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VFC VFC_DESC PROV_TXT MEM_TXT LENGTH OF MEMBER TEXT
0000 $15.00 + 30% NPAR COPAY A $15 and 30% coinsurance applied for nonparticipating provider 63
0001 SVCS PRIOR TO ENROLLMENT THESE SERVICES RENDERED PRIOR TO SUBSCRIBER'S ENROLLMENT FOR COVERAGE.
Payment is not available as the service was provided when the individual was not an active member under this customer ID number
127
0002 INVALID CN-TYPE FOR MEMBER PATIENT IS NOT COVERED UNDER SUBSCRIBER'S CONTRACT
You are not covered under the insured's contract 48
0003 SVC UNDER PRIOR ENROLLMENT SERVICES RENDERED DURING ENROLLMENT UNDER A PREVIOUS GROUP
Services rendered during your enrollment with a previous group 62
0004 NOT ENROLL 2ND DEPENDENT SECOND DEPENDENT CANNOT BE ENROLLED UNDER THIS COVERAGE
Just one dependent is covered under your contract 49
0005 NOT ENROLL SPOUSE/3RD DEP SPOUSE OR THIRD DEPENDENT CANNOT BE ENROLLED UNDER THIS COVERAGE
Spouse or third dependent is not covered by this contract 57
0006 ENROLLED DEP OVER AGE PATIENT OVER AGE LIMIT FOR TYPE OF CONTRACT WHEN SERVICE WAS RENDERED
Over age limit for type of contract when service rendered 57
0007 LINE ITEM SVC AFTER GRACE THIS SERVICE WAS RENDERED AFTER SUBSCRIBER'S COVERAGE EXPIRED
Payment is not available as the service was provided when the individual was not an active member under this customer ID number
127
0008 NO CN COVERS LINE ITEM SVC THIS SERVICE IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT
This service is not covered under your contract 47
0009 SVC DURING GAP GRP ENROLL THIS SERVICE WAS RENDERED DURING A GAP IN GROUP ENROLLMENT
Payment is not available as the service was provided when the individual was not an active member under this customer ID number
127
0010 NOT ENROLL OVER AGE DEP PATIENT IS OVER THE AGE TO BE ENROLLED UNDER THIS COVERAGE
You are over the age to be enrolled under this coverage 55
0011 SVC DURING GAP ENROLLMENT THIS SERVICE WAS RENDERED DURING A GAP IN THE SUBSCRIBER'S ENROLLMENT
Payment is not available as the service was provided when the individual was not an active member under this customer ID number
127
0012 SVC CANNOT SELECT CONTRACT PATIENT NOT COVERED FOR THIS SERVICE UNDER THE SUBSCRIBER'S CONTRACT
Your contract does not cover these services 43
0013 RETRO DENIAL THIS SERVICE WAS RENDERED AFTER MEMBER'S COVERAGE EXPIRED.
Your contract does not cover these services 43
0014 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430015 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430016 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430017 RESERVED FOR MEMBERSHIP Your contract does not cover these services 430018 ALCOH DETOX BENE EXCEEDED BENEFITS FOR THIS SERVICE HAVE BEEN EXCEEDED Benefits for this service have been exceeded 440019 N/C INJECTABLE THIS PARTICULAR INJECTABLE IS NOT COVERED This particular injectable is not covered 410020 LIMIT 30 SVCS PER CAL-YR SERVICES ARE LIMITED TO 30 DAYS PER CALENDAR YEAR
(JAN TO DEC)Services are limited to 30 days per calendar year (Jan to Dec) 62
0021 $400 MAX PER CAL-YEAR THE $400 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $400 yearly allowance for these services has been met 57
0022 $2000 MAX PER CAL-YEAR THE $2000 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $2000 yearly allowance for these services has been met 58
0023 $1000 MAX PER CAL-YEAR THE $1000 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1000 yearly allowance for these services has been met 58
0024 $1000 LIFETIME MAX THE $1000 LIFETIME ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1000 lifetime allowance for these services has been met 60
0025 $500 MAX PER CAL-YEAR THE $500 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $500 yearly allowance for these services has been met 57
0026 ORTHODONTIC PRICING ORTHODONTIC SERVICES ALLOWED TO PREAPPROVED PAYMENT SCHEDULE
Priced according to orthodontic monthly payment schedule 56
0027 $2000 LIFETIME MAX $2000 IS MAXIMUM LIFETIME ALLOWANCE FOR THESE SERVICES
$2000 is maximum lifetime allowance for these services 54
0028 $1500 MAX PER CAL-YEAR $1500 IS MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THESE SERVICES
$1500 is maximum allowance per calendar year for these services 63
0029 OVER USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0030 SVCS FILED PREVIOUS These services have been previously paid or denied This is a duplicate claim. A claim for these services has been previously submitted and processed
98
0031 DENTAL OCL REDUCTION OUR ALLOWANCE REDUCED BY THE OTHER INSURANCE CARRIER'S PAYMENT
Our allowance reduced by the other insurance carrier's payment 62
0032 $50I/$150F CAL-YR DED $50 INDIVIDUAL/$150 FAMILY CALENDAR YEAR DEDUCTIBLE TAKEN
$50 individual/$150 family calendar year deductible taken 57
0033 $1700 MAX PER CAL-YR $1700 IS MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THESE SERVICES
$1700 is maximum allowance per calendar year for these services 63
0034 OVER AGE FOR SERVICE PATIENT'S AGE IS BEYOND THE AGE LIMIT FOR THIS SERVICE
Patient's age is beyond the age limit for this service 54
0035 PRICE AT CHARGE PRICED AT CHARGE Priced at charge 160036 MODE PRICING/NON PAR AMOUNT IS MAXIMUM ALLOWED FOR NON-PARTICIPATING
PROVIDERAmount is maximum allowed for non-participating provider 56
0037 20% COPAY 20% PATIENT COPAYMENT APPLIED TO THIS SERVICE This amount represents your coinsurance. You are responsible to pay your provider directly
91
0038 30% COPAY 30% PATIENT COPAYMENT APPLIED TO THIS SERVICE 30% copayment applied to this service is your responsibility 600039 40% COPAY 40% PATIENT COPAYMENT APPLIED TO THIS SERVICE 40% copayment applied to this service is your responsibility 600040 N/C NON-AFFIL OF LIFESPAN THIS IS A NONCOVERED BENEFIT BECAUSE THE SERVICE
WAS RENDERED BY A PROVIDER WHO IS NOT AFFILIATED WITH LIFESPAN
This is a noncovered benefit because the service was rendered by a provider who is not affiliated with Lifespan
111
0041 $500 MAX PER BEN-YR $500 IS THE MAXIMUM ALLOWANCE PER BENEFIT YEAR FOR THIS SERVICE
$500 is the maximum allowance per benefit year for these services 65
0042 $850 MAX PER CAL-YR $850 IS THE MAXIMUM ALLOWANCE PER CALENDAR YEAR FOR THIS SERVICE
$850 is the maximum allowance per calendar year for these services
66
0043 $850 LIFETIME MAX $850 IS MAXIMUM LIFETIME ALLOWANCE FOR THESE SERVICES
$850 is maximum lifetime allowance for orthodontic services 59
0044 OVER USUAL/CUSTOMARY SERVICE OVER USUAL/CUSTOMARY Service over usual/customary 280045 50% COPAY 50% PATIENT COPAYMENT APPLIED TO THIS SERVICE 50% copayment for this service is your responsibility 530046 40% USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS
SERVICEThis amount is the maximum allowed for this service 51
0047 40% USUAL CHG/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0048 40% MODE PRICE/N PAR THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0049 OVER CUSTOMARY/N PAR THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWED PAYMENT FOR THIS SERVICE
Priced according to orthodontic monthly payment schedule 56
0050 TIMELY FILING SERVICE WAS FILED AFTER THE ACCEPTABLE TIME LIMIT Payment for this service is not available as the claim was not filed within the required timeframe
98
0051 WORKERS COMP SAVINGS PATIENT'S CONTRACT DOES NOT COVER WORK-RELATED INJURIES
Payment is not available for this service because the claim was reported as a potential work-related injury
107
0052 UNDER AGE FOR SVC PATIENT'S AGE IS UNDER THE AGE LIMIT FOR THIS SERVICE Patient's age is under the age limit for this service 53
0053 FMF/DOLLAR INDEMNITY THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0054 DENTAL OCL PAID IN FULL ALLOWANCE REDUCED BY THE OTHER INSURANCE CARRIER'S PAYMENT
Allowance reduced by the other insurance carrier's payment 58
0055 $1700 LIFETIME MAX $1700 IS MAXIMUM LIFETIME ALLOWANCE FOR THESE SERVICES
$1700 is maximum lifetime allowance for orthodontic services 60
0056 $800 MAX PER CAL-YR $800 PER CALENDAR YEAR MAXIMUM FOR THESE SERVICES MET
$800 per calendar year maximum for periodontal services met 59
0057 SVC NEVER PERFORMED RECORDS DID NOT INDICATE THAT SERVICE WAS PERFORMED
Records did not indicate that service was performed 51
0058 $1500 LIFETIME MAX THE $1500 LIFETIME ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1500 lifetime allowance for these services has been met 60
0059 $1250 LIFETIME MAX THE $1250 LIFETIME ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1250 lifetime allowance for these services has been met 60
0060 $750 MAX PER CAL-YR THE $750 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $750 yearly allowance for these services has been met 57
0061 $1200 MAX PER CAL-YR THE $1200 YEARLY ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1200 yearly allowance for these services has been met 58
0062 $1200 LIFETIME MAX THE $1200 LIFETIME ALLOWANCE FOR THESE SERVICES HAS BEEN MET
The $1200 lifetime allowance for these services has been met 60
0063 INTERSCHOLASTIC SPORTS INTERSCHOLASTIC/INTERCOLLEGIATE SPORTS INJURIES ARE NOT COVERED
Interscholastic/intercollegiate sports injuries are not covered 63
0064 ADMIN PURPOSE EXAMS N/C MEDICAL EXAMINATIONS FOR ADMINISTRATIVE PURPOSES ARE NOT COVERED.
Medical examinations for administrative purposes are not covered
69
0065 INFIRMARY SERVICE N/C INFIRMARY CHARGES ARE NOT COVERED UNDER PATIENT'S CONTRACT
Infirmary charges are not covered under your contract 53
0066 NON-ACC PROV SPECIFIC SVC PROVIDER'S CREDENTIALS DO NOT MEET OUR REQUIREMENTS FOR THIS SPECIFIC SERVICE.
This service has been denied. The provider is not authorized to perform this type of service. You are not responsible for the denied service
140
0067 CUSTODIAL CARE N/C PATIENT'S CONTRACT DOES NOT INCLUDE CUSTODIAL CARE
Your contract does not include custodial care 45
0068 ROUTINE DIAGNOSIS N/C ROUTINE PHYSICALS ARE NOT A COVERED SERVICE Routine physicals are not a covered service 430069 HOME NO ALLOWANCE-INST0070 NONCOVERED HOSPITAL LAB LABORATORY CONSULTATIONS OR INTERPRETATIONS ARE
NOT COVEREDLaboratory consultations or interpretations are not covered 59
0071 NONCOVERED POSTMORTEM SVC THIS POSTMORTEM SERVICE IS NOT COVERED This postmortem service is not covered 380072 HOME NO ALLOWANCE-PPO/POS0073 HOME NO ALLOWANCE-CAP0074 STAFF PHYSICIAN N/C SERVICE BY A PHYSICIAN ON THE STAFF OF A HOSPITAL IS
NOT COVEREDService by a physician on the staff of a hospital is not covered 64
0075 ASSOCIATED ROOM CHARGE N/C ASSOCIATED CHARGES DENIED WHEN FACILITY CHARGE HAS BEEN DENIED
Associated charges denied when facility charge has been denied 62
0076 SVC N/C IF NOT BY THE PCP THIS SERVICE IS ONLY COVERED WHEN RENDERED BY THE PRIMARY CARE PHYSICIAN
This service is only covered when rendered by your primary care physician
73
0077 ALT BIRTH CTR N/C PROV ONLY SERVICES BY AN APPROVED BIRTHING CENTER CAN BE REIMBURSED
Only services from an approved birthing center can be reimbursed 64
0078 ACTS OF WAR N/C SERVICES FOR CONDITIONS RESULTING FROM ACTS OF WAR NOT COVERED
Services for conditions resulting from acts of war not covered 62
0079 INSUFF INFO TO DET ER COV INSUFFICIENT INFORMATION TO DETERMINE COVERAGE FOR EMERGENCY ROOM SERVICE; PLEASE PROVIDE MEDICAL RECORDS
Insufficient information to determine coverage for emergency room service
73
0080 90% MDR PRICING THIS IS THE MAXIMUM ALLOWED AMOUNT FOR THIS SERVICE
This is the maximum allowed amount for this service 51
0081 INV DIAG FOR LABOR RM MATERNITY-RELATED DIAGNOSIS IS REQUIRED TO ALLOW LABOR ROOM
Maternity-related diagnosis is required to allow labor room 59
0082 DENTAL CARE NOT COVERED THIS DENTAL CARE IS NOT A COVERED SERVICE This dental care is not a covered service 410083 THERAPY N/C BT AGE 3 - 21 THERAPY BETWEEN AGES 3 AND 21 IS RESPONSIBILITY OF
CITY OR TOWNTherapy between ages 3 and 21 is responsibility of city or town 63
0084 SERVICE NOT COVERED THIS SERVICE IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT
This service is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents
119
0085 N/C PRE ADMIN TEST B/C PRE-ADMISSION TESTING IS NOT COVERED UNDER PATIENT'S CONTRACT
Pre-admission testing is not covered under your contract 56
0086 N/C OPERATING ROOM B/C SERVICE DID NOT MEET CRITERIA FOR COVERED OUTPATIENT SURGERY
This service was denied as it is not covered as outpatient surgery 66
0087 NONCOVERED BLOOD CHARGE THESE BLOOD CHARGES ARE NOT COVERED UNDER PATIENT'S CONTRACT
These blood charges are not covered under your contract 55
0088 FLEX COINSURANCE APPLIED A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.
A flex coinsurance has been applied to this service 51
0089 INV DIAG FOR CHEMOTHERAPY THIS SERVICE IS NOT COVERED FOR THE CONDITION REPORTED
Chemotherapy covered only for treatment of cancer 49
0090 CHEMO ANCILL DENIED CHEMOTHERAPY ANCILLARY DENIED BECAUSE CHEMOTHERAPY ADMINISTRATION IS DENIED.
Chemotherapy ancillary denied because chemotherapy administration is denied
75
0091 BENEFITS EXHAUSTED The maximum benefits for these services have been previously used
Payment is not available because you have exceeded the benefitlimit for this type of service
92
0092 FLEX COPAY HAS BEEN MET0093 SVC NOT MED NECESSARY SERVICES ARE CONSIDERED NOT MEDICALLY NECESSARY This service was denied as it is considered not medically necessary 67
0094 FLEX DEDUCTIBLE APPLIED A FLEX PLAN DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE.
This amount was applied toward your Flex Plan deductible 56
0095 NURSERY W/O MOTHER FLE SEP NURSERY NOT COVERED IF MOTHER'S ROOM AND BOARD CHARGES NOT FILED
Nursery not covered if mother's room and board charges not filed 64
0096 INPATIENT DEDUCT APPLIED AN INPATIENT DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE
An inpatient deductible has been applied to this service 56
0097 NONCOVERED HOME CARE THIS HOME CARE SERVICE IS NOT COVERED UNDER YOUR CONTRACT
This home care service is not covered under your plan 53
0098 FILE WITH MH VENDOR MENTAL HEALTH/SUBSTANCE ABUSE SERVICES SHOULD BE FILED DIRECTLY WITH THE MENTAL HEALTH VENDOR
Mental health/substance abuse services should be filed directly with the mental health vendor
93
0099 N/C TRANSPLANT SERVICE THIS TRANSPLANT SERVICE IS NOT COVERED UNDER PATIENT'S CONTRACT
This transplant service is not covered under your contract 58
0100 ONE EXAM/VISIT PER YEAR THE LIMIT OF ONE VISIT PER YEAR HAS BEEN PAID The limit of one visit per year has been paid 45
0101 I/P DEDUCTIBLE APPLIED INPATIENT DEDUCTIBLE APPLIED. Inpatient Deductible applied 280102 BENE EXHAUSTED FOR CAL YR MAXIMUM CALENDAR YEAR BENEFITS FOR THIS SERVICE
HAVE BEEN METMaximum calendar year benefits for this service have been met 61
0103 $50 DED PER ADMISSION A $50 DEDUCTIBLE HAS BEEN APPLIED TO THIS ADMISSION A $50 deductible has been applied to this admission 51
0104 WITHHOLD APPLIED0105 REDUCE TO ZERO, CAPITATION Capitated service0106 LIMIT 30 HRS PER CALYR MAXIMUM OF 30 HOURS PER CALENDAR YEAR HAS BEEN
PREVIOUSLY PAIDMaximum of 30 hours per calendar year has been previously paid 62
0107 HOST MED ADV CLM IN PROC THIS CLAIM HAS BEEN ROUTED TO THE MEMBERS BLUE CROSS PLAN FOR PROCESSING. PAYMENT TO THE PROVIDER WILL BE MADE ON A FUTURE SETTLEMENT
0108 N/C RADIOLOGY SERVICES DENTAL X-RAYS COVERED ONLY IF RELATED TO AN ACCIDENT
Dental X-rays covered only if related to an accident 52
0109 APPROVED UNITS EXCEEDED ADDITIONAL REIMBURSEMENT MAY BE AVAILABLE. PLEASE CONTACT THE MENTAL HEALTH VENDOR.
Additional reimbursement may be available. Please contact the mental health vendor
82
0110 NONCOVERED MACHINE TEST THIS MACHINE TEST IS NOT COVERED This machine test is not covered 320111 N/C MAINTENANCE THERAPY THESE MAINTENANCE THERAPY SERVICES ARE NOT
COVEREDThese maintenance therapy services are not covered 50
0112 EXCEEDS 3 VISITS PER WEEK THE MAXIMUM OF 3 VISITS PER WEEK HAS ALREADY BEEN REIMBURSED
The maximum of 3 visits per week has already been reimbursed 60
0113 INVALD DX FOR BENEFIT CONT THIS SERVICE IS NOT COVERED FOR THE CONDITION REPORTED
This service is not covered for the condition reported 54
0114 ECHO PREV PAID SAME PROV THIS SERVICE HAS BEEN PAID PREVIOUSLY TO THE SAME PROVIDER
This service has been paid previously to the same provider 58
0115 ECHO PREV PAID DIFF PROV SAME SERVICE WAS PAID PREVIOUSLY TO A DIFFERENT PROVIDER
Same service was paid previously to a different provider 56
0116 ECHO PARTS PRV PD SAME PRV PAYMENT REDUCED BECAUSE PART OF SERVICE HAS BEEN PREVIOUSLY PAID
Payment reduced because part of service has been previously paid 64
0117 ECHO PARTS PRV PD DIFF PRV SERVICE INCLUDED IN CLAIM PREVIOUSLY PAID TO ANOTHER PROVIDER
Service included in claim previously paid to another provider 61
0118 PLACE OF SERV NOT APPROVED SERVICE NOT COVERED IN THE PLACE WHERE IT WAS PERFORMED
Service not covered in the place where it was performed 55
0119 LIMITED TO 45 DAYS/CAL YR AMOUNT EXCEEDS CALENDAR YEAR MAXIMUM FOR MENTAL HEALTH SERVICES
Amount exceeds calendar year maximum for mental health services 63
0120 LIMITED TO 60 SVCS/LIFETIM THE LIMIT OF 60 SERVICES PER LIFETIME HAS BEEN PREVIOUSLY PAID
The limit of 60 services per lifetime has been previously paid 62
0121 DAY HOSP ADMISSION DENIED MENTAL HEALTH SERVICE DENIED WHEN DAY HOSPITAL STAY IS DENIED
Mental health service denied when day hospital stay is denied 61
0122 ACCOMODATIONS MAX EXCEEDED SERVICES NOT ALLOWED BECAUSE ROOM AND BOARD LIMIT HAS BEEN EXCEEDED
Services not allowed because room & board limit has been exceeded
65
0123 XRAY INCL IN PREV PD PROC THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470124 XRAY PREV PAID DIFF PROV PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY TO
ANOTHER PROVIDERPayment reduced by amount paid previously to another provider 61
0125 XRAY PTS PRV PAID SAME PRV PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY TO THE SAME PROVIDER
Payment reduced by amount paid previously to the same provider 62
0126 TOT LIAB PD TO ANOTHER PHY THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470127 INV PROV FOR HEMODIALYSIS PROVIDER IS NOT APPROVED FOR PAYMENT OF
HEMODIALYSIS SERVICESProvider is not approved for payment of hemodialysis services 61
0128 NEW/EXPER SVC NOT APPROVED NEW AND INVESTIGATIONAL PROCEDURES ARE NOT COVERED
New/experimental services not covered. Please refer to the exclusions section of your benefit documents
103
0129 NONCOVERED PSYCH SERVICE THIS SERVICE IS NOT COVERED BY PATIENT'S CONTRACT This service is not covered by your contract 44
0130 INVALID POS OR PROVIDER PROVIDER OR FACILITY IS NOT APPROVED FOR THIS SERVICE
Provider or facility is not approved for this service 53
0131 NO DAY HOSP ADM ON HIST SERVICE NOT COVERED IN THE PLACE WHERE IT WAS PERFORMED
Service not covered in the place where it was performed 55
0132 MULT PSYCH/MED SAME DAY MAXIMUM OF 1 MEDICAL AND/OR MENTAL HEALTH DAILY VISIT WAS PAID
Maximum of 1 medical and/or mental health daily visit was paid 62
0133 120 MAX DAYS/SVCS EXCEEDED Annual MAXIMUM OF 120 DAYS HAS BEEN EXCEEDED Annual maximum of 120 days has been exceeded 440134 PROV IDENT BILLING ERROR PROVIIDER REQUESTED RETRACTION OF CLAIM Provider indicated this claim was billed in error 490135 BRADLEY ADM NOT PD/DENIED BRADLEY HOSP MENTAL HEALTH SERVICES DENIED IF
ADMISSION NOT PAIDBradley Hosp mental health services denied if admission not paid 64
0136 ECT SVC PAID - DENY PSYCH ONLY 1 THERAPY PER DAY COVERED AND VISITS NOT COVERED ON SAME DAY
Only 1 therapy covered per day. Visits not covered on same day 62
0137 OTHER ECT,MED,PSYCH PAID MAXIMUM OF 1 THERAPY SERVICE HAS ALREADY BEEN PAID FOR THIS DATE
Maximum of 1 therapy service has already been paid for this date 64
0138 25% COPAY UP TO $1000 BENEFITS REDUCED BY 25% COPAY UP TO $1000 Benefits reduced by 25% copay up to $1000 410139 DENY SERVICE BY PAR ANESTH0140 $150IND/$300FAM CAL-YR CP PAYMENT HAS BEEN REDUCED BY CONTRACT COPAY
AMOUNTPayment has been reduced by contract copay amount 49
0141 NONCOVERED SUPPLIES CRUTCHES, CANES, AND COLLARS ARE NONCOVERED SUPPLIES
Crutches, canes, and collars are noncovered supplies 52
0142 DENY PSYCH/MED-CONSULTN PD A CONSULTATION SERVICE HAS BEEN PAID PREVIOUSLY A consultation service has been paid previously 47
0143 $250 DED PER ADMISSION A $250 DEDUCTIBLE IS APPLIED TO EACH ADMISSION A $250 deductible is applied to each admission 460144 PAY AVG SEMI-PVT RM RATE PAYMENT FOR PRIVATE ROOM BASED ON ALLOWANCE FOR
SEMI-PRIVATE ROOMPayment for private room based on allowance for semi-private room 65
0145 N/C UNQUAL/SPECIAL RM&BD NO PAYMENT FOR SPECIAL ROOM AND BOARD CHARGES No payment for special room and board services 46
0146 DENY 1ST 10 PT/OT CAL YR0147 INST/FLEX COINS APPLIED AN INPATIENT/OUTPATIENT INSTITUTIONAL DEDUCTIBLE
AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.
An inpatient/outpatient institutional deductible and a flex coinsurance has been applied to this service
104
0148 TREATMENT FEE ALL INCLUSIV THIS SERVICE IS PART OF A PREVIOUSLY PAID CLAIM This service is part of a previously paid claim 470149 UTILIZATION REVIEW DENIAL THESE SERVICES WERE REVIEWED AND DENIED AS
NONCOVEREDThese services were reviewed and denied as noncovered 53
0150 XRAY PARTS PAID SM/DIF PRV REDUCED BY AMOUNT PAID PREVIOUSLY TO SAME OR DIFFERENT PROVIDER
Reduced by amount paid previously to same or different provider 63
0151 DIAG NOT URGENT CARE THE CONDITION REPORTED DOES NOT MEET CRITERIA OF URGENT CARE
The condition reported does not meet criteria of urgent care 60
0152 MACHINE TEST PAID SM PROV PAYMENT FOR THIS SERVICE WAS MADE PREVIOUSLY TO SAME PROVIDER
Payment for this service was made previously to same provider 61
0153 MACH TESTS PD SM/DIFF PRV PAYMENT MADE PREVIOUSLY TO THE SAME OR DIFFERENT PROVIDER
Payment made previously to the same or different provider 57
0154 MACHINE TEST PD DIFF PROV SERVICE INCLUDED IN CLAIM PAID PREVIOUSLY TO DIFFERENT PROVIDER
Service included in claim paid previously to different provider 63
0155 ECHO PARTS PD SM/DIFF PROV REDUCED BY AMOUNT PAID PREVIOUSLY TO SAME OR DIFFERENT PROVIDER
Reduced by amount paid previously to same or different provider 63
0156 LIMIT 70 DAYS/CAL YR BENEFITS LIMITED TO 70 DAYS PER CALENDAR YEAR Benefits limited to 70 days per calendar year 450157 LIMIT 365 DAYS/CAL YR BENEFITS LIMITED TO 365 DAYS PER CALENDAR YEAR Benefits limited to 365 days per calendar year 460158 LIMIT 730 DAYS/CAL YR BENEFITS LIMITED TO 730 DAYS PER ADMISSION Benefits limited to 730 days per admission 420159 NO 2ND OP OR PREAUTH COPAYMENT APPLIED BECAUSE MANAGED BENEFITS
PROCEDURE WAS NOT FOLLOWEDCopayment applied because Managed Benefit procedures not followed
65
0160 $150 INDEMNITY CONTRACT PAYMENT BASED ON THE DOLLAR LIMIT DEFINED IN SUBSCRIBER'S CONTRACT
Payment was based on the dollar limit defined in your contract 62
0161 N/C HOSPICE ROOM AND BOARD HOSPICE ROOM & BOARD CHARGES ARE NOT COVERED Hospice room & board charges are not covered 440162 NO ABORTION COVERAGE SERVICE EXCLUDED BY THE EMPLOYER'S CONTRACT Service excluded by your employer's contract 440163 $150 MATERNITY MAXIMUM PAYMENT BASED ON THE DOLLAR LIMIT DEFINED IN
SUBSCRIBER'S CONTRACTPayment was based on the dollar limit defined in your contract 62
0164 NO COVERAGE FOR THIS SVC THESE SERVICES ARE NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT
This service is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents
119
0165 OTHER COM CARRIER PD PORTN PAYMENT REDUCED BY AMOUNT PAID BY OTHER HEALTH CARE COVERAGE
This is the amount paid by your primary coverage 48
0166 MEDICARE PD PORTION ALLOWANCE AFTER MEDICARE This is the amount paid by Medicare 350167 OTHER BLUE PD PORTION ALLOWANCE AFTER OTHER BLUE CROSS PLAN Allowance after other Blue Cross plan 370168 BILL OTHER CARRIER FIRST SUBSCRIBER'S OTHER INSURANCE COVERAGE SHOULD
PAY FIRSTThis claim needs to be processed by your other insurer before additional benefits under this coverage can be considered.
120
0169 SUBMIT TO MEDICARE FIRST FILE CLAIM WITH MEDICARE FIRST This claim needs to be processed by Medicare before additionalbenefits under this coverage can be considered.
109
0170 NO 2ND OP; PENALTY APPLIED PAYMENT REDUCED BECAUSE A SECOND OPINION WAS NOT OBTAINED
Payment reduced because a second opinion was not obtained 57
0171 INST COINS APPLIED AN INPATIENT/OUTPATIENT INSTITUTIONAL DEDUCTIBLE HAS BEEN APPLIED
An inpatient/outpatient institutional deductible has been applied 65
0172 EXCD 245 ADD MED/PSYCH DYS BENEFITS LIMITED TO 365 DAYS Benefits limited to 365 days 280173 UNLISTED PROCEDURE DENIED ADDITIONAL DOCUMENTATION NEEDED TO DETERMINE
COVERAGE FOR UNLISTED PROCEDURES.ADDITIONAL DOCUMENTATION NEEDED TO DETERMINE COVERAGE FOR UN- LISTED PROCEDURES
79
0174 EXCD 610 ADD MED/PSYCH DYS THE MAXIMUM NUMBER OF ALLOWED DAYS HAS BEEN EXCEEDED
The maximum number of allowed days has been exceeded 52
0175 $30 AND INST COINS APPLIED A $30 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE HAS BEEN APPLIED
A $30 copay and an inpatient/outpatient deductible has been applied
67
0176 EXCD 25 ADD PSY DY,SM ADM BENEFITS LIMITED TO 70 DAYS Benefits limited to 70 days 270177 $20 AND INST COINS APPLIED A $20 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE
HAS BEEN APPLIEDA $20 copay and an inpatient/outpatient deductible has been applied
67
0178 HEMO /MEDICAL SAME DAY MEDICAL CARE IS NOT COVERED ON SAME DAY AS HEMODIALYSIS
Medical care is not covered on same day as hemodialysis 55
0179 EXCD 75 ADD PSY DY,SM ADM BENEFITS LIMITED TO 120 DAYS Benefits limited to 120 days 280180 20% AND INST COINS APPLIED A 20% COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE
HAS BEEN APPLIED TOTHIS SERVICE0181 WHOLE MACH TEST PD SM PROV THIS SERVICE PREVIOUSLY BILLED BY AND PAID TO SAME
PROVIDERThis service previously billed by and paid to same provider 59
0182 WHOLE MACH TST PD DIFF PRV THIS SERVICE PREVIOUSLY BILLED BY AND PAID TO DIFFERENT PROVIDER
This service previously billed by and paid to different provider 64
0183 ROUTINE GENETIC SCREEN N/C ROUTINE GENETIC SCREENING IS NOT A COVERED SERVICE
Routine genetic screening is not a covered service 50
0184 NO INPAT STAY W/IN TIME RQ THERAPY NOT COVERED IF PATIENT WAS NOT HOSPITALIZED
Therapy not covered if patient was not hospitalized 51
0185 MEMBER NOT ELIGIBLE MEMBER IS NOT ELIGIBLE FOR SERVICE. Member is not eligible for service 340186 $30/INST/FLEX COINS APPL A $30 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE
AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE
A $30 copay and an inpatient/outpatient deductible and a flex coinsurance has been applied to this service
106
0187 $125 INDEMNITY CONTRACT BENEFITS LIMITED TO $125 PER DAY FOR ROOM AND BOARD
Benefits limited to $125 per day for room and board 51
0188 BLUECHIP PD PORTION ALLOWANCE AFTER BLUECHIP Allowance after BlueCHiP 240189 BOB-PRI PD PORTION ALLOWANCE AFTER PRIMARY COVERAGE This is the amount paid by your primary coverage. 490190 OTHER GOVT AGENCY PD ALLOWANCE AFTER GOVERNMENT AGENCY OTHER THAN
MEDICAREAllowance after government agency other than Medicare 53
0191 OTHER HMO PD PORTION ALLOWANCE AFTER HMO COVERAGE Allowance after HMO coverage 280192 $20/INST/FLEX COINS APPL A $20 COPAY AND AN INPATIENT/OUTPATIENT DEDUCTIBLE
AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE
A $20 copay and an inpatient/outpatient deductible ans a flex coinsurance has been applied to this service
106
0193 20%/INST/FLEX COINS APPL A 20% COINSURANCE AND AN INPATIENT/OUTPATIENT DEDUCTIBLE AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS SERVICE.
A 20% coinsurance and an inpatient/outpatient deductible and a flex coinsurance has been applied to this service
112
0194 FILE WITH BLUE CHIP CHARGES MUST FIRST BE FILED WITH BLUE CHIP Charges must first be filed with Blue CHiP 420195 FILE WITH HMO CHARGES MUST FIRST BE FILED WITH PATIENT'S PRIMARY
HMO COVERAGEThis claim need to be processed by the other insurer before additional benefits can be considered.
98
0196 FILE WITH OT BC PLAN CHARGES MUST FIRST BE FILED WITH PATIENT'S OTHER BLUE CROSS PLAN
This claim need to be processed by your other insurer before additional benefits can be considered.
99
0197 FILE WITH OT GOVT AGENCY CHARGES MUST FIRST BE FILED WITH THE FEDERAL AGENCY COVERING PATIENT
Charges must first be filed with the federal agency covering you 64
0198 N/C DUE TO WEEKEND ADMISSI PATIENT'S CONTRACT EXCLUDES ADMISSIONS OCCURRING ON THE WEEKEND
Your contract excludes admissions occurring on the weekend 58
0199 REDUCED BY PREV BENE ALLOW REDUCED BY AMOUNT PREVIOUSLY PAID Reduced by amount previously paid 330200 CHARGE 100% GT RI U/C BLUE CROSS/BLUE SHIELD MAXIMUM ALLOWANCE FOR
THIS SERVICEBlue Cross/Blue Shield maximum allowance for this service 57
0201 MAJOR MEDICAL LIABILITY SERVICES ARE BEING PROCESSED UNDER YOUR MAJOR MEDICAL CONTRACT
Services are being processed under your Major Medical contract 62
0202 ONE NEWBORN VISIT/LIFETIME ONLY ONE INITIAL NEWBORN EXAM IS ALLOWED IN PATIENT'S LIFETIME
Only one initial newborn exam is allowed in patient's lifetime 62
0203 N/C SERVICE FOR CONTRACT THIS SERVICE IS NOT A COVERED BENEFIT UNDER PATIENT'S CONTRACT
This service is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents
119
0204 ONE SERV ALLOWED PER DAY ONLY ONE OF THESE RADIOLOGY SERVICES IS ALLOWED PER DAY
Only one of these radiology services is allowed per day 55
0205 ONE SERV ALLOWED PER 7 DAY ONLY ONE OF THESE SERVICES COVERED DURING A SEVEN DAY PERIOD
Only one of these services covered during a seven day period 60
0206 ROUTINE SERVICES NON-COV BENEFITS NOT PROVIDED FOR ROUTINE SERVICES Benefits not provided for routine services 420207 PROV NOT AUTH FOR PROCEDUR THE PROVIDER IS NOT AUTHORIZED TO PERFORM THIS
SERVICEThis service has been denied. The provider is not authorized to perform this type of service. You are not responsible for the denied service
140
0208 TOTAL SVC PREVIOUSLY PAID THIS SERVICE WAS PREVIOUSLY PAID IN FULL This service was previously paid in full 400209 TOTAL SVC PAID DIFF PROV THIS SERVICE WAS PAID PREVIOUSLY TO A DIFFERENT
PROVIDERThis service was paid previously to a different provider 56
0210 MULT SVCS - PRICE REDUCED THIS IS THE MAXIMUM ALLOWANCE FOR SERVICES RENDERED
This is the maximum allowance for services rendered 51
0211 SUB NOT AUTH FOR HOME CARE PATIENT DOES NOT QUALIFY FOR MATERNITY HOME CARE Patient does not qualify for maternity home care 48
0212 ONE SVC ALLOWED/LIFETIME ONLY ONE SERVICE OF THIS TYPE IS ALLOWED IN PATIENT'S LIFETIME
Only one service of this type is allowed in patient's lifetime 62
0213 $20 AND FLEX COINS APPLIED A $20 COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS
A $20 copay and a flex coinsurance has been applied to this 59
0214 SURGERY INCL CONSULT FEE SURGEON'S CONSULTATION IS INCLUDED IN OUR ALLOWANCE FOR SURGERY
Surgeon's consultation is included in our allowance for surgery 63
0215 MULT CONSUL MUST BE OFFICE 2ND & 3RD OPINION CONSULTS ALLOWED WHEN PERFORMED IN MD'S OFFICE
2nd & 3rd opinion consults allowed when performed in MD's office 64
0216 MULT OPINION/SAME PROVIDER PAYMENT WILL BE MADE FOR ONLY ONE SECOND OPINION VISIT PER DOCTOR
Payment will be made for only one second opinion visit per doctor 65
0217 LIMIT 2 OPINIONS EXCEEDED CONTRACT COVERS 2 SECOND/THIRD OPINION CONSULTS WITHIN 6 MONTHS
Contract covers 2 second/third opinion consults within 6 months 63
0218 MUST BE SMOKE-FREE 1 YEAR PATIENT MUST BE SMOKE-FREE FOR AT LEAST ONE YEAR Patient must be smoke-free for at least one year 48
0219 CONSULT MUST BE INPATIENT OFFICE OR OUTPATIENT HOSPITAL CONSULTATIONS NOT COVERED
Office or outpatient hospital consultations not covered 55
0220 1 CONSULT PER SPECIALTY CONSULTATIONS LIMITED TO ONE PER PROVIDER SPECIALTY, PER ADMISSION
Consultations limited to one per provider specialty, per admission 66
0221 TREATMENT NOT W/IN 72 HRS TREATMENT MUST BE RECEIVED WITHIN 72 HOURS OF ACCIDENT
Treatment must be received within 72 hours of accident 54
0222 DIAG NOT TRAUMA RELATED SERVICE NOT COVERED WHEN CONDITION IS NOT RESULT OF TRAUMA
Service not covered when condition is not result of trauma 58
0223 SURGERY PAID - SAME CONDIT NONCOVERED SERVICE WHEN SURGERY PERFORMED BY SAME DOCTOR SAME DAY
Noncovered service when surgery performed by same doctor same day
65
0224 RELATED MED EMERGENCY PAID ONLY 1 RELATED MEDICAL EMERGENCY SERVICE IS COVERED ON SAME DAY
Only 1 related medical emergency service is covered on same day 63
0225 $30 AND FLEX COINS APPLIED A $30 COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS
A $30 copay and a flex coinsurance has been applied to this 59
0226 CONTRACEPTIVE SVC N/C CONTRACEPTIVE MANAGEMENT IS A NONCOVERED SERVICE
Contraceptive management is a noncovered service 48
0227 1 SVC PER 12 DAYS ONLY ONE OF THIS TYPE OF SERVICE COVERED DURING 12 DAY PERIOD
Only one of this type of service covered during 12 day period 61
0228 $100.00 DEDUCTIBLE APPLIED THIS AMOUNT WAS APPLIED TOWARD YOUR $100 DEDUCTIBLE
This amount was applied toward your $100 deductible 51
0229 NOT REFERRED BY VNA COLLECTION FEES FOR LABORATORY TESTS ARE NOT COVERED
Collection fees for laboratory tests are not covered 52
0230 GTT PREVIOUSLY PAID THIS SERVICE WAS INCLUDED IN A PREVIOUSLY PAID CLAIM
This service was included in a previously paid claim 52
0231 GLUCOSE PREVIOUSLY PAID PAYMENT REDUCED BY AMOUNT PAID PREVIOUSLY FOR RELATED TEST
Payment reduced by amount paid previously for related test 58
0232 NOT MED NECESSARY CONDIT THIS SERVICE IS NOT MEDICALLY NECESSARY FOR THE CONDITION REPORTED
This service is not medically necessary for the condition reported 66
0233 MORE THAN 4 SVCS SAME DOS EXCEEDS THE MAXIMUM OF 4 SERVICES PER DATE OF SERVICE
Exceeds the maximum of 4 services per date of service 53
0234 20% COPAY/FLEX COINS APP A 20% COPAY AND A FLEX COINSURANCE HAS BEEN APPLIED TO THIS
A 20% copay and a flex coinsurance has been applied to this 59
0235 HEMO/SURGERY ON SAME DAY HEMODIALYSIS NOT COVERED WHEN SURGERY PERFORMED ON SAME DAY
Hemodialysis not covered when surgery performed on same day 59
0236 DENTAL CONSULTANT DENIAL THIS SERVICE WAS REVIEWED AND DENIED This service was reviewed and denied 360237 > 10 VISITS UNDER AGE 3 EXCEEDS THE 10 PEDIATRIC PREVENTIVE VISITS ALLOWED
UNDER AGE 3Exceeds the 10 pediatric preventive visits allowed under age 3 62
0238 PART OF XRAY PROCEDURE SERVICES INCLUDED IN THE RELATED X-RAY PROCEDURE Services included in the related X-ray procedure 48
0239 NO LACERATION REP PERFORMD SERVICE REQUIRES RECORD OF LACERATION REPAIR Service requires record of laceration repair 440240 REMOVE SUTURES SAME PROV ALLOWANCE INCLUDES PLACING AND REMOVAL OF
STITCHESAllowance includes placing and removal of stitches 50
0241 MULT PROC SAME OPER FIELD ONLY ONE RELATED SURGICAL SERVICE IS COVERED ON THE SAME DAY.
Only one related surgical service is covered on the same day 60
0242 DIAG SURG PRIOR REL SURG DIAGNOSTIC SURGERY NOT COVERED WHEN SAME DAY AS MAJOR SURGERY
Diagnostic surgery not covered when same day as major surgery 61
0243 PER DIEM/CAP/FIXED FEE THE DOLLAR MAXIMUM FOR THIS SERVICE HAS BEEN MET This amount represents the maximum allowance for this type of service.
70
0244 its n/c anes per sub cont This procedure does not warrant services by an anesthesiologist per the subscribers contract.
0245 its no student cert There is no student certification on file for this member.0246 its predeterm req by prov Claim closed until predetermination has been obtained by the
Provider.0247 INCLUDED IN FRACTURE CARE ALLOWANCE FOR THIS SERVICE INCLUDED IN PAYMENT
FOR FRACTURE CAREAllowance for this service included in payment for fracture care 64
0248 its mat cov sub/spouse ITS - MATERNITY SERVICES ARE COVERED FOR THE SUBSCRIBER OR SPOUSE ONLY.
0249 DENY FRACTURE CARE NONCOVERED BECAUSE FRACTURE CARE PROVIDED WITHIN LAST 7 DAYS
Noncovered because fracture care provided within last 7 days 60
0250 its dental coverage only This subscriber has dental coverage only.0251 NOT BY ANESTHESIOLOGIST ANESTHESIA COVERED ONLY WHEN ADMINISTERED BY AN
ANESTHESIOLOGISTAnesthesia covered only when administered by an anesthesiologist 64
0252 its blue shield cov only This subscriber has Blue Shield coverage only.0253 ANESTHESIA SAME DAY PAYMENT FOR ANESTHESIA INCLUDES THIS SERVICE Payment for anesthesia includes this service 440254 its blue cross cov only This subscriber has Blue Cross coverage only.0255 UNITS EXCEEDED DOC REQ ADDITIONAL MEDICAL DOCUMENTATION IS NEEDED TO
ADJUDICATE THIS SERVICE.Additional medical documentation is needed to adjudicate this service.
70
0256 MEDICAL CARE IN HISTORY THIS SERVICE IS NOT COVERED IF MEDICAL CARE PAID ON SAME DAY
This service is not covered if medical care paid on same day 60
0257 ANCILLARY SERVICES DENIED CHARGES ASSOCIATED WITH NONCOVERED ROOM CHARGE ARE ALSO NONCOVERED
Charges associated with noncovered room charge are also noncovered
66
0258 DOC REVIEWED DENY APPROVED UNITS HAVE BEEN DETERMINED BASED ON SUBMITTED DOCUMENTATION.
Approved units have been determined based on submitted documentation
75
0259 ITS HOST - ANNUAL MAX MET MAXIMUM CALENDAR YEAR BENEFITS FOR THIS SERVICE HAVE BEEN MET.
Maximum calendar year benefits for this service have been met 61
0260 PROSTHESES ANCILL DENIED BENEFITS LIMITED TO INITIAL PROSTHESIS ONLY Benefits limited to initial prosthesis only 430261 PROVIDER NOT PEDIATRICIAN PHYSICIAN MUST BE PEDIATRICIAN TO PERFORM THIS
SERVICEPhysician must be pediatrician to perform this service 54
0262 ITS HOST - LIFETIME MAX EXCEEDS THE LIFETIME MAXIMUM FOR THESE SERVICES Exceeds the lifetime maximum for these services 47
0263 ITS HOST - PAYMENT MAX THE MAXIMUM BENEFITS HAVE BEEN PREVIOUSLY USED The maximum benefits have been previously used 46
0264 $300 DED PER ADMISSION PAYMENT REDUCED BY CONTRACT DEDUCTIBLE Payment reduced by contract deductible 380265 MORE THAN 1 INTL SNF VISIT ONLY 1 INITIAL VISIT BY PHYSICIAN PER ADMISSION TO
THIS FACILITYOnly 1 initial visit by physician per admission to this facility 64
0266 MORE THAN 2 SNF VISITS/WK MAXIMUM OF TWO SKILLED NURSING VISITS PER WEEK HAS BEEN PAID
Maximum of two visits per week has been paid 44
0267 EXCEEDED 30 DAYS SAME ADM BENEFITS LIMITED TO 30 DAYS FOR THE SAME ADMISSION Benefits limited to 30 days for the same admission 50
0268 DENY SNF;SURG SAME PRV,DAY VISIT IS INCLUDED IN THE SURGICAL ALLOWANCE Visit is included in the surgical allowance 430269 $35 DOLLAR COPAY A $35 DOLLAR COPAY HAS BEEN APPLIED TO THIS SERVICE. A $35 dollar copay has been applied to this service 51
0270 MORE THAN 1 INTL MED VISIT ONLY 1 INITIAL VISIT IS COVERED FOR EACH HOSPITAL ADMISSION
Only 1 initial visit is covered for each hospital admission 59
0271 1 FLLWUP MED VST ALLWD/DAY BENEFITS LIMITED TO ONE FOLLOW-UP VISIT PER DAY Benefits limited to one follow-up visit per day 470272 WAIVE $3 CP FRESHMAN CLASS Copay waived - Blueprint for Life - The Freshman class 540273 DENY MED SVC;ECT CVRD SMDY DOCTOR'S VISIT NONCOVERED IF ELECTROCONVULSIVE
THERAPY SAME DAYDoctor's visit noncovered if electroconvulsive therapy same day 63
0274 MED SVC PART OF DIAG SURG PAYMENT FOR DIAGNOSTIC SURGERY INCLUDES THESE MEDICAL VISITS
Payment for diagnostic surgery includes these medical visits 60
0275 DENY MED SVC;HEMO CVRD PAYMENT FOR HEMODIALYSIS INCLUDES THESE MEDICAL VISITS.
Payment for hemodialysis includes these medical visits 54
0276 DENY MED CARE WITH SURGERY PAYMENT FOR SURGERY INCLUDES THESE MEDICAL VISITS.
Payment for surgery includes these medical visits 49
0277 DENY MED;HM.SNF OR PSY CVR MEMBERSHIP DOES NOT PROVIDE BENEFITS FOR THIS PHYSICIAN'S HOSPITAL VISIT SINCE OTHER HOME CARE, MENTAL HEALTH CARE OR SKILLED NURSING FACILITY CARE WERE RENDERED TO THE PATIENT ON THE SAME DAY
Benefit limited to 1 visit per day 34
0278 FILE WITH MAJOR MEDICAL FILE WITH MAJOR MEDICAL Submit charges to Major Medical 310279 DENY MED-CONSULTATION CVRD BENEFITS NOT PROVIDED FOR THE PHYSICIAN'S FOLLOW-
UP VISITS TO THE HOSPITAL WHEN THE SAME PHYSICIAN FILED AND WAS PAID FOR CONSULTATION SERVICES DURING THE SAME PERIOD OF HOSPITALIZATION
Follow-up hospital visits by the consulting physician not covered 65
0280 NOT APPV MULTIPLE OPINION CRITERIA FOR SECOND OR THIRD OPINION CONSULTATION NOT MET
Criteria for second or third opinion consultation not met 57
0281 EXCEEDED 45 DAYS SAME ADM BENEFITS LIMITED TO 45 DAYS PER SAME ADMISSION Benefit limited to 45 days per same admission 450282 EXCEEDED 45 DAYS SAME CY BENEFITS LIMITED TO 45 DAYS PER CALENDAR YEAR Benefits limited to 45 days per calendar year 450283 WAIVE $5 CP FRESHMAN CLASS Copay waived - Blueprint for Life - The Freshman Class 540284 WAIVE $10 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540285 COSMETIC N/C BENEFITS ARE NOT PROVIDED FOR COSMETIC SERVICES Benefits are not provided for cosmetic services 47
0286 WAIVE $15 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540287 WAIVE $20 CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540288 N/C SEX TRANS/DYSFUN/INADJ SEXUAL DYSFUNCTION OR SEX CHANGE PROCEDURES ARE
NOT COVEREDSexual dysfunction or sex change procedures are not covered 59
0289 INP ALCOHOL DETOX-DENY SVC THE BENEFIT MAXIMUM OF 21 DAYS HAS BEEN PREVIOUSLY USED
The benefit maximum of 21 days has been previously used 55
0290 INP ALC REHAB 30 DAY MAX 30 DAY CALENDAR YEAR MAXIMUM FOR REHABILITATION HAS BEEN MET
30 day calendar year maximum for rehabilitation has been met 60
0291 OUT OF STATE PROVIDER N/C PROVIDER IS NOT APPROVED BY THE CORPORATION FOR COVERAGE
Provider is not approved by the Corporation for coverage 56
0292 WAIVE 20% CP FRESHMAN CLAS Copay waived - Blueprint for Life - The Freshman Class 540293 HOME CARE N/C SAME DAY MED HOME CARE IS NOT COVERED WHEN PATIENT IS IN
HOSPITAL ON SAME DAYHome care is not covered when patient is in hospital on same day 64
0294 LIMITED TO 6 SVCS PER 30DY THE MAXIMUM OF 6 VISITS PER 30 DAYS HAS BEEN MET The maximum of 6 visits per 30 days has been met 480295 PREEXISTING CONDITION CONDITIONS WHICH EXISTED PRIOR TO ENROLLMENT ARE
NOT COVEREDConditions which existed prior to enrollment are not covered 60
0296 $50 DED FOR MAT SVC A $50 DEDUCTIBLE IS APPLIED TO THESE MATERNITY SERVICES
A $50 deductible is applied to these maternity services 55
0297 90% CHARGE THIS IS THE MAXIMUM ALLOWANCE FOR THIS SERVICE This is the maximum allowance for this service 460298 SINGLE OB, NOT COVERED THESE MATERNITY BENEFITS ARE NOT PROVIDED UNDER
PATIENT'S CONTRACTThese maternity benefits are not provided under your contract 61
0299 ALC REHAB 90DAY LIFE MAX THE MAXIMUM OF 90 DAYS PER LIFETIME HAS BEEN MET The maximum of 90 days per lifetime has been met 48
0300 SVC N/C DUE TO LATE DUES WHEN THESE SERVICES WERE RENDERED, THERE WAS A LAPSE IN THE SUBSCRIBER'S COVERAGE; THEREFORE, THE SERVICES WERE DENIED. PLEASE HAVE THE SUBSCRIBER CONTACT OUR OFFICE
Services noncovered because your payment for coverage was overdue
65
0301 SIU REVIEW; NON-COV SVCS BASED ON INFORMATION PROVIDED, SERVICE DETERMINED TO BE NON-COVERED
Based on information provided, service determined to be non-covered
73
0302 DENY CRITCARE;MED RVW DONE THIS CRITICAL CARE WAS REVIEWED AND IS NOT COVERED This critical care was reviewed and is not covered 50
0303 NOT COVERED FOR PROVIDER SERVICE NOT COVERED FOR PROVIDER. Payment for this service is not available when billed by this type of provider
78
0304 BENEFIT NOT APPROVED SERVICE HAS NOT BEEN APPROVED FOR COVERAGE BY THE CORPORATION
Service has not been approved for coverage by the Corporation 61
0305 BENEFIT NOT COVERED BENEFITS FOR THIS SERVICE ARE NOT COVERED Benefits for this service are not covered 410306 20% CP $10 WAIVED FROSH Out of network COPAY applied - dollar COPAY waived -
Blueprintfor Life - the Freshman Class91
0307 20%CP APP $15 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of network COPAY applied - dollar COPAY waived - Blueprint for Life - the Freshman class
92
0308 20%CP APP $5 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived - Blueprint for Life - the Freshman class
92
0309 30%CP APP $15 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived - Blieprint for Life - the Freshman class
92
0310 DENY CONSULT PSYCH PAID THIS CONSULTATION WAS REVIEWED AND DENIED This consultation was reviewed and denied 410311 CLINIC/OV SAME DOS CLINIC VISIT NOT COVERED WHEN OFFICE VISIT PAID FOR
SAME DATEClinic visit not covered when office visit paid for same date 61
0312 PRICE AT 60% OF CHARGE Amount is the maximum allowed for a non-participating provider 620313 35%CP APP $20 WAIVED FROSH NOT CURRENTLY ASSIGNED Out of Network COPAY applied - Dollar COPAY waived -
Blueprintfor Life - the Freahman class91
0314 PROV N/C FOR CHEMO DAY SVC PROVIDER IS NOT APPROVED FOR THIS SERVICE Provider is not approved for this service 410315 POS N/C FOR CHEMO DAY SVC CHEMOTHERAPY DAY HOSPITAL CARE MUST BE DONE ON
OUTPATIENT BASISChemotherapy day hospital care must be done on outpatient basis 63
0316 CHEMO DAY HOSP SVC NOT APP DOCTOR'S CHARGE NOT COVERED IF OUTPATIENT HOSPITAL CHARGES DENIED
Doctor's charge not covered if outpatient hospital charges denied 65
0317 DIAG N/C FOR CONSULTATIONS NEWBORN WELL-BABY CARE CONSULTATIONS ARE NOT COVERED
Newborn well-baby care consultations are not covered 52
0318 PRICE AT 93% OF CHARGE THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0319 NOT COV FOR SPECIALTY CODE SERVICES NOT COVERED WHEN PROVIDER HAS THIS TYPE OF SPECIALTY
Services not covered when provider has this type of specialty 61
0320 0% COPAY - SYSTEM USE ONLY0321 place of svc not appro THESE SUPPLIES WERE DENIED AS THEY WERE NOT USED
IN THE APPROPRIATE SETTINGThese supplies were denied as they were not used in the appropriate setting
75
0322 ROUTINE FOOT CARE N/C SVC ROUTINE FOOT CARE IS NOT COVERED UNDER SUBSCRIBER'S CONTRACT
This service was denied as routine foot care is not a covered benefit under your plan. Please refer to the exclusions section of your benefit documents
151
0323 BASIC PAID-COVER REDUCE NO ADDITIONAL BENEFITS PROVIDED BEYOND THOSE UNDER BASIC CONTRACT
This amount is the maximum payment under your Basic coverage. The balance has been processed under your Major Medical coverage
127
0324 SUBSTANCE ABUSE LIFE MAX THE LIFETIME MAXIMUM FOR THESE SERVICES HAS BEEN EXCEEDED
The lifetime maximum for these services has been exceeded 57
0325 TREATMENT ORDER REQUIRED SERVICES NONCOVERED AS TREATMENT ORDER NOT SUBMITTED BY PROVIDER
Services noncovered as treatment order not submitted by provider 64
0326 LIMIT 1 PER 3 CAL YRS LIMIT 1 GLUCOSE MONITOR PER 3 CAL YRS Limit 1 Glucose Monitor per 3 cal yrs 370327 NON-COVERED NURSING SVC NURSING CARE MUST BE PROVIDED BY A REGISTERED OR
LICENSED PRACTICAL NURSE.Nursing care must be provided by a registered or licensed practical nurse
77
0328 7 SVCS PER CALENDAR YEAR MAXIMUM OF 7 INTENSIVE MENTAL HEALTH SESSIONS PER ADMISSION
Maximum of 7 intensive mental health sessions per admission 59
0329 16 SVCS PER CALENDAR YEAR MAXIMUM OF 16 MODERATE MENTAL HEALTH SESSIONS PER ADMISSION
Maximum of 16 moderate mental health sessions per admission 59
0330 N/C SAME DAY CHEMOTHERAPY EMERGENCY MEDICAL SERVICES NONCOVERED SAME DAY AS CHEMOTHERAPY
Emergency medical services noncovered same day as chemotherapy
62
0331 $8 INDEMNITY CONTRACT AMOUNT REFLECTS THE CONTRACT MAXIMUM BENEFIT OF $8 PER DAY
Amount reflects the contract maximum benefit of $8 per day 58
0332 $11 INDEMNITY CONTRACT AMOUNT REFLECTS THE CONTRACT MAXIMUM BENEFIT OF $11 PER DAY
Amount reflects the contract maximum benefit of $11 per day 59
0333 $14 INDEMNITY CONTRACT AMOUNT REFLECTS THE CONTRACT MAXIMUM BENEFIT OF $14 PER DAY
Amount reflects the contract maximum benefit of $14 per day 59
0334 $20 INDEMNITY CONTRACT AMOUNT REFLECTS THE CONTRACT MAXIMUM BENEFIT OF $20 PER DAY
Amount reflects the contract maximum benefit of $20 per day 59
0335 N/C SERVICE THIS SERVICE IS NOT COVERED This service is not covered 270336 20% + $15 NPAR/AFFIL COPAY A 20% AND $15 COPAY FOR NON-PARTICIPATING OR
AFFILIATE PROVIDERA 20% and $15 copay for non-participating or affiliate provider 63
0337 $700 MAX PER CAL-YR OUTPATIENT MENTAL HEALTH LIMITED TO $700 PER CALENDAR YEAR
Outpatient mental health limited to $700 per calendar year 58
0338 N/C ELECTRO-SHOCK THERAPY ELECTROCONVULSIVE THERAPY REVIEWED AND DETERMINED TO BE NONCOVERED
Electroconvulsive therapy reviewed and determined to be noncovered
66
0339 INVALID PROVIDER FOR HSC PROVIDER NOT APPROVED BY THE CORPORATION FOR THIS SERVICE
Provider not approved by the Corporation for this service 57
0340 1 ROUTINE VISIT PER YEAR ONLY 1 PEDIATRIC CARE ROUTINE VISIT ALLOWED PER CALENDAR YEAR
Only 1 pediatric care routine visit allowed per calendar year 61
0341 PREEMPLOYMENT SVC N/C PRE-EMPLOYMENT SCREENING IS NOT A COVERED SERVICE
Pre-employment screening is not a covered service 49
0342 INC IN SURG ALLOWANCE THIS SERVICE WAS INCLUDED IN THE SURGICAL ALLOWANCE
This service was included in the surgical allowance 51
0343 INCL IN DELIVERY ALLOW THESE CHARGES ARE INCLUDED IN THE ALLOWANCE FOR THE DELIVERY
These charges are included in the allowance for the delivery 60
0344 ONLY MDS + DOS COVERED A MEDICAL OR OSTEOPATHIC DOCTOR MUST PERFORM THESE SERVICES
A medical or osteopathic doctor must perform these services 59
0345 NOT VALID PLACE OF SERVICE SERVICE MUST BE PERFORMED IN HOME, OFFICE OR OUTPATIENT HOSPITAL
Service must be performed in home, office or outpatient hospital 64
0346 MEDICARE ASSIGNED CLAIM MEDICARE ASSIGNED CLAIM Medicare assigned claim 230347 $25 DEDUCTIBLE PER ADM THIS SERVICE REQUIRES A $25 DEDUCTIBLE PER
ADMISSION.This service requires a $25 deductible per admission 52
0348 FILE W/HOME MHSA VENDOR NOT CURRENTLY ASSIGNED Provider will file claim directly to MHSA vendor 480349 NON-PAR PROVIDER N/C No coverage is provided as the services were rendered by a non-
participating provider without prior authorization113
0350 20% NON-PAR/NON-NTWK COPAY This amount represents your out-of-network coinsurance. You are responsible to pay your provider directly
106
0351 INELIGIBLE DEPENDENT PATIENT IS NOT COVERED UNDER THE SUBSCRIBER'S CONTRACT
You are not covered under the subscriber's contract 51
0352 NO BIOPSY IN HISTORY THIS SERVICE REQUIRES A NEEDLE BIOPSY. This service requires a needle biopsy. 380353 PROVIDER MUST SUBMIT CLAIM Provider must submit this claim for reimbursement 490354 EXCEEDED 30 DAYS SAME YR BENEFIT MAXIMUM OF 30 SERVICES PER YEAR HAS BEEN
EXHAUSTEDBenefit maximum of 30 services per year has been exhausted 58
0355 FEE REDUCTION APPLIED FEE REDUCTION APPLIED FOR N/I NON-RISK PROVIDER0356 N/C SVC WHEN WITH N/C SURG SERVICE NOT COVERED WHEN PERFORMED WITH A
NONCOVERED SURGERYService not covered when performed with a noncovered surgery 60
0357 ADJUSTMENT BY VENDOR ADJUSTMENT BY VENDOR Adjustment by vendor 200358 $20,000 PSYCH LIFETIME MAX LIFETIME MENTAL HEALTH MAXIMUM OF $20,000 HAS BEEN
METLifetime mental health maximum of $20,000 has been met 54
0359 DENIED BY VENDOR DENIED BY VENDOR Denied by vendor 160360 TOTAL PURCHASE PRICE PAID THE TOTAL PURCHASE PRICE HAS BEEN PAID The total purchase price has been paid 380361 MANUAL DENY CLAIM NOT PROCESSED THROUGH AUTOMATED SYSTEM
WAS MANUALLY DENIEDClaim not processed through automated system was manually denied
64
0362 RI MAXIMUM ALLOWANCE THIS IS THE RI MAXIMUM ALLOWANCE This is the RI maximum allowance 320363 PAYMENT BY VENDOR PAYMENT BY VENDOR Payment by vendor 170364 INVALID POS FOR HSC SERVICE NOT COVERED IN THE PLACE WHERE IT WAS
PERFORMEDService not covered in the place where it was performed 55
0365 FILED UNDER INCORRECT CODE PROVIDER MUST FILE SERVICE UNDER CORRECT HEALTH SERVICE CODE
Your provider must re-file this claim using the correct billing code(s) 71
0366 TUBAL/DELIVERY REDUCTION REDUCED IF TUBAL LIGATION DONE ON SAME DAY AS DELIVERY
Reduced if tubal ligation done on same day as delivery 54
0367 SWAN GANTZ/ANEST REDUCTN ANESTHESIA ALLOWED IN FULL; SWAN GANTZ PROCEDURE ALLOWED AT 50%
This is the maximum allowance for services rendered 51
0368 PEDI PILOT PGM DISCONTINUE AFTER HOURS VISITS ARE NO LONGER COVERED After hours visits are no longer covered 400369 THORACIC HERNIA/GB/VAG RED REDUCED IF VAGINAL/GALLBLADDER SURGERY SAME DAY
AS HERNIA REPAIR.This service was included in the surgical allowance 51
0370 GASTRIC SURG REDUCTION REDUCED IF GASTROINTESTINAL SURGERY ON SAME DAY AS STOMACH OPERATION.
This service was included in the surgical allowance 51
0371 SURG-ADM REDUCE / DENY REDUCED/DENIED IF MULTIPLE SURGICAL PROCEDURES AT SAME BODY SITE
This service was included in the surgical allowance 51
0372 TREATMENT NOT W/IN 24 HRS TREATMENT RECEIVED MORE THAN 24 HOURS FROM ONSET OF CONDITION
Treatment received more than 24 hours from onset of condition 61
0373 REDUCED BY SVC PREV PD PAYMENT REDUCED BY AMOUNT PREVIOUSLY PAID Payment reduced by amount previously paid 410374 INCLUDED IN SVC PREV PD THIS SERVICE WAS INCLUDED IN A PREVIOUSLY PAID
SERVICEPayment to the provider for this amount is included in another charge
69
0375 $3.00 COPAY A $3 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES A $3 copayment has been applied to these services 49
0376 $5.00 COPAY A $5 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES This amount represents your $5 copayment. You are responsible to pay you provider directly
91
0377 $10.00 COPAY A $10 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES This amount represents your $10 copayment. You are responsible to pay your provider directly
93
0378 DEPENDENT NOT COV FOR SVC DEPENDENT NOT COVERED FOR THIS SERVICE UNDER THIS CONTRACT
Dependent not covered for this service under this contract 58
0379 1 ROUTINE PAP SMR / CAL-YR LIMIT OF 1 ROUTINE PAP SMEAR PER YEAR HAS BEEN PREVIOUSLY PAID
Limit of 1 routine pap smear per year has been previously paid 62
0380 SUB MUST SUBMIT CLAIM SUBSCRIBER MUST SUBMIT THIS CLAIM FOR REIMBURSEMENT
Subscriber must submit this claim for reimbursement 51
0381 N/C PLAN65 BENEFIT BENEFITS FOR SERVICES NOT PROVIDED UNDER YOUR PLAN 65 CONTRACT
Benefits for services not provided under your Plan 65 contract 62
0382 COPAY APPLIED COPAY APPLIED Copay applied 130383 ONLY IP DENTAL COVERED OUTPATIENT DENTAL SERVICES ARE NOT COVERED UNDER
THIS CONTRACTOutpatient dental services are not covered under this contract 62
0384 EXCEED 365 DYS/SVCS SM ADM BENEFIT MAXIMUM OF 365 DAYS PER ADMISSION HAS BEEN MET
Benefit maximum of 365 days per admission has been met 54
0385 PRICE AT FEE SCHEDULE PRICE AT FEE SCHEDULE Price at Fee schedule 210386 EXCEEDED 60 DAYS SAME ADM BENEFIT MAXIMUM OF 60 DAYS PER ADMISSION HAS BEEN
METBenefit maximum of 60 days per admission has been met 53
0387 EXCEED 60 DAYS SAME CAL-YR BENEFIT MAXIMUM OF 60 DAYS PER CALENDAR YEAR HAS BEEN MET
Benefit maximum of 60 days per calendar year has been met 57
0388 DETERMINED FRAUD & ABUSE AFTER REVIEW, THIS CLAIM HAS BEEN DETERMINED TO BE NON-COVERED DUE TO FRAUD/ABUSE.
After review, this claim has been determined to be non-covereddue to fraud/abuse
80
0389 LIMIT 21 SVCS PER CAL-YR MAXIMUM OF 21 SERVICES PER CALENDAR YEAR HAS BEEN MET.
Maximum of 21 services per calendar year has been met 53
0390 $25 DEDUCT PER CAL-YR THIS AMOUNT REDUCED BY $25 CALENDAR YEAR DEDUCTIBLE
This amount reduced by $25 calendar year deductible 51
0391 RI MAX ALLOW THIS IS THE RI MAXIMUM ALLOWANCE This is the RI maximum allowance 320392 DEDUCTIBLE APPLIED PAYMENT APPLIED OR REDUCED TOWARDS PLAN YEAR
DEDUCTIBLEPayment applied or reduced towards plan year deductible 55
0393 $200 DEDUCT PER ADMISSION A $200 DEDUCTIBLE IS APPLIED PER ADMISSION A $200 deductible is applied per admission 420394 $150 CAL-YEAR MAXIMUM AMOUNT REFLECTS THE $150 CALENDAR YEAR BENEFIT
MAXIMUMAmount reflects the $150 calendar year benefit maximum 54
0395 $200 PENALTY FOR NO PAT COPAYMENT APPLIED BECAUSE PRE-ADMISSION TESTING WAS NOT PERFORMED
Copayment applied because pre-admission testing was not performed
65
0396 DEDUCT APPLIED BY VENDOR DEDUCT APPLIED BY VENDOR Deduct applied by vendor 240397 $550 MAX CAL-YR PSYCH DAY AMOUNT REFLECTS THE $550 CALENDAR YEAR BENEFIT
MAXIMUMAmount reflects the $550 calendar year benefit maximum 54
0398 MULTIPLE ECT ON SAME DAY MORE THAN 1 ELECTROCONVULSIVE THERAPY SESSION ON SAME DAY DENIED
More than 1 electroconvulsive therapy session on same day denied 64
0399 HOME RECIP CLAIM PAID CLAIM PAID BY RECIPROCAL AGREEMENT WITH ANOTHER BLUE CROSS PLAN
Claim paid by reciprocal agreement with another Blue Cross plan 63
0400 TREATMENT NOT W/IN 48 HRS TREATMENT RECEIVED MORE THAN 48 HOURS FROM ONSET OF CONDITION
Treatment received more than 48 hours from onset of condition 61
0401 $100 MAX PER 12 MONTHS BENEFITS LIMITED TO $100 FOR LESIONS, WARTS AND JOINT INJECTIONS
Benefits limited to $100 for lesions, warts and joint injections 64
0402 ER TRIAGE PAYMENT IN FULL RITE CARE ER TRIAGE - PAYMENT IN FULL ER triage payment in full 250403 $1000 DEDUCTIBLE APPLIED PAYMENT REDUCED BY THE $1000 DEDUCTIBLE AMOUNT Payment reduced by the $1000 deductible amount 46
0404 $15,000 PSYCH LIFETIME MAX AMOUNT REFLECTS THE $15,000 LIFETIME BENEFIT MAXIMUM
Amount reflects the $15,000 lifetime benefit maximum 52
0405 $100I/$200F CAL YR DED PAYMENT REDUCED BY CALENDAR YEAR DEDUCTIBLE Payment reduced by calendar year deductible 430406 SVC PREV PAID TO INST PROV PHYSICIAN PAYMENT FOR HEMODIALYSIS INCLUDED IN
FACILITY PAYMENTPhysician service for hemodialysis included in facility payment 63
0407 PENALTY: NO PRECERT & PAT BENEFITS REDUCED BECAUSE MANAGED BENEFITS REQUIREMENTS NOT MET
Benefits reduced because Managed Benefits requirements not met 62
0408 $546 MAX PER CAL YR AMOUNT REFLECTS THE CALENDAR YEAR MAXIMUM OF $546 FOR HEMODIALYSIS
Amount reflects the calendar year maximum of $546 for hemodialysis
66
0409 NOT SEP REIMBURSED THIS SERVICE IS NOT A SEPARATELY REIMBURSED SERVICE WHEN RENDERED BY A PARTICIPATING PROVIDER
Payment to the provider for this amount is included in another charge
69
0410 $25 DEDUCT PER E.R. VISIT PAYMENT REDUCED BY $25 COPAYMENT FOR EMERGENCY ROOM VISIT
Payment reduced by $25 copayment for emergency room visit 57
0411 $3 CP NO GENERIC AVAILABLE A $3 COPAY IS APPLIED BECAUSE THE GENERIC DRUG WAS NOT AVAILABLE
A $3 copay is applied because the generic drug was not available 64
0412 25% COPAY THE 25% COPAYMENT FOR THIS SERVICE IS PATIENT'S RESPONSIBILITY
The 25% copayment for this service is your responsibility 57
0413 1ST YEAR ENROLLED N/C THIS ILLNESS/INJURY IS NON-COVERED SINCE IT OCCURRED PRIOR TO MEMBER'SEFFECTIVE DATE AND THE WAITING PERIOD HAS NOT BEEN MET.
0414 $1000 MAX HAS BEEN MET AMOUNT REFLECTS THE $1000 MAXIMUM BENEFIT FOR THESE SERVICES
Amount reflects the $1000 maximum benefit for these services 60
0415 FILED TRADITIONAL S/B POS CLAIM WAS SUBMITTED UNDER TRADITIONAL BLUECARD PROCESSING, BUT SHOULD BE SUBMITTED UNDER BLUECARD POINT OF SERVICE PROCESSING.
0416 $374 MAX PER CAL YR AMOUNT REFLECTS THE MAXIMUM BENEFIT OF $374 FOR DIALYSIS
Amount reflects the maximum benefit of $374 for dialysis 56
0417 WEEKEND ADM REDUCTION WEEKEND ADMISSION TO HOSPITAL IS REDUCED UNDER THIS CONTRACT
Weekend admission to hospital is reduced under your contract 60
0418 FILED POS MBR NOT ENROLLED CLAIM WAS SUBMITTED UNDER BLUECARD POINT OF SERVICE PROCESSING, BUT MEMBER IS NOT ENROLLED UNDER THAT NETWORK.
0419 INCLUDE IN ANESTHESIA THIS SERVICE IS INCLUDED IN THE ANESTHESIA PAYMENT AND IS NON-BILLABLE TO THE SUBSCRIBER
This service is included the anesthesia payment 47
0420 30% NPAR COPAY A 30% NON-PARTICIPATING PROVIDER COPAY HAS BEEN APPLIED
A 30% non-participating provider copay has been applied 55
0421 TRAUMA SAME DAY INITIAL ACCIDENT ROOM VISIT WAS PAID; FOLLOW-UP VISITS NOT COVERED
Initial accident room visit was paid; follow-up visits not covered 66
0422 INSUFF INFO TO DET ER COV INSUFFICIENT INFORMATION TO DETERMINE COVERAGE FOR EMERGENCY ROOM SERVICE
Insufficient information to determine coverage for emergency room service
73
0423 NOT WITHIN PEDI TIMEFRAME THIS SERVICE WAS NOT PERFORMED WITHIN THE DESIGNATED HOURS
This service was not performed within the designated hours 58
0424 PART OF TRANSPLANT NETWORK CLAIM SHOULD BE SUBMITTED UNDER THE EXISTING TRANSPLANT NETWORK.
0425 CLAIMS DIRECTOR DENIAL SERVICE IS A NONCOVERED THERAPY FOR PLACE OF SERVICE
Service is a noncovered therapy for place of service 52
0426 TOTAL LIAB MET BY MASS BC TOTAL PAYMENT FOR THESE CHARGES MADE BY BC/BS OF MASSACHUSETTS
Total payment for these charges made by BC/BS of Massachusetts 62
0427 MXC 193 PLUS CONTRACT RED THE TOTAL NUMBER OF INPATIENT DAYS EXHAUSTED UNDER YOUR CONTRACT
The total number of inpatient days exhausted under your contract 64
0428 CAROTID SURG REQ/DIAG NC DIAGNOSIS IS NOT COVERED OR CAROTID SURGERY NOT FILED PREVIOUSLY
Diagnosis is not covered or carotid surgery not filed previously 64
0429 ASSISTANT SURGEON N/C ASSISTANT SURGEON SERVICES NOT WARRANTED FOR THIS PROCEDURE.
0430 WRONG PROVIDER PAID (ADJ) Original payment sent to incorrect provider This is a claim adjustment. The original claim payment was not sent to the appropriate provider
96
0431 $50 CAL YR DED A $50 CALENDAR YEAR DEDUCTIBLE HAS BEEN APPLIED TO THIS SERVICE
A $50 calendar year deductible has been applied to this service 63
0432 NO LEGAL OBLIGATION PATIENT IS UNDER NO LEGAL OBLIGATION FOR THIS SERVICE
Patient is under no legal obligation for this service 53
0433 NON-BILLABLE LAB SVC THE LAB SERVICE RENDERED IS NON-BILLABLE AND THE PATIENT IS NOT RESPONSIBLE FOR THE CHARGE.
Payment to the provider for this amount is included in another charge
69
0434 1 PAIR LENSES PER YEAR MAXIMUM OF 1 PAIR OF LENSES PER YEAR HAS BEEN PAID PREVIOUSLY
This pair of lenses was denied as you exceeded your benefit limit of 1 service per calendar year
96
0435 ORTHOPEDIC SHOES N/C ORTHOPEDIC SHOES ARE NOT COVERED UNDER YOUR CONTRACT
Orthopedic shoes are not covered under your contract 52
0436 ONLY OPTH/OPT COV ONLY OPTHALMOLOGISTS AND OPTOMETRISTS ARE PAID FOR THIS SERVICE
Only opthalmologists and optometrists are paid for this service 63
0437 $4 COPAY APPLIED A $4 COPAYMENT HAS BEEN APPLIED TO THESE SERVICES A $4 copayment has been applied to these services 49
0438 DATABASE RETRY ERROR0439 NONCOVERED HEMODIALYSIS THIS PARTICULAR HEMODIALYSIS SERVICE IS NOT
COVERED BY YOUR PLANThis particular hemodialysis service is not covered by your plan 64
0440 MEDISPAN FILE ERROR0441 SVC NOT W/IN PROV CONTRACT THIS SERVICE DOES NOT MEET THE CONTRACTUAL
GUIDELINES AND THE PATIENT IS NOT RESPONSIBLE FOR THE CHARGE.
Payment to the provider for this amount is included in anothercharge. You are not responsible for the charge
109
0442 COMBINED W/SUBSEQUENT LINE PAYMENT FOR OTHER SERVICES INCLUDES PAYMENT FOR THIS SERVICE
Payment for other services includes payment for this service 60
0443 DISPENSING FEE NOT COVERED THE DISPENSING FEE IS A NONCOVERED SERVICE The dispensing fee is your responsibility 410444 IC PRICING AMOUNT REFLECTS THE MAXIMUM ALLOWANCE AFTER
INDIVIDUAL REVIEWAmount reflects the maximum allowance after individual review 61
0445 N/C STATE OF RI THE STATE CONTRACT HAS EXCLUDED COVERAGE FOR THIS SERVICE
The State contract has excluded coverage for this service 57
0446 SPECIAL FEATURES N/C LENSES AND/OR SPECIAL FEATURES ADDED TO GLASSES ARE NOT COVERED
Lenses and/or special features added to glasses are not covered 63
0447 NON-PPO VISION MAX ALLOW AMOUNT REFLECTS MAXIMUM ALLOWANCE FOR NON-PARTICIPATING PROVIDER
Amount reflects maximum allowance for non-participating provider 64
0448 VISION PPO MAX ALLOWANCE AMOUNT REFLECTS MAXIMUM ALLOWANCE COVERED BY THE CONTRACT
Amount reflects maximum allowance covered by the contract 57
0449 MEMBER ELIG. DENIAL MEMBER ELIG. DENIAL Member eligibility denial 250450 INCLUSIVE CODE IN HISTORY PAYMENT FOR THIS SERVICE IS INCLUDED IN A PREVIOUS
CLAIMA claim for these services has been previously submitted and processed
70
0451 SVC REQ SAME DAY ER/ACC RM SERVICES MUST BE PERFORMED ON SAME DAY AS EMERGENCY ROOM CHARGES
Services must be performed on same day as emergency room charges
64
0452 DATABASE RETRY ERROR0453 MEDISPAN FILE ERROR0454 DATE CONVERSION ERROR0455 20% COPAY 20% PATIENT COPAYMENT APPLIED TO THIS SERVICE This amount represents your coinsurance. You are responsible to
pay your provider directly90
0456 DME N/C AFTER 3 MONTHS RENTAL OF NERVE STIMULATORS LIMITED TO 3 MONTHS Rental of nerve stimulators limited to 3 months 470457 SUBMIT TO MEDICARE (DIS) PLEASE FILE DISABILITY ACCOUNTS WITH MEDICARE FIRST Please file disability accounts with Medicare first 51
0458 $500 DED/NO CONS. IN HIST A $500 COPAYMENT APPLIED IF INITIAL CONSULTATION WAS NOT OBTAINED
A $500 copayment applied if initial consultation was not obtained 65
0459 NO BIOPSY IN HIST/DIAG N/C THIS DIAGNOSIS IS NOT APPROVED OR THERE IS NO BIOPSY IN HISTORY
This diagnosis is not approved or there is no biopsy in hist 60
0460 NOT USED SUBROGATION SAVGS NOT CURRENTLY ASSIGNED Not currently assigned 220461 SUBROGATION RECOVERY SUBROGATION RECOVERY Subrogation Recovery 200462 MULT PROV SAME DAY SURG N/ MULTIPLE SURGERIES BY DIFFERENT PROVIDERS ON SAME
DAY NONCOVEREDMultiple surgeries by different providers on same day noncovered 64
0463 INV DIAG FOR THIS SVC SERVICE IS NOT COVERED FOR THE CONDITION REPORTED Service is not covered for the condition reported 49
0464 PRICE AT 80% OF CHARGE NON-PARTICIPATING FACILITY PAID AT 80% OF MAXIMUM ALLOWANCE
Non-participating facility paid at 80% of maximum allowance 59
0465 DATE CONVERSION ERROR0466 VOID ADJUSTMENT-WRONG ADDR ORIGINAL PAYMENT WAS VOIDED BECAUSE WRONG
ADDRESS WAS USEDOriginal payment was voided because wrong address was used 58
0467 ITS AUTO ADJ CLM INCORR ORIGINAL CLAIM PROCESSED INCORRECTLY ITS auto adjust claim incorrect 310468 1 MAMMO PER DOS MAXIMUM OF 1 ROUTINE MAMMOGRAM PER DATE OF
SERVICEMaximum of 1 routine mammogram per date of service 50
0469 1 MAMMO PER 2 YRS 40-49 MAXIMUM OF 1 ROUTINE MAMMOGRAM EVERY TWO YEARS (AGES 40-49) PAID
Maximum of 1 routine mammogram every two years (ages 40-49) paid
64
0470 ROUTINE MAMMO N/C UNDER 35 ROUTINE MAMMOGRAM UNDER AGE 35 NOT COVERED Routine mammogram for women under age 35 is not covered 550471 SVC REQ ASSOC ROOM CHARGE CHARGES ALLOWED ONLY IF ROOM CHARGES ALLOWED
FOR THE SAME DATE(S)Charges allowed only if room charges allowed for the same date(s) 65
0472 CLINIC VISIT NOT CVD BENEFITS FOR CLINIC VISITS NOT PROVIDED UNDER SUBSCRIBER'S COVERAGE
Benefits for these clinic visits not provided under your coverage 65
0473 $35 & 20% COPAY $35 & 20% COPAY $35 & 20% COPAY 150474 ITS HOST - MAX BENEFITS THE MAXIMUM BENEFITS HAVE BEEN PREVIOUSLY USED. The maximum benefits have been previously used 46
0475 PROV RISK; RED NOT APPLIED
0476 >9 ROUT VISITS UNDER AGE 3 BENEFITS LIMITED TO 9 ROUTINE PREVENTIVE VISITS UNDER AGE OF THREE
Benefits limited to 9 routine preventive visits under age of three 66
0477 DATABASE RETRY ERROR0478 5 SVCS PER LIFETIME FIVE DIPTHERIA, TETANUS, PERTUSSIS OR POLIO
VACCINES PER LIFETIMEFive diptheria, tetanus, pertussis or polio vaccines per lifetime 65
0479 4 SVCS PER LIFETIME BENEFITS LIMITED TO FOUR SERVICES PER LIFETIME Benefits limited to 4 services per lifetime 430480 > 1 MAMMO BT AGES 35-40 ONE ROUTINE MAMMOGRAM ALLOWED BETWEEN THE
AGES OF 35 AND 40One routine mammogram allowed between the ages of 35 and 39 59
0481 BENE EXCL; RED NOT APPLIED0482 REQUIRED DME DOC NOT RECVD REQUIRED DURABLE MEDICAL EQUIPMENT
DOCUMENTATION NOT RECEIVEDRequired durable medical equipment documentation not received 61
0483 THERAPEUTIC FILE ERROR0484 > ONE SVC SAME DAY ONLY ONE SERVICE OF THIS TYPE IS ALLOWED ON THE
SAME DAYOnly one service of this type allowed on the same day 53
0485 DATABASE RETRY ERROR0486 THERAPEUTIC FILE ERROR0487 NON-COVERED ABORTION ELECTIVE ABORTIONS REQUIRE DOCUMENTATION OF
MEDICAL NECESSITYElective abortions require documentation of medical necessity 61
0488 WELL BABY NON-COVERED THIS WELL BABY SERVICE IS NOT COVERED This well baby service is not covered 370489 UR DENIAL FOR DME DURABLE MEDICAL EQUIPMENT This claim for durable medical equipment was reviewed and denied 64
0490 NON COVERED HOSPICE THESE HOSPICE CHARGES ARE NOT COVERED These hospice charges are not covered 370491 DENY CONSULT-MED CARE PAID CONSULTATION NOT ALLOWED WHEN MEDICAL CARE PAID
TO SAME PROVIDERConsultation not allowed when medical care paid to same provider 64
0492 PRO FEE NON BILL/TRIAGE RITE CARE TRIAGE, PROFESSIONAL FEE IS NON BILLABLE. Rite Care triage, professional fee is non billable. 51
0493 $300 CALENDAR YEAR MAX THE $300 CALENDAR YEAR MAXIMUM HAS BEEN EXHAUSTED
The $300 calendar year maximum has been exhausted 49
0494 DATE CONVERSION ERROR0495 DATE CONVERSION ERROR0496 CARDI > 6 MOS/INVALID DIAG LIMIT FOR THIS SERVICE HAS BEEN EXCEEDED Limit for this service has been exceeded 400497 CARDIAC REHAB EXCEED 12 MO SERVICES EXCEED THE TWELVE MONTH LIMIT FOR
BENEFITSServices exceed the twelve month limit for benefits 51
0498 EXCEED 36 VISITS IN 6 MOS BENEFITS LIMITED TO 36 VISITS IN A SIX MONTH PERIOD Benefits limited to 36 visits in a six month period 510499 BASIC PAID-MAX REDUCE CHARGES CONSIDERED PREVIOUSLY UNDER BASIC
CONTRACT COVERAGECharges considered previously under Basic contract coverage 59
0500 Mult SG MOD;billing error Denied Provider Billing Error; Multiple SG Modifers Services filed on the same day. Please Resubmit
Claim Denied and Sent Back To Provider, Multiple SG Modifers Services filed on the same day
101
0501 1 SVC PER CAL-YR SERVICE ALLOWED ONCE PER CALENDAR YEAR This service was denied as you exceeded your benefit limit of 1 service per calendar year
89
0502 2 SVCS PER CAL-YR SERVICE ALLOWED TWICE PER CALENDAR YEAR This service was denied as you exceeded your benefit limit of 2 services per calendar year
90
0503 1 SVC PER 3 CAL-YRS SERVICE ALLOWED ONCE IN THREE CONSECUTIVE YEARS Service allowed once in three consecutive years 47
0504 3 SVCS PER CAL-YR SERVICE ALLOWED THREE TIMES PER CALENDAR YEAR Service allowed three times per calendar year 450505 1 SVC PER 12 MONTHS SERVICE ALLOWED ONCE IN TWELVE MONTHS Service allowed once in twelve month period 430506 1 SVC PER 5 YRS SERVICE ALLOWED ONCE IN A FIVE YEAR PERIOD Service allowed once in five year period 400507 DOCUMNTATION NOT SUBMITTED CHARGES WERE DENIED AS DOCUMENTATION WAS NOT
SUBMITTEDCharges were denied as documentation was not submitted 54
0508 CONS RED/DNY SUB RES CONSULTANT REDUCED/DENIED BASED ON OUR DENTAL NECESSITY CRITERIA. PATIENT IS RESPONSIBLE FOR BALANCE.
Consultant reduced/denied based on our dental necessity criteria. Patient is responsible for balance
100
0509 CONS RED/DNY PRV RES CONSULTANT REDUCED/DENIED BASED ON OUR DENTAL NECESSITY CRITERIA. REPRESENTS FULL PAYMENT.
Consultant reduced/denied based on our dental necessity criteria. Represents full payment
89
0510 ASF PROV FILING ERROR SERVICE DENIED; CLAIM MUST BE SUBMITTED WITH THE APPROPRIATE REV CODE
Service denied; claim must be submitted with the appropriate rev code
69
0511 CC RED/DNY SUB RESP CLAIMS COMMITTEE REDUCED/DENIED. PATIENT RESPONSIBLE FOR BALANCE
Claims Committee reduced/denied. Patient responsible for balance 64
0512 CC RED/DNY PROV RESP CLAIMS COMMITTEE REDUCED/DENIED. REPRESENTS FULL PAYMENT
Claims Committee reduced/denied. Represents full payment 56
0513 DOUBLE COVERAGE RED PATIENT HAS DUPLICATE BCD COVERAGE. PAYMENT IS BEING APPLIED ACCORDINGLY.
Duplicate coverage; payment has been made accordingly 53
0514 ADMN RED/DNY SUB RES REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT PAYS BALANCE
Reduced/denied per limitation/policy. Patient pays balance 58
0515 ADMN RED/DNY PRV RES REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. REPRESENTS FULL PAYMENT
Reduced/denied per limitation/policy. Represents full payment 61
0516 PRICE EQ TO PERIODIC EXAM THIS AMOUNT REFLECTS THE MAXIMUM ALLOWED PAYMENT FOR THIS SERVICE
This amount reflects the maximum allowed payment for this service 65
0517 AMALGAM ALLOWANCE ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Amalgam (silver) filling allowance. Patient pays balance 56
0518 BET/ACC 8 = 2150 ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Amalgam (silver) filling allowance. Patient pays balance 56
0519 BET/ACC 9 = 2160 ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Amalgam (silver) filling allowance. Patient pays balance 56
0520 BET/ACC 10 = 2161 ON POSTERIOR TEETH, IF OTHER THAN AMALGAM IS USED AS A FILLING MATERIAL, AN AMALGAM ALLOWANCE WILL BE MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Amalgam (silver) filling allowance. Patient pays balance 56
0521 FULL-CAST ALLOWANCE REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0522 BET/ACC 12 = 6791 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0523 BET/ACC 13 = 6792 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0524 BET/ACC 14 = 2790 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0525 BET/ACC 15 = 2791 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0526 BET/ACC 16 = 2792 REDUCED/DENIED PER PROCESSING LIMITATION/POLICY. PATIENT RESPONSIBLE FOR THE DIFFERENCE UP TO THE BLUE CROSS DENTAL MAXIMUM ALLOWANCE.
Reduced/denied per limitation/policy. Patient pays balance 58
0527 PRICE EQ ANTERIOR RTCNL FOR MULTI-CANAL RCT'S UNDER BENEFIT GROUP 1, AN ALLOWANCE FOR AN ANTERIOR RCT IS MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Contract provides benefits for anterior root canals only 56
0528 BET/ACC 18 = 33110529 PRICE EQ TO ADDTNL EXTRACT THIS AMOUNT REFLECTS THE MAXIMUM ALLOWED
PAYMENT FOR THIS SERVICEThis amount reflects the maximum allowed payment for this service 65
0530 PRICE EQ TO SINGLE EXTRACT FOR SURGICAL EXTRACTIONS UNDER BENEFIT GROUP 1, AN ALLOWANCE FOR A SIMPLE EXTRACTION IS MADE WITH THE PATIENT RESPONSIBLE FOR ANY DIFFERENCE IN COST
Contract provides benefits for simple extraction only 53
0531 1 SVC PER 6 MONTHS SERVICE ALLOWED ONCE PER SIX MONTH PERIOD Service allowed once per six month period 410532 DATE CONVERSION ERROR0533 SPECIALTY EXAMS N/C SPECIALTY EXAMS ARE LIMITED IN SCOPE AND ARE NOT
CONSIDERED A COVERED BENEFITThis type of exam was denied as it is not a covered benefit under your plan. Please refer to your benefit documents
115
0534 SURF ONCE PER 12 MOS SAME TOOTH SURFACE(S) FILLED WITHIN 12 MONTHS. PATIENT CANNOT BE BILLED FOR BALANCE
Tooth surface filled within twelve months. Represents full payment 66
0535 N/C PER DOC SUB RESP SERVICE RENDERED DOES NOT QUALIFY AS A PALLIATIVE TREATMENT TO RE- LIEVE PAIN. PATIENT IS RESPONSIBLE FOR PAYMENT
Service is not covered. Patient is responsible for payment 58
0536 1 EVAL PER COURSE OF TRMT 1 EVALUATION PER COURSE OF TREAMENT (180 DAYS) 1 Evaluation per course of treatment(180 days) 460537 N/C PER DOC PROV RES0538 PRICE EQ TO PER EXAM, NPAR0539 1 SVC PER 2 CAL-YRS SERVICE ALLOWED ONCE IN TWO CONSECUTIVE YEARS Service allowed once in two consecutive years 450540 N/C W/IN 30 DAYS OF R C THIS SERVICE IS INCLUSIVE WITH ROOT CANAL
PERFORMED PREVIOUSLYThis service is inclusive with root canal performed previously 62
0541 RESTOR SAME PROV N/C This service is inclusive with the filling performed previously 630542 CONS N/C BY ATTD DEN Consultations not covered when rendered by the attending dentist 64
0543 APICO NC SAME DAY RC APICOECTOMY IS CONSIDERED INCLUSIVE WITH THE ROOT CANAL WHEN PER- FORMED ON THE SAME DAY
Reduced/denied per limitation/policy. Represents full payment 61
0544 IC RED/DENY PROV RESP INDIVIDUAL CONSIDERATION REDUCED/DENIED. REPRESENTS FULL PAYMENT.
Individual consideration reduced/denied. Represents full payment 64
0545 N/C SAME DAY AS SURG MEDICAL EMERGENCY SERVICES ARE NOT COVERED ON SAME DAY AS SURGERY
This service is not covered with surgery performed on same day 62
0546 IC RED/DENY SUB RESP INDIVIDUAL CONSIDERATION REDUCED/DENIED. PATIENT PAYS BALANCE.
Individual consideration reduced/denied. Patient pays balance 61
0547 1 SVC PER 2 CAL YRS SERVICE ALLOWED ONCE PER EVERY TWO CALENDAR YEARS
Service allowed once per every two calendar years 49
0548 1 RELINE PER 5 YEARS SERVICE ALLOWED ONCE IN A FIVE YEAR PERIOD Service allowed once in five year period 400549 DATE CONVERSION ERROR0550 1 SVC PER 36 MONTHS SERVICE ALLOWED ONCE PER 36 MONTH PERIOD Service allowed once per 36 month period 400551 N/C INDIVIDUAL ACCTS INDIVIDUAL ACCOUNTS DO NOT COVER THIS SERVICE Individual accounts do not cover this service 450552 EXCL FROM FEE REDUCTION EXCL FROM FEE REDUCTION Excl from fee reduction 230553 ANES N/C W/O SURG ANESTHESIA IS NOT PAYABLE UNLESS RENDERED IN
CONJUNCTION WITH A COVERED SURGICAL PROCEDURENot payable without a covered surgical procedure on the same day 64
0554 DENY - I.T.S. HOST0555 3 SVCS PER LIFETIME ONLY THREE SERVICES OF THIS TYPE ALLOWED PER
TOOTH. PATIENT PAYS BALANCEOnly three services of this type allowed per tooth 50
0556 2 SVCS PER 12 MONTHS SERVICE ALLOWED TWICE PER TWELVE MONTH PERIOD Service allowed twice per twelve month period 450557 FILE W MED INSUR CAR THIS SERVICE MUST BE FILED WITH MEDICAL INSURANCE
CARRIERThis service must be filed with other medical insurance carrier 63
0558 1 SVC PER BEN-YEAR ONE SERVICE ALLOWED PER BENEFIT YEAR One service allowed per benefit year 360559 1 SVC PER 3 BEN-YRS ONE SERVICE ALLOWED PER EVERY THREE BENEFIT
YEARSOne service allowed per every three benefit years 49
0560 2 SVCS PER BEN YEAR TWO SERVICES ALLOWED PER BENEFIT YEAR Two services allowed per benefit year 370561 1 SVC PER 5 BEN-YRS ONE SERVICE ALLOWED PER EVERY FIVE BENEFIT YEARS One service allowed per every five benefit years 48
0562 3 SVCS PER BEN-YEAR THREE SERVICES ALLOWED PER BENEFIT YEAR Three services allowed per benefit year 390563 1 EXAM PER 6 MONTHS ONE EXAM ALLOWED PER SIX MONTH PERIOD0564 BET/ACC 19 = 7120 NON-PAR0565 TRANSCOM MAX MET0566 TRANSCOM=PAY CODE 1090567 TRANSCOM=PAY CODE 115 OUR ALLOWANCE REDUCED BY THE OTHER INSURANCE
CARRIER'S PAYMENTOur allowance reduced by the other insurance carrier's payment 62
0568 WRONG PROVIDER ID PROCEDURE PROCESSED UNDER INCORRECT PROVIDER IDENTIFICATION
Procedure processed under incorrect provider identification 59
0569 WRONG SUBSCRIBER ID PROCEDURE PROCESSED UNDER INCORRECT SUBSCRIBER IDENTIFICATION
Procedure processed under incorrect subscriber identification 61
0570 HOME BANK CLAIM - APPROVED0571 HOME BANK CLAIM - DENIED0572 HOME BANK CLAIM - PAID0573 HOME BANK - DEDUCTIBLE0574 HOME BANK - COINSURANCE0575 HOME BANK-PAY BY PAT ACCOM Balance of private room charge is your responsibility 530576 HOME BANK-ANCIL PAY BY PAT BALANCE OF CHARGES ASSOCIATED WITH THE PRIVATE
ROOM CHARGE IS THE PATIENT'S RESPONSIBILITYAdditional cost for a private room is your responsibility 57
0577 HOME BANK-R.C.C.0578 SEALANT N/C ON THESE TEETH SEALANT IS NOT COVERED WHEN APPLIED TO THESE
TEETHSealant is not covered when applied to these teeth 50
0579 SEALANT N/C THESE SURFACES SEALANT IS NOT COVERED WHEN APPLIED TO THIS TOOTH SURFACE OR SURFACES
Sealant not covered when applied to this tooth surface or surfaces 66
0580 SEALANT N/C AFTER RESTOR SEALANTS COVERED ONLY WHEN APPLIED TO NON-RESTORED VIRGIN TEETH
Sealant not covered when applied to previously filled teeth 59
0581 I/P $500 DED CAL/YR A $500 INPATIENT DEDUCTIBLE IS APPLIED PER CALENDAR YEAR
A $500 inpatient deductible is applied per calendar year 56
0582 FILE SINGLE LESION FIRST SINGLE LESION MUST BE FILED FIRST This service must be submitted following an initial procedure 610583 OOA METHOD 01 RULE 00000 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS
SERVICEThis amount is the maximum allowed for this service 51
0584 WORKERS COMP RECOVERY WORKER'S COMP RECOVERY Allowance after worker's comp recovery 380585 SUBROGATION ATTORNEY FEE SUBROGATION RECOVERY Subrogation Recovery 200586 SUBROG-COMPROMISE+LOSS SUBROGATION RECOVERY Subrogation Recovery 200587 NO ER CLAIM IN HISTORY0588 DETERMINED FRAUD AND ABUSE AFTER REVIEW, THIS CLAIM HAS BEEN DETERMINED TO BE
NON-COVERED DUE TO FRAUD/ABUSEAfter review, this claim has been determined to be non-covereddue to fraud/abuse
80
0589 GLOBAL ALLOWANCE PAID THIS SERVICE IS CONSIDERED TO BE INCLUDED IN THE GLOBAL SURGICAL ALLOWANCE
This amount represents the maximum allowance for this type of service
69
0590 $25.00 CO-PAY BENEFIT REDUCED BY A $25 COPAYMENT AMOUNT This amount represents your $25 copayment. You are responsible to pay your provider directly
93
0591 PROV SPEC 69 PD IN HST PAYMENT HAS BEEN MADE PREVIOUSLY TO AN INDEPENDENT LABORATORY
Payment has been made previously to an independent laboratory 61
0592 25% USUAL/CUSTOMARY BENEFITS FOR SERVICE REDUCED BASED ON PLACE OF SERVICE
Benefits for service reduced based on place of service 54
0593 OOA METHOD 10 RULE 00001 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0594 MEDICAL/SNF/CC ON SAME DAY ONLY ONE SERVICE ALLOWED ON THE SAME DAY Only one service allowed on the same day 400595 INAPPROPRIATE MODIFIER USE THE USE OF THIS MODIFIER IS UNAPPROPRIATE FOR THIS
SITUATION.The use of this modifier is inappropriate for this situation. 61
0596 OOA METHOD 10 RULE 00002 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0597 MED CARE INCLUDED SURG CHG MEDICAL CARE IS INCLUDED IN THE SURGERY CHARGE Medical care is included in the surgery charge 460598 APPLIED TOWARDS DEDUCTIBLE TOTAL OR PART OF PAYMENT WAS APPLIED TOWARDS
CONTRACT DEDUCTIBLEThis amount was applied toward your annual deductible. You are responsible to pay your provider directly
105
0599 CARDIAC REHAB SVCS EXCEED THE LIMIT FOR CARDIAC REHABILITATION SERVICES HAS BEEN EXCEEDED
The limit for cardiac rehabilitation services has been exceeded 63
0600 OOA METHOD 10 RULE 00003 THIS AMOUNT IS THE MAXIMUM ALLOWED FOR THIS SERVICE
This amount is the maximum allowed for this service 51
0601 $1000 PEN/NO CONS. IN HIST A $1000 COPAY APPLIED AS SECOND OPINION CONSULTATION NOT OBTAINED
A $1000 copay applied as second opinion consultation not obtained 65
0602 EXCEEDS 36 VISITS EXCEEDS THE LIMIT OF 36 VISITS Exceeds the limit of 36 visits 300603 6 SVC PER CAL-YEAR SIX SERVICES PER CALENDAR YEAR Benefits provided for 6 services per calendar year 500604 $75 CALENDER YEAR MAY EXCE $75 CALENDAR YEAR MAXIMUM HAS BEEN EXCEEDED FOR
THIS SERVICE$75 calendar year maximum has been exceeded for this service 60
0605 OOA METHOD 14 RULE 00004 THIS AMOUNT IS THE MAXIMUM ALLO
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