This section contains information for those electronic billers receiving the electronic remittance file in either the National Standard Format (NSF) or the ANSI ASC X12 format. Electronic billers receiving the remittance file receive the standardized codes in order to convey the reason for claim/line level adjudication. The following sections contain the ANSI and Medicare standardized codes and messages that are provided within your electronic remittance file.
21.2 ANSI Group Codes
An ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.
a. PR - Patient Responsibility
A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiaryĺs behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patientĺs failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (reason code B4), excess charges on an assigned claim (reason code 42), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.
b. CO - Contractual Obligations
A CO group code identifies amounts for which the provider is financially liable. These include, participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, Gramm-Rudman reductions, or medical necessity denials/reductions. The patient may not be billed for these amounts.
c. OA - Other Adjustment
An OA group code is used when neither PR nor CO applies. At least one PR, CO or OA group code appears on each remittance advice. For example, OA would be used when a claim is paid in full at initial adjudication with reason code 93 and a zero amount, or with reason codes such as 69-85 that are components of payments rather than adjustments to payments. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.
d. CR - Correction to or Reversal of a Prior Decision
A CR group code is used whenever there is a change to a previously adjudicated claim. CR explains the reason for the correction; PR, CO and/or OA must always be used in tandem with CR to show the revised information. Separate reason code entries must be used in the NSF for the CR group entry, and any other groups that apply to the readjudicated claim.
21.3 ANSI REASON CODES
ANSI reason codes
explain the reasons for any financial adjustments to claims, such as denials,
reductions or increases in payment.
procedure code is inconsistent with the modifier used, or a required
modifier is missing.
procedure code/bill type is inconsistent with the place of service.
procedure code is inconsistent with the patient's age.
procedure code is inconsistent with the patient's sex.
procedure code is inconsistent with the provider type.
diagnosis is inconsistent with the patient's age.
diagnosis is inconsistent with the patient's sex.
diagnosis is inconsistent with the procedure.
diagnosis is inconsistent with the provider type.
date of death precedes the date of service.
date of birth follows the date of service.
denied because the submitted authorization number is missing, invalid,
or does not apply to the billed services.
lacks information which is needed for adjudication.
denied because requested information was not provided or was
denied because this is a workrelated injury and thus the liability of
the Worker's Compensation Carrier.
denied because this injury is covered by the liability carrier.
denied because this injury is the liability of the nofault carrier.
denied/reduced because this care may be covered by another payer per
coordination of benefits.
denied/reduced because charges have been paid by another payer as part
of coordination of benefits.
for charges denied/reduced. Charges are covered under a capitation
denied. Your stop loss deductible has not been met. (Not Medicare)
incurred prior to coverage.
incurred after coverage terminated.
not in effect at the time the service was provided.
time limit for filing has expired.
are not available for these services until the patient has met the
required waiting or residency period.
denied as patient cannot be identified as our insured.
records indicate that this dependent is not an eligible dependent as
defined. (Not Medicare)
denied. Insured has no dependent coverage. (Not Medicare)
denied. Insured has no coverage for newborns.
maximum has been reached.
does not exceed copayment amount.
does not exceed deductible.
not provided or authorized by designated (network) providers.
denied at the time authorization/precertification was requested.
do not meet qualifications for emergency/urgent care outofarea.
agreed to in Preferred Provider contract.
exceed our fee schedule or maximum allowable amount.
discount (Not Medicare).
exceed your contracted/legislated fee arrangement.
(these) service(s) is (are) not covered.
(these) diagnosis(es) is (are) not covered.
(these) procedure(s) is (are) not covered.
are noncovered services because this is a routine exam or screening
procedure done in conjunction with a routine exam.
are noncovered services because this is not deemed a "medical
necessity" by the payer.
are noncovered services because this is a pre-existing condition.
referring/prescribing/rendering provider is not eligible to
refer/prescribe/order/perform/the service billed.
by an immediate relative or a member of the same household are not
physicians/assistants are not covered in this case.
denied because procedure/treatment is deemed
experimental/investigational by the payer.
denied because procedure/treatment has not been deemed "proven to
be effective" by the payer.
denied/reduced because the payer deems the information submitted does
not support this level of service, this many services, this length of
service, or this dosage.
denied/reduced because treatment was deemed by the payer to have been
rendered in an inappropriate or invalid place of service.
are reduced/denied based on multiple surgery rules or concurrent
for outpatient services with this proximity to inpatient services are
reduced as penalty for failure to obtain second surgical opinion. (Not
denied/reduced for absencer of, or exceeded,
to a prior claim.
reversed per Medical Review.
code was incorrect. This payment reflects the correct code.
Medical Education Adjustment.
Medical Education Adjustment.
days/Room charge adjustment.
Report days. 80 ^Outlier days.
amount represents collection against receivable created in prior over
fees removed from charges.
cost adjustment. (Not Medicare).
fee adjustment. (Not Medicare).
Paid in full.
claim level adjustments.
in excess of charges.
denied/reduced. Plan procedures not followed.
is included in the allowance for the basic service/procedure.
hospital must file the Medicare claim for this inpatient nonphysician
Secondary Payer adjustment amount.
made to patient/insured/responsible party.
anticipated payment upon completion of services or claim adjudication.
Medical adjustment. (Not Medicare).
promotional discount (i.e. Senior citizen discount). (Not Medicare).
withholding. (Not Medicare).
payment option/election not in effect.
denied because the related or qualifying claim/service was not paid or
identified on the claim.
denied/reduced because rent/purchase guidelines were not met.
not covered by this payer/contractor. You must send the claim to the
date predates service date.
covered unless the provider accepts assignment.
denied/reduced as not furnished directly to the patient and/or not
denied because service/procedure was provided outside the United States
or as a result of war.
not approved by the Food and Drug Administration.
denied/reduced as procedure postponed or canceled.
denied. The advance indemnification notice signed by the patient did not
comply with requirements.
denied/reduced because transportation is only covered to the closest
facility that can provide the necessary care.
reduced for ESRD network support.
maximum for this time period has been reached.
is covered by a managed care plan.
refund amount due to overpayment.
refund amount - not our patient.
denied/reduced due to a submission/billing error.
-- Major Medical
-- Major Medical
services are covered in the mother's allowance.
denied - Prior processing information appears incorrect.
calim submission fee.
specific negotiated discount.
demonstration project adjustment.
service is suspended pending further review.
fees removed from charges.
denied. Interim bills cannot be processed.
Denied/Reduced. Plan procedures of a prior payer were not followed.
for Regulatory Surcharges, Assessments, Allowances or Health Related
Secondary Payer patient liability met.
Claim PPS Capital Day Outlier Amount.
Claim PPS Capital Cost Outlier Amount.
Hospitalization or 30-day transfer requirement not met.
denied; ungroupable DRG
denied/reduced because coverage guidelines were not met or were
service/procedure is denied/reduced when performed/billed by this type
of provider, by this type of provider in this type of facility, or by a
provider of this specialty.
provider was not certified for this procedure/service on this date of
not covered/reduced because alternative services were available, and
should have been utilized.
not covered because the patient is enrolled in a Hospice.
amount has been reduced because a component of the basic procedure/test
was paid. The beneficiary is not liable for more than the charge limit
for the basic procedure/test.
claim/service has been transferred to the proper payer/processor for
processing. Claim/service not covered by this payer/processor.
not documented in patients' medical records.
Paid. Payment for this claim/service may have been provided in a
denied because only one visit or consultation per physician per day is
denied/reduced because this procedure/service is not paid separately.
denied/reduced because "New Patient" qualifications were not
denied because this service was not prescribed by a physician, not
prescribed prior to delivery, the prescription is incomplete, or the
prescription is not current.
denied because this procedure code/modifier was invalid on the date of
service or claim submission.
denied/reduced because of the finding of a Review Organization.
denied/reduced because procedure/service was partially or fully
furnished by another provider.
charges were reduced because the service/care was partially furnished by
an other physician.
claim/service is denied/reduced based on the diagnosis.
denied because this provider has failed an aspect of a proficiency
denied. Level of subluxation is missing or inadequate.
lacks the name, strength, and dosage of the drug furnished.
denied because information to indicate if the patient owns the equipment
that requires the part or supply was missing.
does not indicate the period of time for which this will be needed.
denied. Claim lacks individual lab codes included in the test.
denied. Claim did not include patient's medical record for the service.
denied. Claim lacks date of patient's most recent physician visit.
denied. Claim lacks indicator that "xray is available for
denied. Claim lacks invoice or statement certifying the actual cost of
the lens, less discounts or the type of intraocular lens used.
denied. Completed physician financial relationship form not on file.
lacks completed pacemaker registration form.
denied. Claim does not identify who performed the purchased diagnostic
test or the amount you were charged for the test.
denied. Performed by a facility/supplier in which the ordering/referring
physician has a financial interest.
lacks indication that plan of treatment is on file.
lacks indication that service was supervised or evaluated by a
^ - Code value is inactive as of release of version 30.50 of the 835.
¤ - Code value is inactive as of release of version 40.10 of the 835.
21.4 Medicare Reference (REF) Remark Codes
Remark codes must be used to relay service-specific Medicare informational messages that cannot expressed with a reason code. Medicare remark codes are maintained by HCFA.
Remark codes and messages must be used whenever they apply. Although contractors may use their discretion to determine when certain remark codes apply, they do not have discretion as to whether to use an applicable remark code in a remittance notice. A limitation of liability message (m25-M27) must be used where applicable. An unlimited number of Medicare line level remark codes may be entered as warranted in an X12 835 Remittance Advice; there is a limit of 5 line level remark code entries in a NSF Remittance Advice and on a standard paper remittance notice.
|M1||X-ray not taken within the past 12 months or near enough to the start of treatment.|
|M2||Not paid separately when the patient is an inpatient.|
|M3||Equipment is the same or similar to equipment already being used.|
|M4||This is the last monthly installment payment for this durable medical equipment.|
|M5||Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.|
|M6||You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for every 6 month period after the end of the 15th paid rental month or the end of the warranty period.|
|M7||No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price.|
|M8||We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.|
|M9||This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.|
|M10||Equipment purchases are limited to the first or the tenth month of medical necessity.|
|M11||DME, orthotics and prosthetics must be billed to the DME carrier who services the beneficiary's zip code.|
|M12||Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.|
|M13||No more than one initial visit may be covered per specialty per medical group. Visit may be rebilled with an established visit code.|
|M14||No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.|
|M15||Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.|
|M16||Please see the letter or bulletin of (date) for further information.|
|M17||Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions.|
|M18||Certain services may be approved for home use. Neither a hospital nor a SNF is considered to be a patient's home.|
|M19||Oxygen certification/recertification (HCFA-484) is incomplete or is required.|
|M21||Claim for services/items provided in a home must indicate the place of residence.|
|M22||Claim lacks the number of miles traveled.|
|M23||Invoice needed for the cost of the material or contrast agent.|
|M24||Claim must indicate the number of doses per vial.|
|M25||Payment has been (denied for the/made only for a less extensive) service because the information does not substantiate the need for the (more extensive) service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this (more extensive) service, or if you notified the patient in writing in advance that we would not pay for this (more extensive) service and he/she agreed in writing to pay, ask us to review your claim within six months of receiving this notice. If you do not request review, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her (for the/in excess of any deductible and coinsurance amounts applicable to the less extensive) service. We will recover the reimbursement from you as an overpayment.|
Payment has been (denied for the/made only for a less extensive) service because the information furnished does not substantiate the need for the (more extensive) service. If you have collected (any amount from the patient/any amount that exceeds the limiting charge for the less extensive service), the law requires you to refund that amount to the patient within 30 days of receiving this notice.
The law permits exceptions to the refund requirement in two cases:
If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request review of this determination within 30 days of receiving this notice. Your request for review should include any additional information necessary to support your position.
If you request review within the 30-day period, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision.
The law also permits you to request review at any time within six months of receiving this notice. A review requested after the 30-day period does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination.
The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact your office if he/she does not hear anything about a refund within 30 days.
The requirements for refund are in ž1842(l) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program.
Please contact this office if you have any questions about this notice.
|M27||The beneficiary has been
relieved of liability of payment of these items and services under the
limitation of liability provision of the law. You, the provider, are
ultimately liable for the beneficiary's waived charges, including any
charges for coinsurance, since the items or services were not reasonable
and necessary or constituted custodial care, and you knew or could
reasonably have been expected to know, that they were not covered.
You may appeal this determination provided that the beneficiary does not exercise his/her appeal rights. If the beneficiary appeals the initial determination, you are automatically made a party to the appeals determination. If, however, the beneficiary or his/her representative has stated in writing that he/she does not intend to request a reconsideration, or the beneficiary's liability was entirely waived in the initial determination, you may initiate an appeal.
You may ask for a reconsideration for hospital insurance (or a review for medical insurance) regarding both the coverage determination and the issue of whether you exercised due care. The request for reconsideration must be filed within 60 days (or 6 months for a medical insurance review) from the date of this notice. You may make the request through any Social Security office or through this office.
|M28||This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.|
|M29||Claim lacks the operative report.|
|M30||Claim lacks the pathology report.|
|M31||Claim lacks the radiology report.|
|M32||This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service.|
|M33||Claim lacks the UPIN of the ordering/referring or performing physician, physician assistant, nurse practitioner or clinical nurse specialist, or the UPIN is invalid.|
|M34||Claim lacks the CLIA certification number.|
|M35||Claim lacks pre-operative photos or visual field results.|
|M36||This is the 11th rental month. We cannot pay for this until you indicate that the beneficiary has been given the option of changing the rental to a purchase.|
|M37||Service not covered when the beneficiary is under age 35.|
|M38||The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that Medicare would not pay for it, and the patient agreed to pay.|
|M39||The patient is not liable for payment for this service as the advance notice of noncoverage you provided the patient did not comply with program requirements.|
|M40||Claim must be assigned and must be filed by the practitioner's employer.|
|M41||We do not pay for this as the patient has no legal obligation to pay for this.|
|M42||The medical necessity form must be personally signed by the attending physician.|
|M43||Payment for this service previously issued to you or another provider by another Medicare carrier/intermediary.|
|M44||Incomplete/invalid condition code.|
|M45||Incomplete/invalid occurrence codes and dates.|
|M46||Incomplete/invalid occurrence span code and dates.|
|M47||Incomplete/invalid internal or document control number.|
|M48||Medicare payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service.|
|M49||Incomplete/invalid value code(s) and/or amount(s).|
|M50||Incomplete/invalid revenue code(s).|
|M51||Incomplete/invalid, procedure code(s) and/or rates, including "not otherwise classified" or "unlisted" procedure codes submitted without a narrative description.|
|M52||Incomplete/invalid "from" date(s) of service.|
|M53||Did not complete or enter the appropriate number (one or more) of days or units(s) of service.|
|M54||Did not complete or enter the correct total charges for services rendered.|
|M55||Medicare does not pay for self-administered anti-emetic drugs that are not administered with a Medicare-covered oral anti-cancer drug.|
|M56||Incomplete/invalid payer identification.|
|M57||Incomplete/invalid provider number.|
|M58||Please resubmit the claim with the missing/correct information so that it may be processed.|
|M59||Incomplete/invalid "to" date(s) of service.|
|M60||Rejected without appeal rights due to invalid CMN form or format. Resubmit with completed, OMB-approved form or in an approved format.|
|M61||We cannot pay for this as the approval period for the FDA clinical trial has expired.|
|M62||Incomplete/invalid treatment authorization code.|
|M63||Medicare does not pay for more than one of these on the same day.|
|M64||Incomplete/invalid other diagnosis code.|
|M65||One interpreting physician can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.|
|M66||Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.|
|M67||Incomplete/invalid other procedure code(s) and/or date(s).|
|M68||Incomplete/invalid attending or referring physician identification.|
|M69||Paid at the regular rate as you did not submit documentation to justify modifier 22.|
|M70||NDC code submitted for this service was translated to a HCPCS code for Medicare processing, but please continue to submit the NDC on future claims for this item.|
|M71||Total payment reduced due to overlap of tests billed.|
|M72||Did not enter full 8-digit date (MM/DD/CCYY).|
|M73||The HPSA bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components. Use the HPSA modifier on the professional component only.|
|M74||This service does not qualify for a HPSA bonus payment.|
|M75||Allowed amount adjusted. Multiple automated multi-channel tests performed on the same day combined for payment.|
|M76||Incomplete/invalid patient's diagnosis(es) and condition(s).|
|M77||Incomplete/invalid place of service(s).|
|M78||Did not complete or enter accurately an appropriate HCPCS modifier(s).|
|M79||Did not complete or enter the appropriate charge for each listed service.|
|M80||We cannot pay for this when performed during the same session as a previously processed service for the beneficiary|
|M81||Patientĺs diagnosis code(s) is truncated, incorrect or missing; you are required to code to the highest level of specificity.|
|M82||Service is not covered when beneficiary is under age 50.|
|M83||Service is not covered unless the beneficiary is classified as at high risk.|
|M84||Old and New HCPCS cannot be billed for the same date of service.|
|M85||Subjected to review of physician evaluation and management services.|
|M86||Service denied because payment already made for similar procedure within set time frame.|
|M87||Claim/service(s) subjected to CFO-CAP prepayment review..|
|M88||We cannot pay for laboratory tests unless billed by the laboratory that did the work.|
|M89||Not covered more than once under age 40.|
|M90||Not covered more than once in a 12 month period.|
|M91||Lab procedures with different CLIA certification numbers must be billed on separate claims.|
|M92||Services subjected to review under the Home Health Medical Review Initiative.|
|M93||Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.|
|M94||Information supplied does not support a break in therapy. A new capped rental period will not begin.|
|M95||Services subjected to Home Health Initiative medical review/cost report audit.|
|M96||The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.|
|M97||Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.|
|M98||Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN.|
|M99||Incomplete/invalid/missing Universal Product Number.|
|M101||Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier.|
|M102||Service not performed on equipment approved by the FDA for this purpose.|
|M103||Information supplied supports a break in therapy. However, the medical information we have for this beneficiary does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.|
|M104||Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the Medicare fee schedule for this item or service.|
|M105||Information supplied does not support a break in therapy. The medical information we have for this beneficiary does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.|
|M106||Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the Medicare fee schedule for this item or service.|
|M107||Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.|
|M108||Must report the PIN of the physician who interpreted the diagnostic test.|
|M109||We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.|
|M110||Missing/invalid provider number for the provider from whom you purchased interpretation services.|
|M111||We do not pay for chiropractic manipulative treatment when the beneficiary refuses to have an x-ray taken.|
|M112||The approved amount is based on the maximum allowance for this item under the DMEPOS Competitive Bidding Demonstration.|
|M113||Our records indicate that this patient began using this service(s) prior to the current round of the DMEPOS Competitive Bidding Demonstration. Therefore, the approved amount is based on the allowance in effect prior to this round of bidding for this item.|
|M114||This service was processed in accordance with rules and guidelines under the Competitive Bidding Demonstration Project. If you would like more information regarding this project, you may phone 1-888-289-0710.|
|M115||This item is denied when provided to this patient by a nondemonstration supplier.|
|M116||Even though this service is being paid in accordance with the rules and guidelines under the Competitive Bidding Demonstration, future claims may be denied when this item is provided to this patient by a nondemonstration supplier. If you would like more information regarding this project, you may phone 1-888-289-0710.|
|M117||Not covered unless supplier files an electronic media claim (EMC).|
|M118||Letter to follow containing further information.|
|M119||National Drug Code (NDC) needed.|
|M120||Lacks UPIN of the substituting physician who furnished the service(s) under a reciprocal billing or loco tenens arrangement.|
|M121||We pay for this service only when performed with a covered cryosurgical ablation.|
|M122 and higher||Reserved for future use.|
21.5 Medicare Outpatient Adjudication (MOA) Remark Codes
LEVEL REMARKS CODES
A maximum of 5 of these claim level Medicare Inpatient Adjudication (MIA) and 5 of these claim level Medicare Outpatient
Adjudication (MOA) remarks codes may be used per claim. See the Medicare 835 Implementation Guides. Insert these codes
in the space for semantics 5 or 20-23 of the MIA segment or semantics 3-7 of the MOA segment as applicable. Previously
established MIA/MOA semantic codes [MIA01, 03-04, 06-19 and 24, and MOA01-02 and 08-09] are not impacted by this
instruction and must continue to be used as indicated in the Medicare Part A 835 Implementation Guide. MIA01, 03-04,
06-19 and 24, and MOA01-02 and 08-09 as listed in the Part A 835 Implementation Guide do not apply to the NSF, but
individual Medicare MIA/MOA remarks codes listed in this document must also be used in the NSF and the standard paper
remittance notice. See NSF and standard paper remittance notice specifications for use of Medicare MIA/MOA remarks
codes in NSF and paper RAs.
Medicare MIA/MOA remarks codes are used to convey appeal information and other claim-specific information that does
not involve a financial adjustment. As with the 835/NSF reason and Medicare line level remarks codes, Medicare
contractors are also prohibited from use of local MIA/MOA codes.
An appropriate appeal, limitation of liability or other message must be used whenever applicable. Although contractors have
discretion to determine when certain remarks codes and messages apply, they do not have discretion as to whether to use
applicable codes and messages.
|MA01||(Initial Part B determination, carrier or intermediary)--If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the review. However, in order to be eligible for a review, you must write to us within 6 months of the date of this notice, unless you have a good reason for being late. If you meet the criteria for a telephone review, you should phone this office if you wish to request a telephone review.|
|MA02||(Initial Part A determination)--If you do not agree with this determination, you have the right to appeal. You must file a written request for a reconsideration within 60 days of receipt of this notification. Decisions made by a PRO must be appealed to that PRO. (An institutional provider, e.g., hospital, SNF, HHA, may appeal only if the claim involves a medical necessity denial, a SNF noncertified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, and either the patient or the provider is liable under ž1879 of the Social Security Act, and the patient chooses not to appeal.)|
|MA03 (Hearing)||If you do not agree with the Medicare approved amounts and $100 or more is in dispute (less deductible and coinsurance) , you may ask for a hearing. You must request a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been reviewed/reconsidered. This includes reopened reviews if you received a revised decision. You must appeal each claim on time. At the hearing, you may present any new evidence which could affect our decision.|
|MA04||Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.|
|MA05||Incorrect admission date, patient status or type of bill entry on claim.|
|MA06||Incorrect beginning and/or ending date(s) on claim.|
|MA07||The claim information has also been forwarded to Medicaid for review.|
|MA08||You should also submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information as the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.|
|MA09||Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.|
|MA10||The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.|
|MA11||Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources.|
|MA12||You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).|
|MA13||You may be subject to penalties if you bill the beneficiary for amounts not reported with the PR (patient responsibility) group code.|
|MA14||Patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services.|
|MA15||Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.|
|MA16||The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.|
|MA17||We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.|
|MA18||The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.|
|MA19||Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.|
|MA20||SNF stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.|
|MA21||SSA records indicate mismatch with name and sex.|
|MA22||Payment of less than $1.00 suppressed.|
|MA23||Demand bill approved as result of medical review.|
|MA24||Christian Science Sanitorium/ SNF bill in the same benefit period.|
|MA25||A patient may not elect to change a hospice provider more than once in a benefit period.|
|MA26||Our records indicate that you were previously informed of this rule.|
|MA27||Incorrect entitlement number or name shown on the claim. Please use the entitlement number or name shown on this notice for future claims for this patient.|
|MA28||Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice.|
|MA29||Incomplete/invalid provider name, city, state, and zip code.|
|MA30||Incomplete/invalid type of bill.|
|MA31||Incomplete/invalid beginning and ending dates of the period billed.|
|MA32||Incomplete/invalid number of covered days during the billing period.|
|MA33||Incomplete/invalid number of noncovered days during the billing period.|
|MA34||Incomplete/invalid number of coinsurance days during the billing period.|
|MA35||Incomplete/invalid number of lifetime reserve days.|
|MA36||Incomplete/invalid patient's name.|
|MA37||Incomplete/invalid patient's address. (Note: When used, a Medicare contractor must verify that an address, with city, State, and zip code, and a phone number are present.)|
|MA38||Incomplete/invalid patient's birthdate.|
|MA39||Incomplete/invalid patient's sex.|
|MA40||Incomplete/invalid admission date.|
|MA41||Incomplete/invalid type of admission.|
|MA42||Incomplete/invalid source of admission.|
|MA43||Incomplete/invalid patient status.|
|MA44||No appeal rights on this claim. Every adjudicative decision based on Medicare law.|
|MA45||As previously advised, a portion or all of your payment is being held in a special account.|
|MA46||The new information was considered, however, additional payment cannot be issued. Please review the information listed for the explanation.|
|MA47||Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment|
|MA48||Incomplete/invalid name and/or address of responsible party or primary payer .|
|MA49||Incomplete/invalid six-digit Medicare provider number of home health agency or hospice for physician(s) performing care plan oversight services.|
|MA50||Incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.|
|MA51||Incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory.|
|MA52||Did not enter full 8-digit date (MM/DD/CCYY for paper form or CCYY/MM/DD for electronic format).|
|MA53||Inconsistent demonstration project information. Correct and resubmit with information on no more than one demonstration project.|
|MA54||Physician certification or election consent for hospice care not received timely.|
|MA55||Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.|
|MA56||Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.|
|MA57||Patient submitted written request to revoke his/her election for religious non-medical health care services.|
|MA58||Incomplete release of information indicator.|
|MA59||The beneficiary overpaid you for these services. You must issue the beneficiary a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.|
|MA60||Incomplete/invalid patient's relationship to insured.|
|MA61||Did not complete or enter correctly the patient's social security number or health insurance claim number.|
|MA62||Telephone review decision|
|MA63||Incomplete/invalid principal diagnosis code.|
|MA64||Our records indicate that Medicare should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.|
|MA65||Incomplete/invalid admitting diagnosis.|
|MA66||Incomplete/invalid principal procedure code and/or date.|
|MA67||Correction to a prior claim.|
|MA68||We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PAYERID of the insurer to assure correct and timely routing of the claim.|
|MA70||Incomplete provider representative signature.|
|MA71||Incomplete/invalid provider representative signature date.|
|MA72||The beneficiary overpaid you for these assigned services. You must issue the beneficiary a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the beneficiary on this notice.|
|MA73||Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.|
|MA74||This payment replaces an earlier payment for this claim that was either lost, damaged or returned.|
|MA75||Our records indicate neither a patient's or authorized representative's signature was submitted on the claim. Since this information is not on file, please resubmit.|
|MA76||Incomplete/invalid provider number of HHA or hospice when physician is performing care plan oversight services.|
|MA77||The beneficiary overpaid you. You must issue the beneficiary a refund within 30 days for the difference between the beneficiaryĺs payment less the total of Medicare and other payer payments and the amount shown as patient responsibility on this notice.|
|MA78||The beneficiary overpaid you. You must issue the beneficiary a refund within 30 days for the difference between the Medicare allowed amount total and the amount paid by the beneficiary.|
|MA79||Billed in excess of interim rate.|
|MA80||Informational notice. No payment issued for this claim with this notice. Medicare payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.|
|MA81||Our records indicate neither a physician or supplier signature is on the claim or on file.|
|MA82||Did not complete or enter the correct physician/supplier's Medicare billing number/NPI and/ or billing name, address, city, state, zip code, and phone number.|
|MA83||Did not indicate whether Medicare is the primary or secondary payer. Refer to Item 11 in the HCFA-1500 instructions for assistance.|
|MA84||Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.|
|MA85||Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the Payer ID when effective.|
|MA86||Our records indicate that there is insurance primary to Medicare; however, you either did not complete or enter accurately the group or policy number of the insured.|
|MA87||Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter accurately the correct insured's name.|
|MA88||Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter accurately the insured's address and/or telephone number.|
|MA89||Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter the appropriate patient's relationship to the insured.|
|MA90||Our records indicate that there is insurance primary to Medicare; however, you either did not complete or enter accurately the employment status code of the primary insured.|
|MA91||This determination is the result of the appeal you filed.|
|MA92||Our records indicate that there is insurance primary to Medicare; however, you did not complete or enter accurately the required information. Refer to the HCFA-1500 instructions on how to complete MSP information.|
|MA94||Did not enter the statement "Attending physician not hospice employee" on the claim to certify that the rendering physician is not an employee of the hospice. Refer to item 19 on the HCFA-1500.|
|MA95||A "not otherwise classified" or "unlisted" procedure code(s) was billed, but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA-1500.|
|MA96||Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.|
|MA97||Claim rejected. Does not contain the Medicare Managed Care Demonstration contract number, however, the beneficiary is enrolled in a Medicare managed care plan.|
|MA98||Claim rejected. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary.|
|MA99||Our records indicate that a Medigap policy exists; however, you did not complete or enter accurately any of the required information. Refer to the HCFA-1500 instructions on how to complete a mandated Medigap transfer.|
|MA100.||Did not complete or enter accurately the date of current illness, injury or pregnancy|
|MA101||A SNF is responsible for payment of outside providers who furnish these services/supplies to residents.|
|MA102||Did not complete or enter accurately the referring/ordering/supervising physician's/physician assistantĺs, nurse practitionerĺs, or clinical nurse specialistĺs name and/or UPIN.|
|MA103||Hemophilia Add On|
|MA104||Did not complete or enter accurately the date the patient was last seen and/or the UPIN of the attending physician.|
|MA105||Missing/invalid provider number for this place of service. Place of service shown as 21, 22, or 23 (hospital).|
|MA107||Paper claim contains more than three separate data items in field 19.|
|MA108||Paper claim contains more than one data item in field 23.|
|MA109||Claim processed in accordance with ambulatory surgical guidelines.|
|MA110||Our records indicate that you billed diagnostic test(s) subject to price limitations; however, you did not indicate whether the test(s) were performed by an outside entity or if no purchased tests are included on the claim.|
|MA111||Our records indicate that you billed diagnostic test(s) subject to price limitations and indicated that the test(s) were performed by an outside entity; however, you did not indicate the purchase price of the test(s) and/or the performing laboratory's name and address.|
|MA112||Our records indicate that the performing physician/supplier/practitioner is a member of a group practice; however, you did not complete or enter accurately their carrier assigned individual and group PINs. (Substitute "NPI" for "PIN" when effective.)|
|MA113||Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.|
|MA114||Did not complete or enter accurately the name and address, or the carrier assigned PIN, of the entity where services were furnished.|
|MA115||Our records indicate that you billed one or more services in a Health Professional Shortage Area (HPSA); however, you did not enter the physical location (name and address, or PIN) where the service(s) were rendered.|
|MA116||Did not complete the statement "Homebound" on the claim to validate whether laboratory services were performed at home or in an institution.|
|MA117||This claim has been assessed a $1.00 user fee.|
|MA118||Reserved for future use|
|MA119||Provider level adjustment for late claim filing applies to this claim.|
|MA120||Did not complete or enter accurately the CLIA number.|
|MA121||Did not complete or enter accurately the date the X-Ray was performed.|
|MA122||Did not complete or enter accurately the initial date "actual" treatment occurred.|
|MA123||Your center was not selected to participate in this study, therefore, we cannot pay for these services.|
|MA124||Processed for IME only.|
|MA125||Per legislation governing this program, payment constitutes payment in full.|
|MA126||Pancreas transplant not covered unless kidney transplant performed.|
|MA127||Reserved for future use|
|MA128||Did not complete or enter accurately the six digit FDA approved, identification number.|
|MA129||This provider was not certified for this procedure on this date of service. Effective 1/1/98, we will begin to deny payment for such procedures. Please refer to your Medicare Part B Reference Manual for the listing of appropriate contact points in the HCFA Regional Office or State Lab Certification Agencies to correct or obtain CLIA Certification.|
|MA130||Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.|
|MA131 and higher||Reserved for future use|