 450552 EXCL FROM FEE REDUCTION EXCL FROM FEE REDUCTION Excl from fee reduction 230553 ANES N/C W/O SURG ANESTHESIA IS NOT PAYABLE UNLESS RENDERED IN

CONJUNCTION WITH A COVERED SURGICAL PROCEDURENot payable without a covered surgical procedure on the same day 64

0554 DENY - I.T.S. HOST0555 3 SVCS PER LIFETIME ONLY THREE SERVICES OF THIS TYPE ALLOWED PER

TOOTH. PATIENT PAYS BALANCEOnly three services of this type allowed per tooth 50

0556 2 SVCS PER 12 MONTHS SERVICE ALLOWED TWICE PER TWELVE MONTH PERIOD Service allowed twice per twelve month period 450557 FILE W MED INSUR CAR THIS SERVICE MUST BE FILED WITH MEDICAL INSURANCE

CARRIERThis service must be filed with other medical insurance carrier 63

0558 1 SVC PER BEN-YEAR ONE SERVICE ALLOWED PER BENEFIT YEAR One service allowed per benefit year 360559 1 SVC PER 3 BEN-YRS ONE SERVICE ALLOWED PER EVERY THREE BENEFIT

YEARSOne service allowed per every three benefit years 49

0560 2 SVCS PER BEN YEAR TWO SERVICES ALLOWED PER BENEFIT YEAR Two services allowed per benefit year 370561 1 SVC PER 5 BEN-YRS ONE SERVICE ALLOWED PER EVERY FIVE BENEFIT YEARS One service allowed per every five benefit years 48

0562 3 SVCS PER BEN-YEAR THREE SERVICES ALLOWED PER BENEFIT YEAR Three services allowed per benefit year 390563 1 EXAM PER 6 MONTHS ONE EXAM ALLOWED PER SIX MONTH PERIOD0564 BET/ACC 19 = 7120 NON-PAR0565 TRANSCOM MAX MET0566 TRANSCOM=PAY CODE 1090567 TRANSCOM=PAY CODE 115 OUR ALLOWANCE REDUCED BY THE OTHER INSURANCE

CARRIER'S PAYMENTOur allowance reduced by the other insurance carrier's payment 62

0568 WRONG PROVIDER ID PROCEDURE PROCESSED UNDER INCORRECT PROVIDER IDENTIFICATION

Procedure processed under incorrect provider identification 59

0569 WRONG SUBSCRIBER ID PROCEDURE PROCESSED UNDER INCORRECT SUBSCRIBER IDENTIFICATION

Procedure processed under incorrect subscriber identification 61

0570 HOME BANK CLAIM - APPROVED0571 HOME BANK CLAIM - DENIED0572 HOME BANK CLAIM - PAID0573 HOME BANK - DEDUCTIBLE0574 HOME BANK - COINSURANCE0575 HOME BANK-PAY BY PAT ACCOM Balance of private room charge is your responsibility 530576 HOME BANK-ANCIL PAY BY PAT BALANCE OF CHARGES ASSOCIATED WITH THE PRIVATE

ROOM CHARGE IS THE PATIENT'S RESPONSIBILITYAdditional cost for a private room is your responsibility 57

0577 HOME BANK-R.C.C.0578 SEALANT N/C ON THESE TEETH SEALANT IS NOT COVERED WHEN APPLIED TO THESE

TEETHSealant is not covered when applied to these teeth 50

0579 SEALANT N/C THESE SURFACES SEALANT IS NOT COVERED WHEN APPLIED TO THIS TOOTH SURFACE OR SURFACES

Sealant not covered when applied to this tooth surface or surfaces 66

0580 SEALANT N/C AFTER RESTOR SEALANTS COVERED ONLY WHEN APPLIED TO NON-RESTORED VIRGIN TEETH

Sealant not covered when applied to previously filled teeth 59

0581 I/P $500 DED CAL/YR A $500 INPATIENT DEDUCTIBLE IS APPLIED PER CALENDAR YEAR

A $500 inpatient deductible is applied per calendar year 56

0582 FILE SINGLE LESION FIRST SINGLE LESION MUST BE FILED FIRST This service must be submitted following an initial procedure 610583 OOA METHOD 01 RULE 00000 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS

SERVICEThis amount is the maximum allowed for this service 51

0584 WORKERS COMP RECOVERY WORKER'S COMP RECOVERY Allowance after worker's comp recovery 380585 SUBROGATION ATTORNEY FEE SUBROGATION RECOVERY Subrogation Recovery 200586 SUBROG-COMPROMISE+LOSS SUBROGATION RECOVERY Subrogation Recovery 200587 NO ER CLAIM IN HISTORY0588 DETERMINED FRAUD AND ABUSE AFTER REVIEW, THIS CLAIM HAS BEEN DETERMINED TO BE

NON-COVERED DUE TO FRAUD/ABUSEAfter review, this claim has been determined to be non-covereddue to fraud/abuse

80

0589 GLOBAL ALLOWANCE PAID THIS SERVICE IS CONSIDERED TO BE INCLUDED IN THE GLOBAL SURGICAL ALLOWANCE

This amount represents the maximum allowance for this type of service

69

0590 $25.00 CO-PAY BENEFIT REDUCED BY A $25 COPAYMENT AMOUNT This amount represents your $25 copayment. You are responsible to pay your provider directly

93

0591 PROV SPEC 69 PD IN HST PAYMENT HAS BEEN MADE PREVIOUSLY TO AN INDEPENDENT LABORATORY

Payment has been made previously to an independent laboratory 61

0592 25% USUAL/CUSTOMARY BENEFITS FOR SERVICE REDUCED BASED ON PLACE OF SERVICE

Benefits for service reduced based on place of service 54

0593 OOA METHOD 10 RULE 00001 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE


0594 MEDICAL/SNF/CC ON SAME DAY ONLY ONE SERVICE ALLOWED ON THE SAME DAY Only one service allowed on the same day 400595 INAPPROPRIATE MODIFIER USE THE USE OF THIS MODIFIER IS UNAPPROPRIATE FOR THIS

SITUATION.The use of this modifier is inappropriate for this situation. 61



0597 MED CARE INCLUDED SURG CHG MEDICAL CARE IS INCLUDED IN THE SURGERY CHARGE Medical care is included in the surgery charge 460598 APPLIED TOWARDS DEDUCTIBLE TOTAL OR PART OF PAYMENT WAS APPLIED TOWARDS

CONTRACT DEDUCTIBLEThis amount was applied toward your annual deductible. You are responsible to pay your provider directly

105

0599 CARDIAC REHAB SVCS EXCEED THE LIMIT FOR CARDIAC REHABILITATION SERVICES HAS BEEN EXCEEDED

The limit for cardiac rehabilitation services has been exceeded 63



0601 $1000 PEN/NO CONS. IN HIST A $1000 COPAY APPLIED AS SECOND OPINION CONSULTATION NOT OBTAINED

A $1000 copay applied as second opinion consultation not obtained 65

0602 EXCEEDS 36 VISITS EXCEEDS THE LIMIT OF 36 VISITS Exceeds the limit of 36 visits 300603 6 SVC PER CAL-YEAR SIX SERVICES PER CALENDAR YEAR Benefits provided for 6 services per calendar year 500604 $75 CALENDER YEAR MAY EXCE $75 CALENDAR YEAR MAXIMUM HAS BEEN EXCEEDED FOR

THIS SERVICE$75 calendar year maximum has been exceeded for this service 60

0605 OOA METHOD 14 RULE 00004 THIS AMOUNT IS THE MAXIMUM ALLO

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