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2 // See http://www.wpc-edi.com/codes
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9 '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.',
10 '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.',
11 'M7' => 'No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price.',
12 '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.',
13 'M9' => 'This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.',
14 'M10' => 'Equipment purchases are limited to the first or the tenth month of medical necessity.',
15 'M11' => 'DME, orthotics and prosthetics must be billed to the DME carrier who services the patient\'s zip code.',
16 'M12' => 'Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.',
18 '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.',
19 'M15' => 'Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.',
20 'M16' => 'Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.',
21 '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.',
22 'M18' => 'Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient\'s home.',
25 'M21' => 'Missing/incomplete/invalid place of residence for this service/item provided in a home.',
29 'M25' => 'Payment has been adjusted because the information furnished does not substantiate the need for this level of 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 level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request a appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.',
30 'M26' => 'Payment has been adjusted because the information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /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 requirements for refund are in 1824(I) 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. If you have any questions about this notice, please contact this office.',
31 'M27' => 'The patient 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 patient\'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. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.',
32 'M28' => 'This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.',
36 '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.',
37 'M36' => 'This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.',
39 'M38' => 'The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.',
40 'M39' => 'The patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements.',
54 'M55' => 'We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.',
58 'M61' => 'We cannot pay for this as the approval period for the FDA clinical trial has expired.',
61 'M65' => 'One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.',
62 '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.',
64 'M69' => 'Paid at the regular rate as you did not submit documentation to justify the modified procedure code.',
65 'M70' => 'NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item.',
67 'M73' => 'The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.',
69 'M75' => 'Allowed amount adjusted. Multiple automated multichannel tests performed on the same day combined for payment.',
73 'M80' => 'Not covered when performed during the same session/date as a previously processed service for the patient.',
79 'M86' => 'Service denied because payment already made for same/similar procedure within set time frame.',
83 'M91' => 'Lab procedures with different CLIA certification numbers must be billed on separate claims.',
84 'M93' => 'Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.',
85 'M94' => 'Information supplied does not support a break in therapy. A new capped rental period will not begin.',
87 '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.',
88 'M97' => 'Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.',
90 'M100' => 'We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.',
92 'M103' => 'Information supplied supports a break in therapy. However, the medical information we have for this patient 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.',
93 '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 fee schedule for this item or service.',
94 'M105' => 'Information supplied does not support a break in therapy. The medical information we have for this patient 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.',
95 'M107' => 'Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.',
96 '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.',
97 'M111' => 'We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.',
98 'M112' => 'The approved amount is based on the maximum allowance for this item under the DMEPOS Competitive Bidding Demonstration.',
99 '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.',
100 '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.',
102 'M116' => 'Paid under the Competitive Bidding Demonstration project. Project is ending, and future services may not be paid under this project.',
109 'M124' => 'Missing indication of whether the patient owns the equipment that requires the part or supply.',
110 'M125' => 'Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.',
114 'M130' => 'Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.',
117 'M133' => 'Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.',
120 'M136' => 'Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.',
122 'M138' => 'Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.',
126 'M143' => 'We have no record that you are licensed to dispensed drugs in the State where located.',
127 'M144' => 'Pre-/post-operative care payment is included in the allowance for the surgery/procedure.',
128 'MA01' => '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 appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.',
129 'MA02' => 'If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice. Decisions made by a Quality Improvement Organization (QIO) must be appealed to that QIO within 60 days.',
130 'MA03' => 'If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for 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 denied, including reopened appeals if you received a revised decision. You must appeal each claim on time.',
131 '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.',
133 '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.',
134 'MA09' => 'Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.',
135 'MA10' => 'The patient\'s payment was in excess of the amount owed. You must refund the overpayment to the patient.',
136 '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).',
137 'MA13' => 'You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.',
138 '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.',
139 'MA15' => 'Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.',
140 '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.',
141 '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.',
142 'MA18' => 'The claim information is also being forwarded to the patient\'s supplemental insurer. Send any questions regarding supplemental benefits to them.',
143 '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.',
144 'MA20' => 'Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.',
148 'MA24' => 'Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.',
149 'MA25' => 'A patient may not elect to change a hospice provider more than once in a benefit period.',
152 '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.',
167 'MA45' => 'As previously advised, a portion or all of your payment is being held in a special account.',
168 'MA46' => 'The new information was considered, however, additional payment cannot be issued. Please review the information listed for the explanation.',
169 '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.',
171 'MA50' => 'Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.',
172 'MA53' => 'Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.',
174 'MA55' => 'Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.',
175 '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.',
176 'MA57' => 'Patient submitted written request to revoke his/her election for religious non-medical health care services.',
178 'MA59' => 'The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.',
180 'MA61' => 'Missing/incomplete/invalid social security number or health insurance claim number.',
183 'MA64' => 'Our records indicate that we 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.',
187 'MA68' => 'We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.',
191 'MA72' => 'The patient overpaid you for these assigned services. You must issue the patient 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 patient on this notice.',
192 'MA73' => 'Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.',
193 'MA74' => 'This payment replaces an earlier payment for this claim that was either lost, damaged or returned.',
195 'MA76' => 'Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.',
196 'MA77' => 'The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient’s payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice.',
198 'MA80' => 'Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.',
201 '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.',
202 'MA88' => 'Missing/incomplete/invalid insured\'s address and/or telephone number for the primary payer.',
203 'MA89' => 'Missing/incomplete/invalid patient\'s relationship to the insured for the primary payer.',
208 'MA94' => 'Did not enter the statement “Attending physician not hospice employee” on the claim form to certify that the rendering physician is not an employee of the hospice.',
210 'MA96' => 'Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.',
214 'MA101' => 'A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents.',
220 'MA110' => 'Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.',
221 'MA111' => 'Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory\'s name and address.',
223 '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.',
225 'MA115' => 'Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).',
226 'MA116' => 'Did not complete the statement "Homebound" on the claim to validate whether laboratory services were performed at home or in an institution.',
228 'MA118' => 'Coinsurance and/or deductible amounts apply to a claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued.',
233 'MA123' => 'Your center was not selected to participate in this study, therefore, we cannot pay for these services.',
237 '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.',
238 'MA131' => 'Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.',
240 'MA133' => 'Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.',
241 'MA134' => 'Missing/incomplete/invalid provider number of the facility where the patient resides.',
242 'N1' => 'You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.',
243 'N2' => 'This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.',
247 'N6' => 'Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.',
248 'N7' => 'Processing of this claim/service has included consideration under Major Medical provisions.',
249 'N8' => 'Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.',
251 'N10' => 'Claim/service adjusted based on the findings of a review organization/professional consult/manual adjudication/medical or dental advisor.',
253 'N12' => 'Policy provides coverage supplemental to Medicare. As member does not appear to be enrolled in Medicare Part B, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.',
255 'N14' => 'Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.',
257 'N16' => 'Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.',
261 'N22' => 'This procedure code was added/changed because it more accurately describes the services rendered.',
262 'N23' => 'Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.',
264 'N25' => 'This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.',
275 'N36' => 'Claim must meet primary payer’s processing requirements before we can consider payment.',
284 'N48' => 'Claim information does not agree with information received from other insurance carrier.',
288 'N52' => 'Patient not enrolled in the billing provider\'s managed care plan on the date of service.',
292 'N56' => 'Procedure code billed is not correct/valid for the services billed or the date of service billed.',
295 'N59' => 'Please refer to your provider manual for additional program and provider information.',
300 'N65' => 'Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.',
301 'N67' => 'Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient’s admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.',
302 'N68' => 'Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.',
303 'N69' => 'PPS (Prospective Payment System) code changed by claims processing system. Insufficient visits or therapies.',
305 'N71' => 'Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.',
306 'N72' => 'PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.',
307 'N74' => 'Resubmit with multiple claims, each claim covering services provided in only one calendar month.',
315 'N82' => 'Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.',
316 'N83' => 'No appeal rights. Adjudicative decision based on the provisions of a demonstration project.',
319 'N86' => 'A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.',
321 'N88' => 'This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA\'s payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care.',
322 'N89' => 'Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.',
326 'N93' => 'A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.',
327 'N94' => 'Claim/Service denied because a more specific taxonomy code is required for adjudication.',
329 'N96' => 'Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.',
330 'N97' => 'Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.',
331 'N98' => 'Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.',
332 'N99' => 'Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.',
334 'N102' => 'This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely.',
335 'N103' => 'Social Security records indicate that this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while they are in State or local custody under a penal authority, unless under State or local law, the individual is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt.',
336 'N104' => 'This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.hhs.gov.',
337 'N105' => 'This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing.',
338 'N106' => 'Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.',
339 'N107' => 'Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.',
341 'N109' => 'This claim was chosen for complex review and was denied after reviewing the medical records.',
343 'N111' => 'No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.',
346 'N114' => 'During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.',
347 'N115' => 'This decision was based on a local medical review policy (LMRP) or Local Coverage Determination (LCD).An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LMRP/LCD.',
348 'N116' => 'This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency’s (HHA’s) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.',
351 'N119' => 'This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.',
352 'N120' => 'Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.',
353 'N121' => 'Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.',
355 'N123' => 'This is a split service and represents a portion of the units from the originally submitted service.',
356 'N124' => 'Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.',
357 'N125' => 'Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in §§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office.',
358 'N126' => 'Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.',
359 'N127' => 'This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.',
362 'N130' => 'Consult plan benefit documents for information about restrictions for this service.',
363 'N131' => 'Total payments under multiple contracts cannot exceed the allowance for this service.',
364 'N132' => 'Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.',
365 'N133' => 'Services for predetermination and services requesting payment are being processed separately.',
366 'N134' => 'This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service.',
367 'N135' => 'Record fees are the patient\'s responsibility and limited to the specified co-payment.',
368 'N136' => 'To obtain information on the process to file an appeal in Arizona, call the Department\'s Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.',
369 'N137' => 'The provider acting on the Member\'s behalf, may file an appeal with the Payer. The provider, acting on the Member\'s behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority.',
370 'N138' => 'In the event you disagree with the Dental Advisor\'s opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber\'s dental insurance carrier for a second Independent Dental Advisor Review.',
371 'N139' => 'Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor\'s opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber\'s Dental insurance carrier within 90 days from the date of this letter.',
372 'N140' => 'You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor\'s opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber\'s Dental insurance carrier within 90 days from the date of this letter.',
373 'N141' => 'The patient was not residing in a long-term care facility during all or part of the service dates billed.',
375 'N143' => 'The patient was not in a hospice program during all or part of the service dates billed.',
378 'N147' => 'Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.',
382 'N151' => 'Telephone contact services will not be paid until the face-to-face contact requirement has been met.',
386 'N155' => 'Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.',
387 'N156' => 'The patient is responsible for the difference between the approved treatment and the elective treatment.',
390 'N159' => 'Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.',
391 'N160' => 'The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.',
393 'N162' => 'This is an alert. Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future.',
397 'N171' => 'Payment for repair or replacement is not covered or has exceeded the purchase price.',
398 'N172' => 'The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.',
400 'N174' => 'This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group "PR".',
402 'N176' => 'Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.',
403 'N177' => 'We did not send this claim to patient’s other insurer. They have indicated no additional payment can be made.',
405 'N179' => 'Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.',
406 'N180' => 'This item or service does not meet the criteria for the category under which it was billed.',
407 'N181' => 'Additional information has been requested from another provider involved in the care of this member. The charges will be reconsidered upon receipt of that information.',
409 'N183' => 'This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.',
412 'N186' => 'Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.',
413 'N187' => 'You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.',
415 'N189' => 'This service has been paid as a one-time exception to the plan\'s benefit restrictions.',
427 'N201' => 'A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.',
430 'N204' => 'Services under review for possible pre-existing condition. Send medical records for prior 12 months',
439 'N213' => 'Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information',
441 'N215' => 'A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.',
444 'N218' => '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 the time period specified in the contract or coverage manual.',
446 'N220' => 'See the payer\'s web site or contact the payer\'s Customer Service department to obtain forms and instructions for filing a provider dispute.',
450 'N224' => 'Incomplete/invalid documentation of benefit to the patient during initial treatment period.',
456 'N230' => 'Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.',
457 'N231' => 'Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.',
569 'N343' => 'Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.',
570 'N344' => 'Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.',
573 'N347' => 'Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.',
574 'N348' => 'You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.',
576 'N350' => 'Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or an Unlisted procedure.',
578 'N352' => 'There are no scheduled payments for this service. Submit a claim for each patient visit.',
579 'N353' => 'Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.',
581 'N355' => 'The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. 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 appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position. If you request an appeal within 30 days of receiving this notice, 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 an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, 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 our office if he/she does not hear anything about a refund within 30 days',
582 'N356' => 'This service is not covered when performed with, or subsequent to, a non-covered service.',
583 'N357' => 'Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.',
584 'N358' => 'This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.',
586 'N360' => 'Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.',
589 'N363' => 'Alert: in the near future we are implementing new policies/procedures that would affect this determination.',
590 'N364' => 'According to our agreement, you must waive the deductible and/or coinsurance amounts.',
592 'N366' => 'Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.',
593 'N367' => 'The claim information has been forwarded to a Health Savings Account processor for review.',
595 'N369' => 'Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.',
596 );
597 ?>