Claim Adjustment Reason Codes 2023 – Latest CARC Codes List

Claim Adjustment Reason Codes (CARCs) are standardized codes used in the healthcare industry to explain why a claim for payment has been adjusted or denied. They are a way for insurance companies, Medicare, Medicaid, and other commercial insurances to communicate with healthcare providers and patients about the status of a claim and the reasons for any adjustments or denials.

Claim Adjustment Reason Codes – Latest CARC Codes List

CARCs, also known as claim adjustment reason codes can indicate claim denial reasons such as incomplete or incorrect information, services not covered under the patient’s plan, or exceeded limits of coverage.

By using these codes, healthcare providers can understand why a claim was denied and take appropriate action to address any issues, such as correcting information or appealing the decision. You can find the list of all the denial codes along with their detailed description and current status.

Claim Adjustment Reason Codes List

Claim Adjustment Reason CodeClaim Adjustment Reason Code DescriptionStatus
1Deductible AmountActive
2Coinsurance AmountActive
3Co-payment AmountActive
4The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
5The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
6The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
7The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
8The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
9The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
10The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
11The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
12The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
13The date of death precedes the date of service.Active
14The date of birth follows the date of service.Active
16Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
18Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)Active
19This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.Active
20This injury/illness is covered by the liability carrier.Active
21This injury/illness is the liability of the no-fault carrier.Active
22This care may be covered by another payer per coordination of benefits.Active
23The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)Active
24Charges are covered under a capitation agreement/managed care plan.Active
26Expenses incurred prior to coverage.Active
27Expenses incurred after coverage terminated.Active
29The time limit for filing has expired.Active
31Patient cannot be identified as our insured.Active
32Our records indicate the patient is not an eligible dependent.Active
33Insured has no dependent coverage.Active
34Insured has no coverage for newborns.Active
35Lifetime benefit maximum has been reached.Active
39Services denied at the time authorization/pre-certification was requested.Active
40Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
44Prompt-pay discount.Active
45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)Active
49This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
50These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
51These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
53Services by an immediate relative or a member of the same household are not covered.Active
54Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
55Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
56Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
58Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
59Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
60Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.Active
61Adjusted for failure to obtain second surgical opinionActive
66Blood Deductible.Active
69Day outlier amount.Active
70Cost outlier - Adjustment to compensate for additional costs.Active
74Indirect Medical Education Adjustment.Active
75Direct Medical Education Adjustment.Active
76Disproportionate Share Adjustment.Active
78Non-Covered days/Room charge adjustment.Active
85Patient Interest Adjustment (Use Only Group code PR)Active
89Professional fees removed from charges.Active
90Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.Active
91Dispensing fee adjustment.Active
94Processed in Excess of charges.Active
95Plan procedures not followed.Active
96Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
97The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
100Payment made to patient/insured/responsible party.Active
101Predetermination: anticipated payment upon completion of services or claim adjudication.Active
102Major Medical Adjustment.Active
103Provider promotional discount (e.g., Senior citizen discount).Active
104Managed care withholding.Active
105Tax withholding.Active
106Patient payment option/election not in effect.Active
107The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
108Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
109Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.Active
110Billing date predates service date.Active
111Not covered unless the provider accepts assignment.Active
112Service not furnished directly to the patient and/or not documented.Active
114Procedure/product not approved by the Food and Drug Administration.Active
115Procedure postponed, canceled, or delayed.Active
116The advance indemnification notice signed by the patient did not comply with requirements.Active
117Transportation is only covered to the closest facility that can provide the necessary care.Active
118ESRD network support adjustment.Active
119Benefit maximum for this time period or occurrence has been reached.Active
121Indemnification adjustment - compensation for outstanding member responsibility.Active
122Psychiatric reduction.Active
128Newborn's services are covered in the mother's Allowance.Active
129Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
130Claim submission fee.Active
131Claim specific negotiated discount.Active
132Prearranged demonstration project adjustment.Active
133The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).Active
134Technical fees removed from charges.Active
135Interim bills cannot be processed.Active
136Failure to follow prior payer's coverage rules. (Use only with Group Code OA)Active
137Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.Active
139Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.Active
140Patient/Insured health identification number and name do not match.Active
142Monthly Medicaid patient liability amount.Active
143Portion of payment deferred.Active
144Incentive adjustment, e.g. preferred product/service.Active
146Diagnosis was invalid for the date(s) of service reported.Active
147Provider contracted/negotiated rate expired or not on file.Active
148Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
149Lifetime benefit maximum has been reached for this service/benefit category.Active
150Payer deems the information submitted does not support this level of service.Active
151Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.Active
152Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
153Payer deems the information submitted does not support this dosage.Active
154Payer deems the information submitted does not support this day's supply.Active
155Patient refused the service/procedure.Active
157Service/procedure was provided as a result of an act of war.Active
158Service/procedure was provided outside of the United States.Active
159Service/procedure was provided as a result of terrorism.Active
160Injury/illness was the result of an activity that is a benefit exclusion.Active
161Provider performance bonusActive
163Attachment/other documentation referenced on the claim was not received.Active
164Attachment/other documentation referenced on the claim was not received in a timely fashion.Active
166These services were submitted after this payers responsibility for processing claims under this plan ended.Active
167This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
169Alternate benefit has been provided.Active
170Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
171Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
172Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
173Service/equipment was not prescribed by a physician.Active
174Service was not prescribed prior to delivery.Active
175Prescription is incomplete.Active
176Prescription is not current.Active
177Patient has not met the required eligibility requirements.Active
178Patient has not met the required spend down requirements.Active
179Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
180Patient has not met the required residency requirements.Active
181Procedure code was invalid on the date of service.Active
182Procedure modifier was invalid on the date of service.Active
183The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
184The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
185The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
186Level of care change adjustment.Active
187Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)Active
188This product/procedure is only covered when used according to FDA recommendations.Active
189'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/serviceActive
190Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.Active
192Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.Active
193Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.Active
194Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.Active
195Refund issued to an erroneous priority payer for this claim/service.Active
197Precertification/authorization/notification/pre-treatment absent.Active
198Precertification/notification/authorization/pre-treatment exceeded.Active
199Revenue code and Procedure code do not match.Active
200Expenses incurred during lapse in coverageActive
201Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
202Non-covered personal comfort or convenience services.Active
203Discontinued or reduced service.Active
204This service/equipment/drug is not covered under the patient's current benefit planActive
205Pharmacy discount card processing feeActive
206National Provider Identifier - missing.Active
207National Provider identifier - Invalid formatActive
208National Provider Identifier - Not matched.Active
209Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)Active
210Payment adjusted because pre-certification/authorization not received in a timely fashionActive
211National Drug Codes (NDC) not eligible for rebate, are not covered.Active
212Administrative surcharges are not coveredActive
213Non-compliance with the physician self referral prohibition legislation or payer policy.Active
215Based on subrogation of a third party settlementActive
216Based on the findings of a review organizationActive
219Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).Active
222Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
223Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.Active
224Patient identification compromised by identity theft. Identity verification required for processing this and future claims.Active
225Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)Active
226Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
227Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
228Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudicationActive
229Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)Active
231Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
232Institutional Transfer Amount. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.Active
233Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.Active
234This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
235Sales TaxActive
236This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.Active
237Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
238Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)Active
239Claim spans eligible and ineligible periods of coverage. Rebill separate claims.Active
240The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
241Low Income Subsidy (LIS) Co-payment AmountActive
242Services not provided by network/primary care providers.Active
243Services not authorized by network/primary care providers.Active
245Provider performance program withhold.Active
246This non-payable code is for required reporting only.Active
247Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.Active
248Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.Active
249This claim has been identified as a readmission. (Use only with Group Code CO)Active
250The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Active
251The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Active
252An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).Active
253Sequestration - reduction in federal paymentActive
254Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.Active
256Service not payable per managed care contract.Active
257The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)Active
258Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.Active
259Additional payment for Dental/Vision service utilization.Active
260Processed under Medicaid ACA Enhanced Fee ScheduleActive
261The procedure or service is inconsistent with the patient's history.Active
262Adjustment for delivery cost. Usage: To be used for pharmaceuticals only.Active
263Adjustment for shipping cost. Usage: To be used for pharmaceuticals only.Active
264Adjustment for postage cost. Usage: To be used for pharmaceuticals only.Active
265Adjustment for administrative cost. Usage: To be used for pharmaceuticals only.Active
266Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only.Active
267Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Active
268The Claim spans two calendar years. Please resubmit one claim per calendar year.Active
269Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
270Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration.Active
271Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with Group Code OA)Active
272Coverage/program guidelines were not met.Active
273Coverage/program guidelines were exceeded.Active
274Fee/Service not payable per patient Care Coordination arrangement.Active
275Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR)Active
276Services denied by the prior payer(s) are not covered by this payer.Active
277The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)Active
278Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
279Services not provided by Preferred network providers. Usage: Use this code when there are member network limitations. For example, using contracted providers not in the member's 'narrow' network.Active
280Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration.Active
281Deductible waived per contractual agreement. Use only with Group Code CO.Active
282The procedure/revenue code is inconsistent with the type of bill. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
283Attending provider is not eligible to provide direction of care.Active
284Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.Active
285Appeal procedures not followedActive
286Appeal time limits not metActive
287Referral exceededActive
288Referral absentActive
289Services considered under the dental and medical plans, benefits not available.Active
290Claim received by the dental plan, but benefits not available under this plan. Claim has been forwarded to the patient's medical plan for further consideration.Active
291Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's dental plan for further consideration.Active
292Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's pharmacy plan for further consideration.Active
293Payment made to employer.Active
294Payment made to attorney.Active
295Pharmacy Direct/Indirect Remuneration (DIR)Active
296Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.Active
297Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's vision plan for further consideration.Active
298Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's vision plan for further consideration.Active
299The billing provider is not eligible to receive payment for the service billed.Active
300Claim received by the Medical Plan, but benefits not available under this plan. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration.Active
301Claim received by the Medical Plan, but benefits not available under this plan. Submit these services to the patient's Behavioral Health Plan for further consideration.Active
302Precertification/notification/authorization/pre-treatment time limit has expired.Active
303Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered for Qualified Medicare and Medicaid Beneficiaries. (Use only with Group Code CO)Active
304Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's hearing plan for further consideration.Active
305Claim received by the medical plan, but benefits not available under this plan. Claim has been forwarded to the patient's hearing plan for further consideration.Active
A0Patient refund amount.Active
A1Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) The following will be added to this definition on 7/1/2023, Usage: Use this code only when a more specific Claim Adjustment Reason Code is not available.Active
A5Medicare Claim PPS Capital Cost Outlier Amount.Active
A6Prior hospitalization or 30 day transfer requirement not met.Active
A8Ungroupable DRG.Active
B1Non-covered visits.Active
B4Late filing penalty.Active
B7This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
B8Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
B9Patient is enrolled in a Hospice.Active
B10Allowed 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.Active
B11The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.Active
B12Services not documented in patient's medical records.Active
B13Previously paid. Payment for this claim/service may have been provided in a previous payment.Active
B14Only one visit or consultation per physician per day is covered.Active
B15This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.Active
B16'New Patient' qualifications were not met.Active
B20Procedure/service was partially or fully furnished by another provider.Active
B22This payment is adjusted based on the diagnosis.Active
B23Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.Active
P1State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.Active
P2Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.Active
P3Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)Active
P4Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyActive
P5Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.Active
P6Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.Active
P7The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.Active
P8Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.Active
P9No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.Active
P10Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.Active
P11The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)Active
P12Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Active
P13Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Active
P14The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.Active
P15Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.Active
P16Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)Active
P17Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.Active
P18Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.Active
P19Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.Active
P20Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.Active
P21Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P22Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P23Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P24Payment adjusted based on Preferred Provider Organization (PPO). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. Use only with Group Code CO.Active
P25Payment adjusted based on Medical Provider Network (MPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).Active
P26Payment adjusted based on Voluntary Provider network (VPN). Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty only. (Use only with Group Code CO).Active
P27Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P28Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P29Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.Active
P30Payment denied for exacerbation when supporting documentation was not complete. To be used for Property and Casualty only.Active
P31Payment denied for exacerbation when treatment exceeds time allowed. To be used for Property and Casualty only.Active
P32Payment adjusted due to Apportionment.Active
15The authorization number is missing, invalid, or does not apply to the billed services or provider.Deactivated
17Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)Deactivated
25Payment denied. Your Stop loss deductible has not been met.Deactivated
28Coverage not in effect at the time the service was provided.Deactivated
30Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.Deactivated
36Balance does not exceed co-payment amount.Deactivated
37Balance does not exceed deductible.Deactivated
38Services not provided or authorized by designated (network/primary care) providers.Deactivated
41Discount agreed to in Preferred Provider contract.Deactivated
42Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)Deactivated
43Gramm-Rudman reduction.Deactivated
46This (these) service(s) is (are) not covered.Deactivated
47This (these) diagnosis(es) is (are) not covered, missing, or are invalid.Deactivated
48This (these) procedure(s) is (are) not covered.Deactivated
52The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.Deactivated
57Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.Deactivated
62Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.Deactivated
63Correction to a prior claim.Deactivated
64Denial reversed per Medical Review.Deactivated
65Procedure code was incorrect. This payment reflects the correct code.Deactivated
67Lifetime reserve days. (Handled in QTY, QTY01=LA)Deactivated
68DRG weight. (Handled in CLP12)Deactivated
71Primary Payer amount.Deactivated
72Coinsurance day. (Handled in QTY, QTY01=CD)Deactivated
73Administrative days.Deactivated
77Covered days. (Handled in QTY, QTY01=CA)Deactivated
79Cost Report days. (Handled in MIA15)Deactivated
80Outlier days. (Handled in QTY, QTY01=OU)Deactivated
81Discharges.Deactivated
82PIP days.Deactivated
83Total visits.Deactivated
84Capital Adjustment. (Handled in MIA)Deactivated
86Statutory Adjustment.Deactivated
87Transfer amount.Deactivated
88Adjustment amount represents collection against receivable created in prior overpayment.Deactivated
92Claim Paid in full.Deactivated
93No Claim level Adjustments.Deactivated
98The hospital must file the Medicare claim for this inpatient non-physician service.Deactivated
99Medicare Secondary Payer Adjustment Amount.Deactivated
113Payment denied because service/procedure was provided outside the United States or as a result of war.Deactivated
120Patient is covered by a managed care plan.Deactivated
123Payer refund due to overpayment.Deactivated
124Payer refund amount - not our patient.Deactivated
125Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Deactivated
126Deductible -- Major MedicalDeactivated
127Coinsurance -- Major MedicalDeactivated
138Appeal procedures not followed or time limits not met.Deactivated
141Claim spans eligible and ineligible periods of coverage.Deactivated
145Premium payment withholdingDeactivated
156Flexible spending account payments. Note: Use code 187.Deactivated
162State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.Deactivated
165Referral absent or exceeded.Deactivated
168Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.Deactivated
191Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)Deactivated
196Claim/service denied based on prior payer's coverage determination.Deactivated
214Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyDeactivated
217Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)Deactivated
218Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation onlyDeactivated
220The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)Deactivated
221Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)Deactivated
230No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.Deactivated
244Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.Deactivated
255The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)Deactivated
A2Contractual adjustment.Deactivated
A3Medicare Secondary Payer liability met.Deactivated
A4Medicare Claim PPS Capital Day Outlier Amount.Deactivated
A7Presumptive Payment AdjustmentDeactivated
B2Covered visits.Deactivated
B3Covered charges.Deactivated
B5Coverage/program guidelines were not met or were exceeded.Deactivated
B6This payment is adjusted 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.Deactivated
B17Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.Deactivated
B18This procedure code and modifier were invalid on the date of service.Deactivated
B19Claim/service adjusted because of the finding of a Review Organization.Deactivated
B21The charges were reduced because the service/care was partially furnished by another physician.Deactivated
D1Claim/service denied. Level of subluxation is missing or inadequate.Deactivated
D2Claim lacks the name, strength, or dosage of the drug furnished.Deactivated
D3Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.Deactivated
D4Claim/service does not indicate the period of time for which this will be needed.Deactivated
D5Claim/service denied. Claim lacks individual lab codes included in the test.Deactivated
D6Claim/service denied. Claim did not include patient's medical record for the service.Deactivated
D7Claim/service denied. Claim lacks date of patient's most recent physician visit.Deactivated
D8Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'Deactivated
D9Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.Deactivated
D10Claim/service denied. Completed physician financial relationship form not on file.Deactivated
D11Claim lacks completed pacemaker registration form.Deactivated
D12Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.Deactivated
D13Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.Deactivated
D14Claim lacks indication that plan of treatment is on file.Deactivated
D15Claim lacks indication that service was supervised or evaluated by a physician.Deactivated
D16Claim lacks prior payer payment information.Deactivated
D17Claim/Service has invalid non-covered days.Deactivated
D18Claim/Service has missing diagnosis information.Deactivated
D19Claim/Service lacks Physician/Operative or other supporting documentationDeactivated
D20Claim/Service missing service/product information.Deactivated
D21This (these) diagnosis(es) is (are) missing or are invalidDeactivated
D22Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing codeDeactivated
D23This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)Deactivated
W1Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.Deactivated
W2Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.Deactivated
W3The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.Deactivated
W4Workers' Compensation Medical Treatment Guideline Adjustment.Deactivated
W5Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)Deactivated
W6Referral not authorized by attending physician per regulatory requirement.Deactivated
W7Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.Deactivated
W8Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.Deactivated
W9Service not paid under jurisdiction allowed outpatient facility fee schedule.Deactivated
Y1Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Deactivated
Y2Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Deactivated
Y3Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.Deactivated

What are Claim Adjustment Group Codes?

Claim Adjustment Group Codes (CAGCs) are standardized codes used in the healthcare industry to group similar types of adjustment reasons for healthcare claims. Claim Adjustment Group Codes provide a way to categorize the specific reasons for an adjustment or denial of a claim, such as claim submission errors, benefit reductions, and coordination of benefits issues.

They are often used in conjunction with Claim Adjustment Reason Codes to provide additional information about why a claim was adjusted or denied. By using CAGCs, healthcare providers can easily identify and understand the types of adjustments or denials that are common for a particular type of claim or service.

This can help providers to identify areas for improvement, such as reducing claim submission errors, and to better understand the reimbursement process. For ease, the Claim Adjustment Group Codes are mentioned below:

CO – Contractual Obligation

CR – Corrections and Reversal

OA – Other Adjustment

PI – Payer Initiated Reductions

PR – Patient Responsibility

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