RemitBench/Denial codes

Denial codes, in plain words

A denial code tells you why a payer did not pay a line. This reference answers the part you need first: what the code means, who owes the money, and whether an appeal is worth your afternoon.

Read the two letters first

A code on a remittance has two parts. The letters are the group code, and they say who is out the money. The number is the reason code, and it says why. Most people read the number and skip the letters. That is the mistake that gets a patient billed for money the practice already agreed to write off.

Every code with a full page

61 codes, grouped by what they are actually telling you rather than by number. Each page answers the same three questions first: what the payer meant, who owes the money, and whether an appeal is worth your afternoon.

Money the patient owes

These are the lines that go on a statement. Read the letters anyway, because the same number arrives as a write-off on another payer.

• PR-1 The deductible. Not a denial at all: the plan is telling you how much of the patient's own yearly amount this line used up.
• PR-2 Coinsurance. The patient's percentage of a covered service. The percentage comes off the allowed amount, never off your billed fee.
• PR-3 The copay. A flat per-visit fee the patient usually already paid at the desk. The danger is posting it twice, not collecting it.
• PR-26 The visit happened before this plan started. The mirror of PR-27. Check for a retroactive start date, because new enrolments are often loaded late.
• PR-27 Coverage had ended by the date of service. Find the right payer before you bill the patient, because there usually is one.
• PR-35 A lifetime maximum is used up. This one does not reset in January. In dental it is nearly always the orthodontic ceiling.
• PR-49 The plan does not cover routine or preventive care. On a dental claim, suspect the claim reached a medical payer rather than the dental one.
• CO-119 The benefit maximum for the period is used up. The patient stayed covered and the money ran out. In dental this is the annual maximum, and the patient owes it.
• CO-149 A lifetime cap on one category, not the whole plan. Everything else is still covered. This is where dental orthodontic ceilings usually report.

Not covered, or covered but limited

The plan either never covered this or has stopped covering it for now. Records move some of these and not others.

• CO-B9 The patient has elected hospice. Care for the terminal condition is paid through the hospice, so bill them rather than appealing.
• CO-50 The payer decided the service was not medically necessary. This is the one records can overturn, because it is a judgment rather than a rule about the plan.
• CO-55 The payer calls the treatment experimental. This is an opinion, not a plan term, which makes it one of the few coverage denials worth a real appeal.
• CO-96 Not covered, and the number does not say why. A remark code has to come with it. The same 96 arrives as CO, PR and PI, so the letters decide who pays, not the number.
• CO-151 Too many units or visits for what the documentation shows. The phrase "information submitted" is the opening: this is often fixed by sending records, not by arguing.
• CO-167 The diagnosis is not covered, not the procedure. Check the chart for a covered diagnosis before appealing, because this is often a coding fix.
• PR-204 The service is not in the benefits the patient bought. Do not send records, because there is nothing for them to answer. Look for another payer instead.
• CO-234 The service is real, and this payer never pays it as its own line. Stop billing it separately rather than appealing it every month.
• CO-272 A coverage or program rule was not met. Which rule is in the remark, and a guideline is a checklist, which makes this more winnable than a flat exclusion.
• CO-273 A coverage limit was passed, not a condition missed. Documentation usually will not move this one. Find out when the patient is next eligible.

Something was wrong with the claim

Nothing was decided about coverage. The payer could not use the claim as sent, so the fix is a corrected claim rather than an appeal.

• CO-4 The modifier does not go with the procedure code, or one is missing. Nothing about coverage was decided, so fix the pair and resend.
• CO-6 The procedure does not match the age on file. Check the date of birth before the procedure code, because a typo there is the usual cause.
• CO-11 The diagnosis does not support the procedure. A mismatch, not an exclusion. Check the chart for a diagnosis that fits before you appeal.
• CO-16 Something on the claim was missing or wrong, so the payer would not process it. The code itself does not say what. The remark code next to it does. Read that first.
• CO-18 The payer already has this exact line. Go and look at the first claim, because it has usually already paid. Sending the claim again is the one move that never helps.
• CO-29 The claim arrived after the filing deadline. On Medicare there is no appeal to file, because the denial is not an initial determination. There is a short exception list instead.
• CO-31 The payer cannot find this person in its records. Usually one wrong character in the member ID, the name or the birth date.
• CO-140 The member ID and the name do not match. Usually the name: married names, hyphens and nicknames. Bill the name on the card, exactly.
• CO-146 The diagnosis code was not valid on that date. Clusters right after the annual code update, and usually means a stale favourites list.
• CO-181 The procedure code was not valid on that date. Late filed claims need the old code, not today's one.
• CO-182 The modifier was not valid on that date. Different from CO-4, which means the modifier does not fit the procedure at all.
• CO-252 The payer wants documentation before it decides. Not a denial: send what the remark names and the claim carries on.

Pricing, bundling and contract

The service was covered. The money moved for a contractual reason, and most of it is a write-off rather than anything to work.

• CO-45 Your charge was higher than the payer's allowed amount. Usually not a denial at all: the claim paid, and the gap is the discount your contract promised.
• CO-59 Multiple procedure rules reduced the later lines. The claim paid. Not a denial, and not a patient balance.
• CO-94 The payer allowed more than you charged. Usually a sign your fee is below that payer's schedule, which is worth knowing.
• CO-97 The payer says this service is already paid for inside another service on the claim. Often a bundling edit or a global period. The practice writes it off, not the patient.
• CO-131 A discount negotiated for this claim, not your normal contract rate. Ask who negotiated it, because it is often a rented network.
• CO-231 Two procedures the payer says cannot both happen in one session. Different sites or different sessions can be legitimate, but they have to be shown.
• CO-253 Sequestration. Not a denial: the claim paid and a fixed federal reduction came off the payment at the end. Never billable to the patient.

Another payer, or another plan

The claim is not wrong. It is in the wrong place, or it is second in line behind someone else. The money nearly always exists somewhere.

• CO-19 The health plan says this was a work injury, so workers compensation owes it. Do not bill the patient: most states bar billing an injured worker directly.
• CO-22 Another plan is primary and should have been billed first. Not a coverage denial: it is an order of operations problem.
• CO-23 Bookkeeping on a secondary claim: what the primary already paid or adjusted. The code list says use it only with group code OA.
• CO-24 Paid under a capitation or managed care arrangement rather than per claim. Find out who holds the capitation rather than writing it off.
• CO-109 Wrong payer. The service may be perfectly covered somewhere else. Send the claim there rather than writing it off or billing the patient.

Provider, network and authorisation

The care was fine and the paperwork behind it was not. Most of these are preventable before the patient sits down.

• CO-B7 The provider was not eligible to be paid on that date. An enrolment record problem, and often recoverable once the record is corrected.
• CO-8 The procedure does not match the specialty on file. Check the taxonomy code, which is set once at enrolment and almost never reviewed.
• CO-B15 A qualifying service had to come first and be covered. Work the first service, not this one: it usually exists and was denied or billed elsewhere.
• CO-95 Some plan process rule was not followed, and the code will not say which. Find the remark or call, because there is nothing else to go on.
• CO-170 This type of provider cannot bill this service, whoever they are. A category rule, so the fix is usually who bills it.
• CO-185 The provider is not eligible for this particular service. A scope restriction rather than an enrolment gap.
• CO-197 Authorisation was required and the payer has none on file. Check whether one exists and simply did not reach the claim, which is the recoverable version.
• CO-198 The authorisation existed and was exceeded, not missing. A stronger position than CO-197, because the payer already agreed the care was appropriate.
• CO-242 The provider was outside the plan's network. Check your enrolment record, because a stale or pending credentialling file produces the same denial.
• CO-288 A required referral is missing. Not the same as authorisation: a referral comes from another provider, so the fix is usually a call to their office.

Remark codes

A remark code explains a decision. It never makes one. No money is attached to a remark, so the reason code beside it is what tells you who pays. These are the remarks worth knowing on sight, because each one decides a different next step.

• MA04 The primary payer's information is missing from a secondary claim. A request, not a refusal, and one of the most recoverable lines on any remittance.
• N30 The patient was ineligible for this service, not the service itself. Ask what specifically made them ineligible, because the code will not say.
• M86 A same or similar procedure was already paid inside a time window. That word "similar" is where the arguments are.
• N130 A remark code telling you to read the plan's own benefit documents. The most common remark in dental. It carries no money, so read the reason code beside it.
• N425 The service is excluded by law rather than by the plan. Documentation cannot move this one, which makes it one of the few genuinely final denials.
• N640 A frequency limit was passed. The patient is early, not uncovered. Find the date they become eligible again and offer the appointment.
• N822 A remark code meaning a required modifier was missing from the line. It rides on reason code 16, so it is a fix and resend, never a patient balance.
• N823 The twin of N822, for a modifier that is there and wrong. Payers blur the two, so read the payer's own message rather than the code number.